• Dr Sally Ayesa

My advice for e-Film Reading

Anecdotally, it seems that the e-Film Reading exam has become a harder hurdle to clear over the last few years. It is hard to exactly pinpoint why - perhaps the cases are getting harder, maybe the time constraints are working against the candidates. Regardless the reason, it is a unique exam in that the technique and specific preparation is (probably) unlike any examination you have ever sat before.


Accepting that I did put in a lot of preparation for this exam, I freely admit that I got a bit lucky with my paper. As a soon-to-be radiologist with an oncology bent I was relieved to be presented with two cancer cases. I was also shown paediatrics, which I am much stronger in than obstetrics. And I (luckily) had a near identical study to my head and neck case on an overtime shift not three weeks before.


I learned a few lessons along the way from my own preparation and talking to others. Here are a few of my best tips for tackling the e-Film Reading Examination.


Simulate the exam

A great quote which I like to throw out in these situations is about the Roman Army. A historian described their preparation as "their drills were bloodless battles, and their battles bloody drills". This meant that at every opportunity, they tried to simulate the experience of what was to come, so when they got there they were well practiced and efficient. Ultimately, they were more likely to be successful.


So this is what I did. I typed out my answers at every opportunity. I studied the online guide religiously and based my preparation around my best guess of what the exam would be like (you can access the guide here). The guide shows a screenshot of the window in which you type the answers, with the headings broken into: Findings, Likely Diagnosis, Differential Diagnosis and Further Investigations or Management. I created a template with these headings in MS Word.


For my practice sessions, I would use electronic case sets created on Radiopaedia.org by myself or previous candidates. You can see my sets here. I created them early in my preparation (based on previous exams) so I forgot the diagnosis by the time I used them for practice. Try searching the Radiopaedia profiles for the names of colleagues who have recently sat the exam and review their playlists - or ask them what they found useful. Radiopaedia.org has also recently launched formal practice exams (linked here - note there is a registration fee).


When actually getting down to completing the set - and I can't stress this enough - you need to type. You need to practice conveying the information from your brain to your fingers, getting the language right and critiquing your performance on the screen. Plus it allows you to build up your typing speed. Use the scaffold suggested by the exam, remembering management where relevant. Timing your answers is also strongly suggested as it gets your brain practiced in budgeting time and moving through the cases.

I drive a Mac at home. I went so far as to buy a Windows keyboard as the keystrokes were slightly off alignment. This was probably a little over the top.

Report as much and as widely as possible

I have blogged about the benefits of reporting before (click here if you are interested). I am a firm believer that better candidates are the ones who don't shy away from the work - including trying their hand at difficult cases and modalities. It improves your reporting lexicon, your detection speed and synthesis. You are better able to pull together all of the pieces of the puzzle as you have done it hundreds of times before.


Another tip is to look back when you come across interesting pathologies during your daily workload. For example, you may find a follow-up MRI for a patient with a brain tumour. See if you can find their baseline MRI and/or CT and note the relevant findings, even taking the opportunity to read around the topic if it represents a hole in your knowledge.


Keep it brief but relevant

Keeping your answers accurate and to the point is important in terms of time management and clarity. I am a radiologist who likes to create prose in my every day reports, but I switched to short sentences and bullet points for this exam. I threw in some sub-headings where needed for clarity, especially for cancer staging (e.g. primary tumour, lymph nodes, metastases) and signposted when I moved onto new modalities (e.g. CXR, Post contrast CT chest etc.).


There is certainly a balance to strike when creating your responses. Identify and describe the finding as you would in practice, using appropriate lexicon and considering the relevant positives and negatives. Think of what you would want to assess if you saw the case live and include those details (a skill which comes with practice). If you had a case of an anterior mediastinal mass on a CT chest (for example) it would be worthwhile commenting on the contrast enhancement (homogenous/heterogenous), the presence of calcification, fat or necrosis/cystic change, and the borders/margins. In this case - you want to convey to the examiner that you are assessing whether this could be lymphoma, thymoma or teratoma. Depending on the case, you would move on to comment on associated findings, causes or complications. If you suspected lymphoma (or it was on the differential list), commenting on the presence or absence of nodal disease or splenomegaly would be worthwhile.


Look at it as a problem solving exercise

At its core, the e-Film Reading Exam is a not just about detection, but synthesis and problem solving. You are being examined on whether you are ready to become a radiologist - not whether you are a first year safe to progress to on-call. Finding the abnormality is not the main goal, but understanding the implication of the abnormality is.


As you work through complex cases in exam preparation or every day reporting, formulate a habit of asking yourself how things fit together. Think about what could have caused the finding, and then assess for it. Consider what complications may have arisen and assess for those. Work between the provided imaging modalities to synthesise the diagnosis as a whole, rather than working through each examination in isolation. Keep it as simple for yourself as possible - you don't need to earn the next modality as it is already there for you!


Consider where it is, as you decide what it is

Anatomical location is a very important tool to have in your arsenal. If the major finding looks really weird, step back and think about the common pathologies which may occur in that location and whether any of these fit the case in front of you. There is a high chance that you will get a few examples of unusual manifestations of common pathologies to test you. This in mind, if you are trying too hard to make a diagnosis fit the findings you might want to step back and consider alternative diagnoses.


Approach the case as if you have a microphone in your hand

I give this piece of advice to candidates about to sit viva exams, and it is no different for those about to undertake the e-Film Reading. If you are overwhelmed, take a breath and pretend you are on overtime. What suggestions would you make if this patient came in on one of your evening shifts? What additional investigations would you like to help sort out your differential diagnoses? What is the relevant information that the physician or surgeon would like to know when determining management? If you think you are in an oncology case, make sure you stage the cancer (primary, nodes, metastases). For a haematology case, consider the nodal disease, liver and spleen, and extranodal disease.


And for any case - be systematic and check your review areas. The incidental colloid cyst I missed in my exam still haunts me to this day. Hopefully the experience means that I will be less likely to miss one again.


Good luck. Remember that what you are doing isn't easy - be kind to yourself.

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