Passing the FRCR 2B exam – a perspective from an international medical graduate

There are many International Medical Graduates (IMGs), either trainees pursuing a career in Radiology or those who are already consultant Radiologists in their home country, who aspire to get the FRCR qualification. This might serve to fulfill an an ambition to work abroad, pursue further training in a sub-speciality of radiology abroad or merely for self satisfaction – the golden star in your CV.

It is presumed that having already passed the Part 1 and Part 2A of the FRCR examination, candidates will already have a sound working knowledge of Radiology. This blog is to share my perspective (an IMG) on passing the 2B examination. There are several differences in the Radiology training in the UK and elsewhere and thus while preparing for the 2B examination, unique problems are faced by IMGs. I will address these issues under various subheadings below.

Where to take the exam

Technically, London has the highest pass rate for IMGs. The exam fee is also a lot cheaper in London. Singapore would be a good option if you live in South-East Asia or have family in Singapore. Hong Kong is a horrible choice and anecdotally one examiner from Hong Kong himself advised me against taking the exam there!

When to take the exam

The best time to take the exam is when you feel most prepared. Having said that, we must realize that the FRCR 2B exam is meant for ST-3 or ST-4 trainees in the UK. This means that the knowledge expected during the exam is that of a junior consultant in General Radiology and not that of a Professor of Neuroradiology or a senior MSK radiologist! This is important for IMGs to understand as many candidates taking the exam are already well into their career with a focused core knowledge in one or two sub-specialities. Hence, for consultants, it might be best to take the 2B exam early in your career before you sub-specialise. For Radiology trainees, the ideal time to take the exam is as soon as possible after their training. For those practicing general radiology, any time is a good time!

How to make use of the ballot system

The college recently started the rolling ballot system for IMGs to appear for the 2B exam which makes it a little easier to prepare for the exam since you will known approximately when you will be likely to sit the exam. The introduction of the new rolling ballot system means that all IMG applicants are assigned a wait-list number and called according to that number depending on the number of vacant slots remaining after all UK trainees have applied. There are usually around 100-150 slots in the London venue (more IMGs take it in Spring, less in Autumn). At the time of writing, the wait-list extended up till Autumn 2016 or may be even 2017. But this does not mean that you can not take the exam until then because here is the catch: not all IMGs offered the slot according to their waitlist number, accept the offer. This makes the college send out an email 1 month before the exam asking all interested applicants to apply on a first-come basis. ALthough this is unfair to IMGs, the college wants to fill up all slots for the exam. My advise is that unless you are REALLY well prepared, you should not accept this “emergency” slot. One caveat is that you could take a risk by preparing for the Spring session of any year (since more IMGs are usually eligible to take the exam in Spring) and check your email regularly (preferably hourly!) in the weeks after the closing date for UK candidates application has passed and apply immediately to be assured of a spot. On the other hand, if you already have a wait-list number, you should know approximately when you can take the exam and prepare accordingly.

How long do you need to prepare

The short answer is 3-4 months. The long answer is: it really depends on your level of training. If you trained in a center with minimal access to academic case discussions, film reading sessions and clinical conferences, you might need longer. On the other hand, if you are already a consultant general radiologist whose day-to-day practice is basically a mock FRCR 2B exam, two months might be enough. What is crucial to your preparation time is that you dedicate time off your work to prepare for the exam (if you are a consultant). Most UK trainees spend time preparing for the exam through their work hours and with mock sessions with their consultants. What would be ideal is to take around 2-4 weeks off work, the month prior to the exam. Start slowly initially (1-2 hours a day) and increase the intensity as the exam approaches so that you don’t burn out too early.

The exam format

I cannot over emphasize that you have to be thorough with the exam format. You can not appear for the exam without being comfortable knowing what is expected to be written in a Long case or how many Viva sessions will be there. All the details are on the RCR website and I advise you to go through them several times to make yourself familiar. To summarize: there are three components to the exam: Rapid Reporting (RR), Reporting session (Long cases), Viva (a total of 1 hour with four examiners). The RR and Long cases are held on a single day without a break in between (not even to pee!). The viva will be held 1-5 days later depending on your time table.

Each component is scored out of 8 (a total score of 32) and you need a total score of 24 to pass. It is very difficult to score anything more than 7 in long cases since there is no time to write a “perfect answer”. A well performed viva could get you a 7 as well. Although most candidates who pass get an average of 5.5 to 6.5 in both these components making the rapid reporting a vital area to do well.

What to read for LC and Viva

There are several standard books available on the market. Buy, rent, beg or borrow (don’t steal) all these books and read them – at least 2 times each. These books carry standard exam type cases and many of them will appear in your exam verbatim (I got 3 long cases that I had seen in these books). There is plenty of free material available online – just google FRCR 2B and you will find most of it. This will take around 2 months of your time and I suggest that you spend the first two months of your preparation going through these books. At the same time, go through image libraries if you work in an academic institute (or radiopedia has a good FRCR 2B collection).

Courses

It’s almost certain that every candidate will have attended some training course. How many courses should you attend? Well, this is a grey area. My advise is that you attend at least one in your home country and one in the UK. I personally attended two full courses in India (Columbia Asia FRCR course and the Chennai FRCR course) and a rapid reporting course (Bangalore FRCR Rapid Reporting course) and two in the UK (Aintree FRCR 2B course and Rapidology RR course). 5 courses might be an overkill, but I think it really helps in three key areas:

1. You get to see a huge range of cases in a short period of time. This saves a lot of time from searching for cases and study material.
2. You learn how to prepare: The courses in your home country will usually be several months prior to the exam which gives you enough time to modify your study techniques. They give a lot of valuable tips and advise on how to prepare and present in the vivas.
3. You get a feel for the exam: Especially the UK courses help you practice with British examiners with accents and ways of speaking that you may not be comfortable with as an IMG.

Some of the more popular UK  courses have to be booked several months in advance so be aware of this and apply early.

Rapid Reporting

This is the most important part of the exam. It is the make or break component since it is the most objectively marked – you can score an 8 in only this section. If you score an 8, you are almost guaranteed to pass the entire exam as long as you don’t make serious blunders in the other components.

There are several strategies when it comes to preparing for RR. The key in RR is not about making an exotic diagnosis – it is about spotting the abnormality. It is more a test of observation than anything else (it’s like finding Waldo). Practice makes perfect – that summarizes the strategy for RR. Starting from 2 months before the exam, keep doing at least 3-4 packets a day, increasing it to 5-6 packets closer to the exam. The sources for RR packets include the frcrtutorials website (40 packets for free), frcracademy website (which is paid but worth it – GBP 25 for 30 packets), an iOS app (I think around USD 5) which has around 700 cases and some courses give out practice sets to solve at home. This should last for 2 months at least. The strategy you use for your day to day practice should be the same as the strategy you use for the exam. One way, and probably the easiest is this:

1. There are a total of 30 cases
2. On an average 14-18 are abnormal
3. Of these abnormal cases, 9-11 will be gross pathologies that you can spot with one eye closed from 6 feet away. If you go through all 30 cases in 5 minutes, spending around 10 seconds per case, you will spot these and mark them straight away.
4. Of the remaining 6-7 abnormal cases, you will need to spend 40-50 seconds or maybe even a minute on these. This is the time to go through the film systematically: trace EVERY cortex of EVERY bone for fracture, go through the review areas of the CXR for things you commonly miss, the film corners, the side marker (dextrocardia, situs abnormality) etc.
5. Once you find 15 abnormal cases, it is strongly suggested that you do not overcall normal cases with imaginary “subtle” fractures and “grade 1 AC joint subluxations”.
6. In the last 2-3 minutes, go through the abnormal cases one last time and make sure you have not made silly errors like interchanging the right and left or mislabeling the 2nd for the 3rd finger or metacarpal for metatarsal etc.
7. You are guaranteed to pass this module if you get 15 definite pathologies (not cooked up ones) because even if there were 18 abnormal cases, you would still get 27/30 which is a pass.

Long case

All long cases have a unifying diagnosis. You must think hard to get this to score at least a pass (6/8). The main problem is not making the diagnosis but sticking to the time limit of 60 minutes for 6 cases. This seems unnatural, because in a normal work day, you wouldn’t finish reporting 6 full cases with CT, MR, US and whole PET series in 1 hour! But what is crucial is that you stick to the time limit and go to the next case after 8-9 minutes and that you answer all the 6 cases. You must go through the case completely, including management options / suggest further imaging or biopsy as appropriate. Failing to write down something for even one case means you automatically fail unless you get a full (and impossible) 8/8 on the remaining 5 cases.

Viva

Those 60 minutes feel like 60 hours – but if you are well prepared, it should go smoothly. The key to preparing for the viva are the courses. Most courses offer multiple viva sessions with potential examiners and allow you to get used to the viva style. There will be a mix of examiners showing all sorts of cases – bariums and IVUs included. The predominant modality shown will be plain films and most cases with CT / MRI will have a preceding plain film which you have to discuss first before you “earn” the cross sectional imaging (except for neuro cases obviously). The art of presenting cases in the viva comes only with repeated practice – practice speaking out loud in front of a mirror or with colleagues or seniors – anyone will do if you can’t manage to find a willing senior consultant to quiz you (I even practiced presenting cases to my wife, a psychiatrist). Chanting in your mind will not help – you must speak out loud while practicing.

Planning you travel and stay for the exam

Once you decide to take the exam, you must decide on when to travel. If you are taking courses in the UK, you will be traveling early anyway. If not, I would advise reaching London at least 3 days before the exam to avoid jet lag and be well settled and comfortable. I visited the examination venue a few days before my exam so that I won’t be panicking on the day of the exam (in case google maps fails). Although London is expensive, there are plenty of options to stay in London without having to sell your property at home. Look up hostels.com or airbnb.com

The week before the exam

Stay composed and stick to your routine of sleep, study, meals and taking breaks for exercise and relaxation. Do not overdo the preparation and burn out in this period. Go through the college website and watch the videos on the use of the Osirix software several times. You must be very comfortable using the software or else you will be wasting time during the exam fiddling and searching for the tools.

Day of the exam

Arrive early (even though the hall ticket explicitly says DO NOT COME EARLY) – at least 30-60 minutes before the exam. There is a lovely garden right opposite the college where you can sit and relax. Do not stress yourself out by trying to learn new things. Your documents will be checked at the time mentioned on the hall ticket and you will be taken to a room where they will replay the examination video (which you should have seen several times already). After this, you will be taken to the examination hall where you will be assigned a work table with an Apple iMac, an answer book for the long cases, a pencil (which you should use), an eraser and a pen (which you should throw away!).

Long cases

The first component is the Long cases and you should go through each case carefully. Read the history, age and gender provided very carefully and make sure you see all sequences mentioned. The history is usually only one sentence but is the most vital part of the diagnosis. Spend no more than 8-9 minutes per case and fill in SOMETHING in all the columns (observation, interpretation, diagnosis and management – if you have differentials, limit it to 1 or 2). At the end, you should be left with 10 minutes which you should use to fill in extra details of the easy cases to try and score an 8 in these.

RR

Soon after the long cases, the answer books will be collected and you will be given the RR answer sheet. In my exam, I got an 8 in RR (which is 30/30) so I think this technique really should work and I am just repeating the same instructions from before. This is also how you should have practiced and is the same way you should target the actual exam:

1. There are a total of 30 cases
2. On an average 14-18 are abnormal
3. Of these abnormal cases, 9-11 will be gross pathologies that you can spot with one eye closed from 6 feet away. If you go through all 30 cases in 5 minutes, spending around 10 seconds per case, you will spot these and mark them straight away.
4. Of the remaining 6-7 abnormal cases, you will need to spend 40-50 seconds or maybe even a minute on these. This is the time to go through the film systematically: trace EVERY cortex of EVERY bone for fracture, go through the review areas of the CXR for things you commonly miss, the film corners, the side marker (dextrocardia, situs abnormality) etc.
5. Once you find 15 abnormal cases, it is strongly suggested that you do not overcall normal cases with imaginary “subtle” fractures and “grade 1 AC joint subluxations”.
6. In the last 2-3 minutes, go through the abnormal cases one last time and make sure you have not made silly errors like interchanging the right and left or mislabeling the 2nd for the 3rd finger or metacarpal for metatarsal etc.
7. You are guaranteed to pass this module if you get 15 definite pathologies (not cooked up ones) because even if there were 18 abnormal cases, you would still get 27/30 which is a pass

Viva

The Viva will be a few days after the RR and LC. You will be assigned two rooms with two examiners each. They will each show you cases for 15 minutes. At the start of each case, they will tell you a short history. Again, one very useful technique is to repeat what they just said so that it stays in your mind. If they say, this is a 56-year-old male with hip pain, you should start your case with “i am presented with a radiograph of the pelvis of a 56-year-old male with hip pain”. That way you will start looking for the right things in the right places. Viva presentation styles vary from person to person and you should really develop your own style as you practice in the months before the exam. You cannot learn one overnight.

After exam

Do no discuss the LC and RR with your colleagues because no one knows what the answers were. You will simply demoralize yourself before the Viva. Once the viva is over, it’s easier said than done, but do not worry about the results because nothing can be done to change them! Thankfully, the results are usually out in less than a week.

All the best!