• Dr Sally Ayesa

Knowing the 'rules'

This might be a controversial concept, but I believe that the exams themselves are a bit of a game. Not the traditional sense of course, but an experience governed by a set of rules which participants need to follow or disregard at their own peril.


From what I have seen and experienced, candidates who understand the 'game' that is the viva exam traditionally perform better. In contrast, I have seen unsuccessful candidates who strongly assert that they are going to do things 'their way'. Often this doesn't mean that they are less hardworking or well-read. Rather, they have concentrated on facets of the exam that are considered less relevant/high yield, or are unable (or unwilling) to present their information in the manner in which the examiner wants or expects.


The challenge is that there is no written rule book, aside from the syllabus which is really just a list of conditions that you should be across on exam day. Furthermore, each body system will have a slightly different set of expectations for success.


So how can a candidate familiarise themselves with the rules of the game and maximise their chance of success? I tried to watch other candidates ahead of me and pick out the characteristics of the better performing registrars. I took note of the habits and presentation styles those doctors exhibited, and made mental notes of anecdotal tips provided by previous medallists. I prioritised tutorials and teaching sessions with examiners and kept my ear open for sentences like 'better candidates will do this...', 'I hate it when candidates do this...' or 'traditionally, candidates miss this...'.


Do I know the rules of the game? Maybe. I have some ideas. I certainly gave it my best crack and came away pretty well. Here are a few of my hypothesized 'rules' (suggestions) which I worked around.


Stay humble

When I have the brain-space I would like to write a longer blog post about this one. Anecdotally, I have heard of candidates walking out of exams feeling like they had been educating the examiner. Some of these candidates were shocked to learn they failed that station.


Put yourself in the shoes of the examiner. You have dedicated decades to the study and practice of your chosen subspecialty and have given up your time to assist in the examination of the next generation. How would you feel if a candidate came in and felt they needed to educate you? Maybe you might be fine with it - or you could be completely off-sided.


With this in mind I always tried to approach my examiners and tutors with gratitude and respect. I found that humility goes a long way, and this attitude comes across.


The answers aren't just in the textbook

The part II radiology exams tests a range of skills. Within this, there is general knowledge (what you get from a textbook), detection skills (which only come from practice), synthesis (which you develop over your career as a registrar and is improved by reporting volume) and management (again improved by what you learn on the job).


If you spend too much time honing your knowledge from a textbook, but neglect detection and problem solving, your viva presentation will suffer. Cases testing your lateral thinking and synthesis are increasingly more numerous and the proportion of 'Aunt Minnie' diagnoses is decreasing. If you stick to textbooks and case books only, you will nail the Aunt Minnies but potentially struggle with the more complex cases.


Look for the non-verbal cues

Examiners are now discouraged from issuing comments that could redirect a candidate if they are on the wrong path. This means that you can find yourself in a rabbit hole very quickly. Examiners can give non-verbal cues - sitting back, giving an additional pause - which can direct or prompt you a little if you are looking out for them. Occasionally glancing at your examiner, making eye contact as appropriate, will help with developing this skill and picking up cues.


Ask yourself why

Ideally, printed films will be presented on two or three pages in the exam setting. This means that there is limited realestate to provide you with the information needed to progress the case. In most cases, there is a reason why you have been shown the sequences, views or slices that are in front of you. It is your job as the candidate to work out what that reason is.


The point could be that the abnormality is at the edge of the film so you can show the examiner you are safe and thorough. The point could be a common pathology in an uncommon location. The point might be a subtle 'can't miss' diagnosis.


A potential trap is to panic because you don't have a certain sequence or reconstruction that you are used to in your preparation and daily practice. If this happens - ask yourself why you have been given the views in front of you. Maybe it is a susceptibility or gradient sequence of the knee, aimed to help you find the diagnosis of PVNS. Maybe the SWI is in the examiners back pocket, as the skill being tested is to recognise intrinsic T1 signal on MRI brain may reflect blood.


Common things happen commonly

Not everything in the viva is weird and wonderful. You are more likely to be given a common pathology, which has manifested in an uncommon way, e.g. an unusual imaging feature or with an associated cause or complication on the film. You are being examined at the level of a competent general radiologist - not a subspecialist - and therefore you will be expected to tackle cases which are common or represent clinically significant diagnoses.


If you are shown a wrist - for example - don't allow yourself to be panicked because you don't have the anatomy committed to memory. My advice is to look for the fluid sensitive sequence (T2 or STIR), and see if you can localise the abnormality. If you know where it is - in broad terms - you have a better chance of working out what it is. You might immediately identify fluid signal in the scaphoid waist and the film is down before you know it.


Don't forget management

Suggesting appropriate management is an important conclusion to a significant proportion of cases. This might be a single sentence (e.g. 'this is a benign finding and doesn't require further investigation) or a more complicated management plan covering discussion with the team and highlighting the need for urgent intervention.


It is important to take some time in your preparation to work on this part of your technique. You don't want to be the candidate who calls the treating team for every single case regardless of the implication of your diagnosis. It gets old - fast.


Some final thoughts

If you are sitting the radiology part II exam, have gotten this far because you are talented and hard working, and nothing can detract from that. But - there is no substitute for getting the extensive preparation done including volumes of practice and bookwork. Even if you have studied forever, however, you will have trouble getting through if you can't gift wrap your hard earned knowledge and present it to the examiner in an acceptable way. If you are humble, keen and open minded to the learning and development process you will go far. Good luck!

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