The Royal College of Radiologists (RCR) is the professional body responsible for setting the curriculum, conducting examinations and establishing the standards of practice in the specialties of radiology and oncology throughout the United Kingdom. The Fellowship of the Royal College of Radiologists (FRCR) is the qualification awarded by the RCR to candidates who have completed 34 months of training in clinical radiology and have passed all the three steps of the FRCR examination.

For UK radiologists in training, the FRCR is a compulsory examination to be cleared in order to become a practising radiologist.^[1]For non-UK radiologists who wish to practice radiology or gain further subspecialty training in the UK, clearing the FRCR is a must. A faster way for clearing FRCR by bypassing the FRCR part 2B waiting lists via first passing PLAB was mentioned on this website in another blog by Dr. Nameet Hattangadi. ^[2]

In the recent years there has been a trend towards more and more Indian radiologists appearing for the FRCR examination. The reasons for this are manifold.

1. For gaining permanent consultancy in the UK.
2. Applying for fellowships in the UK.

For working in other countries – radiologists who have cleared FRCR are more likely to get a job in the gulf or in Singapore.As an additional qualification and adding another degree to one’s CV. In India, if two candidates with similar qualifications and experience apply for the same radiology job interview, the candidate having additional qualifications such as FRCR may be preferred for the job in some institutes.^[3]5. As a self assessment test to see whether one’s radiology training and knowledge is at par with global standards. The FRCR is the most objective and holistic specialty test available to assess for the same. This is the reason put forth by quite a few radiologists as well to apply for the exam.

Whatever the reasons may be, the FRCR for clinical radiology is considered among the top 3 toughest specialty examinations to pass in the medical profession, along with the FRCA for anesthetists and the FRCPath for pathologists.

The Structure of the FRCR examination

The FRCR exam is divided into 3 parts-

1. FRCR part 1 – consists of one paper of physics and one paper of anatomy. Can be applied for by any candidate who is undergoing clinical training in radiology or who has completed training, with no minimum experience required. Applications for the anatomy module are via a ballot system with no guarantee of candidates getting selected on the first application.
2. Final FRCR part A – also known as FRCR part 2A. From the December 2017 session it has undergone a change in its format with a single day exam of two papers, both having questions on all organ systems in clinical radiology. It can also be applied for by any candidate undergoing training in radiology or who has completed training, and who has cleared FRCR part 1.No minimum experience is required for applying for it. It does not have any ballot as it is a written exam, with candidates getting selected on the first application.
3. Final FRCR part B – also known as FRCR part 2B. It is a practical examination consisting of rapid reporting, long cases and viva. Unlike the previous 2 modules the candidate requires a minimum of 3 years of clinical experience to be eligible for the FRCR 2B exam. It can be applied for by a candidate after clearing FRCR 2A. Applying for it consists of entering a rotating ballot system with new candidates added to the back of the waiting list. Generally a waiting period of 1.5 to 2 years for non-UK candidates is the rule.

FRCR part 1 examination

The FRCR part 1 examination consists of one paper of physics and one paper of radiological anatomy. The physics paper is a written examination with 40 questions, each having 5 options. Each of the options has to be marked as either true or false. The anatomy paper is an image based one, conducted on work-stations.          

Applying for FRCR part 1

The FRCR part 1 examination is held three times a year, usually in the months of March, June and September. Applications for the March exam start in December, for the June exam start in March and for the September exam start in June.

There is an option to appear for the physics paper alone, for the anatomy paper alone and for the physics and anatomy papers combined. Most people appearing for the exam first time opt for the physics and anatomy papers combined option to save time and money. The anatomy and physics papers are held on separate days, either back to back or with a gap of one day.

The anatomy paper is conducted on an Apple Mac workstation with OsiriX software, and as such it has limited seats. Applications for the anatomy paper for non-UK candidates are accepted via a ballot system. Non UK candidates are offered the seats not filled by the UK candidates. Roughly the odds of getting selected when I applied in 2015 were 50-50, but now it has become increasingly tougher to get selected for the anatomy paper, as a result of large number of non-UK candidates applying. The physics paper being a pencil and paper based examination, there is no limit to the number of candidates who can appear for it and it does not have a ballot.

For all parts of the examination, candidates need to bring a print out of the timetable they have been emailed by the RCR on which their venue and timings are provided, along with their passport as an ID proof.

Both anatomy and physics need to be passed separately in order to clear FRCR part 1. Maximum 6 attempts are allowed by FRCR for any examination or module, either FRCR part 1, part 2A or 2B. For the 7^th attempt, candidates need to show proof of additional training to be eligible.

More information about the FRCR part 1 can be found here.^[5]

The Physics Module

The physics paper (or module as it is called) consists of 40 multiple choice questions. Each question has five options, and each option has to be marked true or false. So effectively you have to answer 200 questions within a span of 2 hours, which equals 3 minutes per question or to look at it in a better way, 36 seconds to read and mark every option. Since the questions are complicated, you need to get plenty of MCQ and mock paper solving practice before the examination to finish the paper in time. I preferred solving the paper once fast, marking those questions which you are sure about instead of getting stuck on a single question for a long time. I followed this by moving on to solving the difficult questions during a second reading of the paper. I had finished my first run of solving through the paper in 1 hour, then in the next half hour finished marking the difficult questions I had left. Then in the last half hour I rechecked the whole paper.

There is no limit to the number of true or false options in a question, it is possible that all five options will be true or all five will be false. There is no negative marking, so be sure to attempt all questions.+1 mark is awarded for correct answer and 0 marks for wrong answer. Candidates are required to bring their own HB pencils, sharpeners and erasers to the examination. One water bottle is permitted to be brought by the candidates with them into the examination room.

The examination is held at five UK venues (London, Glasgow, Manchester, Birmingham and Belfast) and two non-UK venues (Singapore and Hong Kong). Sample physics questions can be found on the RCR website.

The Anatomy Module

The anatomy module consists of 100 radiology images being shown on an Apple Mac workstation with OsiriX software, with one structure on the image marked by an arrow. A question is asked related to the marked structure and the candidate is expected to type the answer at the same workstation. Earlier the answers had to be written on a separate answer sheet, but now they are to be typed using the keyboard provided. It is possible to scroll through the questions during the examination, and select any question from 1 to 100 as required.

Total time of the examination is 90 minutes which gives approximately 54 seconds per image. I would suggest keeping a target of solving the easy images in 30 seconds each the first time round, and keep the difficult ones aside for the second time you go through the questions. This gives you approximately 50 minutes for your first run of solving the easy questions through the paper, and around 40 minutes for attempting the difficult ones and rechecking your entire paper. Marks are given for precision of the anatomical description. +2 marks are awarded for a correct answer, +1 mark for a partially correct answer and 0 marks for a wrong answer. Again there is no negative marking.  No writing equipment is required for the anatomy examination as the answers are to be typed.  Candidates are not permitted to bring water or food items into the Anatomy examination room to prevent damaging the workstations.

The examination is held at five UK venues (London, Glasgow, Manchester, Birmingham and Stockport) and two non-UK venues (Singapore and Hong Kong). Sample anatomy questions and examples of the workstation interface can be found on the RCR website, and it is better to go through these before the examination.

Preparing for the Physics module

The physics module generally consists of 3 to 4 questions each on Ultrasound, CT, MRI and Nuclear Medicine and the remaining 24 to 25 questions on radiography and fluoroscopy. Radiation protection and safety regarding various modalities are topics which are almost always asked, so it pays to be thorough with them. Around 4 to 5 questions can be expected from radiation protection regarding radiography including 1 question on the UK radiation protection guidelines of IRMER / IRR99, 1 question on fluoroscopy and radiation safety, 1 question on ultrasound safety (mechanical index, thermal index), 1 question on CT radiation safety (CT dose index, dose length product, etc), 1 question on MRI safety (specific absorption rate, MR zones etc) and 1 question on nuclear medicine safety (guidelines and general safety measures as given in Farr).The number of questions on digital radiography have increased, and as the utility of film-screen radiography has decreased in the real world, questions on it have also decreased with hardly any questions being asked in recent modules. Though there is no fixed rule about the number of questions asked from each modality, the topics generally remain the same as given in the MCQ books.

Physics in radiology itself is a never ending subject with people doing PhDs in radiation physics or MR physics, and one needs to approach this exam strategically and cover all the key areas to pass.

‘Farr’s Physics for Medical Imaging’ is the definitive textbook for the physics module of FRCR part 1. You need to be really thorough with Farr, with at least 2 or 3 readings; and try not to get a single question which comes from Farr incorrect. For radiology residents who have yet to study physics, I would suggest to first go through the topics from Christensen or Bushong to get a detailed idea and master the basic concepts, and then move on to Farr. Farr gives the subject matter in a very concise way which is great for those who have already read physics from other books, but difficult to grasp for novices.

Some topics need to be covered from other books like ‘MRI made easy’ by Govind Chavan or Westbrook’s ‘MRI in Practice’ for MRI. If you have less time go for ‘MRI made easy’; however if you are a resident with long term plan of giving FRCR part 1 in 1-2 years then reading Westbrook will be great for clearing your concepts. Ultrasound physics is given well in Rumack and Doppler physics in Zweibel (now called Introduction to Vascular Ultrasonography by Pellerito and Polak). Nuclear Medicine given in Farr is usually sufficient; however few additional points can be gained from Grainger if you have the time.

I cannot stress this enough: to clear FRCR physics you need to get your basic concepts regarding all modalities crystal clear with a good understanding; mugging does not in any way help. The FRCR questions are structured in such a way to differentiate those who have really understood the topic from those who have mugged a few pages and turned up for the exam. The questions make you think, and apply the knowledge you have gained in a logical way.

Along with Farr, the big key to clearing Physics is a lot of MCQ practice!! Solve as many MCQs as you can get your hands on. There is a specific way in which the physics paper is framed and you need to get used to thinking and solving questions in that way. Keep a separate time daily for reading Farr and for solving MCQs. Try to solve at least 20 MCQs per day. Once the exam gets near, increase the number to 50 or even 100-200 per day depending on your speed. In the last week solve practice papers of 40 questions each from the MCQ books by timing yourself and see whether you are finishing in time.

2.5 to 3 months of studies are sufficient to prepare, with 2 or 3 readings of Farr and solving as many MCQs as possible.

The two MCQ books which I found the most helpful are Shahzad Ilyas’ ‘Physics MCQs for the Part 1 FRCR’ and ‘Get Through First FRCR’ by Grant Mair. The MCQs in Ilyas are the toughest among all the MCQ books available and they are slightly of a tougher level than that asked in the actual exam. This helps as you will find the actual exam quite manageable once you have gone through Ilyas. The explanations given in Ilyas are also quite good with a few exam questions being covered from the explanations as well. Mair’s question quality and accuracy is also quite good.

Other MCQ books available are- ‘MCQs for The First FRCR’ by Varut Vardhanabhuti, ‘Succeeding in the FRCR part 1’ by Pervinder Bhogal and ‘MCQs for FRCR part 1’ by Monica Khanna. After going through Ilyas and Mair, you can pick any of these other books to go through.

The accuracy of MCQ books is variable and if you do not agree with the answer given it is always better to cross-check from a standard textbook. Going through some Radiographics physics articles or Youtube physics videos to clear your doubts would also help.

I have not gone through any paid online resources like R-ITI and would not recommend them, as it is definitely possible to pass and score good marks by being thorough in Farr and 2 to 3 MCQ books.

 Preparing for the Anatomy module

Being strong in your radiological anatomy and doing as much reporting as possible in real life of all modalities is the single best way to prepare for the anatomy examination. That being said, Weir and Abraham’s ‘Imaging Atlas of Human Anatomy’ is the single best resource for covering 90% of the questions asked in the FRCR examination. Residents can learn anatomy by first going through the atlas and then sitting on a workstation and correlating them with real life radiographs, CTs or MRIs or by performing USGs.

In each exam, around 1/3^rd of the questions each are from cross-sectional imaging, plain radiography and contrast studies (including those acquired by cross-sectional means i.e. CT enterography, CT IVU etc. ). Similarly, 1/4^th of the questions asked are from Neuro and Head & Neck; 1/4^th of the questions asked are from Thoracic and Cardiovascular; 1/4^th of the questions are from Abdomen and Pelvis and the remaining 1/4^th are from Musculoskeletal.^[7]

Not all questions asked in the anatomy examination are of ‘identify the structure’ type so always read the question carefully. Some of the questions may be ‘which nerve passes through this foramen’ or ‘at what age does this structure fuse during skeletal development’. Normal variants are a favourite of the FRCR examiners, and be sure to be thorough with all of common ones, as they can be asked in the format ‘name this normal anatomical variant’. Generally those variants which can be mistaken for pathology are commonly asked. No images with pathology are asked, and no questions are asked on normal fetal imaging or normal neonatal cranial ultrasound.^[7]

A list of normal variants important for FRCR can be found here.^[9]

Just like physics, the anatomy examination requires lots of image practice! Many anatomy practice books are available, a few of which include-

1. Grant Mair’s Get Through First FRCR Anatomy
2. Matthew Budak’s First FRCR Anatomy: Mock Papers
3. Usman Shaikh’s First FRCR Anatomy
4. James Thomas’ FRCR Part 1: Cases for the anatomy viewing paper
5. Constantinos Tingerides’ First FRCR Anatomy: Practice Cases

Solving any two of these along with Abrahams’ atlas would be sufficient. Many of these anatomy practice books are according to the old format with multiple arrows shown on a single image. However this format has been changed by the RCR and now you are given 100 different images with a single arrow on each image. However the level of these books generally matches with that of the final examination. Aim to score at least 85 to 90% marks while solving the practice books and papers in order to be confident of passing the final exam.

A common mistake would be focusing too much on physics for the FRCR exam while ignoring anatomy. While it is true that those doing regular reporting find it is easier to answer the anatomy questions as compared to the physics ones, every radiologist has some grey areas where anatomy is considered and it would be helpful to revise at least those areas (for example, skeletal muscles on MRI for some, or skull base foramina on CT for others). It also helps to solve a few practice papers to get a good idea of the level of depth of anatomy to be expected in the examination. Also do not use short forms of words when writing, for example write superior mesenteric artery instead of SMA.

Last but not the least – never ever forget to write “left” or “right” in the examination of the side on which the anatomical structure asked is located! Otherwise you will lose 1 mark unnecessarily. For example writing “superior orbital fissure” gives you 1 mark, and writing “left superior orbital fissure” gives you the full 2 marks.

Passing and statistical analysis of a previous FRCR part 1 examination

The cut-off percentage for passing in any FRCR exam from part 1 to 2A to 2B varies from session to session. However you can get a pretty good idea by going through this document published by the RCR.^[4] It is a statistical report compiled by Dr. John Patterson by studying the results of the Spring 2014 examination and it is the only official statistical analysis of the FRCR examination I could find online.

Over multiple anatomy sets as given in the report, the cut-off percentage of marks for passing varied from 73% to 80% for anatomy; and the cut-off passing percentage of marks was 74% for physics. Bear in mind that the cut-offs are different for every session, although they are usually in this range. The mean score was found to be approximately 80% for anatomy and 77% for physics. Out of the total number of people who appeared for the exam, the failure rate was 25% for anatomy and 35% for physics.

To read more about how to prepare for FRCR part 2A, click here or copy paste this link on your url: https://caferoentgen.wordpress.com/2018/03/12/the-why-and-how-of-frcr-part-i/

Disclaimer – Disclosing questions from any part of the FRCR examination is forbidden by the Royal College of Radiologists under strict penalty. No attempt to divulge questions has been made in the above blog post, with the intention being to impart general guidance and tips to candidates for appearing for the exam.

-Dr. Ameya Kawthalkar, MD,

Senior resident, Tata Memorial Hospital, Mumbai

PS: You can check our other blogs on training abroad in our section ‘Beyond the Shores’. 

 

References

1. Kassamali RH, Hoey ETD. Radiology training in United Kingdom: current status. Quantitative Imaging in Medicine and Surgery. 2014;4(6):447-448. doi:10.3978/j.issn.2223-4292.2014.10.10.
2. https://caferoentgen.wordpress.com/2018/01/14/radiology-in-the-uk-getting-in-and-what-ot-expect/
3. Arora R. The training and practice of radiology in India: current trends. Quantitative Imaging in Medicine and Surgery. 2014;4(6):449-450. doi:10.3978/j.issn.2223-4292.2014.11.04.
4. https://www.rcr.ac.uk/sites/default/files/FRCR_Review_Final_statistical_report.pdf
5. https://www.rcr.ac.uk/clinical-radiology/examinations/first-frcr-examination-0
6. https://www.rcr.ac.uk/sites/default/files/jrf_exam_guidance.pdf
7. https://www.rcr.ac.uk/sites/default/files/cr1_anatomy_advice.pdf
8. https://www.rcr.ac.uk/clinical-radiology/examinations/final-frcr-part-examination
9. https://www.radiologycafe.com/radiology-trainees/normal-variants