FRCR Part 2B (Radiology) Guidance from examiners

It is apparent to the examiners that not all candidates familiarise themselves with the exam delivery platform, risr/assess, before sitting the exam and this puts some candidates at a disadvantage. View the Guidance on RCR image-based exam delivery where there is information on accessing the demonstration site where candidates can familiarise themselves with how images in the short and long case components are displayed and manipulated. We strongly recommend that all candidates login to this demonstration site and practice answering questions well in advance of their scheduled reporting components.  The exam delivery platform is not a PACS so, by necessity, scrolling, image magnification and changing window settings may take longer than in normal clinical practice. 

Many candidates have concerns about their ability to type reports for the reporting components. Minor spelling mistakes will not be penalised unless the error is misleading (e.g. ileum instead of ilium) or the spelling is so inaccurate that the meaning of the report is unclear to the examiner. Candidates would benefit from typing practice ahead of the exam if this is not their normal practice and production of short, concise reports will reduce the amount of typing required. Presenting findings as bullet points is perfectly acceptable in both long case and short case reports.

Candidates are provided with 25 plain radiographs to report.  For each case the patient age and sex, source of referral and clinical details are provided to mimic normal clinical practice. Candidates should ensure that this information is read and remembered when writing the report as, for example, a destructive bone lesion will have completely different aetiology in an adult compared with a child. All cases are abnormal, and more than one pathology may be present on each radiograph.  Normal variants of anatomy, if present, will not be pathological. Approximately 25% of cases are of children, approximately 50-60% are chest radiographs with the remainder composed of musculoskeletal cases. An abdominal radiograph may be present in each set.  All images will have clear side markers, and the candidate should assume that the side-marker is correct.  Where a paired structure is shown (e.g. ribs, clavicles, and scapulae on CXR or images showing both hands or feet), it is essential to state ‘left’ or ‘right’ in the answer.  Failure to do so will result in the candidate scoring a lower mark and incorrect laterality (e.g. stating that a right radial buckle fracture is on the left) will result in a lower mark. Minor spelling mistakes are not penalised, but candidates will score lower for errors such as calling a metacarpal a metatarsal. 

Each answer is marked independently by two examiners who may award up to five marks per case.  Marks are awarded for good plain radiographic observational and interpretative skills as well as report structure and clarity. Reports are entered into a single text box and should be logical and concise. Listing findings as bullet points is preferable to a paragraph of text although, if accurate, both formats will score equally well. Candidates do not need to describe every radiographic sign if they are confident about a finding.  For example, it is sufficient to state that lobar collapse is present, and state the likely cause based on the presence or absence of a hilar mass, without listing all the signs that led to that deduction. Each report should contain advice on further management or appropriate escalation of the report if appropriate. Where there is no relevant management advice (for example, in a routine outpatient follow up radiograph for a longstanding condition) it is acceptable to write ‘no management advice required’. 

To avoid misinterpretation, acronyms should not be used without explanation. It is, however, acceptable to write cystic fibrosis (CF) and subsequently to use the acronym CF in the remainder of the report.  A systematic approach to image interrogation is advised to avoid missing ‘edge of image’ findings.   Candidates should not state ‘bones normal’ without having carefully reviewed all the bones.  When identified, pathology should be described accurately and in full to avoid losing marks. ‘Fractured radius’ is not a sufficiently detailed answer either for the examiners or for clinical practice. ‘Undisplaced, intra-articular fracture of right radial head with associated joint effusion’ or ‘Salter-Harris II physeal fracture of the left distal tibia’ are examples of the level of detail that is expected in the short case reporting component.  

Candidates will score a lower mark for failing to suggest possible pathological causes for a finding.  Stating left lower lobe collapse due to left lower lobe bronchial occlusion is insufficient for a high score. Candidates should consider the patient’s age and the clinical history and provide a list of possible causes.  For an older patient, lung cancer is more likely than a mucus plug or inhaled foreign body, whereas an inhaled foreign body will be more likely in a young child. A ‘descriptive’ report where no diagnosis or differential diagnosis is given for an observed finding is strongly discouraged. Simply stating that there is increased opacification in the right lower zone and that CT and lung MDT referral is recommended is not enough to score well in this exam.  The candidate should use the history, patient demographics and their radiological/clinical knowledge to decide the most likely underlying diagnosis.  Candidates are expected to give an opinion on whether the opacification is likely to be due to infective consolidation, pleural or chest wall pathology or a lung cancer and to make sensible recommendations on how to advance the diagnosis.  For example, in suspected pneumonia, a repeat chest radiograph after antibiotic treatment would be preferable to CT thorax or MDT referral. 

Examiners have noticed that some candidates appear less secure in plain radiographic interpretation, particularly in paediatric cases and would benefit from more plain radiographic experience in preparation for this exam to improve their likelihood of passing the short case reporting component. 

Candidates are provided with six complex cases to report. The clinical details contain relevant information and help to narrow the list of possible diagnoses, so candidates should ensure they read and remember this information before viewing the images and writing the report. There may be more than one imaging modality per case and candidates should make sure they review all images in each series. Each answer is marked independently by two examiners who may award up to five marks per case. Good time management is essential for success in this component of the exam and candidates should ensure that they have attempted all six cases.  It is unlikely that a candidate can pass this component if one or two cases have not been answered so it is better to write incomplete answers for all six cases, than to write detailed answers for fewer than six cases.  

Candidates should approach each case with a systematic, thorough approach and enter the report according to the answer boxes provided in risr/assess (for observations, interpretation, principal diagnosis, differential diagnosis, and management). Please note that these sections are simply a guide for report structure, and it is not critical which box is used as all entered text is clearly visible to the examiners at the time of marking. Candidates should avoid unnecessary typing. The patient details and clinical history do not need to be retyped into the report. Bullet points are the most efficient way to list the observations and findings, and this format is easier for the examiners to mark than dense paragraphs of text. A well-structured and concise report will score higher marks than a disorganised report where important information is buried in dense text and could be missed or overlooked by the referrer.

Candidates should be precise in their descriptions e.g. on CT, fat density should be described as such and not just called ‘low density’ which could mean fluid or fat and for musculoskeletal MRI, candidates should be precise with side and location of abnormality rather than relying on gradings alone. For example, it would be safer to describe a ‘partial medial collateral ligament tear’ rather than a ‘grade 2 MCL tear’.  Likewise, precise anatomical description is preferable to eponymous descriptions of pathology e.g. an ‘intra-articular two-part fracture of the base of the first metacarpal (Bennett fracture)’ rather than ‘Bennett fracture’ alone. 

Not all sections need to be completed for all cases.  If there is only one possible diagnosis, the candidate should state ‘no differential’ or ‘none’ in the differential diagnoses box since completing that box with inappropriate differential diagnoses may imply lack of candidate knowledge to the examiners. Candidates should discuss further patient management and, rather than just referring the patient to a particular multidisciplinary team (MDT), show the examiners that they know what action the MDT will likely take or what further investigations may be requested based on the content of the report.  In trauma cases, candidates should look for significant neurological or vascular complications, and if critical/life-threatening findings such as active bleeding or bowel ischaemia are seen, candidates must escalate the report appropriately.  Although candidates do not need to know detailed medical or surgical management for every condition, they should know when urgent medical, surgical or interventional radiological input is indicated and any tests that might advance the diagnosis such as tumour markers that might be helpful in determining the underlying aetiology of a suspected malignant tumour.  

Candidates will score lower for ‘picking up the phone’ in every case, unnecessary over-investigation or unsafe practice, and candidates should demonstrate knowledge of current RCR recommendations on alerting critical findings to the referrer in the NHS.  Candidates should make sure they review carefully any plain radiograph provided rather than concentrating on the cross-sectional imaging alone.  Radiographic findings, particularly those related to the bones, may be critical in coming to the correct diagnosis. Finally, please ensure that CTs are viewed on all relevant windows as would be carried out in clinical practice.  Candidates will score a lower mark for missing important findings, having failed to view lung or bone windows. Where possible, the examiners will pair images to be viewed simultaneously, where that will aid image review such as T1W and T2W MRI or dual-phase CT, but this will limit the candidates’ ability to re-window.  In such CT cases, a separate, unpaired series will be available to the candidate to use for re-windowing. 

Candidates are shown a set of six cases during each of their two oral sessions and the 12 cases will be the same for any given day during exam week. The cases are a mix of easy, intermediate and difficult cases and the difficulty mix is the same for every day.  A variety of imaging modalities (plain radiographs including mammography, ultrasound, computed tomography, magnetic resonance imaging, nuclear medicine, and fluoroscopic studies) may be shown to test different areas of the curriculum, and the two sets of cases will be balanced to avoid pathology already shown in the short and long case reporting exams. Candidates need to demonstrate competence across the whole core curriculum including paediatric, breast and vascular imaging. Core interventional radiology is also tested. 

Before each oral session starts, candidates will be shown a test CT case to make sure that they are confident in knowing how to scroll through an image set and change window levels. If the candidate would like to view another window setting during the session, they should ask the examiner first as it may not be necessary. The number of images in each case is limited to ensure candidates have adequate time to review the entire stack.  Use of the left and right arrow keys on the keyboard, may provide smoother navigation through the images than the mouse wheel for ultrasound and fluoroscopic series.   

Examiners are provided with information, agreed with the candidate, relating to any reasonable adjustment considerations. Candidates should be reassured that both pairs of examiners will be fully aware of specific requested adjustments for each candidate.

The oral component is designed to test observational skills, radiological knowledge, analytical skills/clinical reasoning, clinical safety and management and communication skills.  When presented with an image or image stack, candidates should describe the findings, interpret the observations, and suggest a diagnosis or list of possible diagnoses to be considered, given the clinical history.  Only after this has been done should the candidate ask for further imaging. As in the reporting components, candidates should avoid simply referring the patient to a particular multidisciplinary team (MDT) but show the examiners that they know what action the clinical team will likely take or what further investigations may be requested.  Candidates are expected to be aware of the common diagnostic and management pathways in the NHS.   

Candidates should listen particularly carefully to the examiner when each new case is shown as the information provided is designed to aid case interpretation. They should not hesitate to ask the examiner to repeat this information if necessary.  After the candidate has made their initial interpretation, the examiner may ask them to clarify certain points, but none of their questions will be designed to trick a candidate or to make them doubt their original diagnosis.  A certain amount of examiner prompting is to be expected, in every oral session and candidates will not lose marks for this unless excessive examiner prompting is needed.  In many cases the precise diagnosis will not be clear, as in real life, and an examiner simply wants to find out what a candidate would advise, to help move the diagnostic pathway forward. Candidates should not hesitate to change their initial diagnosis, if appropriate, as they progress through the case.  Examiners will ask all candidates two or three standardised follow-on questions for each case, and these may be more generic to assess knowledge rather than directly relating to observations already made. If, however, the candidate has already answered these questions during their preliminary description and discussion, the examiner will move onto the next case. Candidates should be aware that if their interpretation of the case is completely incorrect, they will not gain marks for giving correct answers about a wrong diagnosis.  It is the responsibility of both the examiner and the candidate to complete all six cases during each oral session.  Candidates should therefore expect the examiner to interrupt occasionally to help move them through the cases and should listen carefully to the examiner who will be trying to help them perform at their best.   

Examiners have commented that candidates who perform well tend to demonstrate a systematic approach to reviewing imaging, show logical thinking and present their findings succinctly without over-reliance on examiner prompting.  Well-performing candidates also volunteer information about useful further imaging or referral with minimal prompting and listen carefully to all information provided by the examiner.  Some candidates demonstrate specific areas of weakness such as plain radiographic interpretation, ultrasound, nuclear medicine and paediatric imaging, all of which are important parts of the oral component. Examiners have also noticed that many candidates have limited experience of interpretation of emergency ultrasound and candidates should ensure that they gain sufficient experience in on-call ultrasound, as competence in this area of the core curriculum is important for patient safety.