Disclaimer: The thoughts, comments and figures provided are personal and are in no way endorsed by the Royal College of Radiologists (RCR). This article is aimed at trainee clinical radiologists but doctors of other specialists may find it an interesting insight into the greyscale world of radiology.

Having talked at length previously about the structure of the FRCR and how it fits into the grand scheme of radiology we now all know what the FRCR is about and why it’s important but how much work is needed to pass it?

First and foremost, I do not believe there’s a maximal amount of work you can do to get your Fellowship but there is almost certainly a minimum. There is simply no way of knowing what that is as there is so much individual variation. That being said, I would like to think that I have a reasonable work-life balance and have managed to pass the FRCR at my first attempt so a look at my efforts might provide a good baseline for trainees.

To try to keep things simple, I think we can look at preparation for the exam in terms of three categories:

  1. Reporting numbers
  2. Revision hours
  3. Viva practice

This post covers my reporting figures. I also should point out that these figures do not include work done at the beginning of ST4 (I did not sit the 2B until three months into ST4). During these three months I was probably reporting more plain films than ever before but those numbers are not included for two reasons:

  1. Core radiology is allegedly supposed to be delivered in 3 years
  2. I changed the format of my logbook to stop recording individual body parts

Reporting numbers

This is contentious but, like it or loathe it, we as radiologists are being reduced to a graph of reporting numbers vs time spent at work. That statement merits a blog post of its own but for now let us just accept that we need to report a lot of studies. That is, after all, our trade.

There is at least anecdotal evidence that the number of plain films reported by trainees prior to sitting the Final 2B exam correlates closely with passing (i.e. the more films reported, the more likely you are to pass). There is no suggestion that this reporting needs to be immediately before the exam (i.e. cram-reporting) but merely that they should be reported during the candidate’s training.

As an obsessive compulsive overly organised person, I have kept very accurate records of what I’ve reported during my training. When I log a study as reported in my logbook that means I actually wrote the report or performed the scan myself. Often it will have subsequently been verified by a consultant but the initial report was done by me. If I just looked through already reported studies, they don’t count (at least in terms of logbook numbers). With that in mind, lets take a look at some graphs pulled from my logbooks for my first three years of clinical radiology training:

Total studies reported ST1-3

Total studies reported ST1-3

Perhaps nothing too surprising here. As you can see, my numbers (all modalities) increased year-on-year. Our training scheme has set some absolute minimum numbers of plain films that every trainee needs to report per week (25 films per week per year of training). Therefore, a first year needs to report 25 plain films per week, a second year 50 and so on. Did I achieve this? Well, lets break down the above numbers by modality:

Studies reported by modality ST1-3

Studies reported by modality ST1-3

Assuming the average radiology registrar works 44 weeks per year (6 weeks annual leave and about 2 weeks of Bank Holidays), I was reporting an average of 33 plain films/week in ST1, 57/week in ST2 and 86 plain films/week by ST3. Whilst that’s comfortably above what’s required, it still only equates to 17 plain films each day as a peri-FRCR registrar. Given that you have 70 seconds to report a plain film in the rapid reporting part of the FRCR that roughly equates to 20 minutes of work per day. Before we address this issue, let’s quickly look at the types of plain films I reported.

Plain films reported by region

Breakdown of plain films by region

As this Pac-Man look-alike graph demonstrates, CXRs make up the lion share of the plain films (about a quarter). Approximately 15% of films were wrists or ankles with other appendicular skeletal regions making up the remainder. Rather comically, I’ve formally reported 348 finger X-rays in three years. That’s 4.5% of all of my plain film numbers or the equivalent of looking at the fingers of 43 individual people (remember, there’s only 8 fingers on a hand). For what it’s worth, about 40% of all plain films I report now I’m ST4 are chest X-rays.

Cross-sectional imaging

As I alluded to earlier, cross-sectional imaging (in particular CT) starts to take up a bigger proportion of the working day as one becomes more senior. As an example, I solo reported 1039 CTs in ST3. Cross-sectional work definitely takes longer to report and learn from than plain film imaging so lets look at this area a little more closely. Here’s three graphs in quick succession:

CT scans reported in ST1

CT scans reported in ST2

CT scans reported in ST3

They look pretty similar don’t they? The only real anomaly is the relatively large proportion of CTKUBs reported in my first year. This is simply because the numbers were so small. I think it’s probably fair to say that the proportion of heads, abdomens, brains and chests reported is fairly constant over the junior registrar years. What does start to increase is the proportion of everything else reported as you get more senior (up to 13% of the total in ST3). This makes sense as one is supposed to be coming to the end of core training and will be starting to report a number of more specialised scans. Incidentally, the large number of brains reported in ST2 is due to a three month neuroradiology attachment.

If you take a look at the earlier graph you’ll see that my MRI reporting numbers are pretty small, certainly by comparison to CT and plain film. Why? Well, remember that my logbook only records studies that were either dictated or typed by myself. These numbers therefore do not reflect the total number of MRIs I have studied/looked at during my career. This is true for all of the figures in this document but it merits repetition here before you start to think I’ve very little exposure to MRI.

Since we’re dealing with small numbers, I think a table would summarise things best.

MRI scans reported by body part

To my eyes, there are no surprises here. By far the most commonly reported studies are spines (almost all for possible cauda equina syndrome) and brains (mostly during my time at Cheltenham in ST3 where I actively sought them out). MRI is still a specialised area and this is reflected in the lack of solo-exposure to it during core training in years 1-3.

Ultrasound

The last area we will look at in this post is ultrasound. Below are my numbers:

Ultrasound by body part and year

Initially I blamed my low numbers on a poor setup in my training scheme but having spoken to a lot of trainees from other regions, I came to realise that it’s poorly taught everywhere. I think the root cause is that the previous generation of radiologists allowed this modality to be largely taken over by sonographers (trained ultrasound radiographers) during the rapid growth in availability of CT. This has meant that they’ve become deskilled. Subsequently, there are far fewer consultant lists available for registrars to learn the trade. You’ll notice I did twice as many ultrasounds in ST2 than any other year - this is down to my three month paediatric radiology attachment which is very ultrasound-heavy.

Ultrasound is vitally important to radiologists and I’m making a conscious effort to expose myself to more. Since I’m hoping to become a paediatric radiologist, I fully expect I will manage to get all the ultrasound exposure I desire during my next few attachments. If one is brutally honest though, you only need to recognise pathology and anatomy on still ultrasound images for the FRCR, not perform the test yourself, although obviously that’s necessary for day-to-day clinical work.

Summary

Whilst this post is a frank and honest exposé about my personal reporting figures I need to stress that I strongly believe that radiology is not just about the number of scans you report or perform. It’s an apprenticeship. Much of what I’ve learned over the last few years has come from attending or running multidisciplinary meetings or sitting with consultants learning from them as they report. Neither of these two activities are reflected in these numbers.

So, what’s the answer to the question, “how many studies do you need to report in order to pass the FRCR?”. I would say, as many as is needed to fully grasp the fundamentals of radiology. If I add to the above numbers those studies reported from the beginning of ST4 up until the day of my exam, that figure for me was 11,873.