How to Prepare for the ACEM Fellowship Written Exam

Preparing for the ACEM Fellowship Written Examination is one of the most demanding challenges in emergency medicine training. The exam tests not just knowledge, but the ability to apply clinical reasoning under time pressure across the full breadth of the FACEM Curriculum. This guide draws on ACEM's own candidate preparation guidelines to cover how to approach your preparation practically — from setting a timeline and choosing references to practising questions and assessing your readiness.

Start with a realistic timeline

ACEM strongly recommends allowing at least 12 months of dedicated study. Some candidates begin up to 24 months before their intended sitting. ACEM's own guidance states plainly: “It is strongly suggested that you do not attempt this examination unless you have allowed an adequate amount of preparation time.”

Because the required preparation period is long, you need a structured plan for how you will pace your study. ACEM recommends balancing continuous focused study that escalates toward the exam date with a broader review of key topics in the weeks before the exam.

If you are working full-time clinical shifts, be realistic about how much time you can commit each week. Consistency matters more than volume. Forty-five minutes of focused study five days per week is more effective than a single marathon weekend session.

Understand what the exam tests

The FEx Written consists of two papers: an SAQ paper (morning) and an SCQ paper (afternoon), both completed on the same day. From 2026.1, the SCQ contains 120 MCQs only (EMQs are no longer used), and the SAQ contains approximately 26 questions worth 330 marks total with 10 minutes of reading time before 3 hours of writing.

The exam is designed to test whether you can demonstrate sufficient knowledge to progress to the Fellowship Clinical Examination (OSCE). It tests theoretical knowledge and the application of that knowledge to patient scenarios, as outlined in the FACEM Curriculum. Questions range from common “bread and butter” scenarios to rarer presentations requiring deeper reasoning.

For a detailed breakdown of each component, see our exam format guide.

Know the curriculum domains

The FEx Written is blueprinted against six of the eight FACEM Curriculum domains. Understanding this weighting is essential for allocating your study time:

A common mistake is spending disproportionate time on clinical topics you find interesting while neglecting the non-clinical domains. The non-medical-expertise questions (administration, professionalism, scholarship) account for approximately 10 of the 120 SCQ questions and feature regularly in SAQs. These are frequently where discriminating questions appear.

Build a study plan around the curriculum

ACEM advises that you carefully reflect on your knowledge base and identify where your strengths and weaknesses lie. Map out all curriculum domains and create a monthly timetable that balances studying your weaker subjects with revising your stronger ones. Having this balance will build confidence alongside knowledge.

The SCQ topic matrix provides a useful guide to weighting. The highest-yield groups — resuscitation/airway (10 questions), cardiovascular (10), and the large medical and surgical subspecialty clusters (20 each) — deserve proportionally more study time, but you cannot afford to ignore smaller domains entirely.

Choose your references strategically

ACEM recommends specific reference texts, and examiners mark from these texts. Using non-recommended sources risks studying content that conflicts with what the College considers correct. ACEM notes that “candidates who perform well use at least two textbooks as references.” The core texts most candidates use are:

• Cameron's Textbook of Adult Emergency Medicine — the primary recommended text, now in its 6th edition (2026)
• Tintinalli's Emergency Medicine — comprehensive coverage of emergency medicine principles
• Rosen's Emergency Medicine — strong on pathophysiology and clinical reasoning

However, textbooks are often partly out of date by exam day. ACEM advises supplementing your reading with peer-reviewed national references such as national clinical guidelines, the Medical Board of Australia and Medical Council of New Zealand websites (which have good medicolegal resources), and ACEM's own policies and clinical statements (which are all peer-reviewed). Be wary of non-peer-reviewed websites — they may represent opinion-based medicine rather than evidence-based medicine.

Practise questions early and often

Reading alone is not sufficient preparation. The exam tests applied reasoning, not recall. ACEM's own preparation guidelines emphasise: “Practise, practise, practise.”

Start doing practice questions from month 3 or 4, even before you have covered all the content. Early question practice helps you understand what the exam is actually testing and highlights gaps in your knowledge while there is still time to address them. Aim to practise questions from a variety of sources.

Question practice strategies

• Do MCQ questions in timed blocks (90 seconds per question) to build exam-pace familiarity
• Review every question you get wrong and understand why the correct answer is best
• Track your performance by topic domain so you can direct revision to your weakest areas
• For SAQs, practise structured written answers under time pressure — the DEMT network maintains a bank of practice SAQs, and ACEM publishes two SAQs with model answers each year
• Use the ACEM practice online SAQ examination to familiarise yourself with the typing format

Try creating your own questions

ACEM specifically recommends this as a preparation strategy. Writing exam questions is harder than it appears, and the process provides a novel way of revising content knowledge. It forces you to think about what can and can't be tested in the exam format, and deepens your understanding of the topic. Study groups provide a good opportunity to write, share, and answer each other's questions.

Use teaching as a study tool

Many successful candidates find that teaching a subject promotes their own understanding. ACEM's preparation guidelines recommend several approaches: participating in a study group where members teach each other, volunteering to teach a particular topic in your hospital's formal teaching program, or presenting at journal club.

Teaching allows you to receive feedback about whether your coverage of a topic is comprehensive. Encouraging questions from the group that probe for more detail will test the depth of your knowledge and reveal areas needing further consolidation.

Use your clinical shifts

Identifying teaching and learning moments during clinical shifts will benefit your preparation. Don't just concentrate on your own patients. ACEM recommends supervising at least one junior doctor for some shifts and asking and answering questions about their patients. You may be surprised at how much you know — and it will also help you identify areas that need further study.

Form or join a study group

Studying with peers is one of the most consistently recommended strategies by both successful candidates and ACEM itself. A study group lets you discuss difficult questions, practise SAQ answers, teach each other topics, write and share questions, and hold each other accountable to a study schedule. Even a small group of 2–4 people meeting weekly can make a significant difference.

If you cannot find a local group, consider online options — many registrars connect through hospital networks, social media groups, or exam preparation courses.

Use spaced repetition

The volume of material in the FACEM Curriculum means you will forget content unless you actively revisit it. Spaced repetition — reviewing material at increasing intervals — is the most evidence-based approach to long-term retention. Tools like Anki flashcard decks can help, or you can achieve a similar effect by cycling through question banks multiple times with increasing gaps between attempts.

Do at least one trial examination

ACEM specifically advises undertaking at least one trial examination before sitting the real thing. The experience of answering questions under exam conditions helps with time pressure, stamina, and the mental shift between question topics (which appear in no particular order, reflecting the unpredictable nature of an ED shift).

In the final 2–3 months, do 2–3 full timed mock exams under realistic conditions. This means sitting for the full duration without pausing, checking references, or taking extra breaks. Many candidates report that timing is one of the biggest challenges — you need to be comfortable with the pace before exam day.

Are you ready? The ACEM readiness checklist

ACEM publishes a readiness checklist designed to help you reflect on whether you are prepared to attempt the FEx Written. Going through these questions with your DEMT, mentor, or trusted tutor is strongly encouraged:

• Do you have a large body of knowledge about preparing for patient care before a patient arrives in the ED?
• Can you instinctively recall relevant findings on history and physical examination for the diagnosis of most presentations?
• Can you adjust your differential diagnosis for the same presentation type across different patient groups — a healthy adult, an infant, an elderly patient with comorbidities, a patient who is more vulnerable due to demographic or cultural factors?
• Can you select appropriate investigations to narrow your diagnosis, justify your selections, and analyse and interpret the results?
• Do you know the common clinical decision-making tools, their components, and whether they are validated?
• Do you have a large body of knowledge about ED treatment including drugs, fluids, gases, monitoring, equipment, and procedures?
• Can you apply all that knowledge in a prioritised framework applicable to the patient scenario in an exam question?
• Do you have knowledge of research methodology and how to analyse research?
• Do you understand how emergency departments work and what system-related issues may arise?
• Do you understand the knowledge required regarding patient disposition?

Protect your wellbeing

ACEM's preparation guidelines place significant emphasis on work–life balance during the study period. Ensuring your health and wellbeing is maintained through appropriate balance between study, clinical work, and personal life is especially important during this extended preparation period. Don't forget to incorporate periods of rest and relaxation — trainees who neglect this may experience burnout and not perform optimally at the examination.

Being unsuccessful in the FEx Written can have a significant personal impact and affect your confidence for subsequent attempts. If you are unsuccessful, ACEM encourages seeking support from your DEMT and other supporters, reviewing feedback carefully, and allowing yourself a period of recovery rather than rushing into a reattempt.

The final week

In the last week before the exam, taper your study. Do light revision of your summary notes and broad review of key topics, but avoid trying to learn new material. Get adequate sleep, maintain your normal routine, and trust that the months of preparation have built a solid foundation. Cramming at this stage does more harm than good.

Key takeaways

• Allow at least 12 months of dedicated study — some candidates start up to 24 months out
• Use at least two ACEM-recommended textbooks, supplemented by peer-reviewed national guidelines
• Know the six curriculum domains assessed and their weighting — Medical Expertise is ≥80%
• Practise questions from early in your preparation, not just at the end
• Try writing your own questions and teaching topics to deepen understanding
• Track your performance by domain and focus on weak areas
• Do at least one full trial exam under realistic timed conditions
• Seek objective feedback on your readiness from your DEMT and supervisors
• Protect your wellbeing — rest and balance are part of the strategy, not a luxury