Advice for Vivas

Last updated on Jan 4, 2024

It's a sales pitch

You are not trying to teach the examiner about the nuances of muscle relaxant pharmacotherapy, nor are you trying to convince them that you've performed a caudal epidural before.

You are trying to show the examiner that you are a safe, methodical and knowledgeable anaesthetic trainee who is ready to progress to the next stage of training.

This might sound completely obvious but it often gets forgotten in the stress of preparing for a daunting exam.

Yes you need a solid understanding of a wide variety of topics
Yes you need to be able to recite certain numbers and draw certain graphs

But these all feed into the overarching theme of 'I'm a solid anaesthetic trainee', which is the main aim of the exam.

It doesn't matter if you don't know a particular nuanced fact
It is far more important that you come across as calm, methodical and in control
They would much rather a humble and self-aware candidate with some knowledge gaps than an arrogant encyclopaedia who doesn't know when to call for help

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For single mark, closed questions, "I don't know" is better than rambling or guessing.

You are convincing the examiner that you know your stuff, and to do this you should offer it to them in enticing, bitesize chunks that make it easy for them to unpack and tick off on the mark scheme.

Don't try and blurt out everything you know about the question - this is not the aim - instead show them that you have answered this question before, and you know about the topic, by offering them intro categories. Then stop talking.

Allow the examiner to decide what to ask you next. By saying less, you give the impression that you have an encyclopaedic knowledge of both categories, but they need to decide which one to explore further.

Examples of intro categories

Example #1

Tell me about local anaesthetics

"Local anaesthetics reversibly inhibit voltage gated sodium channels in peripheral nerves in a use-dependent fashion. There are two categories - amides and esters."

Okay, so tell me more about an amide that you have used...

Example #2

What are your concerns when anaesthetising a patient with ischaemic heart disease?

"The main concern is balancing myocardial oxygen supply and demand, avoiding myocardial ischaemia and ensuring adequate organ perfusion."

Okay, so what are the determinants of blood flow...?

Remember this is just for the 'information' style questions.

For 'resuscitation' or 'immediate actions' questions, see below.

Action questions

These questions ask you 'what you would do next' and require you to describe a sequence of events or actions appropriate to the scenario.

You should be acting at the level of a core trainee anaesthetist
You should be calling for help or skilled assistance
Always mention ABCDE, and say that you would correct life threatening issues as they arise
You should re-assess after any meaningful intervention
You should know the ALS algorithm inside out

The A-Q checklist that will never fail you

If you're completely stuck on a resuscitation station, and you don't know what's going on, if you do the following you will be absolutely fine.

Airway
Breathing
Circulation - Divert down ALS algorithm if needed
Disability and neurology
Exposure and examination
Fluids and catheter
Glucose
Haematology and bleeding
Infection and antibiotics
Just in case - prepare emergency drugs and equipment
K - potassium
Last gas - anything immediately correctable, anything getting worse?
Myself - if going on a transfer etc - money, food, toilet, phone, charger
Notes
Oxygen - how much does the patient need, have you got enough supply?
Phone calls - do I need help, which departments need to know about this patient and are they expecting them?
Questions - ask other team members, nurses, parents etc if they have any questions

There is nothing that will fall through this net.

You might not have diagnosed the condition exactly, or understand what's going on, but the patient will be alive long enough for someone who can.

"What else could this be?" is far more useful than "I think it's this".

Embrace the silence

Silence is your friend in an exam, if you can learn how to use it.

If you are asked a question, and you pause for five seconds before starting your answer, several things happen:

The initial fear of 'oh god do I know the answer' will reduce substantially
Your ideas will begin to align into a more useful chain of thought
The examiner will feel that you have taken due time to consider the options and think about your response
The examiner will have time to think about their assessment of your answer
You will come across as more measured and in control than if you immediately start rambling

As an examiner, if you hear silence, you assume the candidate is thinking. If you hear 'ummm' you assume the candidate doesn't know what they're talking about.

Five seconds of silence feels like a long time, so it can take some practice to get comfortable using it, but it can absolutely transform your response, and your mark.

Have faith

Learn how you learn, and ignore everyone else
Do not get distracted by other people's stress
Courses work for some people, not for others - not attending a specific course will not ruin your exam chances

Practice

You wouldn't train for a bicycle race by doing hundreds of bicep curls - your training needs to be relevant to the test.

If the exam requires you to talk, you need to practise talking.

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Video yourself answering questions to the camera

Most people hate the way they sound and look when presenting to a camera,

Practice talking to yourself in the mirror, watching your hands and facial expression
If you're going to practice with someone else, find someone who critiques you
If you do a viva practice session with someone and they say 'yeah that was good' and provide no meaningful advice for improvement, then it is not helping you - find someone who will help you improve

Learn the mark schemes

This will not be news to anyone who has sat medical exams - knowing what scores marks and what doesn't is crucial, especially in a time-sensitive verbal exam.

Go to your hospital's library and look through the viva exam preparation books. Many of them will have mark schemes for specific questions, which are invaluable for two reasons:

They tell you what sentences and words score points
They show you which questions and topics keep coming up

They're often looking for specific points that you might not necessarily say unless you know what they want (e.g. mentioning laudanosine when talking about atracurium)

Let them lead you

Every question starts with a feeder, an introduction to get the ball rolling that will then head off down a particular avenue.

The examiner has to stick to this structure, and cannot go off piste.

Tell me about lidocaine - you're probably heading via pKa and ion channels towards local anaesthetic toxicity management
What respiratory changes are seen at altitude? - you're starting at immediate response to hypoxia and ending up at explaining the alveolar gas equation
What does LASER stand for? - after a brief tour of lasing media, you're likely going to be asked how to manage an airway fire or look at a laser-safe tube

The point is you as the candidate don't know where you're heading, but the examiner does. So you want to answer the initial question that they ask you, and then stop.

Do not waste time waffling about about what you think they want to know, just let them show you the way.

It's better to drop a mark at the start but finish the whole question than to miss out half the station due to time constraints.

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The examiner is trying to help you - let them!

Draw Big

You're probably going to have to draw a graph or sketch something during the SOE component of your exam.

Use the whole sheet of paper for each graph - they have more paper.

A large graph not only looks better and is easier to draw, it gives off vibes of confidence and authority that will work in your favour.

Talk while you draw

This takes practice, so invest time early in your revision working out how you like to do it best.

Some prefer to draw the axis and labels, then start talking
Others start talking immediately

You will have your own style, but you only find out what that is by practising.

Body language

None of this will come as new information, but it makes such a difference that it bears repeating:

Dress smart
Sit still
Relaxed but attentive posture
Maintain eye contact - but not too much
Be polite and humble
Take your time
Try and look like you're interested and enjoying talking about science!

If you don't pass

You're allowed to feel spectacularly rubbish.

However please don't feel that it makes you a rubbish anaesthetist. Even the best sports teams lose from time to time, they're still pretty darn good.

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It is widely agreed that a single, high-stakes exam does not accurately measure the quality of an anaesthetist

First, allow yourself time to diffuse and treat yourself to some self-care
Try to take one learning point away from the experience
View it as the most realistic exam preparation course you could ever hope to attend

If the RCOA set up an optional SOE practice course, with real examiners, real exam stations and a true-to-life marking experience, a lot of people would pay to go on that course to prepare for the exam.

If you can pretend that you just did exactly that, it might take some of the nerves away next time.

Then try try again - and remember we're here to help!

Primary FRCA Toolkit

This is our tailor-made resource for the Primary exam, particularly geared towards the OSCE/SOE component.

The information is laid out as viva-style questions, and answered in the structure expected for the exam.

Members receive 60% discount off the FRCA Primary Toolkit. If you have previously purchased a toolkit at full price, please email anaestheasier@gmail.com for a retrospective discount.

Discount is applied as 6 months free membership - please don't hesitate to email Anaestheasier@gmail.com if you have any questions!

Just a quick reminder that all information posted on Anaestheasier.com is for educational purposes only, and it does not constitute medical or clinical advice.