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, but for any individual candidate the four vivas will occur on the same day. It is perhaps worth putting the vivas into context: between them the vivas contribute 48 of the 96 marking episodes in Section 2. The clinicals (intermediate and short cases) together make up the other 48 episodes, but in general it is more common for a poor mark in the vivas to be compensated for by a good mark in the clinicals than vice versa. Employing the training principles of a heptathlete, effort may be better spent on the weaker disciplines than becoming better at one’s strengths.

This chapter will review the overall marking structure for the exam and outline the contribution of the structured clinical orals to the overall result. The process will then be explained in detail so that you, the candidate, can understand why the exam has evolved into its current form (incidentally, one of the most reliable high-stakes professional examinations in the world). 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 standards are set to reassure the regulator (GMC), employers and, most importantly, patients that those being awarded a certificate of completion of training today are of the same high standard as those awarded it last year and the year before. The FRCS (Tr & Orth) is one component of that assessment and if everyone presenting for the examination shows themselves to meet that standard, then every candidate will pass!

Marking scheme

In Section 2 of the FRCS (Tr & Orth) an examiner has only five choices of mark to award for each marking episode. A mark of 6 is a pass mark; 7 is a good pass and 8 a very good pass; 5 is a fail and 4 a bad fail. 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. Altogether, therefore, there are 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. This skewed examiner behaviour and now no such ‘killer’ mark exists. 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 to pass 95 episodes with marks of 6 and therefore fail the exam because of a single score of 5. There is no discussion around the marks at the end: no vouching for candidates by examiners who know them is possible. Examiners award a mark at the end of each marking episode independently of their co-examiner and enter it in their tablet computer. The sum of 96 episodes determines the total mark and if this is 576 or above the candidate has passed. If it is 575 or below the candidate has failed.

The mark awarded is not simply a grading based on the examiners’ whim. There is a marking scheme which ascribes descriptors to levels of quality in response and this determines the mark that should be awarded. 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-setting meeting, which will be described later. Examiners are not allowed to confer before awarding their marks (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 setting discussion. Therefore, marks do not vary significantly – although it is acceptable for the examiners to give different marks, only a difference of one mark is accepted and examiners are not allowed to change their mark after allocating it. 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. Candidates are examined in groups, which may therefore have vivas either side of a coffee break. Each group of candidates receives a briefing from the Chairman of the Board immediately before their block of vivas begins.

The examiners use the same batch of standardized questions for each session. Resist the temptation to find ways of discovering what others in your group have been asked – this could give you an unfair advantage and is unprofessional. 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. The examiners will stand, greet you and check your candidate number. They will not know whether you are a trainee or out of training. They will not know if this is your first attempt or if you are a returning candidate. Your heart will be racing and your mouth dry, but the examiners will be aware of this. 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, and some candidates have further to walk to their examiners than others. Commonly the topic is introduced by asking you to look at an image or diagram on a tablet computer screen and describe what you see, which leads into the questioning.

There will follow 30 minutes that seem to rush by, punctuated by bells at 5-minute intervals. When a bell sounds the examiner moves on to the next question – you will not be interrupted if you are part-way through a sentence in response to the previous question, but the examiner will simply stop the line of inquiry related to the previous question and introduce the next question. After six questions, three with each examiner, 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. However, they are trained to get the best from you and to minimize the chances that your performance in one component of the exam will affect it in another. There is a significant amount to consider in an examiner’s training course, 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. They should not give you the impression that you are performing very well (‘Excellent! Well done!’) or very badly, as this may influence your performance in subsequent questions and vivas. They should not harass you and co-examiners are trained to intervene appropriately if unacceptable examiner behaviour is witnessed. 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. The examiner who is not asking questions is still actively participating and will be marking you. This examiner may also take some notes – do not be concerned if you see this happening. Of course, notes may be made for feedback purposes or to indicate why a low mark has been given. 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. Notes can also be for more mundane reasons, such as completing a topic sheet (which is passed ahead of the candidate so that examiners know what the candidate has been asked about previously – including a note of the short and intermediate cases). 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. Eventually you will be asked a question that you cannot answer, or you can only partly answer. The examiner may rephrase the question or ask it in a different way. You may or may not be able to answer it, but the examiner then moves on to a related path 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. The basic message is do not try to second-guess what mark you have achieved by the way you have been asked questions and answered them. Just treat every bell as a new start and try not to be influenced by whatever experience you perceived in the previous question.