ACEM Primary Exam 2026 Study Guide: What You Actually Need to Know

A practical guide for emergency medicine trainees sitting the ACEM Primary in the next twelve months. PRIMEX started in 2025 when an anaesthetic trainee at a regional NSW hospital built study tools for the ANZCA Primary. It now covers 21 colleges because trainees from each specialty asked us to build for them. The ACEM Primary Exam curriculum on PRIMEX is maintained against the college's published syllabus, with topic mapping reviewed for accuracy.

The exam at a glance

The ACEM Primary Examination is the basic science gateway into ACEM advanced training. It tests applied knowledge of the four core disciplines (anatomy, physiology, pharmacology, pathology) as they relate to emergency medicine practice. The exam runs in two stages and you must pass the written component before you can sit the integrated viva.

Written paper

• 150 questions in single-best-answer multiple choice and extended-matching format
• Approximately 3 hours, computer-based at approved test centres
• Curriculum-mapped to the April 2017 ACEM Primary syllabus across all four disciplines
• Calculator policy: a basic on-screen calculator is provided where calculations are needed
• Sittings: typically twice a year (May and October as of 2026, check the ACEM site for the current dates)

Integrated viva

• 4 separate vivas on the same day, each scored out of 10
• Each viva runs about 20 minutes and is themed around a single body system
• Within each viva you are probed sequentially across all four disciplines: anatomy, then physiology, then pharmacology, then pathology
• You only sit the viva if you pass the written paper at that sitting
• Viva sittings typically run about a month after the written, in June and November

Pass mark and standardisation

The college does not publish a fixed pass mark for the written paper; the cut score is set per sitting using a standard-setting method, so the percentage required varies. Approximate first-attempt written pass rates have sat around 65 percent in recent rounds, though this fluctuates and the college publishes the figures after each sitting. Viva pass rates are higher than written pass rates because the viva cohort is already filtered by the written paper. Treat any single percentage as a rough guide only and check the ACEM examiner reports for current figures before you sit.

Day of logistics

The written paper is computer-based at a Pearson VUE or college-approved test centre. Bring photo identification and arrive early. The viva is held in person at an ACEM venue (typically Melbourne, Sydney, or another major centre depending on the round); travel and accommodation logistics matter and most candidates book flights and a hotel weeks in advance once the viva date is confirmed. Confirm equipment, dress code, and venue rules with the college close to your sitting date because some details change between rounds.

What the college actually tests

The ACEM Primary curriculum is the April 2017 syllabus, with 415 mapped learning objectives spread across the four sciences. Every written question and every viva probe traces back to one or more of these objectives. The PRIMEX curriculum tracker reflects all 415 LOs grouped under their parent sections (anatomy, pathology, physiology subdivided by system, pharmacology subdivided by class, plus physics, statistics, and professional practice as small ancillary sections).

Rough domain weighting in past papers and viva content runs approximately physiology 45 percent, pharmacology 30 percent, anatomy 15 percent, pathology 10 percent. That weighting is a guide, not a guarantee, but it is a useful planning frame.

A handful of areas come up in nearly every sitting. These are the seven highest-yield clusters based on the curriculum, examiner report patterns, and the basic science topics that dominate the integrated viva:

1. Cardiovascular and respiratory physiology

Cardiac output and its determinants, Starling curves, the cardiac cycle, the oxygen-haemoglobin dissociation curve and its shifts, control of ventilation, ventilation-perfusion relationships, and the oxygen cascade. Examiners expect you to draw the curves, label the axes with units, and explain the shifts mechanistically. Generic statements like "the curve shifts right" without a Bohr or 2,3-DPG mechanism score poorly.

2. Acid-base and renal physiology

The Henderson-Hasselbalch equation, anion gap calculation, primary disorders and compensation, fluid compartments, sodium and potassium handling, glomerular filtration and its regulation, and the renal concentrating mechanism. A favourite written and viva area because it connects directly to ED resuscitation. Get the direction of compensation right, give the expected pCO2 or HCO3 numbers, and quantify the gap.

3. Pharmacokinetics and emergency drug pharmacology

ADME (absorption, distribution, metabolism, excretion), bioavailability, first-pass metabolism, volume of distribution, clearance, half life, and the practical pharmacology of the drugs you actually use in ED: adrenaline, opioids, ketamine, propofol, suxamethonium, rocuronium, local anaesthetics, antiarrhythmics, anticoagulants and their reversal. Drug doses, infusion rates, and contraindications are expected. "Adrenaline 1:1000 0.5 mg IM for anaphylaxis" beats "adrenaline for anaphylaxis" every time.

4. Anatomy applied to emergency procedures

Airway anatomy and innervation, the brachial plexus, femoral triangle, intercostal space and chest drain insertion, cervical spine, scalp layers and meningeal anatomy, the circle of Willis. Anatomy without a clinical correlate scores fewer marks than anatomy linked to a procedure or pathology. If you can describe the brachial plexus, also describe what happens with a shoulder dislocation or a clavicular fracture.

5. Shock pathophysiology and the inflammatory response

The pathophysiology of hypovolaemic, septic, cardiogenic, anaphylactic, and neurogenic shock; acute and chronic inflammation; cell injury and death; ischaemia-reperfusion. Shock is one of the most reliable cross-discipline themes in the integrated viva because it touches all four sciences in a single body system. Be ready to explain mechanisms with specific mediators (TNF-alpha, IL-1, complement), not just lists of cells.

6. Coagulation, haemostasis, and transfusion

The coagulation cascade (intrinsic, extrinsic, common pathways), platelet function, fibrinolysis, oxygen transport, blood groups and transfusion reactions, DIC. Coagulation is dense and easy to confuse under pressure, so candidates who memorise pathways without understanding the regulators (antithrombin, protein C, tissue factor pathway inhibitor) tend to come unstuck on probing questions.

7. Autonomic, neurological, and endocrine physiology

Cerebral blood flow autoregulation, intracranial pressure and the Monro-Kellie doctrine, autonomic nervous system pharmacology, the neuromuscular junction, adrenal physiology and the stress response, thyroid and insulin regulation. These come up most often in the physiology phase of the viva and they connect cleanly to drugs like atropine, adrenaline, and corticosteroids in the pharmacology phase. Connect them out loud during the viva and the examiners give you marks for it.

Common pitfalls that fail candidates

• Rote facts without mechanism. Listing the components of the coagulation cascade without describing the role of each is a typical written paper distractor and a viva trap. Examiner reports flag this every round.
• No quantification. Normal cardiac output is 5 L/min, GFR 120 mL/min, tidal volume 7 mL/kg or about 500 mL, MAP 65 to 100 mmHg, ICP 5 to 15 mmHg. Numbers and units score marks. "Normal" without a value does not.
• Direction of physiological change confused. Getting compensation, reflex direction, or shift direction backwards is heavily penalised. If shifting the O2-Hb curve right means easier offloading, say it; do not get this back to front.
• Anatomy without clinical correlate. Pure textbook anatomy, no link to an ED procedure or injury, scores fewer marks than anatomy bookended by clinical relevance.
• Pharmacology without clinical effect. Stating a drug class without explaining the downstream physiology and the bedside effect is a recurring examiner complaint.
• Disjointed viva answers. The integrated viva expects a structure: define the term, explain the mechanism, give the values, link to the ED scenario. Candidates who jump straight to a list of drugs or a clinical anecdote without setting up the basic science get pushed back into the basics by the examiner and lose minutes.

A realistic study timeline

The right run-up depends on your hours of clinical work, how comfortable you already are with the basic sciences, and whether you have studied this material recently (medical school physiology fades quickly). Three sample plans, in rising order of comfort:

Nine-month plan (8 to 10 hours per week)

Suits a registrar working full-time clinical hours with other commitments who wants steady curriculum coverage rather than a sprint.

• Months 1 to 3. Read through the ACEM Primary syllabus and pick two domains to cover per week (one physiology system plus one pharmacology class, alternating with anatomy and pathology). Build a flashcard deck as you go. 30 to 50 MCQs per week.
• Months 4 to 6. Add SAQ-style written practice. Even though the Primary written paper is MCQ and EMQ, writing structured basic science answers builds the integrated knowledge the viva tests later. Two SAQ-style answers per week, marked carefully. Continue MCQ volume.
• Months 7 to 8. Past paper MCQs under timed conditions. Begin viva practice once a week with a study partner or a viva simulator, focusing on one body system at a time.
• Final month. Two full timed MCQ mocks. Daily viva practice for the last fortnight. Polish weak domains and run through the highest-yield body systems (cardiovascular, respiratory, neurological, GI) under viva conditions.

Six-month plan (12 to 15 hours per week)

The standard plan for most candidates. Tight enough to keep momentum, long enough to cover the curriculum properly.

• Months 1 to 2. Walk through every section of the syllabus. Cover one or two sections per week. Build the flashcard deck. 50 to 80 MCQs per week, mixed across all four domains.
• Months 3 to 4. SAQ-style written practice becomes the main work. Three to four answers per week with marking and revision. Keep MCQ volume up. Start viva practice once a week from month four.
• Month 5. First full timed MCQ mock under exam conditions. Increase viva sessions to two or three a week. Cycle through high-yield body systems and force yourself to integrate across all four disciplines in each session.
• Final month. Two more timed MCQ mocks. Daily viva practice for the last two weeks. Final round of weak-area work, especially on values, mechanisms, and the topics you keep getting wrong.

Four-month plan (18 to 22 hours per week)

The compressed plan. Doable if you have study leave or are part-time clinical, painful otherwise. Most candidates regret it if they did not have to compress.

• Month 1. Speed-read the syllabus. Two to three sections per week, focused on the high-yield clusters above. Heavy MCQ volume from week one (100+ per week).
• Month 2. SAQ-style written practice daily. MCQs continue. Start viva practice twice a week, even if you feel under-prepared; the reps matter more than the polish at this stage.
• Month 3. Full timed MCQ mocks every fortnight. Viva practice three or four times a week.
• Final month. Polish weak areas. Two MCQ mocks. Daily viva practice. Sleep and wind down for the last 48 hours; cognitive sharpness on viva day is worth more than another marathon revision session.

When to start each component

• MCQs: from week one. They build curriculum recall and surface weak areas faster than reading. Do them with explanations, not just answer keys.
• SAQ-style written practice: from month two at the latest, even though the written paper is MCQ format. Writing structured basic science answers forces you to consolidate the integrated knowledge that the viva tests later. The Primary does not have formal SAQs but the skill transfers directly.
• Viva practice: from month three at the latest, even on a four-month plan. Viva fluency takes reps to build; reading about how vivas run does not transfer.
• Timed past paper MCQ mocks: last six to eight weeks. Earlier than that and you have not yet covered enough ground for the result to be meaningful.

Weekly study split that actually works

Most candidates run into trouble because their week is shapeless and the work that feels easy crowds out the work that matters. A simple template: two MCQ sessions per week of 60 to 90 minutes each, two written practice sessions per week of 60 to 90 minutes each, one or two viva sessions per week from month three (rising to daily in the run-in), and one curriculum reading session per week tied to whatever weak area emerged from the practice. Flashcards run in the background as ten-minute blocks on commutes or between patients, not as scheduled sit-downs. Protect your viva slot the way you protect a clinical commitment; if you let it move, it stops happening.

Track what you got wrong, not what you got right. Keep a running list of missed marking points by curriculum section. After a month you will see two or three sections that come up repeatedly and you can target them directly, rather than re-reading material you already know.

The single biggest mistake people make

You memorise facts without practising the integrated structure the viva demands. The written paper rewards recall, so you front-load months of MCQs and flashcards because the score is a number and the feedback is immediate. Then you walk into the viva and discover that knowing the cardiac output equation does not help you when the examiner gives you a body system theme and expects you to weave anatomy, physiology, pharmacology, and pathology into a coherent twenty-minute answer.

The viva is a performance under time pressure. It asks you to define the term, explain the mechanism with specific values, and link the basic science to an emergency medicine scenario, all inside about five minutes per discipline. The only way to get fluent at it is to do it badly thirty times before you do it well. You need the muscle memory of opening with the definition, drawing the curve in your head, quoting the values, then bridging to the clinical relevance.

Start viva practice in month two or three of your run-up, even if it feels too early. Even one session a week is enough to keep the skill alive. Practise out loud. Pick a body system, set a timer, and answer through anatomy, physiology, pharmacology, then pathology. Get verbal feedback from a study partner, a senior trainee, or a viva simulator. By the time you sit, the structure should feel automatic and your conscious bandwidth should be available for the harder probing questions.

How PRIMEX helps

• The SAQ grader writes Primary-style basic science questions and marks each answer with a tier, a marking checklist, an examiner-style comment, and a Distinction-level model answer with values throughout. Open the ACEM Primary page on PRIMEX to see the grader format.
• The integrated viva simulator runs the real ACEM Primary format: one body system theme across anatomy, then physiology, then pharmacology, then pathology, twenty minutes total with voice mode and a per-discipline debrief. Open the simulator from the viva feature on the ACEM Primary page.
• The MCQ bank generates curriculum-mapped single-best-answer and EMQ-style questions across all four sciences, with full explanations for every option including distractors and community answer distributions after each question.
• The curriculum tracker maps every study note and flashcard to all 415 ACEM Primary learning objectives, so you can check coverage rather than guess at it.
• Spaced-repetition flashcards across mechanisms, drug profiles, anatomical correlates, and pathological processes, with image cards for curves, diagrams, and physiological graphs.

Frequently asked questions

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