Abstract
The FRCS (Tr & Orth) exam comprises two parts, and transition to the Part 2 clinical and viva voce exam is dependent upon candidates passing the Part 1 written component.
The FRCS (Tr & Orth) exam comprises two parts, and transition to the Part 2 clinical and viva voce exam is dependent upon candidates passing the Part 1 written component.
The Exam Format
Part 1 is the written component of the Intercollegiate Examination in Trauma and Orthopaedic Surgery. In 2018 the Joint Committee on Intercollegiate Examinations (JCIE) agreed to phase out extended matching item (EMI) questions. When compared to single best answer (SBA), EMI questions were less able to differentiate candidates and were difficult to construct. Subject to General Medical Council (GMC) approval, EMI questions will not feature in the FRCS (Tr & Orth) examinations from January 2021 onwards.
Part 1 exams are currently held at Pearson VUE Test Centres at multiple locations throughout the United Kingdom and Ireland. Candidates can choose their preferred centre during registration. These test centres often host unrelated tests (e.g. driving theory, USMLE) that take place alongside the Part 1 exam. Computer stations are separated by dividers to help minimise visual distraction. Be prepared to focus so as not to be distracted by the movements of others. Some candidates may choose to travel further to utilise quieter test centres.
Candidates should bring photographic identification on the day of the exam. This is checked at registration and again before entry into the examination room. Exam conditions are strict. Bags and all but essential items will be stored in the lockers provided at most centres. Unsurprisingly, no mobile devices are permitted in the examination room. Video surveillance of candidates is common. Depending on the location, it is recommended to bring lunch, as some centres do not have local facilities to purchase food. Paper and a pencil are provided for making notes.
The computer-based questions include multimedia images such as radiographs and clinical photographs. Candidates are not permitted to read ahead but will be able to flag difficult or ambiguous questions for later review.
Overview
At the time of publication, the Part 1 exam consists of two papers as follows:
Paper 1 (2 hours)
Single best answer (SBA) – 110 questions
Paper 2 (2 hours 30 minutes)
Extended matching item (EMI) – 135 questions
– 45 themes with option lists
– 3 questions using each of these option lists
Total
4 hours 30 minutes – 245 questions
From January 2021 onwards (subject to GMC approval), the Part 1 exam will consist of two papers as follows:
Paper 1 (2 hours 15 minutes)
Single best answer (SBA) – 120 questions
Paper 2 (2 hours 15 minutes)
Single best answer (SBA) – 120 questions
Total
4 hours 30 minutes – 240 questions
Candidates will have a 2-year period from their first attempt to pass the Part 1 exam, with a maximum of four attempts with no re-entry. Details are available on the JCIE website (www.jcie.org.uk). Candidates with proven dyslexia may be eligible for the Part 1 examination times to be extended and this should be highlighted in advance of the exam.
There is no negative marking; therefore, all questions should be attempted. Sample questions can be viewed on the JCIE website. Experienced examiners perform a formal process of standard setting to decide the final pass mark for each paper. The SBA questions are subject to quality assurance procedures, including feedback from both examiners and candidates. Difficulty level, content, discrimination index and internal consistency are analysed. Ambiguous questions or those deemed insufficient to differentiate between candidates are removed through this process.
The SBA questions consist of an introductory theme, a question stem and five possible responses (listed A–E), of which one is the most appropriate answer. SBA questions are exactly what the name suggests: candidates choose the best from five possible answers. It is important to note that this is not a ‘single correct answer’ but a ‘single best answer’. Moreover, all five possible answers could be considered correct, but candidates are asked which is best, or most appropriate, given the information provided. As questions are designed to test higher order thinking, this could mean that limited or irrelevant information is provided. Questions require a judgement based on interpretation of the available evidence. Questions that candidates later complain about, for example, ‘there was more than one correct answer’ or that a question was ‘too ambiguous’, can often prove the best performing questions. Although the standard is widely publicised to be set at the level of a day one consultant working in the generality of trauma and orthopaedics, candidates should appreciate that some questions will appear more niche and stretch them more than others.
Advantages of SBA questions:
They can assess higher order learning and discriminate between candidates of differing ability.
They can assess a broad sample of the curriculum within a relatively short period of time, which helps to improve reliability and validity.
With all trainees assessed using the same highly standardised questions, they make for a fair assessment.
Automated marking helps to remove examiner subjectivity and reduce costs.
The pitfalls of other question formats (e.g. EMIs, true/false) make SBA questions a popular choice for high-stakes examinations like the FRCS.
Disadvantages of SBA questions:
A candidate’s reasoning for selecting a particular answer cannot be assessed.
Despite permitting a broad assessment of the curriculum, there is little opportunity to focus in-depth on a particular subject.
They rarely reflect the real-life practices of surgical diagnosis and management, which are varied and nuanced.
The five example SBA questions provided on the JCIE website are shown below.
1. A 4-year-old girl has had a swollen, painless left knee joint for 8 weeks. In the last ten days her left ankle has become swollen. It is uncomfortable after she has been sitting for 20 minutes. Examination of her eyes shows an irregular pupil on the right side.
What is the most appropriate first step in the management of this patient?
2. A 19-year-old motorcyclist is brought to the Emergency Department following an RTA. He is complaining of difficulty moving his left arm. Clinical examination suggests the latissimus dorsi, subscapularis, pectoralis major and pectoralis minor are functioning, but infraspinatus is not functioning.
Which part of the brachial plexus is most likely to have been injured?
3. A 35-year-old man has a combined ACL rupture and posterolateral instability. There is a bony varus knee deformity with lateral thrust in the stance phase of gait.
What is the most appropriate treatment for this patient?
4. A 25-year-old man had an acute dislocation of his shoulder, which was reduced. During the follow-up visit he was found to have wasting of the deltoid and infraspinatus muscles.
Injury to which one of the following neural structures accounts for this finding?
5. A 20-year-old woman has had low back pain for the past 6 months. She has no fever or constitutional symptoms. Radiographs of her thoracic spine show coarse striations of the vertical trabeculae of the 12th thoracic vertebra. Her ESR is normal.
What is the most likely diagnosis?
What is the Relevance of the FRCS (Tr & Orth) Exam?
The FRCS (Tr & Orth) exam helps to reassure patients, the GMC and employers that a candidate has reached the necessary standard required for independent practice as a consultant. The reference level is that of a day one consultant working in a district general hospital in the generality of trauma and orthopaedic surgery. It is important for the public to have confidence in the process. The exam assesses knowledge and judgement, clinical acumen, management and treatment planning, as well as communication skills.
Related posts:
Chapter 11 – Shoulder/Elbow II Structured SBA
Chapter 20 – Pathology I Structured SBA
Chapter 19 – Structure and Function of Connective Tissue Structured SBA
Chapter 5 – Knee Structured I SBA
Chapter 26 – Clinical Environment, Evidence Management and Quality Improvement Structured SBA
Chapter 15 – Hand II Structured SBA
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