CICM Second Part (Fellowship) Exam 2026 Study Guide: What You Actually Need to Know

A practical guide for advanced trainees sitting the CICM Second Part (Fellowship) Exam 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 CICM Second Part (Fellowship) Exam curriculum on PRIMEX is maintained against the college's published syllabus, with topic mapping reviewed for accuracy.

The exam at a glance

The College of Intensive Care Medicine of Australia and New Zealand (CICM) sets the Second Part Examination as the final hurdle before Fellowship. It is a clinical exam, not a basic science exam. The college expects consultant-level reasoning across the breadth of intensive care medicine, with the depth that lets you safely run an ICU on your own. There are three components: a written paper made up of short answer questions, a hot case viva pair, and a structured oral viva. All three components contribute to the overall result, and the college sets the standard with reference to examiner judgement and structured marking, not a fixed numerical pass mark.

The written paper (Short Answer Questions)

• 15 SAQs in 150 minutes, roughly 10 minutes per question
• Variable marks per question, with most SAQs worth 10 marks split across multiple sub-parts
• Paper-based at college-nominated venues, although the format has been updated periodically. As of 2026, confirm the delivery format directly with CICM ahead of your sitting
• Tests clinical management of the critically ill patient at specialist level. The First Part exam tests basic science. The Second Part is an entirely different register
• An on-screen or supplied calculator is available where required

The hot cases

• Two unseen ICU patients, examined live with the bedside team. Roughly 20 minutes per patient including history, focused examination, summary, and management plan
• Examiners assess your ability to take a complex critically ill patient, organise the problem list, and present a prioritised management plan in real time
• Hot cases are run at major Australian and New Zealand ICUs nominated by the college for the sitting. The patient is real, ventilated, often on multiple infusions and devices, and you have one chance to get it right
• The component rewards the trainee who can integrate organ systems quickly, name the differential, and articulate what they would do next at the consultant level

The structured viva

• 6 to 8 structured oral vivas, each approximately 10 minutes long, with 2 minutes of preparation time per station
• Each viva opens on a clinical scenario stem and probes management priorities, drug doses, monitoring targets, complications, and the ethical or communication dimension
• Examiners use a structured mark sheet. The questions are standardised across the cohort to keep the assessment fair across centres
• The viva is where vague answers go to die. "Start vasopressors" is a fail-track answer. "Noradrenaline 0.1 to 0.5 mcg/kg/min titrated to a MAP greater than 65 mmHg, with arterial line and CVC monitoring" is the register

Sittings and pass standard

The exam runs twice a year. The written paper is sat first, followed by the clinical components (hot cases and structured viva) at college-nominated centres. Recent cohorts have run at roughly 60 to 70 percent overall pass per sitting, although the figure varies. CICM publishes the pass rates and a detailed examiner report after each round on its website, and the college does not publish a fixed numerical pass mark for the Second Part exam. As of 2026, treat any single percentage as a rough guide, and read the examiner reports carefully because they signal exactly which patterns of answer were marked down.

What the college actually tests

The CICM Second Part curriculum on PRIMEX maps to 128 published learning objectives across 20 curriculum sections, drawn from the CICM Second Part Examination Curriculum 2024. Every SAQ stem, hot case, and viva scenario maps to one or more of these objectives. The 20 sections cover the breadth of the consultant intensivist role: Cardiovascular Intensive Care, Respiratory Intensive Care, Renal and Fluid Management, Neurocritical Care, Sepsis, Infection and Antimicrobials, GI, Hepatic and Metabolic Critical Care, Haematological and Coagulation Disorders, Endocrine and Metabolic Emergencies, Trauma and Surgical Critical Care, Toxicology in ICU, Obstetric Critical Care, Paediatric Critical Care, Retrieval and Transport Medicine, ICU Procedures and Point-of-Care, Sedation, Analgesia and Neuromuscular Blockade, ICU Pharmacology and Dosing, Ethics, Law and End-of-Life Care, Research, Quality and Patient Safety, ICU Organisation and Leadership, and Special Topics in Intensive Care.

The breadth is genuinely large, and the depth is consultant-level throughout. A handful of clusters come up disproportionately based on examiner reports and past papers. These are seven of the highest-yield areas to anchor your preparation.

1. Sepsis, septic shock and source control

Sepsis is the perennial SAQ and the perennial viva. The college expects you to know the Surviving Sepsis Campaign bundles cold, including the time targets for antibiotics and lactate clearance, the role of vasopressors with specific dose ranges, fluid responsiveness assessment, and source control as an active priority rather than an afterthought. Antimicrobial stewardship, augmented renal clearance and PK/PD optimisation in critical illness all turn up. Candidates who recite a bundle without articulating what they would do at hour two if the patient was not improving are exactly the candidates the examiners are filtering out.

2. ARDS and mechanical ventilation

The Berlin definition, lung-protective ventilation with tidal volumes of 6 mL/kg of predicted body weight, plateau pressure under 30 cmH2O, the role of prone positioning following the PROSEVA evidence, the threshold for VV-ECMO, and the haemodynamic interaction of high PEEP. Expect at least one ventilation question per sitting and expect it to push into trouble-shooting: patient-ventilator dyssynchrony, auto-PEEP in obstructive disease, weaning failure, and the specific decisions that change ventilator settings at the bedside. Generic answers about lung protection do not score. Numbers and decision points score.

3. Acute kidney injury and renal replacement therapy

KDIGO staging, the indications for renal replacement therapy in critical illness, the choice between continuous and intermittent modalities, anticoagulation of the circuit (regional citrate versus heparin), drug dosing on RRT, and contrast-associated and nephrotoxic AKI. Examiners want a structured approach: define the stage, address the cause, manage volume and electrolytes, and set clear escalation criteria for RRT initiation. The trainee who can name when they would not start RRT is often the one who scores best.

4. Neurocritical care

Severe traumatic brain injury with ICP and CPP targets, multimodal monitoring, osmotherapy choices, the role of decompressive craniectomy and the decision framework for it, subarachnoid haemorrhage with vasospasm management and the timing of nimodipine, status epilepticus stepping through the management algorithm, brain death testing, and the donation after circulatory determination of death (DCD) pathway. Neurocritical care turns up across all three components and rewards specificity in numbers (ICP under 22 mmHg, CPP 60 to 70 mmHg, sodium targets, mannitol or hypertonic saline doses).

5. Trauma, haemorrhage and resuscitation

Damage control resuscitation, the haemostatic resuscitation principle and the 1:1:1 ratio in massive transfusion, TXA within 3 hours, ROTEM or TEG-guided correction, and the management of severe traumatic brain injury and chest trauma in the ICU. Hot cases regularly feature the post-trauma patient on day two with a mix of haemodynamic, ventilatory, and renal issues. The trainee who can prioritise the multi-system problem, give specific numbers, and explain when they would call for surgical review without flinching is the trainee scoring well.

6. Toxicology and obstetric critical care

Paracetamol overdose with the King's College criteria for transplant referral and the NAC protocol, tricyclic antidepressant toxicity with sodium bicarbonate for QRS widening, calcium-channel and beta-blocker toxicity with high-dose insulin and lipid rescue, serotonin syndrome and neuroleptic malignant syndrome differentiation. On the obstetric side, severe pre-eclampsia and eclampsia with magnesium therapy, obstetric haemorrhage, amniotic fluid embolism, and the physiological changes of pregnancy that change ventilator and haemodynamic management. These are perennial SAQ topics and they reward specific drug doses and clear escalation thresholds.

7. Ethics, end-of-life care and the family meeting

Withdrawal and withholding of treatment, medical futility, capacity and consent, the structured family meeting, organ donation discussion (DCD versus DBD), and the management of conflict between patient wishes and family expectations. Examiner reports have repeatedly flagged that candidates who deliver flawless clinical management but never address the ethical dimension or the multidisciplinary team component lose marks they did not need to lose. The Second Part exam is a test of the consultant role, not the encyclopaedia.

Common pitfalls that fail candidates

• Defaulting to First Part-level basic science. The single most common comment in published examiner reports. The Second Part is a clinical management exam. Recall of pathophysiology without specific management decisions does not score.
• Vague, non-consultant phrasing. "Manage the airway", "give fluid", "start vasopressors". The expected register is specific: drug name, dose, route, infusion rate, monitoring target, and what you would re-assess.
• Missing ethics and communication. Many SAQs and most vivas have an explicit ethics or family component. Candidates who treat them as add-ons lose easy marks.
• Skipping landmark trial evidence. ARISE, PROCESS, ProMISe, ARDSNet, PROSEVA, NICE-SUGAR, TRICC, ACURASYS, EOLIA. You do not need to recite the methods, but you should be able to anchor your management to the trial that informs it.
• Insufficient attention to complications and contingency planning. The college rewards anticipatory thinking. Answers that stop at acute management lose marks for not stating what would change the plan.
• Hot case: presenting before structuring. The candidate who walks straight from the bedside to the examiner without thirty seconds of mental structuring tends to ramble. Take the breath. Order the problem list. Then present.
• Viva: giving examiners what they did not ask for. A viva question about ventilation in ARDS is not the place to recite the Berlin definition. Answer the question asked, give specific numbers, and stop.

A realistic study timeline

The right run-up depends on your full-time-equivalent ICU exposure, how recently you sat the First Part, and how comfortable you already are with the breadth of the curriculum. Three sample plans, in rising order of comfort.

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

Suits an advanced trainee working full-time clinically with significant non-work commitments who wants slow steady coverage rather than a sprint.

• Months 1 to 3. Walk through the CICM Second Part curriculum systematically. Cover two or three sections per week. Build a flashcard deck as you go and answer 30 to 50 recall items per week to surface gaps. Read examiner reports in parallel; they tell you exactly which content patterns are being marked.
• Months 4 to 6. SAQ practice begins. Aim for two timed SAQs per week (10 minutes each), marked carefully against a model answer. Begin viva practice with one structured station per week, ideally with a study partner or a simulator that plays the examiner.
• Months 7 to 8. Past paper SAQ mocks under timed conditions. Viva practice scales to two or three stations per week across the major content domains. Identify weak curriculum sections and target them. If you are not yet rotating through ICUs running hot cases, organise sessions with consultants who are willing to run a mock at the bedside.
• Final month. Two full timed SAQ mocks (15 SAQs in 150 minutes). Hot case practice scales up: two patients per session at minimum, ideally on different ICUs to expose you to different patient populations. Final polishing on high-yield clusters: sepsis, ARDS, AKI, neurocritical care.

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 curriculum section. Cover three or four sections per week. Build the flashcard deck. 50 to 80 recall items per week. Begin reading every recent CICM examiner report.
• Months 3 to 4. SAQ practice becomes the main work. Three to five timed SAQs per week, marked carefully against a model answer. Maintain recall practice. Start viva practice at one to two stations per week, mixing clinical management with ethics and communication scenarios.
• Month 5. First full timed SAQ mock (15 SAQs in 150 minutes). Viva volume doubles to two or three stations per week. Hot case practice begins in earnest: one to two bedside cases per week with consultant feedback if you can get it.
• Final month. Two more SAQ mocks under exam conditions. Daily hot case or viva practice. Final round of weak-area content reading. Sleep and wind down for the last 48 hours.

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

The compressed plan. Doable if you are part-time clinical or have a study leave block, painful otherwise.

• Month 1. Speed-read the curriculum. Three to four sections per week, focused on weak areas. Heavy recall volume from week one (100 plus items per week). Begin SAQ practice in week three.
• Month 2. Timed SAQs daily or every second day. Viva practice begins twice a week. Target a mix of clinical management, ethics, and family-meeting stations. Hot case practice begins by week six at the latest.
• Month 3. Full timed mocks start. SAQ mock weekly, viva mock weekly with a peer or simulator. Hot case practice three times per week with consultant feedback wherever you can get it.
• Final month. Polish weak areas. Two SAQ mocks, daily viva practice, two or three hot case sessions per week. Sleep and wind down for the last 48 hours.

When to start each component

• Recall and content reading: from week one. They build curriculum coverage and surface weak areas faster than passive reading.
• Timed SAQs: from month two at the latest. The 10-minute discipline is brutal until it is practised, and then it is fine. Untimed SAQs for the first two weeks are sensible. After that, write to the clock.
• Viva stations: from month three at the latest, even on a four-month plan. Verbal performance under time pressure needs reps. Reading about the viva does not transfer.
• Hot case practice at the bedside: from month three at the latest. The hot case skill is structured rapid assessment under observation, and that has to be built on real ventilated patients with real lines and infusions. Reading cases on paper builds knowledge, not the bedside skill.
• Past papers and full mocks: last six to eight weeks for SAQ. Earlier than that and you have not yet covered enough ground for the result to be meaningful.

Weekly study split that holds up

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 that works: two SAQ sessions per week of 60 to 90 minutes each, two viva sessions per week of 45 to 60 minutes each from month two onward, one hot case session per week from month three, one curriculum reading session tied to whichever weak section emerged from the practice, and flashcard reps in the background as ten-minute blocks between patients or on commutes. Protect your viva and hot case slots the way you protect a clinical commitment. If you let them move, they stop 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. The worst study plans are the ones that confuse curriculum coverage with curriculum mastery.

The single biggest mistake people make

You leave the hot cases until the last six weeks. The written paper feels concrete and tractable, so you grind SAQs first because the feedback is immediate and the score is a number. The viva feels manageable because you can practise it sitting at a desk with a study partner. The hot cases sit at the back of the plan, untouched, and you tell yourself you will get to them when you are closer to the date.

Then you wake up two months out, realise you have never run a structured bedside assessment under observation on a real ventilated patient, and try to compress all your hot case work into the run-in. By that point your SAQ stamina is good, your viva is rehearsed, and your hot case is the rate-limiting weakness in your sitting. The pattern that breaks competent candidates in the CICM Second Part is exactly this: strong SAQ, acceptable viva, hot case below standard, overall result below the line.

The hot case is not a knowledge test. It is a performance under observation in real time, on a real patient, with real numbers and real risks, and 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 structuring the bedside assessment, organising the problem list under pressure, presenting back to the examiner with a clear management plan, and answering the follow-up probes without losing your structure. That muscle memory takes months to build, not weeks. Start hot case practice in month one or two of your run-up. One bedside case a week is enough to keep the skill alive. By the time you sit, the structure should feel automatic and your conscious bandwidth should be free for the clinical reasoning.

How PRIMEX helps

• The SAQ grader generates CICM Second Part SAQs and marks each response at specialist level with examiner-style feedback against marking points, including the doses, monitoring targets and ethical components that examiner reports flag. Open the CICM Fellowship page on PRIMEX to see the format.
• The structured oral viva simulator runs FCICM-format vivas with a consultant examiner persona, voice mode, and a debrief that flags missing ethics, complication management and multidisciplinary team components. Open it from the oral exam feature on the CICM Fellowship page.
• The curriculum tracker maps every study note and flashcard to the 128 CICM Second Part learning objectives across 20 curriculum sections, so you can check coverage rather than guess at it.
• Ask PRIMEX is a clinical question tool that pulls answers from the ICU study notes and references the underlying landmark trial evidence. Available inside the app at primexstudy.com.au/app.

Frequently asked questions

Related study guides

• CICM First Part 2026 Study Guide
• FACEM Fellowship 2026 Study Guide