FRCR 2B Long Case Exam


The Facts

The long case section of the FRCR exam always contains six cases for which you are given 75 minutes to complete. The images are presented on PACS software and the answers have to be inserted electronically via keystroke. Although the number of cases stays fixed at six, each case may have more then one imaging modality. 

The section is marked 4 to 8 as the other 2 sections of this exam.

4 Fail    5  Borderline Pass     6 Pass     7  Good Pass     8  Excellent

Answer Format in the exam is:

1.Observations 2. Interpretation 3. Principle diagnosis 4. Differential diagnosis 5. Further management

Mark Allocation System

Candidate ResponseMark
Fail, No answer3
Fail, significant observations missed, correct diagnosis not made4
Borderline, one out two observations made, some observations made5
Pass,  most observations made,  correct diagnosis6
Good Pass, additional relevant material7
Excellent, perfect answer8

Scoring system

Total MarksOverall Marks
  • 18-25
  • 25.5-28
  • 28.5-31
  • 31.5-34
  • 34.5-37
  • 37.5-40
  • 40.5-43
  • 43.5-46
  • 46.5-48
 

  • 4
  • 4.5
  • 5
  • 5.5
  • 6
  • 6.5
  • 7
  • 7.5
  • 8

 

 

HOW TO PREPARE FOR THIS EXAM

I personally feel that the Long Case component of the FRCR 2B exam is the closest to reflecting the actual work we do as Radiologists. However, the proviso is that the range of cases presents a breadth that maybe we do not practice in our day to day routine. To get a better picture of the types of cases in the Long Case Exam, it is useful to understand the nature of the UK Radiology Training Programme. Trainees at the end of the Third Year before sitting the FRCR 2B will have to have completed core competencies in a range of modalities extending from Breast to Intervention and also have had to pass the FRCR 2A. The case profile in this exam is a reflection of this core curriculum and you can get for instance a mammogram, MRI knee and a CT chest, abdomen and pelvis. I do not feel it is practical to see lots of cases with just the 2B Long Case in mind (unlike the other two parts). However, it is useful to reflect on your Core Experiences. For example if you always knew that you would become a specialist Neuro-radiologist you might have neglected Intervention, Gynae and Mammography in your training and did the bare minimum to pass the rotation. My suggestion is that you personally reflect on your areas of weakness and make sure, if you get an MRI knee or mammogram that you at least have some idea how to navigate this. For International Doctors sitting the exam, use the FRCR 2A as a guide and also ask questions on the networking Groups to gain a better picture.  

 

WHAT ARE THE MAIN REASONS FOR FAILING THIS EXAM

The two main reasons for failing this exam in my opinion are for missing significant findings in two or more cases and more commonly for not finishing the exam! Within the UK training programmes there is structured feedback for all components of training. Therefore provided you have satisfied your supervisors in the different rotations of training, a UK delegate at the start of the fourth year should not miss findings in this exam and ideally this should not be a reason for failing this exam. If you failed the exam because you are missing findings then this is something for you to address before the next time. From my experience of working with a large number of International doctors on my courses the majority are already practising as General Radiologists at Consultant Grade and therefore tend to have enough experience to report accurately. Therefore missing findings does not tend to be a major problem for this group of doctors.

 

FINISHING THE EXAM

I feel that your focus in the revision should be to get right your technique on how much to write per case and how long to spend to ensure you finish the exam. 75 minutes, divided by 6 equals 12 minutes per case, with three minutes of change. I would advice you spend two minutes of your 75, to flick through the six cases and make sure you know what to expect in the next 73 minutes. For example if case two is a CXR but case four is a barium swallow, CT chest abdomen pelvis and a PET scan, it stands to reason you dedicate more then 12 minutes for case four and less for case two. My second piece of advice is that you write the bare minimum per case.

 

HOW TO MODEL AN ANSWER

I strongly recommend you review the material on the Royal College Website. I have provided two model answers, one good and one bad to try and provide you with a frame work on how to structure yourself.

Answer 1. 

  • Observation. Chest X-ray.  There is partial left upper lobe collapse.
  • CT chest.  Partial left upper lobe collapse.  Thick walled cavity in the superior aspect of the left lower lobe. Thoracic vertebrae lytic metastases. No pleural effusions.  No additional metastases.  No PE.
  • Interpretation. Metastatic neoplastic process.
  • Principal diagnosis. Lung cancer with metastases.
  • Differential diagnosis. Disseminated tuberculosis.
  • Further management. Urgent chest consultation suggested.

Analysis This answer is adequate as the principle findings are mentioned and not too many words are used. This will enable you to spend more time  looking for abnormalities as compared to writing.

Answer 2

  • Observation. Chest X-ray: There is density in the left upper lobe with no air bronchograms and volume loss.  partial collapse of the left upper lobe.  No additional lung lesions.  No pleural effusions.  No hilar adenopathy.  No destructive bony changes.  No acute bony injury.  No rib fractures.
  • CT chest.  There is partial collapse of the left upper lobe.  No endobronchial mass lesion is appreciated.  Within the left lower lobe there is a further cavity measuring 5 cm.  This is thick walled.  No associated bone destruction.  No additional lung lesions.  No pleural effusions.  No evidence of metastases within the abdomen.  Evidence of bony metastases within T4 thoracic vertebrae.  No additional bony metastases.  No PE.
  • Interpretation. Metastatic lung cancer.
  • Principal diagnosis. Metastatic cancer with cavitating metastases to the left upper lobe and bones. Likely endobronchial lesion in the left upper lobe.
  • Differential diagnosis. Extensive inflammatory process.
  • Further management. Chest consultation suggested.  Refer to MDT.  Informed referring general practitioner.  Review case for consideration of radiology guided biopsy.

Analysis This is a good answer for actual practice as it is more systematic but bad for the exam for the simple reason that you are spending a lot of time writing i.e. time that should be used to look at things and try and finish the exam. This is not an answer you should replicate in the exam.

 

HOW USEFUL ARE COURSES AND TEACHING RESOURCES

When I did the exam in 2012 the only preparation I did was attend two courses which included Long Cases and used the free FRCR tutorials website created by Dr Sameer Samshuddin. I only worked on this component towards the end of my revision. I did not use any paid platforms or do any extra work, apart from making sure I was comfortable with reporting basic cases across a range of areas as per my training port folio. Try and speak to people who have done the exam recently to get a better idea on the paid platforms.

 

AMARADIOLOGY COURSES

The Two Day Course has a range of topics including Mammography, Barium, Nuclear Medicine, Gynae and Hepatobiliary Radiology. A lot of MRI cases are shown on Day Two. The aim is to help with the Viva but the knowledge, exposure and discussion on management is also helpful for the Long Case Component.  

 

HOW TO USE THIS WEBSITE 

I would recommend you attempt these packets in the last month of your revision. There are five packets on this website. The packets have been designed to try and represent the range of cases you might encounter. My principle aim is to help you develop your technique on how to model answers to make sure that you finish the exam. The longcases are uploaded as six Zip Dicom folders per packet to reflect six cases of the exam.  Remove from the Zip Folder onto a separate folder.  Please download all the cases onto your laptop before you attempt the exam. Open using a dicom viewer. I personally recommend Radiant viewer. Time yourself to do all the cases within 75 minutes. Doing it outside of exam time will diminish the value.

 

Key Advice

  1. The most important piece of advice is to finish the exam. Do not leave any sections unanswered.
  2. Spend two minutes at the start quickly looking at all 6 cases so you are mentally ready for what is coming ahead.
  3. Write the minimum amount per question. Focus on significant positives and only one or two relevant negatives.