Past candidates’ approach to undertaking the Primary FRCA
Dr J Fortune Anaesthetics Northern Deanery
Dr I Walker Anaesthetics Northern Deanery
Dr C Browell Anaesthetics Northern Deanery
Dr D Kelly Anaesthetics Northern Deanery
It’s as certain as death and taxes that on your first day in anaesthetics training, ‘hello and welcome’ will swiftly be followed by ‘when have you thought about sitting the Primary?’ It then becomes quickly apparent that these exams are going to be difficult. Very difficult . Not just because of the enormity of the curriculum (print out the syllabus only before a particularly long case with a very slow surgeon) but also the high standards expected. The four authors of this article all used a relatively uniform approach to complete the Primary FRCA within a year, passing each component at first attempt. As such, we hope sharing our experiences of how we tackled the exams will help other candidates to do the same.
The Primary FRCA
The Primary is divided into two parts – the written Multiple Choice Questionnaire (MCQ) and the practical OSCE/Viva (or Structured Oral Examination – SOE). Candidates must initially pass the MCQ before they can sit the OSCE/Viva. The MCQ is a three hour exam consisting of 60 true or false MCQ questions (divided into 20 each of Physics and Clinical Measurement, Pharmacology, and Physiology – 1 mark per correct answer) and 30 single best answer (SBA) questions – 4 marks per correct answer. A pass in the MCQ is valid for three years, and candidates have a maximum of six attempts. The OSCE consists of 17 stations in one hour 42 minutes. The current topics covered in the OSCE stations are anatomy (and procedures), technical skills, history-taking, resuscitation, physical examination, anaesthetic hazards, radiological interpretation and communication skills. At each station, the candidate has one minute to read an introduction to the station, and five minutes of examination. The Viva consists of two thirty minute examinations. The first exam is broken down into six questions; three in Pharmacology, three in Physiology. The second examination consists of fifteen minutes regarding a clinical scenario, followed by three five minute questions on Physics and Clinical Measurement. These questions are face to face with two examiners in a small booth. Water is provided for your inevitable dry mouth. The components of the OSCE/Viva must initially be sat together, with a pass in one component valid for two years. A maximum of six attempts are allowed.
The Preparation Phase
There is no escaping the fact that success in the Primary will mostly be due to hundreds of hours of hard work over about ten to twelve months. The first step in preparing for the exam for us was accepting this and mentally committing before we first picked up a book, and it was a less painful experience as a consequence. Our partners and friends were thoroughly briefed in advance that most evenings a week for several months would be taken over by after work study, and for the short term we missed out on social gatherings.
We wanted to revise for 6 months before the MCQ, and have at least 3 months to prepare for the OSCE/Viva, so we set a target at the very beginning of our CT1 year by looking at the exam dates on the Royal College of Anaesthetists website to plan our work over the year.
A revision buddy was essential to our success. We cannot urge you enough to find someone you feel is at your level with a similar approach to learning as you. A like-minded friend to revise with provides an alternative source of knowledge for the MCQs and someone who can explain difficult concepts, share resources, as well as being the only person who’ll laugh at your mnemonics. Revision becomes quite insular and our revision buddies were one of the few people who understood the long and at times seemingly insurmountable challenge of exam preparation. When morale is low you can support each other.
Amount of Work and Revision Styles
Every individual varies in their speed of acquiring knowledge and understanding concepts, but revision for us started 6 months before the exam. The target revision time was 15-20 hours per week. This was gradually increased over three months, with the final three months at the upper limit of the target revision time. We found that treating revision as a few more hours of the day job made completing the curriculum more manageable.
Many written medical exams are in an MCQ format, and arguably candidates can be successful solely by doing enough practice questions beforehand. We would not recommend this. We recommend first establishing a good knowledge base before mixing in practice questions as the MCQ approaches. We initially concentrated on studying the material in books full time, then from approximately three months before the exam started doing MCQs, giving a greater proportion of study time to these as we got closer to the day. Single Best Answers are now a significant part of the written paper and carry heavily weighted scores. They require a good knowledge base to derive the correct answer from a list of options about a given scenario -understanding beyond pattern recognition is vital to SBA success. Dynamic understanding of knowledge and concepts is also essential for the Viva, so by learning theory for the MCQ you’re also preparing for the Viva months later.
There are a number of MCQ books available in the form of the ‘Q-Base’ series but we found the best resource for MCQs was the Royal College of Anaesthetists ‘Guide to FRCA Examinations: The Primary’. This contains example questions, some of which appeared verbatim in our exams. To our knowledge at the time of writing, there are three published editions -2001, 2007 and 2010 (note the example questions in the 2007/2010 are the same, but different in the 2001 edition). Anaesthesia UK also has an ever-growing bank of questions on their website submitted by previous candidates. Similarly, candidates who attended the Coventry course have submitted their exam questions, which are available to view for free at www.mededcoventry.com/courses/anaesthesia. Paid subscriptions to online questions banks are available, for example Pastest, 123doc, FRCAQ or Onexamination; our only experience was with Pastest, but we felt it had questions representative of what to expect in the primary. The single best answer section has not appeared alongside the MCQ for many sittings, and so examples are difficult to come by. We used the samples available on the Royal College website, and volume two of ’Single Best Answer MCQs in Anaesthesia’ (Mendonca, Chaudhari, Pitchiah).
The key to success in the Viva for us was to start early: for about three months before the exam we revised at least 15-20 hours per week. While book work is fundamental to MCQ preparation, discussing theory is fundamental to the Viva. Revision time was split between answering questions aloud face-to-face and studying theory in our own time. Our typical Viva practice session would consist of us alternating the examiner/candidate roles, with timed fifteen minute mock examinations split into five minute question slots. This was followed by about twenty minutes of feedback, exploring learning points and discussing how our answers might be improved – although clearly this would not be possible without a revision buddy. As part of Viva revision we would also practice drawing graphs and diagrams accurately and quickly – a well drawn graph can illustrate in seconds what it would take much longer to explain verbally. By the time we sat the exam we could draw all of the popular graphs from memory quickly, accurately and with labeled axes and relevant numbers included.
We found the sooner we lost our inhibitions about answering out loud, the sooner we were able to focus on our structure to answers, using a ‘define and classify’ approach. Our initial focus was to be able to generate an opening response to any question that defined what we were being asked about, followed by a list of categories and subcategories the answer might be broken down into. Answering a question like this has three benefits; firstly and most importantly, it makes you look like you have a good breadth of knowledge. Secondly, you don’t panic and immediately say something extremely specific that forms the basis for the rest of your five minute Viva. Thirdly, it’s a good aide memoire to go back to if you get lost. We begged anyone who’d passed the Primary for all the practice we could get. With regular practice, we became a bit more conditioned and were less stressed on the day. Being caught out over gaps in your knowledge in a mock Viva, in areas you thought you knew, really focuses your private study, so we aimed to have at least one Viva a day in work hours as well as practice after work.
Most of our revision focused on the Viva, partly in anticipation of the breadth of knowledge that can be tested, but also the psychological aspects of facing two examiners for half an hour. Consequently it’s easy to neglect the OSCE, but remember it is a whole exam in itself, and many people we knew failed the OSCE through lack of specific preparation.
We started thinking about the OSCE about three weeks before the exam and in the final week focused entirely on it. The pass mark is not based on the number of stations passed/failed but from a total overall score, so every mark counts. We strongly advise using books containing not only OSCE-station style questions but also mark schemes for OSCE preparation. We were surprised to see unexpected marks awarded for asking certain questions or making certain statements in the role play stations. Familiarising ourselves with these mark schemes allowed us to potentially gain the marks we would otherwise have missed. Similarly, in a procedure station we would always rattle off a statement such as “I’d make sure I was performing the procedure on a patient who was appropriately consented, in the presence of a trained assistant, and using an aseptic technique. That adequate resuscitation facilities were available, the patient had working IV access and was monitored using standards as recommended by the AAGBI” in case there were any marks available for this, even if we didn’t know how to do the procedure!
Our book of choice was ‘The OSCE in Anaesthesia’ (Mendonca, Balasubramanian). In addition, the OSCE may contain anatomy stations (we did not revise anatomy for the MCQ) – we used ‘Concise Anatomy for Anaesthesia’ (Erdmann) for this preparation. We also made sure we knew our examinations of systems from medical school finals back to front.
The bulk of examined material can be split into Physics/Clinical Measurement, Pharmacology and Physiology. None of us had read any physics since at least A-level, so started with ‘Basic Physics and Measurement in Anaesthesia’ (Davis,Kenny), supplemented with ‘Essentials of Anaesthetic Equipment’ (Al-Shaikh). Next we revised Pharmacology and used ‘Pharmacology for Anaesthesia and Intensive Care’ (Peck, Hill,Williams). This is a comprehensive text and is written in a way that forms a good structure to use when answering a question about a drug in the Viva. It is also available as an app for mobile devices. We did, however, find the pharmacokinetics section a bit too detailed, so searched for more general review articles in Anaesthesia and the BJA to supplement knowledge in this area. We targeted Physiology last – conscious it is potentially the largest topic, but we felt it was the subject we tended to have the greatest intrinsic knowledge of from past medical studies and everyday practice. Nevertheless, an extremely thorough understanding of respiratory, renal and cardiovascular physiology is required. We used ‘Physiology at a Glance’ (Ward+Linden) as a general text and supplemented this with ‘Respiratory Physiology’ (West) and ‘Fundamentals’ (Pinnock) for cardiovascular and renal physiology. As an overall general reference or ‘bible’ to topics either not covered or not explained fully in the other books, we used ‘Anaesthesia and Intensive Care A-Z’ (Yentis, Hirsch+Smith).
Online and digitally, we used E-learning for anaesthesia (www.e-lfh.org.uk), a free to register site with clear tutorials covering a range of topics in the syllabus which also has a bank of standalone MCQs, plus MCQs associated with the tutorials. We listened to purchased ‘Dr. Podcast’ tutorials (downloaded from www.dr-podcast.co.uk) in the car whilst driving to work. We were careful not to overload ourselves though – we just selected 2 or 3 specific podcasts and listened to them on repeat for the week. The podcasts are often fact heavy, and this way we absorbed more of the detail.
For Viva books, we used the ‘MasterPass’ books (McComb, Wijayasiri, Patel – two volumes), which cover many classic questions plus challenging patient groups and critical incidents. We also knew the latest DAS airway algorithms, ALS/APLS algorithms and AAGBI machine check/anaphylaxis/local anaesthetic toxicity protocols (all available free online at www.aagbi.org, www.resus.org.uk and www.das.uk.com).
Finally our constant companion was ‘Physics, Pharmacology and Physiology for Anaesthetists –Key Concepts for the FRCA’ (Cross,Plunkett). We found this concise, relatively inexpensive and containing most of the graphs or diagrams that may need to be drawn in a Viva.
[Note from David Mayne, TPD:
See www.NSAICM.com for details about the newly restructured Primary Revision course run by the School of Anaesthesia]
We managed to obtain a sufficient amount of old MCQ papers from colleagues and books (approximately 1000). For the OSCE, we would strongly recommend a course with simulated exam condition stations – many are available throughout the UK.
The Day of the Exam
By this stage of training we have all done more than our fair share of exams, and will have our own firmly instilled routines for the day. The MCQ is held in centres across the UK – you can indicate your preference when you apply for the exam.
The OSCE/Viva is only held at the College building in London. We were from out of region and travelled down the day before. We didn’t want to do too much on that day so set a simple revision goal – we learnt a table comparing the volatile agents, and it was the first question we were asked in both the MCQ and Viva! Our other big tip for the Viva relates to the clinical exam. Before entering the examination room candidates have approximately ten minutes in which they are given a card with the scenario they will be asked about. We tried to use this time effectively to compose ourselves, anticipate the questions we may be asked and to think through what critical incident may occur relating to the case. We had a paediatric emergency case, and had already estimated the weight and done the relevant drug calculations before the exam started.
The OSCE/Viva day will last hours – exams commonly start before 10:00am and we did not finish until after 5pm. It takes serious composure not to let the atmosphere get to you with thirty candidates all nervously last minute cramming everywhere you look (toilet and cloakroom included). We took a break after each exam and left the college building to recharge, banning any post-mortem chat until the end of the day.
No matter how bad things are going DO NOT LEAVE EARLY! It’s still possible to pass if you have a few poor stations in the OSCE, or a Viva didn’t go as well as you’d hope, so stay for all the exams. On our OSCE/Viva day, a candidate left early thinking their OSCE had been a disaster, missing their Viva sitting: they had actually comfortably passed.
Finally, all of us booked time off after each exam. You should too – whatever the outcome you’ll have worked hard and will deserve it. Plus when it’s all over it’s only a matter of time before everyone starts to ask you ‘when are you thinking of sitting your finals?’
Approx Cost Breakdown
|Travel & Accommodation Exam/Courses||£45|
|Courses||£500 (from SL budget, for NSAICM course)|
|Travel & Accommodation Exam/Courses||£205|
(Books: All books/paid for resources mentioned here – except online question banks – if bought latest editions new)
- Pair up with a revision buddy early
- Work hard, and set time goals for revision
- Use every resource available to you for MCQs and SBAs
- Get as much Viva practice as you can-develop an answer structure early
- Don’t neglect the OSCE