Chapter 2 Candidate guidance

Introduction#

The FRCS (Tr & Orth) structured oral viva is a daunting prospect because of its high-stakes nature and the uncertainty surrounding it.

The structured, standardized oral exam#

The FRCS (Tr & Orth) represents the standard of knowledge and aptitude required for clinical practice by a day one consultant in the generality of Trauma and Orthopaedics.

Achievement of the FRCS (Tr & Orth) enables the erstwhile candidate to apply for his or her

Certificate of Completion of Training and therefore a consultant postIn turn, it leads to largely unsupervised surgical practice.

The examiners expect a competent candidate to have a broad knowledge, possess sound basic principles and demonstrate the requisite key skills and atitudes in their judgement and professionalism.

In effect, they are someone with whom they could entrust the treatment of a family member, or work with as a fellow colleague.

In contrast to examiners in other postgraduate objective structured clinical examinations (OSCEs),

the ensuing discussion depends upon whether a candidate correctly identifies the problem from the information, Candidates who are well rehearsed at answering problems in clinical scenarios will score highly, compared to those who are unable to apply their knowledge to hypothetical dilemmas which the examiners believe you should be able to manage competently as a day one consultant in practice.

Viva preparation#

1. Aptitude and mind set

Crucially, you must be prepared to do this for all of the important topics on the curriculum.

It is important to focus your preparation on the high-yield topics during viva practice, so that you stand the best chance of maximizing your score.

You should be able to generate a list of topics that are recurrently asked every year based on questions from good viva revision textbooks

accreditation.

For instance, in the trauma viva, you must be conversant on all of the topics discussed in a departmental trauma meeting from the management of elbow Terrible Triad to the classification of acetabular fractures. To ensure your answer is fluent and that the diagram contains all of the essential features means repeated practice.

2. Speech and communication in the viv a

It is important to realize before commencing preparation for the vivas that when it comes to answering questions universally without exception a t the start,

Preparation for the viva is an individual process Many candidates find the use of index or flash cards an invaluable memory aid during this process (Figure 2.1a,b). Alternatively recording your speech onto a Dictaphone and playing this back can be a powerful revision tool, especially when commuting to work.

Figure 2.1a,b Revision cards.

For many candidates, you sound credible to a consultant to whom you have just been formally introduced.

According to the JCIE marking descriptors, to achieve a level 7 or 8 answer you should be fluent and confident without prompting.

Before the start of the viva For some, this even extends to rehearsing the phrases or ‘discourse markers’ that occur during your conversation:

‘I would want to discuss with a consultant who specialises in ... but essentially , the treatment principles are ...’

‘My primary concern is that I’d want to establish this was in fact a closed, isolated injury.

‘I’m really sorry. I’ve made a mistake. I’ve started on completely the wrong track. Can I please start again?’

‘Excuse me. I’m very sorry it’s quite noisy. Can I please clarify what you’ve asked?’

Remember that constantly asking for clarification every time you are asked a question quickly becomes irksome, but you are allowed to do this once or twice because it gets noisy in the exam hall. Thereafter, once you’ve surpassed this and your answer takes off, you can achieve the atiribut es of a fluent and confident higher-level answer.

3. Study group practice

The merits of a study group cannot be overstated. Meeting regularly to discuss your answers will improve the quality of what you say, as well as highlighting areas where your deficiencies lie. By far this represents the most efficient use of your time in the final months; and will yield the greatest improvement.

Remember that every deanery has a set of consultants who are fully expecting you to approach them for viva practice.

Typically, they will be FRCS examiners already, or have a role in the deanery mock exam or viva courses.

Often they have a FRCS viva PowerPoint presentation on their laptop. Should you be asked the same question in the viva, you can recite a brilliant answer and almost certainly score 7–8. If you are in the fortunate position of being able to do this on the first question, you have a high chance of passing that station because the other examiner will also be silently impressed with the level of knowledge you demonstrate on the starting question.

Skyping and FaceTime can be useful if there are difficulties arranging a regular meeting due to on call commitments or long distances that have to be travelled. and any irritating mannerisms which you weren’t consciously aware of doing will be highlighted to you.

4. Assigned educational supervisor practice

It is important in the run-up to the exam that you let all of the trainers know in your unit that you have the Part 2 coming up, and you need help! For instance, if any spare time arises in your timetable, they know you have to focus on viva and clinical revision. Similarly, if your placement in hand surgery was lacking, you need to make amends for this.

Your educational supervisor and the other consultants you work with can play a vital role in the last few months.

The number of vivas that have a plain radiograph as the starting point is ridiculously commonplace.

How to deal with a peri-prosthetic fracture in apa tien t with loosening, for instance, or a complex primary hip in apa tien t with protrusio or ankylosing spondylitis, are everyday topics that you see in clinic with your trainer saying ‘Have a look at this X-ray on PACS and tell me what you think.’

5. FRCS viva courses

For example, to cover the entire basic science syllabus for the viva is a substantial amount of work and going on a good course that covers basic science will save you considerable time, as it recaps the numerous weighty topics such as: stress–strain, free body diagrams, viscoelastic material properties, types of lever, nerve action potential and numerous others that sequester hours of revision.

It is true that there is some variability in the quality of the teaching on courses. that almost all courses are run by practising consultants who have to make time to organize them for litile or no recompense Also, most reputable courses will have a current or previous FRCS examiner in the faculty, although this may not be openly advertised

General approach and what to do when things go wrong#

The format for oral viva questions is detailed in David Limb’s account. Oral exam questions are prepared so as to be crystal clear and explicit, with default competence questions if candidates are unable to discuss the more challenging topic areas in the syllabus.

At some point, most candidates require help from the examiner. and the answer sheets contain more information than all but the highest-flying candidates will be expected to cover.

Occasionally you may experience the unpleasant sensation of becoming completely unstuck. it is absolutely imperative that you have listened to every single word and think carefully before launching into an answer. It is also important to have some means to compensate for a bad score by being strong elsewhere in a particular viva subject.

Likewise, examiners expect that if a candidate knows a topic well, unprompted they will start confidently reciting vast amounts of knowledge to score highly. This form of prolific data dump is often rewarded with the examiner siting back in their chair, and then interrupting only to change to start a new topic after 5 minutes.

Formulating answers to oral questions

Before you answer the question, This avoids blurting out the first thing that comes into your head and gives the examiners the impression you are giving a logical,

If you are confident on a topic keep talking, keep to the question that was asked, and go for it! Avoid the temptation to fill the silence by adding superfluous information to the end of your answer, as this falsely gives an impression that you are waffling. The examiners may cut you off mid-sentence, it can happen whether you are doing well or not so don’t let this put you off.

Just concentrate on the next question.

If the examiner asks you if you are sure about your answer this generally means you have answered incorrectly, so unless you are very self-assured, which again is usually the wrong answer!

It is better not to argue with the examiners if they point out your answer is wrong, even if deep down you are convinced it reflects the latest evidence or opinion. Although to defuse some of the tension in this situation you can preface this with ‘In my humble opinion’, or ‘there is some controversy in this area, and I’m aware of this evidence’. Offer your considered reasoning of the issue without being patronizing.

Quoting the literature#

Being able to discuss the evidence for a particular treatment or justifying how and why you do something is the hallmark of understanding in the exam and a clear sign that you are someone suitable for consultant practice.

This means that trawling through every JBJS in the last 12 months is not necessarily a good use of time. It is more important to have some appropriate papers to talk about, which either you will have come across from your study group, from a revision course lecture or from listening to your peers being quizzed.

One guide for the important hallmark papers is to look through any FRCS viva revision textbook, this one included, for the references for papers mentioned in the model answers in the endnotes of each chapter. If the same paper is recurrently signposted overmany topics – such as the Lidwell3 paper on the effect of ultraclean air theatres on deep infection in joint replacement, which is a reference for prosthetic joint infection in adult pathology as well as theatre sterility in basic science – this probably means you should be familiar with it.

Final advice#

It rapidly becomes apparent to the examiners how well a candidate has prepared for the structured oral exam. Grasping that second chance is dependent on being practised sufficiently so that you can perform under the inevitable pressure that you will feel in the next viva station, as well as having an adequate knowledge to raise your score.

This is why if you put in the hard work and preparation early, then you will be able to withstand the setbacks which almost inevitably occur on the day, and come through the viva with a pass!

References

1. Blo mAEd.) Apley and Solomon’s System of Orthopaedics and Trauma, 10th Edition. Boca Raton: CRC

Press; 2017.

2. Kocher MS, Zurakowski D, Kasser JR. Differentiating … algorithm. J Bone Joint Surg Am.

1999;81(12):1662–1670.

3. Lidwell OM, Lowbury EJ, Why teW et al. Effect of … study. Br Med J. 1982;285:10–14.

Section 2

Adult Elective Orthopaedics and Spine#