How to pass the ANZCA Faculty of Pain Medicine Fellowship Exam — A personal reflection

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I had one goal in 2023.

To pass the Faculty of Pain Medicine Fellowship exam.

And thus, I took this task seriously.

How could I not? 

We’d made the big move from Albany to Perth as a family and I tell you that it wasn’t easy. 

Our idyllic, peaceful and comfortable life changed in an instant. 

Everyone in the family was either starting at a new school or job.

More than the burden of post-graduate study, it was a professional departure from being the boss for the last 11 years.

However, I needed the change. We as a family needed a refresh, a reset.

Whilst my clinical work was rewarding, I had hit a professional ceiling within my scope of practice as a Generalist. 

I knew I was ready for the next step. 

But who in their right mind at age 42 decides to become a registrar again, take a pay cut and hit the books for a seemingly daunting exam?

Me.

Jonathan Ramachenderan.

Life-long learner, big-thinker, change maker and husband and dad in training. 

And as you will see, massive Pain Medicine nerd.

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This article is about how I approached the Faculty of Pain Medicine Fellowship exam in 2023 and the strategy I employed to study. 

I have attempted to summarise the approach and strategy and include my own experience through the piece.

Ultimately through this journey, I became a better clinician, more informed, measured and thoughtful.

It was a rewarding process to reflect a year later at simply how much I’d learnt and the cool new skills I’d acquired. 

My Practice Development Year in 2024 will be focused on learning procedures and integrating this into my Palliative Care practice.

I chose to sit the exam in my first year due to my experience as a rural GP Anaesthetist and Palliative Generalist, work that I have done for the last eleven and five years respectively. 

Winning the Merit award was a bonus but a private, secret and personal goal that I set for myself in July 2023.

This is the guide that I wish I had and the direction, encouragement and warm hug I needed when I started seeing patients with chronic pain and studying for the FPM exam in 2023. 

There are no shortcuts, you have to take this seriously.

It was challenging to study with a family and it cost me dearly in time. I had to squash the notion that I was missing out on life, fun and adventures every day. 

Please feel free to contact me with your advice too as I’ve found there are multiple ways to study for the exam. 

Start early and take it seriously 

Before we start, let me talk about one strategy that did not work and can cause a great deal of undue stress.

Starting study too late and “ramping up” at the end.

This is a poor judgment call and can reflect professional immaturity. 

James Clear’s quote about the difference between professionals and amateurs guided my approach to the exams but also to my wider professional and personal life.

Professionals stick to the schedule, amateurs let life get in the way. 

Professionals know what is important to them and work towards it with purpose, amateurs get pulled off course by the urgencies of life.

Before you start, ask yourself, are you going to have a professional approach to the FPM exam or the lacklustre attitude of an amateur? 

We found that starting 5–6 months before the written exam provided the best results, especially for those with multiple non-medical commitments. 

And it will be challenging, putting time into study when everyone seems to be having the time of their life.

But let me tell you that every small bout of study held within a schedule matters and it makes a difference.

Having a plan always trumps the anxiety and worry that you are going to fail – you can tell those feelings to get stuffed.

I started in March because I had to get my head around visceral pain and other concepts that I had never thought about in that much detail.

Mindset and visualisation

Mindset 

I’d like to start with your mindset and how you will frame your thoughts and behaviour towards the exam. 

If you can nail this before you start your campaign, it will make all the difference when the urgencies and distractions of life compete for your attention. 

I love sports, but more specifically I love the mindset and the discipline behind elite sports performance. 

And so, in my preparation for the 2023 FPM exam, I focussed on my mindset and set clear goals and behaviour expectations for myself — I became an intellectual athlete.

1. Have a clear strategy

My strategy for 2023 was simple.

I was going to do everything in my power to pass the FPM exam.

That meant every decision that I made in 2023 would either bring me closer towards passing comfortably or ultimately failing the exam. 

I made sure that every single thing that I did in 2023 was directed towards passing the exam.

And so this meant controlling the controllables. 

And most controllable part of my life was where I spent my time and attention. 

This started first as the clearing of all my commitments and time-heavy priorities — this began in October of the year before. 

I cleared my calendar.

I stepped off all committees and decided in 2023 not to pursue any lucrative GP Anaesthetic locums, emergency after-hours work or volunteer for anything (committees, talks and lectures, serving at church, coaching basketball or hosting family events). 

I cleared out everything in my life except for:

1) Time with my wife and my three boys 

2) Saturday afternoons to play, goof off and do nothing

3) Monthly weekend Palliative Care on-call (to stay in touch with Palliative Medicine)

Understanding our current economic conditions (high interest rates and steady inflation), do what you can to keep your schedule as clear as possible. Do extra work if you need to but in general, the exam year is not the time to earn extra money and to smash financial goals. Whilst we did not have any debt, our savings certainly took a hit.

2) Took a break/time out from Social Media

Secondly, I stopped using all forms of social media. 

My last post on Instagram was in March 2023, a few weeks after my TEDx talk. 

Social media is the biggest distraction in my life.

What I have found is that passive scrolling implants ideas, anxieties and unhelpful time-wasting thoughts in my mind. 

I wanted everything in my life to point towards passing the exam and learning how to be a Pain Specialist.

It had to be extreme because I did not want to sit this exam twice — I had better things to do in 2024!

I had failed a Fellowship exam before and two exams in medical school and the common denominator was distraction — my mind was everywhere but the one place it had to be.

3) Rest, recreation and healthy habits

Thirdly, rest and recreation were important, so I followed a simple routine of rest, study, exercise and goofing around time. 

Saturday afternoons were for complete rest, even during my study weeks, I would watch sports, hang out with Kylie my wife and do cool things.

With regards to exercise, I kept everything short, sweet and interesting. I didn’t break any long-held goals but it was enough — running, weights and cycling. 

The more I learnt about exercise’s effect on the descending modulating nervous system, I recognised that hypoalgesia and the enkephalins and dynorphins and endorphins released were real and I was hooked but also thoroughly refreshed.  

And the one thing that got me through those dark Perth winter months was watching sports — the Tour De France in July, the start of the NFL season in August and our local NBL1 league.

2. Discipline

Discipline is well known to most doctors but as we get older and become more senior in our career, the spartan ways in which we used to pass exams in Medical School and our Primary Fellowship, can fade with time.

And so, I kept it simple with two things. 

A clear plan and almost daily visualisation. 

My mantra during this time was “keep going” and towards the end, it was“I will do everything for this to be over”. 

“Over” was what I visualised every day and communicated out loud to my friends, colleagues, study mates and family. 

“Over “looked like this to me in my head as I practiced visualisation.

1. Hot, 38-degree Christmas in Perth. Sweltering in the sun, wondering why we weren’t inside, sitting around the table, not listening to the conversation but secretly smiling because I passed the FPM exam!
2. Breakfast the day after the exam. Coffee. How it tastes with no study to do afterwards.
3. Christmas Day Parkrun. 27 mins 5km, sweating profusely. But insanely happy that I don’t have to study after!
4. Watching the NBL and NFL on Kayo all summer with no study to do!
5. Holiday at Rottnest in January 2024 with the family with no study to do!

All of us visualise outcomes whether we know it or not. 

And for most of us, we’ve never harnessed the power of imagining the future and the clear outcome that we desire and want. 

We’re good at visualising what we don’t want, especially if we have children.

And some may think that visualisation is like using crystals and essential oils to heal broken bones, but I assure you it’s not. 

This is because everything is created twice — first in our minds and subconscious and then in reality in our tangible world! 

Imagining the clear future outcome that we want uses our sensory, pre-motor and motor cortex to start subconsciously working for us.

For me, it worked perfectly especially when Dr Charles Brooker called my name for the winner of the Merit Certificate — my visualisation from July 2023

Exam Strategy

Summary

I systematically went through each Essential Topical Area, read all the references and made handwritten notes and quick revision palm cards (I’m an analogue type of guy first before all my fancy tech).

Looking through the FPM curriculum was daunting at first but as I made my way through the ETA’s it became easy to tick these off. Be mindful to go through OTA’s 4.1 – 4.4 as these are assessed too.

I read through each of the Faculty of Pain Medicine documents and understood where they fit in the practice of Pain Medicine.

The FPM tutorials were excellent. I couldn’t attend these in real time but I used them to complement my notes and learning retrospectively. My favourite sessions were those on Pelvic pain, Acute Pain and all Dr Michael Nicholas’s sessions – if you want to understand how central the psychological dimension is to Pain Medicine. To be clear, I didn’t go through all of them – I didn’t have time as I did this retrospectively.

Running through past exam questions was a key part of my study (right back from the year 2000) and I also researched and memorised relevant evidence, criteria and ways of assessing different pain presentations. 

I attended all the FPM online exam sessions and found the live practice Viva and Written exam sessions (we did 4 questions in real time over an hour) extremely helpful to understand timing, content and practice!

The secret sauce – I stayed late at work and studied in my office and in the library, a strategy that helped with traffic and getting quiet time each day (I have 3 boys and a boisterous home environment). It was hard work for someone who’d last sat a Fellowship exam in 2014. Even if it was 30 minutes, I was grateful.

Another James’s Clear quote for you about adaptability being the key to consistency.

In practice, consistency is about being adaptable. Don’t have much time? Scale it down. Don’t have much energy? Do the easy version. Find different ways to show up depending on the circumstances. Let your habits change shape to meet the demands of the day.

FPM ANZCA Fellowship Exam Strategy in detail: 

1) Become familiar with the ANZCA website and the Learn ANZCA portal and become proficient at finding relevant pages through this portal.

The pages that I used the most were:
1. Pain Medicine Training Overview – this was the link to all the ETA’s and relevant references. There are more references here than in the modules on Learn ANZCA
2. Learn ANZCA portal:
– FPM Essential topic areas (modules)
– Trainee support resources (Click Module – where exam reports are, POST exam, formulation etc)
– Examination of patients with pain issues (informative videos of examinations)
– Trainee tutorials (available after the tutorial)
3. ANZCA library page – for searching/getting access to articles that I wanted to read

2) I planned 3 runs through the curriculum (I managed 2.5ish)

3) Covered each “Essential Topical Area” (ETA) and Optional Topical Area (OTA)
– Read through all the references listed here under each ETA (I did this in my first run-through)
– Go through each of the modules on Learn ANZCA (I did this in my second run-through)

4) Did all the questions related to the ETA modules on Learn ANZCA interspersed through the modules to understand the topic. I also ran through the case study example that is included in each module.

5) Discuss the questions weekly or fortnightly with a group — we had a schedule that was quite tight but good, we covered an ETA every week.

6) Have a consultant or senior fellow help to direct the study group and provide input into the answers to the questions. We were fortunate in WA to have an FPM consultant group who volunteered their time for 1-2 hours on Saturday morning to help us run through questions relevant to the ETA of the week. I am thoroughly grateful for their collective wisdom and exam encouragement.

If anyone from the college is reading this, massive credit to the consultants in WA for doing this and Dr Stephanie Davies from Fiona Stanley Hospital for organising our ETA Study group schedule.

7) Make notes and summarise the key ideas included in the ETA’s
– I made notes and palm cards of the relevant and key topics, diseases, pain syndromes and evidence related to the ETAs.
– For example, I made sure I knew what Complex regional pain syndrome was, the pathophysiology, the controversies, the Budapest criteria and how to manage this with the latest evidence (2023 Cochrane) 

8) Learn how to answer and frame the written questions through the socio-psycho-bio model of care and management. Have a way of assessing and managing pain problems that you can rely on in the exam and in clinical work.

This is important and it will take practice. This approach will help you in clinical practice to have a holistic view and approach to the management of chronic cancer, and acute and chronic non-cancer pain. This is what makes us Pain Specialist Physicians.

I’ve included my process below together with a worksheet that Associate Professor Paul Wrigley sent to us on his suggested approach to answering questions. And to my surprise, our approaches were similar.

9) Towards the end (the last 8 weeks before the written exam, I started practising typing and answering questions under exam conditions). 

In the last 2 weeks (study fortnight), I was completing between 8–10 questions under exam conditions/day — It was exhausting but necessary. 

My aim was to have finished revising the curriculum by the study fortnight. I then spent each day doing a mock exam in the morning between 9am and 10am (real-life exam time) and then spent the afternoon marking the paper from the day before – this was my revision too. I’d throw in a palm card session too if I still had energy (I did these in the garage where I wouldn’t be disturbed)).

I created a spreadsheet of all the questions and picked questions at random to make up an exam until I had covered nearly ten years of questions (96).

I set clear targets of what I wanted to reach by when — 100 questions by study week then 100 questions in a two-week study break (I did 84).

Study week was soul-destroyingly relentless, waking up knowing you had a 2-2.5 hour exam to sit that day. Left, right, left, right, I just kept going because I wanted it all to be over.

By the end, 2-3 days before the written exam, I felt like I was ready because I was completely sick of the ground-hog-day-like existence I was living.

On the day before the exam, I did a half-day of work then chilled out with my wife, had sushi and did a workout.

I’ve included my Excel spreadsheet below with my question matrix and how I organised practice exams etc – emotion not included.

10) The written exam — the barrier of entry to the big dance. 

The morning started poorly because my practised run into Perth city was stymied by a full Convention Centre car park. After running more than a kilometre to the testing centre due to where I parked (without paying for parking and didn’t get a ticket), I registered and waited with the others, only 5 minutes after the suggested time – I was lucky.

Earlier, I had a normal breakfast, toast with jam and banana and a protein shake. I also went for a run — no records broken, it was simply to clear my head and energise myself, a routine that had been the backbone of my preparation.

This was the first year that the Written Exam was conducted online — a typing exam together with the option for written paper (for those who opted to write) and from my perspective, it ran well. 

We had a great deal of information provided to us from the college and a sample website for us to trial the interface.

It was held at Cliftons around the country, an examination and educational centre and the room, desk, climate and facilities were fine.

We started with little fuss with a large countdown clock projected in front of us. The reading time was essential, I wrote notes about how I’d answer the first few questions — I did this for 6–7 questions I think. 

Everyone’s online exam was different as all ten questions were randomised.

The practice certainly helped with typing and time management. One of the first things that I wrote down was the timing intervals that I needed to come under with all ten questions. 

In practising for the exam, I was told to work with ten minutes per question, while others said twelve and I was alarmed constantly that I was hitting fifteen and sixteen minutes per practice question no matter what I did. In practice even if I had an 11-minute question, I’d blow my advantage with a 17-minute answer — I gave up in the end, I simply said “Go hard JR”. That’s why we practice — to understand the craft.

For me, it flowed well. The exam consisted of ten questions with multiple short answer stems vs a long essay-like answer it had been in the past. 

For example in the question on Neuropathic pain, the first part asked what the risk factors for neuropathic pain were, the second part was on something else and the third and fourth parts were on management and evidence. It was well broken up. No long pieces of essay-like writing were required. 

It flew past and there were no questions that stopped me in my path except the statistics question on confirmation bias. Of all the sections within the exam, this was the one in which I knew the least. I did my best and cracked on.

I stayed on time for all of the questions and spent a little longer on my last one and when I finished, there were twenty seconds to go, so I counted down with it.

I didn’t feel rushed, the practice certainly helped with the mental stamina and judging when you were slowing down and when you were in the flow state.

The first emotions after the exam are probably the most accurate and I was happy, and satisfied with my solid effort and started planning the viva study sessions with the group straight after — not everyone shared my sentiments!

11) Take a week off. 
This was solid advice from a colleague who’d passed the exam a year before. I called him the day after to debrief and by then my initial confidence had been shredded and I was in a panic.

I was worried that I had failed – Oh Jonathan, you poor tortured soul.

As he listened to me, he said “Mate, you’ll be fine. Sounds like you did a good job. Take a week off. Go to the movies, go out for dinner. Chill and then get back into it”. And so I did. It was surreal to rest for a week and I did go to the movies with the boys to see Teenage Mutant Ninja Turtles.

I intentionally had to push my worry and anxiety behind me because I had 7 weeks to prepare for the Viva and OSCE, and 3 weeks before I found out the result. It was nerve-wracking and I lived for about a week in a constant state of mental anguish about my performance. However, it was out of my hands — I had given the written a solid go. I prayed that God would do the rest and that my answers would find favour in the eyes of the examiners.

On Friday 13th of October at 6:41am WST, I received the email and letter — I had passed. 

12) After passing the written (if not before) I started organising practice sessions with various consultants where I ran through viva questions. They’d give me a question and I’d have the 10-minute time limit to answer and run down the question/answer tree. I drove all over Perth to get practice. For the last 4 weeks before the Viva and OSCE I had a couple of “standing” appointments with a couple of consultants who ran through questions with me – I am absolutely grateful to Dr Eric Visser, Dr Donald Johnson, Dr Leah Power, Dr Brian Lee, Dr Eric Remedios, Dr Dana Weber, Dr Chiu Chong, Dr Stephanie Davies, Dr Ravi Agrawal, Dr Ganesh for their intense grilling and pointed questions! You only know what you don’t know after you are confronted with it.

13) I did quite a bit of practice of my own using the palm cards saying things like “Tell me about the evidence of Fibromyalgia, Talk to me about the effectiveness of anti-neuropathic or Run me through all you know about spinal cord stimulators”. During this time, if I had a gap in my knowledge and I needed a quick answer, I’d ring up one of the consultants and have them run through an issue with me. I did this with the scenario of an “infected spinal cord stimulator” and “Syringomyelia and Autonomic dysreflexia”. As you can see, I was at the top end of the knowledge tree and completely dialled in.

14) For the OSCE I wrote out all the relevant examinations that I would need to know and practised these daily. We had a consultant guide (Thank you Dr Reza Feizerfan) and critique us and we eventually became slick in performing these examinations. 

In the last 2 weeks, I ran through all the examinations every day with a pretend patient. I’d say hi, introduce myself, get consent and explain what I was going to do, wash my hands and crack on.

I practiced the hand, hip, knee, shoulder, neck, upper body, lower body, back, headache, Type 2 Diabetes, Pain orientated sensory testing each day. I watched the videos on Learn ANZCA to guide me — the new ones.

15) We organised a mock OSCE/VIVA at Royal Perth Hospital one week out from the OSCE in Melbourne. This consisted of 4 stations — 3 VIVA and one OSCE. Again, it was invaluable for our practice in getting used to the flow of exams. In our consultant faculty, we had two prize winners and a current examiner. We (the Perth crew) were extremely grateful for the Consultants who gave up their time and those who attended, passed!

16) Get to Melbourne early— I arrived in Melbourne on Wednesday night (from Perth) to acclimatise to the time difference, get into a sleep pattern, exercise, have coffee, settle in and study in a nice hotel room (which was walking distance from the Royal Melbourne Hospital) and tried my best not to get COVID. 

The exam was on Saturday morning and by then I’d had two full days to rest, study, exercise and time to get my mind into the right space. I was nervous, but I had a plan — I was sweet.

17) On the day, I woke up at my normal time, read my bible went for a short run, and had a coffee and breakfast — all normal stuff. Exercise is energising and it’s my “ study and performance hack” that produces alertness and energy.

During the day, I quieted my mind with deep breathing and found peace in prayer. I smiled and engaged with others and was happy that this day had finally come — I experienced joy. 

This was what I had trained for, my Olympics as an Intellectual athlete.

Things went well. There were questions that I could answer on spinal cord stimulators and Complex Regional Pain Syndrome, Cancer Pain, there was a Palliative Care station with a distressed actor, a Radiology and MSK station, a neck and shoulder examination, an older patient station, a Medicinal cannabis station and finally an Acute pain station (which was interrupted by a Code Blue alarm and featured methadone!).

After the morning quarantine, I went back to the hotel, had a shower, had some McDonald’s hot cakes (could only finish half) and had THE best coffee from the cafe at the hotel. Following the VIVA in the afternoon, I went back to the hotel again, reflected and watched “Tusla King” to unwind. 

By the time I walked to the bar where everyone had arranged to meet, one of my OSCE group mates told me that I had passed (he’d seen my candidate number on the email). The results were released at 4:45 pm. The rest is history and brings us to now, writing a guide to help others pass the Pain Medicine Exam and in turn to become better Pain Medicine Specialists.

18) After the exam I was exhausted, a feeling which stayed with me for nearly 6 weeks. This was true fatigue, but nothing sinister.

I was completely spent. I’d run a marathon for 6 months — consistent study and relentless focus.

Be prepared for the slump when the adrenaline is no longer driving you! 

In retrospect, I should have had a week off work to recover, sleep and play. I suggest the Maldives.

You will have a fair amount of extra time so don’t commit to anything until you have recovered. I started writing this piece 6 weeks after the exam because I knew it could help. 

19) Help others. Be a resource of hope, direction and encouragement. Don’t talk in riddles and circles about the exam to new trainees and those wanting advice — be specific and excellent in adding value, this is how we progress together. It became clear to me the people who wanted me to succeed and those who couldn’t care less or viewed me as a threat — it was in the depth and quality of their advice and help. If I do well, you do well — that is my view. I am only in competition with Dr JR – do you know him?

Specific topics and evidence to cover for the FPM Fellowship Examination 

1. Faculty of Pain Medicine position statements, documents and policies 
– Acute pain
– Opioids in non-cancer pain 
– Cultural safety and competence
– Ketamine
– Procedures
– Medicinal cannabis 
– Practitioner health
– Intrathecal opioids

I am certain that there may be more BUT these are the core documents. Some of them have background papers (BP) associated with them with additional information – look them up on the college site.

College-associated National Australian Clinical Care Standards that you know — high-value low back pain care and opioid stewardship clinical standards

Low Back Pain Clinical Care Standard. High value low back pain management was a question in 2022 and this is essential bread and butter Pain Medicine knowledge.

Opioid stewardship Clinical Care Standard — you must know what Opioid Stewardship is not just for the exam but for how you practice and provide advice as a Pain Specialist. This was a question in 2022.

*This list is not exhaustive — please have a look for yourself*

2. Find, learn and memorise key evidence:

-Psychology: Know what Psychologists do and how cognitive and behavioural therapies work!

This is a good start – The position statement from the Australian Pain Society about the role of Psychologists in Pain Management.
These questions were poorly answered in all the exams, pointing to a lack of understanding of how psychologists contribute.

-Exercise: How does exercise (strength, stretching, mobility aerobic exercise) help in patients with chronic pain
–Multidisciplinary pain programs and the use of psychometric assessments: DASS-21, PSQ, PCS, BPI — what are these?
-Medications — Ketamine, Lignocaine, Opioids, Anti-neuropathic, NMDA receptors antagonists, metabolism of relevant medications, what to use in older patients, and patients with renal or liver dysfunction
– Opioids — understand their use inside out, evidence for and against (plenty), their metabolism (not to great detail but their active metabolites), the consequences of long-term use and the combination with benzodiazepines, marijuana and gabapentinoids (DANGER!!)
-Interventions — Spinal cord stimulators, lumbar and cervical injections (facet joint injections, median branch blocks, epidural), lumbar surgery, CRPS interventions
– Cancer pain — there are only a few key topics here to learn and know the evidence. Mucositis, cancer bone pain, visceral cancer pain, chemotherapy-induced peripheral neuropathy, cancer pain assessment, palliative care, interventional cancer pain (it’s not always injections!)

3. Acute pain mastery
-Attend Acute pain ward rounds and watch how the consultants manage common issues, this by far is the best way to learn acute pain management.
– Read the Acute Pain Scientific Management book by Schug and Macintyre
– Make sure you attend the Acute pain tutorials
– Read the college document on Acute Pain
– Formulate in your head situations in which you would be called to the ward to manage common emergencies (inadequate analgesia, failed regional, opioid-induced ventilatory impairment, patient groups – older, obese, COPD, psychological distress, opioid-tolerance, opioid use disorder, discharge advice and analgesic stewardship)
– What do you need to consider when assessing a patient in acute pain?
– The role of regional anaesthesia in acute pain management. What are the commonly used blocks in routine anaesthesia, trauma units and emergency departments to reduce pain and prevent chronic post-surgical pain
– Chronic post-surgical pain, how to prevent and treat this condition in the pre, intra and post-operative setting and what is the evidence (there is plenty – look at APMSE). What are the pre-operative/intraoperative and post-operative risk factors and management techniques prescribed by the evidence.

An approach to answering written assessment and management questions

Please see this example of my approach to answering assessment and management written questions.

It’s something that I’ve worked on and developed through study and clinical work.

And it is certainly just that – my approach.

It is not FPM college endorsed nor is guaranteed for your success but system that you can build on and mould into your own.

I’ll illustrate using this question below and have linked Associate Professor Paul Wrigley’s proforma below – it’s excellent!

Please provide assessment and management of a 65-year-old woman, a retired Principal on high-dose opioids post knee surgery referred with increased distress and would like more pain relief.

Oxycodone 60mg BD with 30mg PRN
Pregabalin 300mg BD
Diazepam 5mg TDS

Brief summary – This is a middle to older woman with chronic non-cancer pain -chronic musculoskeletal secondary to likely osteoarthritis and post-surgical pain.

Issue assessment (not asked, I simply did one)

The main issues are:
1) High dose opioids 150mg Oxycodone, nearly 200 oral morphine equivalents
– High risk of sudden death
– High risk of opioid-related side-effects
– Almost certain opioid-induced hyperalgesia
– High intensity of pain and impact on mood and activities

2) High distress
– Impact on mood and self-management

3) High likelihood of sedation and misadventure
– Co prescribed pregabalin and benzodiazepine
– High likelihood of:
Sleep-disordered breathing
Falls
Driving crash/accident

The main thing here is to build a relationship with this patient – listen to her truly and validate how she is feeling, we need to help reduce her distress.

Assessment – This is quite a thorough assessment (not my original but the headings are similar)

Rule out red flags
– Physical (cancer, infection, fracture, myelopathy, cauda equina, visceral pain, ankylosing spondylitis)
– Opioid (withdrawal, hyperalgesia, tolerance, aberrancy)
– Psychiatric (suicide, insomnia, hopelessness etc)
Clarify the pain
– Where and what is it and what does it feel like
– Nociceptive/Neuropathic/Nociplastic
– Does it fit into an ICD-11 stem
What is it affecting
– Function, work, family life, hobbies, rest, relaxation
– Sleep, mood, activities
Substances and
– Smoking, ethanol, cannabis, illicit drug use, benzodiazepines, gabapentinoids
– Opioid dose (?>100 OME – 3-11x risk of sudden death)
– Naloxone intranasal
OIVI contributors
Obesity, OSA, OME >100, Organ failures, COPD, Gaba, BZD, OIVI (sedated)
What are you doing about the pain?
– Medications: everything and anything
– Interventions: surgery, injections, radiation, chemotherapy
– Non-pharmacological: stretching, TENS, heat/cold packs, acupuncture, massage, heat rubs
– Exercise: mobility, stretching, cardiovascular, strengthening
– Behaviours: pacing, meditation, active relaxation, mindfulness, distraction, goal setting, modified work, desensitisation, vocational rehabilitation, healthy habits – is there a focus on active >passive therapies
– Social: connection with others, information sharing, advocacy groups, financial, domestic, familial and functional supports, loneliness and isolation, migrant or refugee support
Are there any psychiatric or psychological vulnerabilities here?
– Axis 1 diagnosis? Depression, anxiety, PTSD, schizophrenia, bipolar affective disorder, personality disorder, substance use disorder
– Catastrophisation, fear-avoidant behaviour, excessive worry and anxiety, passive management focus?
What are your beliefs, expectations and concerns about your pain?
– What do you believe and where is this going in the future
Medical background
– Organ failures (Hepatic, renal, respiratory, cardiac)
– Obesity
– Respiratory disease
– Renal and hepatic function (analgesic metabolism)

Management – After the assessment, I would manage this patient in the following way:

Biological
Medication
– slow taper of opioids
– Reduce by 10% every 1-2 weeks as per FPM guidance
– Slower if the patient is in significant distress
– Due to the benzodiazepine I would involve and refer to an Addiction Specialist too
– Patient may need or decide on opioid substitution therapies
– Explain and educate to patient of course about the harm from opioids
– the risk of sudden death with OMED over 100mg/day
– likely cause of her worsened pain and several endocrine, respiratory, immune, bone and GIT side effects

May need rotation once below 100omed to buprenorphine patch if the patient doesn’t do OST
Can be referred for OST
Consider adjuncts such as duloxetine, which has shown benefit for patients with chronic non-cancer pain

Paracetamol and NSAID if patient can tolerate and has normal renal and hepatic function
And patient requires naloxone spray and education on how to use this due to high OME dose

Non-pharm biological
Refer patient to a physiotherapist for graded exercise and a home plan
Refer patient to a group program inclusive of physiotherapy and psychology for deeper engagement
Advise patient and help with better sleep, diet and exercise
Help patient with reducing ethanol and stopping smoking

Psychological
Patient requires referral to a psychologist and would benefit from one-on-one support as she tapers her opioids
– The purpose of CBT is to help introduce better behavioural therapies to the way she thinks and acts on her pain
She may benefit from a more intensive group program with an OT, Psychologist and Physio too. This would help in teaching patient behavioural therapies to employ – pacing, goal setting, relaxation, distraction, mindfulness, desensitization therapy
The aim of this all is to reduce her worry about opioids and medications and to reduce catastrophisation

Social – connection
This is all about connecting the patient to the right information, people, services and advocacy
Referral to services that could help her at home
Referral to support groups of people maybe suffering to the same issues
Support to family with education and help build their self-efficacy to support the patient in her recovery

Final on answering questions note:

*I find it difficult to launch into the management without ensuring that we are not missing any red flags and that we thoroughly understand what type of pain we are treating and how the patient is currently managing – talk it over with your consultants and study group as this is simply my take and certainly NOT Pain Fellowship Exam Gospel.*

Criteria, definitions, classifications and evidence to be memorised 

DSM-5 criteria

Depression
Generalised Anxiety Disorder
Post-traumatic stress disorder
Functional Neurological Disorder
Somatic Symptom Disorder
Substance use disorder 
Personality Disorder (Borderline)
– These are invaluable to know in practice and in formulation because we encounter presentations like these each day. And countless exam questions incorporate knowledge of these criteria.

Substance use disorder – Understand the spectrum of substance use disorder and the terminology used — tolerance, addiction, dependence misuse, abuse etc.
Reference pages 806–807 (Acute pain management scientific evidence APMSE) 

Complex Regional Pain Syndrome — Budapest Criteria

Fibromyalgia — 2016 American College of Rheumatology criteria

Nociplastic pain Lancet – key paper to understanding overlapping pain conditions, primary pain syndromes and the relevant pathophysiology- the same conditions! There was a question in the 2023 written paper on this.

The best article that summarises neuroinflammation and why acute pain becomes chronic — my “aha” moment came after reading this in May. 

– If you can understand this paper you will understand peripheral and central sensitisation, glial cell activation, why opioids potently trigger neuroinflammation, and why neuroinflammation is central to the development of chronic pain, cognitive impairment and neurodegeneration.

– This diagram below wonderfully illustrates how all paths to chronic pain lead to neuroinflammation – I love this diagram, like really love it with proper emotions and everything. I often draw it to remind myself what the big picture is. Can you see how the ICD-11 etiologies lead to neuroinflammation?

Irritable Bowel Syndrome — Rome 4 Criteria 

ICD-11 Chronic Pain Classification
– I found that learning, memorising and applying the ICD-11 to what I was seeing in the ward and clinics helped me understand the big picture of Pain Medicine. 
– Whenever I see a new patient or an old one, I will place their pain medicine problem(s) into an ICD-11 classification to help me with the broad picture and differing management approach potentially.
– E.g Chronic Low back pain may be 1) Chronic low back pain secondary to spondylosis 1.1 Chronic post-surgical pain post spinal surgery 1.2 Chronic peripheral neuropathic pain secondary to radiculopathy – each of these conditions requires a slightly different approach to bio-psycho-social multidisciplinary care.

– Chronic Primary Pain
– Chronic secondary Orofacial and headache pain 
– Chronic secondary musculoskeletal pain
– Chronic secondary visceral pain
– Chronic post-traumatic and post-surgical pain
– Chronic cancer pain
– Chronic neuropathic pain

Orofacial Pain
Excellent article that outlines the breadth of what we should consider in orofacial pain

International Classification of Headache Disorders — 3

Headaches can broken down into:

– Primary headaches
1) Migraine
2) Tension-type headaches
3) Trigeminal autonomic cephalgias (All 4)
4) Hypnic headache
5) New daily persistent headache

-Secondary headaches — there is a list of main headaches to know in the LEARN ANZCA module

Evidence and topics to know

Start collecting and writing summaries for these topical areas as you start going through the ETA modules.

1)Exercise and chronic pain
There are Cochrane studies on the benefits of exercise on hip, knee and lower back pain and fibromyalgia — look them up. Also, have reasons for the rationale and benefits of exercise in Chronic Pain management

This can get you started –
Exercise therapy for chronic lower back pain, Hayden et al 2021

2) Psychological interventions and chronic pain (cognitive behavioural therapy, acceptance and commitment therapy, cognitive functional therapy)

3) Spinal cord stimulators and chronic pain — there is a great deal of controversy surrounding spinal cord stimulators with a scathing Cochrane review released by Traeger in 2023 slamming its use in lower back pain.

Despite this there is evidence for its use in Complex regional pain syndrome, failed back surgery pain, diabetic neuropathy, refractory angina and ischemic limb pain. I found this paper a useful starting point.

4) Procedures are chronic pain (Facet joint injections, medial branch blocks and rhizotomy, epidurals)

– Facet joint injections and epidurals for non-specific low back pain
– Epidurals for low back pain with radiculopathy
– Medial branch rhizotomy in facet arthropathy low back
– Medial branch rhizotomy in facet arthropathy cervical 
– Bogduk — all these papers are a must-read.

5) Pain programs and chronic pain
6) Multidisciplinary chronic pain management
7) Ketamine — cancer, chronic non-cancer and acute pain
8) Lignocaine — chronic non-cancer and acute pain
9) Medicinal cannabis — cancer, chronic non-cancer and palliative care. 

-Have a look at this issue of Pain from July 2021. It is entirely on Medicinal cannabis. 

-Also, this was the first Australian publication on Medicinal Cannabis by the TGA. I quoted and talked about this during my viva in 2023

-When you think about the use and evidence of Ketamine or Lignocaine or Medicinal Cannabis, break it down into: 
1) Acute pain 2) Chronic non-cancer pain 3) Cancer pain 4) Palliative Care 

10) Fibromyalgia management and evidence — there are Cochrane reviews. 
11) Complex regional pain syndrome management and evidence

12) Chronic low back pain — evidence for management, high-value care and clinical standards, role and evidence of surgery, and evidence of interventions. 

-The clinical standard was published and there is an excellent article in the MJA 2023. One of the written questions in 2022 was on High-Value Low back pain management. The original article was published in the Lancet with a commentary here.

13) Opioid stewardship — what is this and how does it apply to pain medicine? There is a national clinical standard which is a good starting point. 

14) Paediatric chronic pain management Good article here. As a study group we covered in some detail 1) Mature and Immature differences in Pain Physiology, Paediatric Complex Regional Pain Syndrome, Acute pain, Cancer pain in kids (mucositis and CIPN), Adolescents and pain assessment – Gillick competence.

15) Opioids — evidence for and against its use, chronic side-effects of use, how to evaluate use. This needs to roll off the tongue. A good place to start is the FPM ANZCA college document — the reference section is where I got the majority of my evidence from.

16) POINT Study — brilliant Australian study that showed the effect of opioids on patients with chronic pain. The sub-studies on Benzodiazepines and Cannabis should inform your understanding of how detrimental these medications are in addition to opioids. I continue to come back to this paper time and time again

17) Opioid-tolerant patients and how to manage pre and post-operatively (APMSE). This is an excellent article too 

18) Prevention of chronic post-surgical pain (APMSE) reference pages 21–28

19) Become familiar with all forms of radiology that are used in Pain Medicine. From plain films to CT scans to MRIs, to Bone Scans, have an idea about when they are used and what common abnormal pathology looks like. 

20) Cultural dimension of Pain Medicine practice especially issues related to First Nations People. This college document is a good place to start and ETA 4 has good references relating to First Nations People and Cultural and Linguistically Diverse People.

Podcasts that helped 

Compass Opioid Stewardship Clinical Cases
Opioid use disorder — this podcast was brilliant and provided me with a great deal of what I needed to know for the Substance Abuse ETA.

The podcast is in a case-based format which makes it digest. After listening to it and doing some study on the topic, I felt that I could confidently assess, manage and troubleshoot patients with chronic pain and opioid use disorder.

Suggest that you listen to Season 2 which features the patient “Jay” who has Chronic pain and an opioid use disorder and then Season 1 which features “Anne” who has chronic pain and opioid use.

Neurology Exam Prep Podcast
Excellent teaching on migraine headaches and other headaches (Trigeminal Autonomic Cephalgia). 
Headache Part 1 
Headache Part 2
Migraine therapy 

Study resources 

I have been asked several times to provide my notes and the resources that I used to prepare for the exam.

I do not have extensive electronic study resources to share other than my advice and strategy on how I passed the FPM Fellowship exam.

As mentioned before, I created Dr JR-style handwritten notes which I would encourage others to do too (to some degree). If you are in Perth, you are welcome to borrow and scan them.

Writing notes helped me understand the pathophysiology and management of painful conditions and this was part of the process of growing as a pain medicine specialist. I’m one of those people that needs to understand vs memorise. 

I do empathise that having access to ready-made electronic notes is desirable, so ask a colleague or around the place, you might get lucky.

I do however have a few resources that may help below.

1. Acute pain scenarios and management (My notes referenced from APMSE and Acute Pain Management book)
   
2. Past FPM Exam question matrix

Useful websites with FPM-related topics and information 

These websites are excellent and have been written and curated by fellows of the college. 

Dr Andrew Huang
– Good summary of relevant opioids in non-cancer pain literature, clinical skills and criteria to know

Dr Rob Park — Pain Less Study Pain Education
– Brilliant breakdown of all the FPM topics. This could be your study resource to get you going or complement your study. Rob is a helpful and top bloke and the convenor of the 2024 FPM ASM in Brisbane.

Churack Chair of Chronic Pain Education and Research
– Excellent collection of PowerPoint presentations and study notes from Professor Eric Visser. He is the Churack Chair of Pain Medicine at Notre Dame University and I found this incredibly helpful, especially the Visceral Pain presentation.

The best advice that I received for the FPM exam

This is a collection of the advice that I received from past fellows, examiners and prize winners about the exam.

1. Try and run through the curriculum 2–3 times. Two would be excellent, 3 is a slam dunk
2. Practice exam questions under exam conditions and do this frequently as part of your study routine (typing or writing to the 10–15-minute time limit per question). If you find something that you do not know about, look it up — the ETA, journal article search, write notes and understand it. One prize winner shocked me when they said they’d prepared by covering 10 questions a day and did that for a couple of weeks — that’s nearly 20 years of questions! I thought, well if that is your capacity I will slide in just a bit below at 8 questions 🤣
3. Low pass mark questions are a good place to start as this is where candidates may have struggled in the past. Make a point of going through these at least once (I did a few more).
4. Having a clear plan and sticking to it religiously trumps the anxiety that you are going to fail every single time — the advice I give to myself. I kept saying to myself “Just keep going”. 
5. No one is trying to trick you. Everything is related to the curriculum and the issues around it. 
   In 2023 we had a question about the Opioid Crisis in the US and the factors around it. After freaking out for a few moments I got it. They were looking for substance use disorder risk factors — Pain factors, substance factors, social and psychological factors (what I didn’t write — Political and Business factors). However, risk factors for substance use are embedded into the curriculum, it’s simply being asked a different way and getting us to think. 
6. Find a group of people whom you can study with and share the pain and grind of studying with — study groups do help and connection matters. 
7. Adhere to safety in all your answers (as you would in real life) and recognise high-risk groups (older patients, the opioid-tolerant, organ dysfunction, cancer pain, paediatric, substance use disorder, those with a psychiatric diagnosis, those at risk of suicide) in all your answers and have a clear way of being safe.
8. Be neutral. You can have your right or left view after the exam. The exam is not the place to take a stance or be woke.
   In 2023 we had a Medicinal Cannabis question and I was clear during the viva that I adhered to the FPM college’s line that Medicinal Cannabis did not have a role in chronic pain management. I quoted the evidence for and against but reiterated the point. The journalist pressed me and I talked about its use in Palliative care, chronic non-cancer pain and cancer pain but clearly described the evidence as it is — poor. On a personal level, I have a middle-ground view. As a Palliative Care Generalist, there is poor evidence for its role in cancer pain management but if patients want to try this, I will refer them but it will not be on my menu of options. 
9. Approach the VIVA and OSCE as a junior Pain Medicine Consultant, with confident humility. Show the examiners that they will be able to trust you with that exact patient in a clinical setting. You aren’t there to show off but rather to convey that you are competent with knowledge and skills and that you are safe. I took this advice to heart due to my previous 11 years of working independently as a Palliative Care and Anaesthetic Generalist.
10. Read the question carefully, nothing has been included by accident. They are all clues and signposts that the examiners want you to consider and include.

Viva and OSCE advice from Professor Eric Visser

We were blessed to have Prof Visser help us in the last few weeks before our VIVA exam and he started the series of sessions with these pieces of advice as a former FPM examiner and convener. 

1. Have a system and be systematic in how you answer — not all over the place. 
2. Use keywords and talk about key concepts
3. If you are not sure, move on and come back to the question (I did this)
4. Always be safe in your management and assessment of patients
5. Stick to the FPM college line on what it endorses
6. Where people lose marks are from being unsafe (committing a fatal error), or not moving on during the VIVA (getting stuck)
7. Examiners are time focused and they will move you on when you answer the question. Do not be alarmed if you are being “hurried along” after your comprehensive answers. 
8. Use common sense — no one is there to trick you.
9. Getting 4–5/10 is achievable with key concepts, being safe and systematic, the mark increases from there with deep knowledge and wide thinking about the station
10. Where people lose marks or fail is that they don’t say anything for long periods or say something quite outrageous (that they would never do as a consultant!)

Summary

Thank you for reading this article. If you found it helpful, please share it with others and if you want to add your comment on how you studied and passed the exam, please do so below. 

There may be aspects that I have forgotten to add but to the best of my recollection, these are the steps that I took to prepare, study and pass the Australia and New Zealand Faculty of Pain Medicine Fellowship examination and win a Merit award in 2023.

I understand that the assessment style and format may change in the future but I dare say the content will be the same and that some degree of effort and consistency will be required.

This was my approach but certainly not the only approach. 

I came across many others with different timelines and methods by which they passed the exam too.

As a married dad of 3 boys with big plans for the future, I only wanted to do the exam once and hence I took it all extremely seriously..

The secret to all of this is putting in the work and having a system — it’s that simple but not easy to do in a distracted and FOMO-obsessed world.

And like all exams, it will suck and feel difficult in the middle, like you have no quality of life. But you will get through this. It will pass and life will get better. Left, right, left, right, left, right every day as it all compounds beautifully at the end. The bonus is that you will get better at your job too!

I have faith in you.

Jonathan Ramachenderan

Live intentionally.
Love relentlessly.
Enjoy your health.