• Dr Sally Ayesa

Talking viva technique

You would have heard it time and time again over the course of your medical training to date - exam technique is the key to success. RANZCR radiology Part II exams are no different, with technique playing a crucial role in the success of most candidates.


Having good viva technique isn't just about sounding good on the day, it can give you a solid framework to hang your knowledge and organise your thoughts. If you are continually considering new cases and concepts in terms of how you would present it in a viva or a film writing exam, there is a good chance that the more relevant information will stick better and be expressed at the crucial moment.


One of the biggest mistakes in technique I see working with candidates (and saw in myself at times) is the death spiral, or as I like to call it - viva poison. This is when a candidate can't quite wrap up a case, and they pull themselves round and round in circles of repeated description and differential diagnosis. Every time the examiner reaches to pull the film down - thinking that they are finished - the candidate will start describing again and loses another 30 seconds to a minute on the case.


There is no denying that viva exams are a numbers game. You only have 25 minutes to convince two examiners that you are safe and reliable enough to move out into the world. Anecdotally, you have to get through at least seven cases in that time to be considered for a pass. Candidates want to make the most of every second of that time.


No case is identical, and you don't want to have a rigid formula which you force every scenario into. That said, you can practice with a rough plan for how to progress through the case. Everyone will be different, however this is an idea of how I worked through a typical and straightforward case. Let's use an example of terminal ileitis.


Introduction

To start my presentation, I restated the clinical history and the films I had in front of me. I was occasionally questioned by tutors as to why, but I felt that it gave me 15 seconds thinking time (where I glanced at the films) and cemented the clinical history in my head. The clinical history is the most important pieces of information you will be given - use it wisely.


Finding

In a case where the abnormality is obvious, go for it. Don't waste time if it jumps out. Describe the main finding with relevant radiological terminology which is appropriate to the modality you are working in. You can address important relevant positives or negatives in order to better characterise the key abnormality. Keep the clinical history in the back of your mind.


"There is thickening and enhancement of the terminal ileum, with adjacent fat stranding. There is less marked thickening in the adjacent caecum."


Complications

What would you consider as important complications if you were looking at this case on overtime? It is the same for the viva. In this case, it would be worthwhile addressing whether there is evidence of perforation (e.g. pneumoperitoneum, abscess formation), infarction (e.g. pneumatosis, portal venous gas) or bowel obstruction.


Causes (and considering associated findings)

Considering the cause of a finding is an important part of synthesising the case. For a case of terminal ileitis, you may already be considering diagnoses such as Crohn's disease or infective causes such as tuberculosis. The patient demongraphic (e.g. a female in her 20s) will help narrow the list of possible causes.


In the course of the viva, better candidates will build a case for the diagnosis by collecting findings. When you consider that the cause could be Crohn's disease, you can articulate that you are examining the biliary tree for dilation, the remainder of the GI tract for skip lesions/other areas of inflammation and would review bone windows to assess for sacroiliitis. If you consider the possible cause to be tuberculosis, you would examine for low density lymph nodes in the mesentery and retroperitoneum.


Synthesis

By this stage, you will hopefully have an idea of the diagnosis and differentials you will offer to close the case. It is crucial at this point, to consider your clinical history and patient demographic as you come down to your conclusion. You can also have a brief discussion as you build the case for your preferred differential. It is not advisable, however, to spend time divulging shopping lists of facts about the diagnosis. This is not necessary and wastes valuable time.


You could say something like "the combination of terminal ileitis in the presence of low density lymph nodes in the mesentery and retroperitoneum, in a patient with fever, suggests a unifying diagnosis of tuberculosis", or "terminal ileitis with sacroiliitis in a young female with abdominal pain is suspicious for an underlying diagnosis of Crohn's disease".


Manage

You do not need to call the referrer for every case. If you repeat this as the conclusion of every case, you run the risk of off-siding the examiner. It also doesn't show consideration of the specific case in front of you and sounds scripted. The obvious exception is a medical emergency, such as an acute aortic syndrome or an unexpected finding such as pneumoperitoneum. If the pathology is life threatening - say so.


To conclude, I would usually offer something tailored to my clinical history and offered diagnosis. Would you suggest another imaging test? Would opinion from another specialty be beneficial to the patient? Would you be sufficiently concerned to recommend biopsy correlation?


A final tip - I always smile when I hear candidates say that they will 'urgently call orthopaedics' or neurosurgery or another specialty team. In practice, I usually let the referring team (often the emergency department) refer the team appropriately. Maybe I was just lazy?

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