Chapter 1 General guidance

David Limb

Introduction#

The structured oral (viva) examinations are the second component of Section 2 of the Intercollegiate examinations, usually occurring over a two-day period after the clinical section

between them the vivas contribute 48 of the 96 marking episodes inSection 2. The clinicals (intermediate and short cases) together make up the other 48 episodes

This chapter will review the overall marking structure for the exam and outline the contribution of the structured clinical orals to the overall result. By understanding this process you will be in the best position to prepare yourself for assessment against the examination standards. These standards are not set to ensure examination income for colleges, or to impose a limit on the supply of qualified professionals. The FRCS (Tr & Orthis one component of that assessment and if everyone presenting for the examination shows themselves to meet that standard, then every candidate will pass!

Overall structure of Section 2

To reach Section 2 of the Intercollegiate examination candidates must first pass Section 1. Therefore, to arrive at Section 2 you have already shown that you have a knowledge base and can apply that knowledge to solve problems posed in clinically relevant scenarios.

Section 2 moves us higher up the ladder of higher-order thinking Decisions have to be made on information elicited by the candidate and these have to be in the patients best interests.

The clinical examination will involve two 15-minute intermediate cases, one upper limb/cervical spine and one lower limb/thoracolumbar spine and two 15-minute short case examinations with the same upper/lo wer limb split and each with three cases for 5 minutes each.

This chapter focuses on the structured oral examinations and each candidate will undertake four such vivas, each 30 minutes in length.

Trauma (including spine)

Basic science

Adult and pathology (including spine)

Children and hands (including upper limb)

Note there are qualifications against some viva titles – this is to ensure that wide syllabus coverage is possible, and this is facilitated by each candidate being preceded at the viva table by a topic sheet indicating the specific questions they have been asked to that point.

Each viva is now quite rigidly structured – a 30-minute viva with two examiners will consist of

15 minutes with each examiner. Each viva therefore involves six topics and each of these is marked independently by the two examiners, giving a total of 12 marking episodes for each of the four vivas.

Marking scheme#

As noted above, the vivas carry a total of 48 marking episodes and that is matched by 48 marking episodes in the clinical section: 24 in the intermediate cases and 24 in the short cases.

96 marking episodes and a score of 6 in every episode reaches the pass mark for the exam, which is therefore 576.

In the past a mark of 4 in any part of the clinical examination meant an automatic fail, no matter what marks were achieved in the vivas. It is possible to compensate for a 4 in one marking episode by achieving an 8 in another episode, or indeed by two 7s in two separate marking episodes. The disaster of course would be topass 95 episodes with marks of 6 and therefore fail the exam because of a single score of 5. If it is 575 or below the candidate has failed.

Although it is still up to the examiner to assess your performance and allocate the appropriate mark, the quality of response needed to achieve a 6, 7 or 8 is agreed at the examiner standard-seting meeting , which will be described later.

(except to clarify matters of fact, such as might occur if the co-examiner mishears something but is not allowed to interrupt), and they should mark according to the standards agreed at the standard seting discussion. A discrepancy of two marks triggers an investigation, but fortunately this is rare.

Practicalities#

For examiners the day is split into three or four sessions with three to six vivas in each session.

The GMC would take a dim view of any attempt to gain such an advantage in the examination process and a GMC referral is not helpful in gaining access to a consultant post.

You will be led into the examination hall and accompanied to your table by a member of intercollegiate staff who will identify your table and indicate your candidate number to the examiners. It is their job to find out how well you can perform, not to humiliate you, so expect a polite introduction, a check of your candidate number, an orientation to which viva you are about to sit and an outline of how the next

30 minutes will be spent (‘three questions of 5 minutes from myself with a bell between, followed by three more from my colleague’). The actual questioning doesn’t start until the first bell sounds, ensuring that all candidates receive the same time, particularly when the hall is long

There will follow 30 minutes that seem to rush by, punctuated by bells at 5-minute intervals. the final bell will be met with a polite but swift termination of the viva and you will be invited to leave the hall with the other candidates. Outside the Intercollegiate staff will organize you in preparation for your next viva, or allow you to leave if you have come to the end.

Examiner behaviour#

Examiners are human beings and will naturally be different. and examiners then attend an exam as ‘examiners in training’, so what follows is a very brief outline of how that training should impact on you.

Apart from being polite and courteous, examiners can steer you through a viva question and give you opportunities to elicit responses that show that you have reached a certain level in the marking scheme.

In doing so you should find that most of the examiners’ responses are emotionally flat, encouraging you to impart more or steering you away from areas that do not gain marks. Of course, personalities will come through and you may hear beforehand of examiners who are reputed to be fierce

– it may interest you to know that the marking behaviour of examiners is very strictly observed and analysed and bears no relation to candidates’ perceptions.

Each viva will involve two examiners, each asking three questions. They can also be made simply to document areas discussed, identify any clarification the co-examiner might want from the examiner before marking or even to indicate why an ‘8’ was awarded. When optical marking sheets were used a candidate even apparently complained that he saw the examiner award him two 4s and a 5 before the viva was over, when in fact the examiner had been filling in his unique three-digit examiner number on the mark sheet.

The general pattern of a viva will be that the examiner asks you a series of questions. This pattern is the same for all vivas, whether the candidate ends up with a 4 or an 8. If the examiner is having to rephrase the basic ‘competence questions ’

that gain you a 6, then you may not pass. If you have quickly responded to the competence questions early on you may soon be in to the questions determining whether you should get a 7 or an 8 and in many cases candidates at this level are asked more questions that they cannot answer.

Who are the examiners?#

They are consultants who have been in practice for at least 5 years and in that time have demonstrated an interest in, and continuing involvement in, training and education. They must also demonstrate that they have remained active in research and that they can make the time to fulfil the role (which includes unpaid weekends away from home).

Successful completion of this allows them to attend an examination as an ‘examiner in training’, where they will observe and learn, and discuss marking (without influencing it) until eventually they can examine with an experienced examiner.

In every diet of the examination there will be a small team of ‘examiner assessors’. They report back to the Intercollegiate Board on all aspects of the examination, from facilities and case mix to catering arrangements and environment. These assessors are also trained (usually after finishing the maximum 10-year terma san examiner) to assess and feedback on examiner performance.

The assessors ensure the standard of examining remains high, but this is supplemented by detailed analysis of the marking behaviour of examiners afterwards, again being fed back to the examiners after the event.

Dovish tendencies can be observed and reflected upon. such an examiner would be a wide outlier and could not continue thus.

How are marks allocated?#

The key to this quest ionis the examiners’ standard-seting meeting , which takes place the day before the clinical examinations. The questions themselves are taken from the Section 2 question bank and the Section 2 question writing commift ee has a lead examiner for each section, who chooses the questions to be used in each viva ensuring a spread of questions covering the curriculum widely. As a group the examiners agree what level has to be achieved to reach a ‘6’, what higher-order responses will take the candidate to a ‘7’ or ‘8’ and what unsatisfactory or dangerous responses might earn the candidate a ‘4’. This also ensures that the standard of the ‘day one consultant’ can be identified and agreed and should be consistently applied.

This process means that candidates examined by different pairs of examiners have the same chance of achieving a pass mark when it is applied to the 48 different sets of marks a candidate will be awarded across the vivas, ensures the same standard is required topass the examination for all candidates.

What do the marks mean?#

A closed marking system is used from 4 to 8 and this equates to the following.

4 – Bad fail.

5 – Fail.

6 – Pass.

7 – Good pass.

8 – Exceptional pass.

Examiners assess nine trainee characteristics during the standardized oral examination.

1. Personal qualities.

2. Communication skills.

3. Professionalism.

4. Surgical experience.

5. Organizational and logical, step-wise sequencing of thought processes, ability to focus on the answers quickly.

6. Clinical reasoning and decision making.

7. Ability to handle stress.

8. Ability to deal with grey areas in practice and complex issues.

9. Ability to justify an answer with evidence from the literature.

This has been simplified into three domains.

Overall professional capability/patien t care

Personal qualities professionalism and ethics, surgical experience, ability to deal with grey areas.

Knowledge and judgement

Knowledgeability to justify clinical reasoning.

Quality of response

Communication skills organisation and logical thought process. Assess questions answers and prompting (QAP).

Detailed marking descriptors indicate the behaviours typical of each mark

4 – Unsafe and potentially dangerous. A very poor answer. Gross basic mistakes and poor knowledge.

Should not be siting the exam. Candidate is scoring a 4 in the first instance. Poor basic knowledge/judgement/understanding to a level of concern.

5 – Some hesitancy and indecisiveness. Repeats the same ATLS and/or radiograph talk with each oral viva question. Difficulty in prioritizing , large gaps in knowledge, poor deductive skills, patchy performance, struggled to apply knowledge and judgement.

6 – Satisfactory performance. Important points mentioned, no major errors and required only occasional minor prompting.

7 – Good performance. Articulate and to the pointAble to identify some literature to support their answers, knows various guidelines and publications. No prompting needed for answers but prompting required to identify the literature.

8 – Potential g old medal or prize-winning performance. Able to succinctly discuss controversial orthopaedic issues in a sensible way.

Stretches the examiners, no prompting necessary. Confident, clear, logical and focused answers.

While it is impossible to reference this list while computing an answer, knowledge of the principles of

‘what makes a good answer’ can certainly help your preparation.

Answering questions#

From the above it should be apparent that advice to ‘steer the examiners to ask about something you know about’ is a tactic that is doomed to failure. Of course, the examiners will resist and steer you back to the line of discussion they had started, but in the process you will have wasted time.

The wise candidate will answer the question posed by the examiners. If the examiner seems to be wanting to interrupt then allow this, as they are probably saving you from wasting your time or you have said something ambiguous that they need you to clarify before they can move on.

If one considers some of the underpinning educational theory, it may help understand the marking structure and how you can best approach answering questions (and even preparing for the exam).

Bloom’s taxonomy describes levels of complexity in using learned material:

1. Knowledge/recall.

2. Comprehension or understanding.

3. Application.

4. Analysis.

5. Synthesis.

6. Evaluation.

Level 1, factual recall, has almost been removed from the Intercollegiate exam.

1 questions (particularly basic sciences) in the SBA paper. The vivas will be structured where possible to take you along this pathway.

From a set of described symptoms and signs, or by looking at a radiograph, your first question might be ‘what do you think is going on here?’ Even interpreting a radiograph, for instance classifying loosening of a hip prosthesis or identifying an AP3 pelvic fracture, shows that not only do you have knowledge and understand it

The examiners will then move you on to adding further clinical detail, for example whereas the constraints of thew rift en secft on mean that although it can test the curriculum very broadly, it is largely restricted to level 2 and 3 knowledge.

You can make safe decisions on how to initiate management and you will initiate the next steps to fill in the missing data that allow you to come to a conclusion that is effective Finally, why do you do it like that? To score 7s and 8s an argument based on good-quality evidence quoted from the literature and justified by your own training and experience gets you there.

Preparation#

It is easy to fall into the trap of believing that you need to spend months working in the library and working through textbooks in order topass the examination. managing the majority and identifying those that need more specialist care.

However, demonstrating that you have level 1 knowledge far wider even than the examiners does not help if you can’t apply the more mainstream elements of that knowledge base to solve clinical problems.

Sure, the books will help a lot, especially with basic sciences and rare conditions that you may not have met

Vivas are about discussing clinical scenarios There are a few ways to approach this.

Probably the best way is what the best candidates have unconsciously done through their training –discussing cases with peers and with trainers.

‘what if?’ questions whenever you get an answer. Talk through cases from presentation through management to outcome.

Talking over cases with trainers and peers can be morphed into ‘viva practice ’ as the exam draws near. It is no surprise that the most commonly asked questions in the children’s viva, for example, relate to DDH, SUFE, clubfoot, septic arthritis of the hip and cerebral palsy. Courses are available that specifically offer viva practice, and many find these useful, if only to get them into the frame of mind to work and to give them some idea of what to expect. Remember, however, that examiners are not allowed to take part in

Examiners can, however, help their own trainees to prepare as they will never be called on to examine their own trainees in the real exam.

Most will not have had any examiner training, so the practice may not be a good mirror of the genuine event.

Finally, I would recommend that you try doing some preparation for vivas in the same way that gymnasts can train for complex routines even between training sessions – just think it through in your head. The same could be said for viva practice –imagine you are asked a question; how will you answer it? You may find that the form of words that comes to your mind in the first instance is clumsy

– could you say it better? In this way a lot of useful viva preparation can actually be done while ‘relaxing’ or siting on the journey to and from work each day.

On the day#

Don’t stay up late trying to pack in last-minute revision and missout on sleep as a consequence. but if you are scruffy and unkempt for such an important event the examiners will probably assume that you will present yourself in no better a light in the outpatient clinic where you are supposed to be gaining the patient trust and confidence.

Undoubtedly you will be nervous. The examiners expect this and will try to put you at ease.

Remember that anxiety improves performance up to a point, so nerves can be helpful. Each bellis therefore a new opportunity to score points and just forget about what has gone before.

However, do not deliberately try to slow things down as you will only restrict the opportunity for yourself to progress through the marking structure. If your mouth is dry take a sip of water – it is always provided. Do not try to pack in more detail on the last question as you will be receiving no marks after the bell and will eat into the opportunities to score on the next question.

potentially in a very general post and with a trauma take that includes the full range of emergencies that can present anywhere at any time.

Summary#

The viva section of the Intercollegiate examination is rather like a clinical examination without patient sIt is used to see if you have the knowledge base needed to work as a day one consultant in the generality of orthopaedics and trauma.

Analysis suggests that the FRCS (Tr & Orthis one of the most reliable high-stakes professional examinations in the world.