Visual Element: An infographic timeline titled "The Road to Fellowship," showing the 12-18 month preparation phase, study group formation, trial exam period, and the final exam week structure.

The Summit of Surgical Training

The Fellowship of the Royal Australasian College of Surgeons (FRACS) examination is widely regarded as one of the most difficult specialist examinations in the world. It is the gatekeeper to consultancy. It is not just a test of knowledge; it is a test of stamina, safety, and psychological resilience.

To pass, you must understand the rules of the game. This guide breaks down the exam structure component by component.

Exam Components Overview

The exam is split into four distinct sections, usually held over 2-3 days (Written/ISAWE) and then a separate Clinical week.

1. The Written Paper (MCQ)

This is a test of breadth.

• Format: 150 Questions. "Type X" (True/False).
• The Structure: Each question has a stem and 5 items. You must mark each item as True or False.
• Scoring: There is usually no negative marking (check current year regulations). This means you must answer every single option.
• Content:
  • Trauma: ~25% (The biggest chunk).
  • Adult Recon: ~15%.
  • Subspecialties: ~10% each (Hand, Foot, Paeds, Spine, Sports, Onc).
  • Basic Science: Statistics, Tribology, Immunology.

Trap: The "Double Negative." Questions like "Which of the following are NOT contraindications?" Read the stem twice.

2. ISAWE (Integrated Clinical/Imaging)

ISAWE stands for Interactive Scenario Assessment With Examiner (though now computer-based).

• Format: ~50 scenarios.
• Time: ~2.5 minutes per scenario.
• The Stimulus: High-quality monitors displaying X-rays, MRI slices, histology slides, or clinical photos.
• The Task: Type short answers. "Diagnosis?", "Pathology?", "Next step?".
• Strategy:
  • Be Specific: Don't just write "Fracture." Write "Commuted intra-articular distal radius fracture with dorsal tilt."
  • Don't Linger: If you don't know it, guess and move on. The clock does not stop.
  • Pattern Recognition: This section rewards those who have looked at thousands of images.

3. Clinical Viva (The "Patient" Stations)

This is the heart of the exam. You will rotate through 6 stations (usually 15 mins each).

• The Setup: Two examiners. Real patients (or actors for history).
• Short Cases (5 mins): "Examine this hip."
  • Goal: Demonstrate a slick, automated, professional examination routine. Pick up the signs (scars, wasting, ROM). Synthesize a diagnosis.
• Long Cases (10 mins): "Take a history from this patient with back pain."
  • Goal: Uncover the red flags, the social impact, and formulate a management plan.

Examiner Tip: "I am not looking for a professor. I am looking for a colleague. Is this candidate safe? Would I let them cover my on-call?" Safety is the #1 marking criterion.

4. Operative Viva (Surgical Anatomy & Technique)

This tests your ability to do the job.

• Stations: 6 stations × 15 mins.
• Props: Bones, Sawbones models, instruments, implants on the table.
• The Questions:
  • "Position the patient for a posterior approach to the hip."
  • "Mark your incision."
  • "What structure is at risk here?"
  • "How do you fix this fracture?"
  • "The screw strips. What do you do now?" (The bail-out question).

Clinical Pearl: When describing surgery, use the "Position, Incision, Deep Dissection, Action, Closure" framework. Never jump straight to the bone.

The Marking System: Modified Angoff

The FRACS exam does not have a fixed pass mark (e.g., 50%). It uses the Modified Angoff method.

1. A panel of experts reviews every question.
2. They ask: "What percentage of borderline safe candidates would get this right?"
3. The average becomes the "Cut Score."
4. This ensures fairness. If the exam is harder one year, the pass mark drops.

Preparation Strategy: The 18-Month Timeline

• 18-12 Months Out: Read the big books (Miller, AAOS). Cover the syllabus broadly.
• 12-6 Months Out: Form a study group. Practice Vivas 2-3 times a week. Start doing MCQ banks daily.
• 6-3 Months Out: Intensive Viva practice. Visit other hospitals to get "grilled" by consultants you don't know.
• 3-0 Months Out: Refinement. Memorize the classification systems and lists. Stop learning new concepts; consolidate what you know.

Conclusion

The FRACS exam is a beast, but it is a conquerable beast. It rewards consistency, system, and safety. It punishes arrogance and dangerous decision-making.

Orthovellum's Role: We have built our platform specifically to mirror this format. Our MCQs use the X-Type logic. Our Topics are structured for Viva recall. Our Image Bank prepares you for ISAWE.

Use the tools. Put in the hours. Join the Fellowship.

References

1. Royal Australasian College of Surgeons (RACS). "Fellowship Examination Policy."
2. Orthopaedic Association (AOA). "Training Regulations and Curriculum."