Back in the dim distant past when I took my FRCPath exam it was very different to what it is now. In 2003 the FRCPath consisted of two parts, and was sat after 1-3 years in a Registrar post. You needed to “lose some sense of reality” my wife says in order to submerge yourself enough to pass!
Part 1 was a day of essays and short notes. There were two papers, one in the morning and one in the afternoon. Each paper was 3 hours long and you had to hand write 4 out of a choice of 5 essays or short notes. Examples of the questions include:
- “The Chief Executive of your Hospital Trust has received a directive to reduce Sharps Injuries and has asked you to respond. Outline your approach” (March 2001)
- “Describe briefly the role toxins play in diseases caused by THREE of the following bacteria: Bordetella pertussis, Corynebacterium diphtheria, Staphylococcus aureus or Clostridium difficile” (March 2001)
The pass mark was an average of 50% in all of the questions, so if you failed to answer a question or wrote brilliant answers for 3 but messed up the fourth, then you would fail. It was a pretty tough exam for those of us who hadn’t written a proper essay since medical school and cramp in your hand whilst trying to write for 6 hours in a day was a common occurrence and may have been the cause of the high failure rate!
If you passed this exam then you were “invited” to sit the practical exam 4-6 weeks later; the letter did not actually tell you you’d passed, just invited you to attend another gruelling set of tests, part 2 of part 1 - the practical exam. This lasted for 2 ½ days and during this time you were given specimens to process as though you were the Biomedical Scientist. You then had to report and give advice on your results. During this time examiners would wander round the room asking questions about what you were doing, looking at your plates or Gram films and generally causing distraction and mayhem. To top it off you had to keep stopping what you were doing to do spotter exams (where you had to identify pictures) as well as short question papers about result interpretation. You were only allowed to take a Standard Operating Procedure folder of your own making and 1 book in with you. Many people took good old “Mandell Douglas and Bennett’s Principles and Practice of Infectious Diseases”… I took “The Identification of Pathogenic Fungi by the Public Health Laboratory Service (PHLS)”… but more on that later…
At the end of this process you had a 30 minute viva voce exam with two of the examiners… just to finish you off! It was a punishing few days, but it did generate a sense of camaraderie amongst the candidates, hence the “good old days”, I guess.
I can still remember some of the scenarios from my practical exam in Newcastle:
- Brain abscess containing Pseudomonas aeruginosa, Streptococcus anginosus, Bacteroides fragilis and a Coagulase negative Staphylococcus spp. (I had bad laryngitis at the time and managed to cough a Staphylococcus aureus into this sample just to make it even more difficult!), I didn’t get extra points for identifying it!
- An organism that looked and behaved like Vancomycin Resistant Enterococcus but was in fact Leuconostoc spp.
- A stool specimen containing an Escherichia hermanii pretending to be E. coli O157, a Hafnia alvei pretending to be a Salmonella spp. and finally a Campylobacter jejuni which was the pathogen.
- A Gram film from a person with severe pneumonia on ITU which had a Bacillus spp. in it and we were supposed to consider Bacillus anthracis (Anthrax) and the possibility of a bioterrorist event. This was post 911 and everyone was still a bit twitchy.
- Two Candida spp.; no one had time to incubate the old Candida API as it needed reading after 48-72 hours and we only had 24 hours left! The only possible way to identify it was to grow it on corn meal agar and identify it using the book I took with me… I think I was the only person able to give them a name - what a show-off huh?!
I have to say, I quite enjoyed my practical exam (Note from Editor: he is lying, it was hell; hell for him and his fellow examinees and hell for spouses and significant others who had to put up with them!!!). Newcastle put on a good show for us and the choice of questions really tested what we knew.
So with the Part 1 FRCPath out of the way we had to move on to the Part 2. This was taken after about 4 years in post and consisted of a detailed research project (about the standard of an MD project I have been told) followed by an open viva voce exam consisting of 2 one hour exams with two examiners in each who can ask you questions about anything to do with microbiology. I remember questions about how to process a brain abscess sample, Corynebacterium jeikeium line infections, legionellosis and cystic fibrosis microbiology. It was pretty scary but if you had been doing the job day-to-day then there was unlikely to be something that came up which would really catch you out.
So there it was; exam(s) passed. You could now add the letters FRCPath after your name and start to think about finishing your training and looking for Consultant jobs. Easy! (Or “character building”, especially as you only had 4 attempts (costing approx. £1,500 each attempt) before you were no longer entitled to sit the exam again, training over, find a new discipline or end your career as an “associate specialist”).
The exam changed during my training and what was once the old Part 1 became the Part 2. The format was the same but the essay and practical exam where all sat in the same week. The exam was also moved to around the 4th year of training. The research and viva voce were dropped and a new Part 1 consisting of 125 multiple choice (MCQ) questions was introduced.
I’m not really sure why the exam was changed. I expect it was principally because it was getting increasingly difficult to find examiners for the viva voce exam or to mark the research projects. As the essays and practical had long been known to be very hard exams to sit early in training it probably seemed a good idea to move them later in training and introduce a simpler to organise Part 1 which could also be marked by a computer!
So that was how things stood until autumn last year (2017) when a new style exam was introduced.
So what is the new FRCPath exam?
The new FRCPath exam still consists of Part 1 and Part 2; however the format of the exam has changed completely.
The new FRCPath Part 1 exam, also called the Combined Infection Certificate Exam (CICE), consists of 2 exam papers of 100 MCQs each in the style of best of five or single best answer questions where the answers are graded as to which are better than others. Each paper is 2 ½ hours long and both are sat on the same day.
The new FRCPath Part 2 exam consists of two papers, but this Part 2 exam is only for microbiology trainees! Unfair I know but it’s the “exit” exam and I believe what makes us learn (and be tested on) the detail needed to be microbiology consultants, remember we are the “experts” advising other consultants when things go wrong, unexpectedly or something rare and complex presents. Or think of it as “character building”!
The first exam consists of two papers sat on the same day. In Paper 1 candidates have to write ONE essay out of a choice of TWO followed by 10 Structured Answer Questions (SAQs). Paper 2 is also a choice of ONE out of TWO critical appraisal questions followed by another 10 SAQs. Each paper is 3 hours long.
The second exam is another two 3 hour papers and is sat the day after the second exam. Paper 1 consists of 10 long case questions and paper 2 consists of 15 nine minute objective structured pathology exam (OSPE) stations. These questions can cover almost any aspect of microbiology including clinical, laboratory, infection control and antimicrobial stewardship. Two of the OSPE stations involve face-to-face “role-playing” scenarios. What!!! Heck, I’d have hated this!!!
So why has the exam changed?
In my opinion there are a number of factors driving the changes to the FRCPath exam.
Firstly microbiology training has changed. Microbiology training has been combined with infectious diseases training and this is a blog in its own right. However, in a nutshell there is now a period at the beginning of training in “infection related disciplines” that is common to all trainees called Core Infection Training (CIT) regardless of what Higher Specialist Training (HST) you are going to be doing later (microbiology, infectious diseases, tropical medicine, etc.). Whatever HST, you have to do CIT. Not only has training been combined but the exam for this training has also been combined; the FRCPath Part 1 or CICE …gosh doctors and acronyms!
If you are going to be training in microbiology then this exam is your Part 1 and you will have to do Part 2 later in order to get the FRCPath qualification. If you are going to be doing infectious diseases or tropical medicine then you don’t need to do Part 2 and only have to sit the CICE as your final exit exam from training. As a result of this the CICE has to be generic to all specialties and contain questions relating to each area; all trainees taking the exam should have spent some time in both microbiology and infectious diseases during CIT. One issue I see is that the microbiology trainees have to take this exam early (to allow for the later Part 2 exam) but the infectious diseases trainees can take this at any time during training therefore infectious diseases trainees might have a bit of an advantage.
The second reason for changing is the logistical challenges of putting on the practical exam. This exam has become increasingly difficult to arrange as we have fewer and fewer laboratories due to pathology mergers across the country. As laboratories have merged many have become increasingly “disconnected and distant” both physically and “emotionally” from their clinical staff and more in line with a private business model. As a result there is reluctance to “waste” resources on setting an exam plus no extra capacity within willing laboratories to run the exam. This has meant that even if a practical exam was still wanted it is unlikely that all except a few laboratories would ever be able to run them.
The final reason for the change, I suspect, stems from a legal challenge in 2014 faced by the Royal College of General Practitioners (RCGP) and the General Medical Council (GMC) from the British Association of Physicians of Indian Origin (BAPIO) who claimed the Clinical Skills Assessment (CSA) component of the MRCGP exam was “racially discriminatory”. The judicial review by Mr Justice Mitting found the CSA exam to be lawful and fair but did warn the RCGP and GMC that they had to work to “provide better assurance of the fairness of their exams”. This has led to all of the medical colleges looking at their examination processes in order to ensure they can clearly demonstrate that their exams are lawful and fair.
I suspect that the old style practical exam would be hard to defend, post Mr Justice Mitting’s review, as it is hard to control whether all specimens would grow as expected, candidates who had had little experience or access to practical bench level microbiology would probably be “disadvantaged” and an examiner wandering the benches asking random questions could be open to allegations of “unfair practise” or “discrimination”. Because of this it is probably inevitable that the practical exam had to go.
One thing to remember about this exam is that it is for Fellowship of the Royal College of Pathologists UK; it is based on how microbiology is practiced in the UK using UK policies and guidelines. This is very different to how microbiology is practiced in almost any other country (many of which have purely laboratory based microbiologists with the clinical work being done by Infectious Diseases Physicians whereas the in the UK we do a bit of both).
The new styles of exam can all be readily “assessed for fairness” prior to the exam being sat and a pass mark set using something known as Angoff scoring. In this method a panel of experts decide what an imaginary “borderline-pass candidate” would be expected to answer for each question. This process determines the minimum standard expected for each question and therefore the overall pass mark for the exam; this could be 40%, 47%, 53% or whatever the assessors feel is the minimum standard for a pass, which could and will change from exam-to-exam.
So there we have it, a trip down memory lane for those of us who sat the old style FRCPath exam, some explanation for why this style exam had to change and what the new style exam now is. If you are thinking about a career in clinical microbiology you will now take this CICE followed by part 2; if you are doing infectious diseases training you will just sit the CICE. If you are one of our overseas colleagues looking to take the exam to gain the qualification then keep in mind it is based on UK policies and guidelines which can be found here and we may do things very differently to your own country.
So if you are sitting the FRCPath exam good luck, read the questions carefully, have a set plan (blog to follow) and stay calm; I hope it goes well.