FRCR 2B Viva Exam
Information about the exam
There are four consecutive viva exams each lasting fifteen minutes. You will be tested by a pair of examiners whom will be based in one room. They will take it in turn to show cases and ask questions with the examiner observing scoring. There are no fixed number of cases that get shown per examiner. You are scored from 4 to 8 with 4 a fail and 8 an excellent. 6 is a safe pass. The marks in each room are averaged to give you two scores for the viva exam. A further score for the rapids and one more for the longcases makes a total of four individual marks which get totalled to give an overall score. The viva scoring system is further explained below but in total across the four individual scores you need 24 to pass with a minimum of two scores above 6.
- SCORE 4. FAIL
Key findings missed with help. Wrong diagnosis. Dangerous diagnosis
- SCORE 5. BORDERLINE
Slow to spot problem. Poor differential diagnosis. Need help to get correct diagnosis
- SCORE 6. PASS
Some abnormalities diagnosed with help. Principle diagnosis made. Limited differential diagnosis
- SCORE 7. GOOD PASS
Key findings spotted. Correct deductions made with diagnosis. Good differential diagnosis
- SCORE 8. EXCELLENT
Correct diagnosis. Succinct answer. No errors. Excellent differential diagnosis
The viva component of the FRCR 2B exam is the most difficult to prepare for and the one a lot of candidates struggle in. No matter how hard you work there will be many cases you see for the first time or cases in areas where you might be weak. It is hard to predict the case profile one is likely to encounter from exam to exam and the questions asked are governed by how you approach the case. The examiner might not be satisfied with your answer and push you to try and get the correct answer. Alternatively, they might be pushing you as you are on course for an excellent, difficult to sometimes gauge the situation when you are stressed in the middle of the exam. The cases and questions get adjusted based on how you are doing. They can show the same cases to two candidates and ask very different questions resulting in a very different exam experience. Conversely two people going into the same room after each other can get very different cases.
How many cases is normal per viva?
The answer to this question is that there is no such as a fixed number of cases! One candidate saw three cases in one viva and went onto win the gold prize. A different candidate presented 7 cases and failed. The number of cases does not constitute a pass or fail.
To answer this question, we must first answer the question of the myth of the pass and fail case. The official answer to this question is that there is no such things as a pass or fail case………or is there ? For arguments sake late us take the example of a pneumothorax on a CXR which you have missed even with prompting (see above for score). Missing this pneumothorax does not automatically constitute a fail although you will score 4 in this case but it alerts the examiner that you might not be safe ! They will most probably show more difficult cases and ask harder questions, to convince themselves that you are good enough to pass. This puts you in a position where you can either shine by performing in a series of challenging cases but it puts you at high risk of coming undone. Therefore by missing the pneumothorax you will score a 4 but not fail that exam but if you struggle in the subsequent cases the series of low marks can equate a fail and a tough exam experience. Conversely you can score a 4 in your failed pneumothorax case but then score 6s and 7s and pass. Compare this to a trainee whom has done ok in case 1, 2 and 3…. The examiner challenges them by showing a harder case in which the candidate may struggle but because they have built solid credit in the bank with 6s and 7s in the prior cases the examiners might just decide not to push them as hard as they might think ‘this person is good enough to pass but not gold prize material’, thereby the exam experience becomes a lot easier.
The FRCR is a core exam within the United Kingdom Radiology Training Scheme. It is typically taken at the start of the fourth year of a five-year programme. Passing the FRCR is a requirement to enter the final year of specialist training and UK trainees who have not passed the FRCR by the fifth year are offered a one year extension. Important for the purpose of this review is that the FRCR is a intermediate exam and not an exit exam like many others in countries. It is meant to be an adjunct to the 2A exam, practically testing theoretical knowledge obtained in the 2A. The operative word is a safe candidate. What does this mean… it roughly translate into ‘a trainee who can spot emergency conditions and make sensible interpretation and diagnosis’. However, they will expect 2A knowledge of management of conditions at the level of the MDT. For example they might show you a liver lesion on ultrasound, graduate the case to an MRI and then ask you management of the condition. In terms of modality anything you experienced in FRCR 2A you can get in 2B. This is where ‘luck’ comes in. When I did the exam in 2011 a very solid trainee I know got a breast mammogram and came undone when they asked about micro-calcification. I personally would have struggled with that question. In my exam I was shown a case of polio-myelitis. This is a condition you don’t see often in the UK, but I remember seeing a case in India whilst on my elective in 2005 as a medical student and applied this knowledge. One might say luck, someone else might say the more work I do the luckier I get!
To answer this question let us take an example of a case with a mock scenario
Examiner: This is CXR taken of a 63 year presenting with productive cough for 1 week.
Candidate: I am presented with a frontal chest radiograph of a patient demonstrating multiple lung lesions with more confluent change in the right lower lobe. I am concerned for a lung malignancy and would urgently organise a CT chest.
Examiner: are you sure it is lung malignancy…could it be anything else?
Candidate: sir I am certain this is malignancy and would recommend a CT chest.
First let us take the history. Is this a history of malignancy or infection? Why didn’t the examiner say weight loss ? why such a short history? This should alert you that this might be infection. Second the answer, there is no structure, no significant negatives or positives. The delegate has not shown good thought process to the examiner. Thirdly the examiner has given a prompt! Are you sure! at this stage you can still redeem yourself and change your answer, you may not score a 7 or 8 but still score a 6. Fourth the candidate does not accept the prompt from the examiner.
Below is a 6/7 score module answer of the same case.
This is a chest radiograph of an adult female patient who has presented with a short history of productive cough. I see both breasts are intact. There is extensive shadowing in both lungs with more focal change in the right lower zone. No effusions. No hilar adenopathy. The heart is not enlarged. No focal pulmonary lesions and no bone destruction. Taken together I suspect this is an inflammatory process. I would recommend a course of antibiotics and a repeat CXR in 6 weeks.
The examiner may take down the case but might show you a another CXR after 6 weeks and ask you what happens next.
Examiner: this is a 67 year old man who has presented with abdominal pain with bowels not open
Candidate: I am presented with an abdominal radiograph demonstrating bowel obstruction. I would proceed to a CT scan to assess this further.
Let us analyse the response of the candidate. This is a very typical answer that I get from people when I give them mock exams. The answer is not incorrect but it is not an FRCR answer. The question is why did the candidate answer in this manner. The reason for this is simple….this is real life! In reality we see bowel obstruction everyone including the surgeons proceeds to CT scan. No one really looks at a plain film anymore. This is reflected in people’s poor performance at plain film reporting in the exam. Yes, we look for cause of obstruction on the CT, we look for a perforation, we look for bowel ischaemia and we look at everything else but this is not reflected in the answer when the plain film is projected. The reason for this is because people have not structured and organised their thought process in their heads to answer in this manner. The knowledge is there but merely requires organisation.
Below is a 6/7 answer
Radiograph of a 67 year old man presenting with abdominal pain with bowels not open. The x ray shows dilated small bowel loops and large bowel located on the right side of the abdomen. Distal large bowel is normal calibre. Appearance in keeping with mechanical obstruction. No evidence of perforation. No free air. No surgical clips. No hernias. No destructive bony changes but I note fractures on the right pubic rami. Difficult to ascertain if this is acute or chronic. This is a surgical emergency and I this was in my reporting pile I would urgently convey the findings to the referring doctor.
The examiner might move on to show you a CT scan and take the case forward.
To pass the exam we have to show we are safe! Safe isn’t doing a CT, safe is speaking to someone of an emergency quickly. You can do a CT if the clinician wants it (which of course they will want).
I have developed a specific technique of presenting cases for the exam and I teach this in my course. I have also included a number of free viva cases on this website for you to practice if you find this useful. Please also contact me and I will try and give you a free mock exam (time permitting).
Why do British Trainees do better at the viva compared to International candidates?
This is the £4000 pound question. I say this amount because I have approximated this is the loss of income for International doctors coming for the FRCR. There are many reasons for this but to answer this question I have to use an example of a non-related subject. The subject is a ‘snow environment’.
When there is heavy snow in the UK, the country comes to a standstill. The airports stop working, children get sent home from school etc. Compare this to Scandinavian countries where snow is an everyday occurrence but people carry on as normal with minimal disruption! The reason the UK struggles is because snow is an occasional event. It is cheaper to suffer a few days of disruption rather then invest in snow infrastructure!
Applying this to the FRCR the British Trainee practices in a ‘FRCR environment’ getting constant teaching, exposure from senior trainees and Consultants alike. They do the 2B exam immediately after passing 2A, therefore have huge amount of knowledge. If they fail 2B they can repeat in 6 months thereby being even more prepared. They also encounter FRCR 2B examiners and although it is not permitted to share exam questions, they learn to interact with the examiners due to the combination of exposures.
Prior to my 2B exam I was fortunate enough to be based at a hospital with a 2B examiner who gave me multiple teaching sessions. This enabled me to gain a massive insite into the exam.
For International doctors the FRCR is not part of daily life but something they ‘encounter.’ This is the problem. As a result their understanding of the exam is limited, they don’t know how their strengths and weaknesses relate to this and are unclear on how to interact with examiners as much.
You might have heard about the ‘10,000 hour’ rule suggest by Professor Anders Ericsson in 1993 in his paper titled ‘The role of deliberate practice in the acquisition of expert performance’ and popularised in Malcom Gladwell’s book. The theory based on violinists postulates you require 10,000 hours of deliberate practice to become a world expert at something. What does deliberate practice mean ? This is a very specific term and relates to stepping out of your comfort zone and trying activities beyond your current abilities. This also requires well defined goals and a mentor to provide feedback to improve.
How does this relate to my advice for FRCR. Whereas not practical to spend 10,000 hours with dozens of other commitments, the key is creating an environment where you can learn, be challenged and receive feedback. 10,000 hours is not practical but I would recommend 15 hours a week for 6 months. For the viva component of the exam I prepared by practising presenting in front of a mirror, practising with friendly consultants and difficult ones to take me out of my comfort zone. I worked with friends asking for feedback and did a lot of personal reflection.
1. Develop a systematic approach to presenting cases.
2. Work with friends, use the social media groups, facebook, whatsapp, telegram to engage in cases presented by people.
3. The viva cases on this website should give you a basic flavour of how to present cases but please use all books and resources to develop presentation technique
It is important to understand that you cannot prepare everything! you might get an area that you have not prepared for well i.e. breast mammogram or a gynae ultrasound, but do the best you can.
When presenting cases be structured in comments. If you spot the abnormality and know what it is go for it. If unsure describe things systematically. I.e. significant positives and significant negatives. Our suggestion is try and offer three differential diagnosis. The differential diagnosis needs to be sensible common things. Our suggestion is not to mention the 1 in 237,000 incidence differential diagnosis as your top differential of three. If you cannot spot the abnormality then go through things systematically. ‘Do not make up signs. Try not to panic (easier said than done)’. Some cases will have two findings which you use to come to the diagnosis i.e. lung cavity on a CXR with a lytic lesion in the humerous. LAST BUT NOT LEAST, REMEMBER IT IS A DIALOGUE. PRESENT YOUR CASE AND THEN STOP ALLOW THE EXAMINER TO ASK QUESTIONS AND INTERACT WITH YOU!
I organise both paid and free webinars to offer advice for the FRCR. Please message me on mobile +447825292556 with your name and location to be included in my telegram group for support and advice.