Achieving Success in the FRCS Section 2 (General Surgery) Exam: Understanding the Marking Scheme

Manikandan Kathirvel

Consultant HPB and Liver Transplant Surgeon

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The Fellowship of the Royal College of Surgeons (FRCS) Section 2 exam is a pivotal milestone for surgical trainees in the UK. It is also a crucial examination for non-trainees in the UK pursuing the CESR/portfolio pathway to CCT, and for overseas surgeons who aim to excel in their surgical careers. This exam evaluates candidates across four primary domains:

Basic Knowledge
Higher Order Processing
Clinical Skills
Professionalism.

To help prospective candidates navigate this rigorous assessment, we’ve dissected the marking scheme, highlighting both passing and failing grades with detailed examples.

Common Causes of Failure in section 2 exams:

Understanding the common pitfalls that lead to failure in the FRCS Section 2 exam is crucial for candidates aiming to succeed. Many candidates fail because they do not fully comprehend the structure and expectations of the exam. Others may not answer questions with the depth and confidence expected of a consultant, instead providing responses that do not reflect practical, real-world decisions. Failure to understand what the examiners expect can also lead to inadequate answers. Poor professionalism, including immature body language and argumentative conversations, can significantly detract from a candidate’s performance. Additionally, improper time management often results in incomplete scenarios, as candidates fail to allocate sufficient time to address all questions thoroughly. This blog will delve into how the FRCS – general surgery Section 2 exam is marked, providing insights and examples to help you avoid these common mistakes and excel in each assessed area.

The FRCS Section 2 exam employs a scale ranging from 4 to 8, with scores 4 and 5 indicating failure and scores 6-8 indicating passing grades. All your responses are marked in this grade. Here’s a closer look at what each score signifies:

4: Poor
5: Below Average
6: Competent
7: Good
8: Excellent

Each score is collectively applied to evaluate four critical areas, ensuring a comprehensive assessment of a candidate’s capabilities

Basic Knowledge:

Basic Knowledge forms the bedrock of the FRCS exam. A candidate’s grasp of fundamental concepts and their ability to apply this knowledge in clinical scenarios are crucial. The examiner assesses your understanding of core topics, evaluating how well you can explain and apply these concepts under pressure. Marks will be based on your ability to demonstrate a comprehensive understanding of surgical principles, anatomy, pathophysiology, and evidence-based practices. The marking criteria evaluate whether your knowledge is thorough, accurate, and relevant to the clinical scenarios presented during the exam.

Marking criteria:

Poor (Score 4): Candidates at this level exhibit significant gaps in basic knowledge, often failing to understand essential concepts.
Below Average (Score 5): These candidates demonstrate some understanding but with notable gaps.
Competent (Score 6): Competent candidates exhibit adequate knowledge with no major errors.
Good (Score 7): These candidates display strong knowledge and handle difficult problems comfortably, often providing supporting evidence for their answers.
Excellent (Score 8): At this level, candidates show exceptional knowledge, understanding the breadth and depth of topics, and provide high-level supporting evidence.

Example Scenario: Managing Symptomatic Bilateral Hernia

Here’s how various responses to the management of a symptomatic bilateral hernia would be marked:

Poor (Score 4): “I would try to repair the hernia, but I’m not exactly sure of the specific steps or the anatomy involved.”
Below Average (Score 5): “I would perform a hernia repair, but I might need assistance understanding whether it’s a direct or indirect hernia and the implications for the repair method.”
Competent (Score 6): “I would perform a bilateral hernia repair using a mesh. I would identify and reduce the hernia sac and place the mesh to reinforce the inguinal canal. This should help prevent recurrence.”
Good (Score 7): “For a symptomatic bilateral hernia, I would opt for a laparoscopic approach due to its quicker recovery time and lower recurrence rates. I would ensure proper identification of the hernia sac, reduce it, and place a mesh bilaterally. Studies show this method is effective in preventing recurrence.”
Excellent (Score 8): “For a symptomatic bilateral hernia, I would recommend a laparoscopic TEP (totally extraperitoneal) repair. This approach minimizes postoperative pain and reduces the risk of complications. I would carefully dissect the preperitoneal space, identify and reduce the hernia sacs, and place a pre-shaped mesh. Evidence suggests this technique has a high success rate and low incidence of chronic pain. Additionally, I would counsel the patient on the benefits and risks, including the potential for seroma formation and strategies for its management.”

Higher Order Processing: Beyond Basic Knowledge

Critical thinking and decision Making/ Higher order processing evaluates a candidate’s ability to think critically, organize information, and make sound clinical decisions. This involves assessing the candidate’s skills in organization, logical thought processes, judgement, decision making, prioritization, interpretation of data, and the quality of their responses. Let discuss a bit more on what are these.

Organisation: How well the candidate organizes and structures their thoughts and actions.
Logical Thought Processes: The clarity and rationality of the candidate’s reasoning.
Judgement: The candidate’s ability to make informed and sensible decisions.
Decision Making: How effectively the candidate chooses between different management options.
Prioritisation: The candidate’s ability to identify and act on the most critical issues first.
Interpretation of Data: How accurately the candidate interprets clinical and diagnostic data.
Quality of Response: The overall coherence, relevance, and professionalism of the candidate’s responses.

Marking criteria :

Poor (Score 4): Candidates show no higher-order thinking or logical thought processes and fail in clinical management. They might suggest harmful management plans for patients with multiple comorbidities.
Below Average (Score 5): These candidates exhibit poor higher-order thinking and struggle with logical thought and decision-making, often failing to prioritize interventions in emergency scenarios.
Competent (Score 6): Competent candidates display adequate higher-order thinking and organization. They can develop a clear and logical plan for managing post-operative complications, ensuring patient safety.
Good (Score 7): These candidates demonstrate strong clinical reasoning and effective integration of clinical guidelines into management plans for complex cases.
Excellent (Score 8): At the top level, candidates exhibit superior decision-making skills, developing strategic and evidence-based management plans for critically ill patients.

Example Scenario: Management of Post-Operative Breathlessness

Here’s how various responses to the management of a post-operative patient presenting with breathlessness would be marked:

Poor (Score 4): “The patient is breathless; I would give some oxygen and wait to see if it improves.”
- Explanation: This response shows a lack of organization, poor decision-making, and no logical thought process or prioritization. It fails to address potential causes or necessary investigations.
Below Average (Score 5): “I would check the patient’s oxygen levels and give oxygen if needed. If it doesn’t improve, I would consult a senior.”
- Explanation: This response demonstrates some basic steps but lacks depth in decision-making and prioritization. It shows limited higher-order thinking and poor planning for further investigation.
Competent (Score 6): “I would assess the patient’s airway, breathing, and circulation (ABCs). I would check vital signs, perform a physical examination, and order a chest X-ray and blood gases. I would administer oxygen and monitor the patient closely.”
- Explanation: This response is organized and logical, showing competent higher-order thinking. The candidate demonstrates an adequate plan for investigation and management.
Good (Score 7): “I would perform a thorough ABC assessment, check vital signs, and conduct a focused physical examination. I would order a chest X-ray, blood gases, and consider an ECG to rule out cardiac causes. Administering oxygen and considering potential causes like pneumonia, pulmonary embolism, or heart failure, I would start appropriate initial treatments while awaiting results.”
- Explanation: This response shows strong clinical reasoning, good organization, and logical thought processes. The candidate integrates clinical guidelines effectively into the management plan.
Excellent (Score 8): “Upon noticing post-operative breathlessness, I would immediately perform a thorough ABC assessment and initiate high-flow oxygen. I would review the patient’s history for risk factors like DVT, pneumonia, or heart failure. I would order urgent investigations including a chest X-ray, arterial blood gases, ECG, and possibly a CT pulmonary angiogram if PE is suspected. I would manage the patient based on findings, starting empirical treatment for the most likely causes while ensuring close monitoring and preparation for potential advanced interventions.”
- Explanation: This response shows superior decision-making and strategic planning. The candidate demonstrates excellent organization, prioritization, and logical thought processes, providing a comprehensive, evidence-based management plan.

Clinical Skills: The Art and Science of Practice

Clinical Skills are essential for effective patient management and care. This area assesses a candidate’s ability to perform thorough examinations, take accurate histories, and make correct diagnoses. The examiner evaluates how well candidates can gather clinical information, interpret findings, and develop appropriate management plans. Key skills assessed include clinical history taking, clinical examination skills, and clinical diagnostic skills. It’s important to note that post-COVID, clinical examination is often tested through verbalization rather than actual examination, using actors or case scenarios instead of real patients.

Marking criteria:

Poor (Score 4): Candidates at this level miss significant clinical signs and propose incorrect, potentially harmful treatment plans. Their history-taking and examination skills are inadequate.
Below Average (Score 5): These candidates struggle with clinical history taking and examination, leading to misdiagnosis and ineffective management.
Competent (Score 6): Competent candidates perform complete and accurate clinical examinations, correctly identifying key findings and making sound diagnoses.
Good (Score 7): These candidates effectively assess patients, integrating clinical findings with laboratory results to form robust diagnostic impressions.
Excellent (Score 8): Top candidates conduct meticulous examinations, uncover subtle signs, and provide highly accurate diagnoses and management plans.

Example Scenario: Management of a Patient Presenting with a Neck Lump

Here’s how various responses to the management of a patient presenting with a neck lump would be marked:

Poor (Score 4): “I would feel the lump and then maybe order a biopsy if needed.”
- Explanation: This response shows a lack of systematic approach in history taking and examination. It misses critical steps in assessing the neck lump, leading to potential misdiagnosis and inappropriate management.
Below Average (Score 5): “I would take a history and examine the neck lump. I might order some tests if I’m unsure.”
- Explanation: This response demonstrates some effort in history taking and examination but lacks depth and specificity. It shows limited ability to integrate findings and form a diagnostic plan.
Competent (Score 6): “I would take a thorough history including duration, associated symptoms like pain, dysphagia, and weight loss. I would perform a systematic neck examination, checking for lymphadenopathy and characteristics of the lump. I would then order relevant investigations such as ultrasound and fine-needle aspiration biopsy.”
- Explanation: This response is organized and logical, showing competent history taking and examination. The candidate demonstrates an adequate plan for investigation and management.
Good (Score 7): “I would take a detailed history focusing on the duration, growth, and associated symptoms of the neck lump. I would perform a comprehensive examination including palpation of the neck, assessing for mobility, consistency, and tenderness of the lump, and check for regional lymphadenopathy. I would then proceed with targeted investigations like ultrasound, fine-needle aspiration, and potentially a CT scan to evaluate the extent.”
- Explanation: This response shows strong clinical reasoning, good organization, and logical thought processes. The candidate effectively integrates clinical findings into the management plan.
Excellent (Score 8): “For a patient presenting with a neck lump, I would start with a detailed history focusing on the onset, duration, growth rate, associated symptoms such as dysphagia, voice changes, and systemic symptoms like weight loss or night sweats. I would perform a meticulous physical examination, palpating the lump to assess its size, consistency, mobility, and any signs of local invasion or lymphadenopathy. I would then order appropriate investigations including an ultrasound of the neck, fine-needle aspiration biopsy for cytology, and a CT scan to determine the extent of involvement. I would discuss the differential diagnosis, including benign and malignant causes, and outline a management plan based on the findings, ensuring clear communication with the patient about the next steps.”
- Explanation: This response demonstrates superior clinical skills, with a thorough and systematic approach to history taking and examination. The candidate provides a comprehensive, evidence-based diagnostic and management plan.

Professionalism: The Human Aspect

Professionalism evaluates a candidate’s behavior, empathy, communication skills, and ethical understanding. This area assesses attitudes and behaviors towards volunteers, carers, colleagues, and examiners, as well as how candidates handle ethical issues. Professionalism is crucial in building trust with patients and ensuring ethical and respectful interactions.

Marking criteria :

Poor (Score 4): Candidates may be abrupt, rude, and demonstrate a lack of empathy and inappropriate attitudes, ignoring ethical issues and failing to establish rapport.
Below Average (Score 5): These candidates show limited empathy and consideration, often struggling to handle ethical issues appropriately.
Competent (Score 6): Competent candidates maintain a professional demeanor, effectively communicate with patients, and understand ethical principles.
Good (Score 7): These candidates quickly build rapport, show genuine empathy, and adeptly handle ethical challenges.
Excellent (Score 8): At this level, candidates exhibit outstanding professionalism, forming strong patient relationships and navigating ethical issues with exceptional skill.

Example Scenario: Management of an 80-Year-Old Living Alone with Peritonitis

Here’s how various responses to the management of an 80-year-old patient living alone with peritonitis would be marked:

Poor (Score 4): “The patient needs surgery. I would tell her she has to be admitted immediately.”
- Explanation: This response shows a lack of empathy and consideration for the patient’s circumstances. It is abrupt and fails to address the patient’s emotional and social needs or to involve her in the decision-making process.
Below Average (Score 5): “I would inform the patient about the need for surgery and ask if she has any relatives to contact.”
- Explanation: This response shows some consideration but lacks depth in handling the ethical aspects and patient’s emotional needs. It is limited in empathy and support for the patient’s situation.
Competent (Score 6): “I would explain the diagnosis of peritonitis to the patient, discuss the urgent need for surgery, and assess her understanding and consent. I would also explore her living situation and support network.”
- Explanation: This response demonstrates a professional demeanor and adequate communication, showing understanding of ethical principles and the patient’s social context.
Good (Score 7): “I would explain the severity of peritonitis and the necessity of surgery in a compassionate manner, ensuring the patient understands the procedure and its risks. I would discuss her living situation and ensure social services are involved to arrange post-operative care and support.”
- Explanation: This response shows genuine empathy, effective communication, and an adept handling of ethical challenges. The candidate builds rapport quickly and ensures comprehensive care planning.
Excellent (Score 8): “I would approach the patient with empathy, explaining her condition and the urgent need for surgery while ensuring she feels supported. I would involve her in the decision-making process, addressing any fears and concerns. Given her living situation, I would coordinate with social services and her healthcare team to arrange for a carer and post-operative support, ensuring a safe and supported recovery. I would also discuss potential ethical issues, like informed consent and autonomy, with sensitivity and respect.”
- Explanation: This response exemplifies outstanding professionalism, with a strong patient relationship, exceptional empathy, and skillful navigation of ethical issues. The candidate demonstrates a comprehensive and patient-centered approach to care.

Conclusion

The FRCS Section 2 exam is a comprehensive and rigorous assessment that tests a wide range of competencies. Understanding the marking criteria and focusing on developing strengths in each area is crucial for a candidate’s success in the exam. This guide provides a clear framework for effective preparation. By mastering the knowledge, honing clinical skills, and embodying professionalism, candidates can confidently navigate the FRCS Section 2 exam.

Preparation for the exam requires identifying weak areas early and practicing diligently to improve them. Smart preparation is vital; it’s not just about hard work, but about working strategically to address gaps and enhance strengths. This multifaceted approach not only prepares candidates for the exam but also equips them with the skills necessary for their surgical careers.

All the best.