Chapter 2 – Candidate guidance | Musculoskeletal Key

Abstract

The FRCS (Tr & Orth) structured oral viva is a daunting prospect because of its high-stakes nature and the uncertainty surrounding it. The aim of this chapter is to consolidate insights from successful former candidates as well as the perspective of a senior examiner to guide you through the difficult challenges and achieve exam success!

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. Passing the exam is an important milestone which symbolizes the pinnacle of a stressful period of intensive study. It is also seen as an opportunity to demonstrate the learning and knowledge you have accumulated over many years of training!

Chapter 2 Candidate guidance

Firas Arnaout and John Davies

Introduction

The structured, standardized oral exam

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 post. In 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 attitudes 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), in the FRCS (Tr & Orth) oral viva examiners are not forced to recite verbatim a prescriptive text. As detailed in David Limb’s account, they follow a predetermined mark scheme ensuring reproducibility and fairness. However, to make certain each candidate can achieve their highest possible score, by the process of exploring the limits of their knowledge, this culminates in the experience of a particular viva station being unique to that individual. For instance, despite being asked the same initial starter question from an image as a prompt, the ensuing discussion depends upon whether a candidate correctly identifies the problem from the information, or picks up on hints if they start to veer off topic. 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

During the exam, your knowledge aptitude only becomes evident to the examiners when you demonstrate it talking around a subject in a competent fashion. Crucially, you must be prepared to do this for all of the important topics on the curriculum. For most candidates, this means a broad rather than narrow knowledge base will allow them to deliver an answer that displays higher-order thinking.

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. For each viva station, you will often be tested on topics from the curriculum encountered in daily practice that are critical to manage correctly for patient safety. You should be able to generate a list of topics that are recurrently asked every year based on: those that you have already been quizzed on in deanery and departmental teaching; questions from good viva revision textbooks; as well as a list from any past candidate or consultant with FRCS (Tr & Orth) 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. The examiners will expect a comprehensive knowledge because turning up to be quizzed in the morning trauma meeting should have been part of your normal day job for the last five years. In the basic science viva, surgical approaches are often asked after being shown a photograph of an anatomical prosection. Being able to draw a brief line diagram and confidently talk about the important biomechanical principles involved is routinely expected for high-ranking topics such as articular cartilage or the stress–strain curve. 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 viva

It is important to realize before commencing preparation for the vivas that when it comes to answering questions, universally without exception at the start, every single candidate due to sit the exam has a poor technique. Much hard work is needed in rehearsing for the viva beforehand to stand a chance of success.

Preparation for the viva is an individual process, but it bears many similarities to how you might go about rehearsing to give a vast number of podium presentations scheduled at a scientific conference for the same day with the added feature that you will be doing it without the use of notes. Part of that preparation would involve several months memorizing every day the content of what you will say. It would also be imperative to prepare answers on areas that are likely to invite interested questions. If some of the audience appeared hostile or indifferent this would not affect your performance, because you know the material well and can talk about it confidently. 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, it is essential to work on your public speaking so that on the spot, you sound credible to a consultant to whom you have just been formally introduced. Even the late Alan Apley, of Apley’s System of Orthopaedics and Fractures,¹ painstakingly memorised ‘off-the-cuff’ comments and repartee, so that he delivered a polished performance during a presentation. 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, while in the holding bay of the exam hall, the myriad candidates flicking through reams of notes in their bags is a testament to how desperate a situation the majority of people find themselves in! Unfortunately, it is extremely difficult under pressure to be able to read something, internalize it and then speak it aloud minutes later in a flawless performance. That is why it is so important to rehearse the answers. 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. What is the state of the soft tissue envelope … Whilst a cast is an option there is a likelihood it will displace, and managing late displacement is a difficult situation.’

‘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?’

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