The European Diploma in Radiology (EDiR) is a qualification awarded by the European Board of Radiology (EBR), and is the new popular kid on the block for foreign certification exams given by Indian radiologists. It is intended to be an additional qualification of excellence, and a tool to set a benchmark to standardize radiology across Europe. The examination is open to radiologists around the world, and recently was held for the first time in New Delhi. In this article we will look at the advantages which one may get from clearing EDiR, the pattern of the exam and how to clear the exam on the first attempt. While preparing for the exam I could not find any online resource or guidance for clearing EDiR (unlike the many online resources for FRCR, including our own blogs on part 1, 2A and 2B) and this article is meant to fill the lacuna.

1. What is EDiR?

The European Diploma in Radiology or EDiR (pronounced Edeer by European radiologists) is an additional radiology qualification awarded by the European Board of Radiology (EBR) and officially endorsed by the European Society of Radiology (ESR) and European Union of Medical Specialists (UEMS). Like the Fellowship of Royal College of Radiologists (FRCR) is the exam to clear if one wants to practice as a consultant or do fellowship in the United Kingdom (UK), similarly if one wants to practice or do fellowship in some of the mainland European countries, clearing EDiR will give you an advantage over other radiologists applying for the post (more details below).

The exam is held in multiple cities across Europe throughout the year, including usually in Vienna during the European Congress of Radiology (ECR) in Feb-March. It has recently been started in India in collaboration with the Indian Radiological and Imaging Association (IRIA) with the first EDiR examination in India being held on 31 March 2019. The next sitting of the exam in India is on November 16 2019.

2. What are the advantages of giving EDiR?

a. Eligibility to work as a consultant or do fellowship in mainland Europe. Remember that to work/do fellowship in UK you need to clear FRCR and to do the same in some of the mainland European countries, clearing EDiR is one of the routes available. For example, as of today in order to practice in Netherlands, one must pass either the Dutch board examination or pass EDiR. Other European exit examinations for which the EDiR is equivalent are those in Poland, Finland and Turkey. But for many other mainland European countries you have to pass their individual board and language exams in order to practice. However in these countries, EDiR still has additional value when applying for a job or fellowship and will give you an edge over other radiologists who have applied.

b. A radiologist clearing the exam is certified to be up to European standards of excellence in the field. FRCR and EDiR are much more objective examinations in radiology than Indian MD/DNB exams and they require certain minimum standards to pass. For many, it is a way to test oneself and see whether one’s knowledge stands at par with other radiologists around the world. In addition, due to the nature of the questions and cases asked in these exams, preparing for these examinations ensures a thorough reading of the subject and makes one a better radiologist. I for one can attest that preparing for and giving FRCR and EDiR improved me as a radiologist and especially increased my confidence in reporting plain radiographs by a huge degree!

c. It adds to one’s curriculum vitae (CV), always useful when applying for jobs/fellowships in India or in Europe. Indian radiologists who clear EDiR examination in India are awarded Diplomate of Indian College of Radiology and Imaging (Dip.ICRI) by ICRI.

d. Compared to FRCR, this exam happens in India so no need to go abroad to give EDiR. EDiR is a single day exam, whereas FRCR is spread out over 3 separate sessions and 5 exam days in all. Therefore overall costs for giving the exam are also less compared to FRCR.

e. Completely computer based exam; even the long and short cases are computer based. No rapid reporting, physics and viva components which mostly trip up FRCR candidates!

3. Who is eligible to give EDiR?

Indian radiologists who wish to give EDiR –

1. Must have finished four years in radiology i.e one year after 3 years of MD or primary DNB /2 years after DMRD at the time of the examination.
2. Must be life members of Indian Radiological and Imaging Association (IRIA).
3. Must be members of European Society of Radiology (ESR) in the year of the examination (membership of ESR is free if you apply during your residency!).

4. What is the pattern of the EDiR examination?

It is a single day exam consisting of three components. All components are conducted online on a computer. There is no viva. The exam is designed to evaluate a radiologist’s skill in interpretation of the imaging findings, arriving at a diagnosis, giving a sensible differential diagnosis whenever feasible and advising further management.

Part 1 of the exam is Multiple Response Questions (MRQs) and Short cases. Part 2 of the exam is CORE (Clinically Oriented Reasoning Evaluation).

It is advised that candidates sitting for the examination go through the online sample exams available on the EBR website to get a feel of the examination interface and the type of questions which can be asked.

The components of the exam are –

a. Multiple response questions (MRQs): This is the first part of the exam. It consists of 75 questions to be solved in 90 minutes. It has 3 types of questions:

1. General multiple response questions: The question is in the form of text with 5 options, and one or more of the options provided are correct.
2. Image related questions: A radiological image is shown and a question is asked based on the image with 5 options, and one or more of the options provided are correct.
3. Annotated questions: Areas are labelled within an image and you have to match the labelled area with the correct answer. These are mostly anatomy based questions with anatomical structures labelled on a CT or MRI.

One can click on the images to enlarge them. There is a ‘magnifying glass’ icon at the bottom of the image which one can use to zoom the images. Option of changing the window level and width is not provided in multiple response question images.

It is possible to skip questions and come back to them later. However questions once answered and saved cannot be changed.

b. Short cases: It consists of 24 short cases to be solved in 90 minutes.

Few radiological images are provided (no scrolling). The questions are of the following types-

1. Indicate area questions: The centre of the abnormality on the image has to be clicked.
2. Multiple response questions: The question is in the form of text with 5 options, and one or more of the options provided are correct.
3. Free text questions: The answer has to be typed in the box provided. Generally use less than 5 words and use the provided spell checker to check your answer. All free text questions are evaluated by the EDiR examiners in person.

Every short case has a few images with 3 to 5 questions.

One can click on the images to enlarge them. There is a ‘magnifying glass’ icon at the bottom of the image which one can use to zoom the images. Option of changing the window level and width is not provided in short cases.

Within short cases, it is possible to skip entire cases and come back to them later. Questions within cases once completely answered and saved cannot be changed.

c. CORE (Clinically Oriented Reasoning Evaluation):

This is equivalent to long cases and consist of 10 practical oriented cases to be solved in 90 minutes. In this section the images open in a DICOM viewer where there is ability to scroll, change the window settings, zoom and pan.

To familiarize yourself with the layout go through the sample exams. Once saved, the answer cannot be changed. Skipping of cases is allowed. Just like in short cases, the questions in CORE are of multiple response question, indicate area and free text type.

To pass it is necessary to complete at least 8 cases, which includes 1 “compulsory” case which will be marked as such in the examination.

The number of questions from each organ system which are asked in an EDiR exam are given in this published article.⁵

5. What is the scoring system in the EDiR examination and how is passing calculated?

The EDiR instructions email which you will receive prior to the exam and the invigilators at the exam centre will say that there is no negative marking for marking wrong options. This means your score for a question can never drop below zero. However it does not mean that you can mark all 5 options to a question and expect to pass. You lose marks for marking wrong options.

This applies to all 3 components of the exam wherever you have multiple response questions with more than one option which may be correct. We will look at a sample question and some scenarios to explain this.

You can try this out for yourself on the EDiR sample exams to get a hang of the marking system:

This is the first sample EDiR question from the EBR website for MRQs:

Q. Which of the following are recognized indications for contrast enhanced breast MRI?

1. Suspected implant rupture
2. Inflammatory breast cancer
3. Fibrocystic disease
4. Lobular breast cancer
5. BRCA1 gene carrier

Out of these the correct answers are inflammatory breast cancer, lobular breast cancer and BRCA1 gene carrier. Implant rupture does not require contrast and fibrocystic disease does not require MRI. Based on this question, here are a few of the scenarios:

1. Scenario 1: You mark all 3 right options correctly and do not mark any of the wrong answers. You get 1 mark which is the maximum for any multiple response question in this exam.
2. Scenario 2: You mark only 2 of the right options correctly and do not mark any of the wrong answers. You get 0.66 marks.
3. Scenario 3: You mark only 1 of the right options correctly and do not mark any of the wrong answers. You get 0.33 marks.
4. Scenario 4: You mark all 3 right options correctly but you also mark 1 of the wrong answers. Here you lose 0.5 marks and your score is only 0.5.
5. Scenario 5: You mark all 3 right options correctly but you also mark 2 of the wrong answers. Here you lose 1 mark and your score for this question becomes zero.
6. Scenario 6: You mark either 1 or 2 wrong options and do not mark any of the right options. You get zero marks.

So your score will not fall below zero even if you mark all the wrong options. That is the reason why the exam instructions say there is no negative marking. But many candidates misunderstand this to mean they are free to mark any or all of the options to a question, only to end up failing the exam! It would be really funny if a multiple response question exam was conducted where you do not lose marks for marking wrong options.

If there are 2 wrong options for a question, you lose 0.5 marks for every wrong option you select. So if you mark both wrong options you lose 1 mark and your score for that question becomes zero.

Similarly if a question has 3 wrong options, you lose 0.33 marks for every wrong option you select. So if you select all 3 wrong options you lose 1 mark and your score for that question becomes zero.

The examination instructions themselves state:

The scoring system was developed to acknowledge partially correct answers but also takes steps against guessing. Candidates are highly recommended to avoid guessing and to only select answers that they know to be correct so their knowledge is reflected accurately.

To summarize- only mark those options which you are sure about, because if you mark wrong options you will lose marks.

The score for Part 1 (i.e. MRQs + Short cases) is calculated as follows:

Score for Part 1 = 0.3 x (Short cases score) + 0.7 x (MRQs score)

Marks in Part 2 are assigned by an examiner for every case on a 4 point rating scale. The minimum criteria to pass Part 2 are-

1. The candidate has to complete at least 8 of the cases shown
2. At least 50% of the cases should have a positive mark (above zero).
3. The candidate will fail if any of these situations occur: The candidate has two cases with an unsafe score, or the candidate has one case with an unsafe score and one case with a -2.

The unsafe score will be assigned for a case by the examiner when a catastrophic error (an error of observation, interpretation or management) with major adverse impact on patient management is done.

The passing cut-off mark for each of Part 1 and Part 2 is calculated as follows:

Pass mark(PartX ) = Mean(PartX )− 0.5x(Standard  Deviation(PartX ))

As per available literature, around 70% candidates pass the EDiR examination on an average and the passing percentage has remained more or less the same.⁵

6. How to prepare for EDiR?

The best preparation for any exam whether MD, DNB, FRCR or EDiR is spending maximum time in the department and reporting as many cases as possible of all modalities. This holds true especially for FRCR and EDiR which test your practical diagnostic skills in an objective manner.

There is as such no reliable book for EDiR and the ones available have too many mistakes and inaccurate answers.

It is first recommended to go through the EDiR practice exams available online to get an idea of the type of questions asked.

A. The MRQs asked in EDiR are different from the MCQs asked in Part 2A of FRCR. The obvious difference is that EDiR’s MRQs have multiple correct options to be marked, while the questions in FRCR 2A have a single correct answer. Another difference is that every single question asked in FRCR 2A is a clinical case scenario with a long paragraph of a question provided. The MRQs in EDiR test your concepts but they are much more straightforward single line questions, with case based MRQs having images provided with them.

Because of the nature of MRQs asked in EDiR, the best book to prepare for them would be a book which condenses most of the important radiology points in less than 500 pages. That book, IMHO, is ‘The Final FRCR Complete Revision Notes’ by Vincent Helyar and Aidan Shaw. The point-wise topics given in this book are ideal for EDiR preparation. Another similar book is ‘Revision Notes for the Final FRCR Part A’ by Kshitij Mankad. Reading any one of these should be sufficient. If you still want to practice FRCR MCQs for EDiR, the best practice book would be Richard Lindsay’s ‘SBAs for the Final FRCR 2A’.

B. The best preparation for the short cases and CORE components of EDiR is to report as many cases as possible in plain radiography, CT, MRI and ultrasound. Online resources are the best preparation for EDiR and Aunt Minnie’s Case Library contains a huge number of cases followed by questions similar to the ones asked in EDiR:

Useful books for case preparation in EDiR are two of the good FRCR 2B preparation books:

1. Final FRCR 2B Long Cases – A Survival Guide by Jessie Aw
2. Long Cases for the Final FRCR 2B by Rebecca Hanlon

The organ-system based Case Review Series of books is helpful for both FRCR 2B and EDiR, and one can solve these for EDiR if one has the time.

If you have cleared FRCR 2B, 2 weeks of revision should be sufficient to clear EDiR. If not then I would recommend 2 months of dedicated preparation before the EDiR exam with regular case practice.

Other tips:

1. Go through the ESUR (European Society of Urogenital Radiology) guidelines on contrast media as one or two questions on contrast media are guaranteed to come. Being a European examination, they expect answers based on the current European guidelines.

2. Just like any other exam, do not take EDiR lightly. I have seen good radiologists fail for lack of revision and taking the pattern of questions asked lightly. Only a certain percentage of candidates pass (depending on the mean score and standard deviation as I have described above), and if you are giving the exam in India, be ready as you are going to be up against a much tougher group of competitors than if you would give the exam in Vienna or Barcelona. Many of the people who pass the EDiR exams held in Europe are Indians, and Indian radiologists are in general known to be thorough with their knowledge and diagnostic skills.

3. Apply for the examination early if you are planning to give the exam in India when the online notification on the EBR website comes up. The place to check is the EBR home-page: https://www.myebr.org. For the first EDiR examination in India held in March 2019, the examination places were full in 24 hours! On the contrary the places for the EDiR exam in cities like Vienna, Paris or Istanbul remain vacant for months.

References

1. EDiR Exam Dates and Notifications: https://www.myebr.org
2. Apply for EDiR: https://www.myebr.org/edir/application-guide#terms-and-conditions
3. EDiR sample exams: https://www.myebr.org/edir/examination-structure
4. Contrast media guidelines from the European Society of Urogenital Radiology (ESUR) – http://www.esur.org/guidelines/
5. European Board of Radiology. The European Diploma in Radiology (EDiR): investing in the future of the new generations of radiologists. Insights into Imaging. 2018; 9:665. https://doi.org/10.1007/s13244-018-0665-7
6. Aunt Minnie Case Library: https://www.auntminnie.com/index.aspx?sec=olce&sub=view

– Ameya Kawthalkar, MD, DNB, FRCR, EDiR, Dip.ICRI, Fellowship in Musculoskeletal and Sports Imaging and Interventions at SMKH, Netherlands*

Assistant Professor, Sir JJ Hospital and Grant Medical College, Mumbai

*Thanks to EDiR!

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