Below is advice that I have written pertaining to the ANZCA Primary exam and how it is marked. I don’t know how the CICM Primary is marked, the marking scheme may very well use a different system. However, the principles that I outline remain applicable.

The Marking Rubric

In the appendix of the 2019A Examiners Report, the College published an example of the marking rubric that is used to mark the SAQs.

Question: Describe the metabolism and excretion of tramadol, including the implications for clinical practice.

Marking Domain



Describes metabolic pathway for tramadol

Hepatic metabolism via cyp450 to active metabolite

Accurate – at least cyp2D6 to O-desmethyl tramadol (M1)

Describes excretion of tramadol

Realises metabolites are renally excreted

Renal excretion of metabolites but also some for active drug

Describes the genetic polymorphism associated with metabolism

Knows of cyp2D6 polymorphism and describes at least one of poor or ultra rapid metaboliser

Able to describe 4 basic groups of metabolisers at cyp2D6.

Realises implications of active metabolite for tramadol

Describes some implication but not well elucidated

Main opioid activity for tramadol provided by M1 metabolite ( up to 200x more potent at mu receptor than tramadol)


Poor metabolisers – limited opioid analgesia and converse for ultra rapid metabolisers.

Understands the clinical implications of tramadol metabolism in general for practice


May suggest caution in renal impairment, but not accurate details of reason.


Ultra-rapid metaboliser plus renal impairment – risk of respiratory depression.

Dose adjustment required in renal failure ( decreased dose or better to increase dosing interval to allow clearance of metabolite)

Answers both parts of the questions

May answer one part well but misses the other


Internally consistent



This is a kind of tabulated marking grid that has 2 salient features:

  • The marking grid is broken down into domains. These are points that you are expected to address in your answer, that can earn you marks
  • Each domain is scored out of 5. The more accurate and detailed your answer is in addressing the domain, the higher your score for that domain

This makes it very clear that there are 2 important strategies to maximise your mark:

  • Identify and address every marking domain
    • This maximises your potential mark – if you address all domains, you could get full marks, if you only address half the domains, you can only get a maximum of 50% even if your answer is perfect
    • This is done by correct question interpretation. You need to recognise what is within the scope of the question – the marking domains – and also what is outside the scope of the question, so that you don’t waste your time writing stuff that can’t get you any marks
    • This is what people mean when they say “you have to answer the question!”
  • Maximise your mark for each domain by clearly demonstrating your understanding of the concepts
    • Step by step explanations, without any large logical leaps
    • Use relevant diagrams
    • Support your point with an example or data
    • Highlight clinical relevance
    • Specific points trump generic points
    • Use keywords/buzzwords
    • Use precise language

Clearly Demonstrating Your Understanding of a Concept

Step by step explanations

  • If you are explaining why poorly controlled diabetics might get polyuria, saying “hyperglycaemia → osmotic diuresis”, whilst not incorrect, would not get full marks because there are too many intermediate steps in the mechanism that have been skipped
  • A better answer might be “high plasma glucose → freely filtered in glomerulus → incomplete reabsorption in PCT (exceeds transport maximum) →↑ luminal osmotic load → prevent water and solute reabsorption in LoH → dissipate medullary concentration gradient → unable to concentrate urine → osmotic diuresis”
  • Use point form and lots of arrows

Use relevant diagrams

  • Sometimes it is quicker to make your point graphically than to write it out
  • There is no point for duplicating information both in a graph and also in writing, eg if you label the P50 as being 27mmHg on your ODC graph, there is no extra mark in writing that fact again below the graph

Support your point with an example or data

  • You’ve just said that the closer the pKa of an LA to physiological pH → faster the speed of onset because of higher unionised fraction (lipid soluble) → can penetrate cell membrane to reach target site
  • Now support that point by providing evidence: lignocaine, pKa 7.9, unionised fraction 25%, has faster onset than ropivacaine, pKa 8.1, unionised fraction 15% (at pH 7.4)

Highlight clinical relevance

  • You’ve just said that because of Fick’s Law, the closer the LA is deposited to the nerve, the faster the onset of action
  • Follow that up by making the point that ultrasound guidance is useful to speed onset by ensuring LA is deposited in close proximity to the nerve

Specific points trump generic points

  • When discussing factors that affect blood flow to the left ventricle, some candidates focus on Poiseuille’s Law and the factors that affect resistance
  • Whilst this is not incorrect, specifically for the left ventricle the most important factors to discuss are diastolic time and pressure and this is what should be emphasised

Use keywords/buzzwords

  • If you use the right key phrases in the right context, you can save yourself a lengthy explanation and still get full credit for understanding a concept, eg “Starling resistor” to describe West Zone 2 or CBF, “perfusion limited transfer” to describe transalveolar oxygen uptake

Use precise language

  • If you mean alveolar dead space, write “alveolar dead space”, not “dead space” and certainly not “V/Q mismatch”!

Common Mistakes / Misconceptions

Misreading the question

  • It is surprisingly easy to misread a question under the pressure of the exam environment – you need to be aware of that and deliberately read each question carefully
  • It is easy to read over a question and think “ah, I’ve seen this repeat question before, great…” and miss that an important word has been changed
  • It may be helpful to underline key words in the question as you read it

Relying on a generic answer structure template rather than analysing what the question is actually asking

  • A common strategy is to start each answer with a section titled “Definitions” and define every key word in the question, then have a section titled “Introduction/Background” and write about the topic of the question generally, in the vain hope that this will get a few marks and possibly disguise a lack of knowledge – it will not, it will only waste time you could be using for another question
  • The examiners DO NOT want a nicely structured prose style essay answer, they just want you to put down information that answers the question asked
  • See this LA speed of onset model answer (scored 5/5) written by the examiner who wrote the marking rubric for the question. Notice that there are no definitions and no preamble/introduction – it just answers the question

Getting hung up on classifications/structure

  • Some people insist on trying to classify everything under nice neat headings, sometimes making up categories that, if anything, are more confusing than not having a classification
  • Sure, if a topic has a conventional classification, then use it – it will help make sure you don’t forget to cover something – but don’t feel that you need to force a classification onto everything
  • For example, questions like discuss the factors that affect duration of action of LAs, list the potential causes of inaccuracy for a pulse oximeter… I recommend just listing the factors and explaining each one

Strategies For the SAQ Paper

  • You ABSOLUTELY MUST stick to the 10 minute time limit per question. If you haven’t finished writing your answer at the end of 10 minutes, move on to the next question. If you have spare time at the end, come back to finish off your answer then