Intercollegiate Committee For Basic Surgical Examinations .
Intercollegiate Committee for BasicSurgical ExaminationsGuide to the intercollegiate MRCSexaminationJanuary 2013(Amended July 2018)Page 1
Guide to the intercollegiate MRCSexaminationAugust 2017The Intercollegiate Committee for Basic Surgical Examinations (ICBSE) hasproduced this guide to the intercollegiate MRCS examination. It contains thefollowing sections.Section 1 – Background and overviewPage 3Section 2 – Recommended textbooks and other resourcesPage 5Section 3 – Topics and skills that may be examined in the MRCS Page 7Section 4 – The intercollegiate MRCS examinationPage 19Section 5 – Part A information and sample questionsPage 20Section 6 – Part B information and sample questionsPage 28ICBSE gratefully acknowledges the contribution of the following to the production ofthis guide: the Intercollegiate Surgical Curriculum Programme contributors, the MCQpaper panel, the Question Quality group, the OSCE subgroup, the MRCS Syllabusgroup and the MRCS examination departments of the surgical Royal Colleges.Note that this guide is a living document that will change over time. Please check theintercollegiate MRCS website for Page 2
Section 1 – Background and overviewBackgroundThe complete MRCS syllabus is contained within the General Medical Council(GMC)-approved curriculum for the Early Years of Surgical Training in the UnitedKingdom and reflects the Core Surgical Training Syllabus of the IntercollegiateSurgical Curriculum Project (http://www.iscp.ac.uk). The curriculum is competencebased, requiring the trainee to demonstrate both applied and theoretical knowledgeand practical skills, together with the professional behaviours described in the GoodMedical Practice document of the General Medical Council of the United Kingdom(http://www.gmc-uk.org/).The MRCS examination is an integral part of this Early Years training programmeand is a requirement for progression to higher surgical training in the United Kingdomtogether with a satisfactory progression of training evaluated using the workplacebased assessments in the trainee’s Annual Review of Competency Progression(ARCP).A central aim of the MRCS examination is to test aspiring surgeons over a broadrange of surgical conditions and not just the area of surgery they hope to train in.ICBSE believes that many aspects of the different surgical specialties require thesame core areas of applied basic knowledge and skills and that these are essentialboth for successful higher training and to achieve a surgeon’s full clinical andacademic potential.This guide has been produced in order to indicate to candidates and their tutors theextent and level of knowledge that is required to pass the MRCS examination. Eachexamination will contain a range of questions that cover a representative sample ofthe syllabus but not every topic will be tested on each occasion.Page 3
OverviewThe purpose of core training (CT1–CT2), and early years training in the run-throughspecialities (ST1– ST2), is to provide trainee surgeons with the essential knowledgeand skills common to all surgical specialties. During the early years of training someadditional specialty-specific experience and skills will inevitably be obtained.However, the MRCS examination will only test knowledge at the level expected of alltrainees completing core training irrespective of their chosen specialty.The syllabus is divided into 10 modules:Module 1Basic science knowledge relevant to surgical practiceModule 2Common surgical conditionsModule 3Basic surgical skillsModule 4The assessment and management of the surgical patientModule 5Perioperative care of the surgical patientModule 6Assessment and early treatment of the patient with traumaModule 7Surgical care of the paediatric patientModule 8Management of the dying patientModule 9Organ and tissue transplantationModule 10Professional behaviour and leadership skillsPage 4
Section 2 – Recommended textbooks and otherresourcesBasic science textbooksAnatomyAgur AMR, Dailey AF. Grant's Atlas of Anatomy, 12e. Lippincott, Williams & Wilkins,2008.Netter FH. Atlas of Human Anatomy, 5th edn. Saunders, 2010.Sinnatamby CS. Last’s Anatomy: Regional and Applied, 12th edn. ChurchillLivingstone, 2011.PhysiologyBarrett KE, Barman SM, Boitano S, Brooks HL. Ganong's Review of MedicalPhysiology, 23rd edn. McGraw-Hill, 2009.PathologyKumar V, Abbas AK, Fausto N, Mitchell R. Robbins Basic Pathology, 8th edn.Saunders, 2007.Clinical textbooksGarden OJ, Bradbury AW, Forsythe JLR, Parks RW. Principles and Practice ofSurgery, 5th edn. Elsevier, 2007.Williams NS, Bulstrode CJK, O’Connell PR, eds. Bailey and Love's Short Practice ofSurgery, 25th edn. Hodder Arnold, 2008.Courses and websitesATLS courseCCrISP courseIntercollegiate basic surgical skills courseGeneral Medical Council. Good Medical Practice. http://www.gmcuk.org/guidance/good medical practice.aspThe knowledge required for the MRCS examinationAs a guide, the level of knowledge required to pass the MRCS examination can beobtained by studying the recommended texts listed above. Trainees should havemastery of the subjects outlined in the syllabus to the depth covered within thesetexts and should be able to make use of that knowledge in the context of surgicalpractice.The curriculum and MRCS examination require a professional approach fromsurgical trainees. It is expected that trainees will read beyond these recommendedtexts and, where appropriate, make critical use of original papers and review articlesin the related scientific and clinical literature, so that they may aspire to achieve anexcellent standard in their surgical practice.Page 5
The recommended texts provide a clear guide to the extent and depth of knowledgerequired but alternative text books and online publications may suffice. Over time,changes in the curriculum and syllabus will inevitably occur, and it is anticipated thatthose who manage this process will provide an up-to-date list of relevantrecommended texts.Page 6
Section 3 – Topics and skills that may be examined inthe MRCSModule 1 Basic sciencesObjectiveTo acquire and demonstrate sufficient knowledge of the basic scientific principleswithin the six categories listed below to understand, investigate and manage thecommon surgical conditions specified in module 2:1 applied surgical anatomy2 applied surgical physiology3 applied surgical pathology (principles underlying system-specific pathology)4 pharmacology (centred around the safe prescribing of common drugs) as appliedto surgical practice5 microbiology as applied to surgical practice6 imaging (principles, advantages and disadvantages of various diagnostic andinterventional imaging methods)Knowledge1. Applied Surgical Anatomy Regional anatomy of thorax, abdomen, pelvis, perineum, limbs, spine, head andneck. Microscopic anatomy of tissues and organs of surgical relevance. Surgically related embryology and development. Surface anatomy. Imaging anatomy.2. Applied Surgical Physiology General physiological principles including:o homeostasiso thermoregulationo metabolic pathways and abnormalitieso blood loss and hypovolaemic shocko sepsis and septic shocko fluid balance and fluid replacement therapyo acid–base balanceo bleeding and coagulationo nutrition. The physiology of specific organ systems relevant to surgical practice includingthe cardiovascular, respiratory, gastrointestinal, urinary, endocrine andneurological systems.3. Applied Surgical Pathology General pathological principles including:o inflammationo wound healingo cellular injuryo tissue death including necrosis and apoptosiso vascular disorderso disorders of growth, differentiation and morphogenesis. Surgical immunology. Surgical haematology. Surgical clinical chemistry. Principles of neoplasia and oncology including:o classification of tumourso tumour development and growth including metastasiso staging and grading of cancersPage 7
o cancer therapy including surgery, radiotherapy, chemotherapy,immunotherapy and hormone therapyo cancer registrationo cancer screening. The pathology of specific organ systems relevant to surgical care including thecardiovascular, respiratory, gastrointestinal, genitourinary, central and peripheralneurological, skin, lymphoreticular and musculoskeletal systems; and pathologyof the breast, endocrine and exocrine glands.4. Pharmacology as applied to surgical practice The pharmacology and safe prescribing of drugs used in the treatment ofsurgical diseases including analgesics, antibiotics, cardiovascular drugs, antiepileptics, anticoagulants, respiratory drugs, renal drugs, drugs used for themanagement of endocrine disorders (including diabetes) and local and generalanaesthetics.5. Microbiology as applied to surgical practice Surgically important micro-organisms including bloodborne viruses. Soft tissue infections including cellulitis, abscesses, necrotising fasciitis,gangrene. Sources of infection. Sepsis and septic shock. Asepsis and antisepsis. Principles of disinfection and sterilisation. Antibiotics including prophylaxis and resistance. Principles of high-risk patient management. Hospital-acquired infections.6. Imaging Core knowledge of diagnostic imaging and interventional techniques to includebasic interpretation of X-rays, ultrasound, CT, MRI, PET and radionuclidescanning.Module 2 Common congenital and acquired surgicalconditionsObjective To demonstrate understanding of the relevant basic scientific principles(described in Module 1) for each of these surgical conditions and to be able toprovide the relevant clinical care as defined in Modules 4 and 5.This module lists within nine topics the common surgical conditions, affecting bothadults and children, for which trainees need to be able to demonstrate understandingof the relevant basic science specified in Module 1 in order to provide the clinicalcare described in Modules 4 and 5. These topics are: gastrointestinal disease; breastdisease; vascular disease; cardiovascular and pulmonary disease; genitourinarydisease; trauma and orthopaedics; diseases of the skin, head and neck; neurologyand neurosurgery; and endocrine disease.Gastrointestinal diseasePresenting symptoms or signs Dysphagia Vomiting Abdominal pain Dyspepsia Abdominal mass Abdominal distension Change in bowel habit Intestinal obstructionPage 8
Gastrointestinal haemorrhage Rectal bleeding JaundiceTo include the following conditions Common congenital anomalies Benign and malignant disease of oesophagus, stomach, small and large boweland appendix Perianal and rectal disease Benign and malignant disease of the liver, gall bladder, pancreas and spleen Abdominal wall hernia and stomas Acute abdominal emergencies, including adhesions, peritonitis and perforation ofa viscus. Acute presentation of gynaecological pathologyBreast diseasePresenting symptoms or signs Pain and tenderness Breast lump Nipple discharge GynaecomastiaTo include the following conditions Benign and malignant breast disease Mastitis and breast abscessVascular diseasePresenting symptoms or signs Common congenital anomalies Intermittent claudication Ischaemic rest pain Gangrene and ischaemic ulceration Acute limb ischaemia (embolism, thrombosis) Leg ulceration Varicose veins Swollen leg Pulsatile abdominal mass Transient ischaemic attacks and strokeTo include the following conditions Atherosclerotic arterial disease affecting the cerebral, mesenteric, renal andupper and lower limb arteries Embolic and thrombotic arterial occlusive disease Diseases of the veins and lymphatics Vascular and neuropathic consequences of diabetes Abdominal and peripheral arterial aneurysms Amputations and rehabilitationCardiovascular and pulmonary diseasePresenting symptoms or signs Breathlessness and leg swelling Chest pain Cough and haemoptysis Cardiac arrhythmias and murmursTo include the following conditions Common congenital anomalies Coronary heart disease Diseases of the heart valves Cardiac failurePage 9
Benign and malignant lung disease including:o obstructive airways diseaseo restrictive lung diseaseo acute and chronic respiratory infectiono bronchial carcinomaGenitourinary disease in males and femalesPresenting symptoms or signs Loin pain Haematuria Lower urinary tract symptoms (painful micturition, frequency) Urinary retention Renal failure Scrotal swellings Testicular pain Penile pathology Acute gynaecological symptomsTo include the following conditions Common congenital anomalies Genitourinary malignancy Urinary calculus disease Urinary tract infection Benign prostatic hyperplasia Obstructive uropathy and urine diversion Testicular tumours and benign scrotal swelling Penile ulcers and carcinoma Gynaecological conditions relevant to the general surgeonTrauma and orthopaedicsPresenting symptoms or signs Traumatic limb and joint pain and deformity Chronic limb and joint pain and deformity Back painTo include the following conditions Common congenital anomalies Simple fractures and joint dislocations Fractures around the hip and ankle Degenerative and inflammatory joint disease Bone and joint infection Compartment syndrome Spinal nerve root entrapment and spinal cord compression Metastatic bone cancer Metabolic bone disease Common peripheral neuropathies and nerve injuries Amputations and rehabilitationDiseases of the skin, head and neckPresenting symptoms or signs Common congenital anomalies Skin lesions Palpable neck lumps Common neck swelling, including salivary glands Lesions of the oral cavity Upper airway obstruction Ear pain and hearing lossTo include the following conditionsPage 10
Benign and malignant lesions of the skin, head and neck, including mouth,tongue and earNeurology and neurosurgeryPresenting symptoms or signs Headache Facial pain Visual impairment Confusion and memory loss ComaTo include the following conditions Common congenital anomalies Space-occupying lesions from bleeding and tumour Cranial and peripheral nerve palsies General features of cerebral abscess and meningitisEndocrine diseasePresenting symptoms or signs Thyroid nodules and goitre Acute endocrine crisesTo include the following conditions Common congenital anomalies Thyroid and parathyroid disease Adrenal gland disease DiabetesDiseases of the Lymphoreticular systemPresenting symptoms or signs Lymphadenopathy HepatosplenomegalyTo include the following conditions Benign and malignant tumours ImmunosuppressionModule 3 Basic surgical skillsObjectives Understanding the principles of safe surgery Preparation of the surgeon and patient for surgery Safe administration of appropriate local anaesthetic agents Acquisition of basic surgical skills in instrument and tissue handling including:o incision of superficial tissues accurately with suitable instrumentso closure of superficial tissues accuratelyo tying secure knotso safe use of surgical diathermyo haemostasis of superficial vesselso methods of retractiono use and selection of drainso handling tissues gently with appropriate instruments Biopsy techniques Appropriate use of assistants Understanding the formation and healing of surgical woundsKnowledgePage 11
Principles of safe surgery Preparations for surgery Hand washing, scrubbing and gowning Use of surgical checklists including WHOAdministration of local anaesthesia Choice of anaesthetic agent Safe practiceSurgical wounds Classification Principles of wound management Pathophysiology of wound healing Scars and contractures Incision of skin and subcutaneous tissue:o Langer’s lineso choice of instrumento safe practice Closure of skin and subcutaneous tissue:o options for closureo suture and needle choiceo safe practice Knot tying:o range and choice of materials for suture and ligationo safe application of knots for surgical sutures and ligatures Haemostasis:o surgical techniqueso principles of diathermy Tissue handling and retraction:o choice of instruments Use of drains:o indicationso typeso management/removalBiopsy techniquesPrinciples of skin cover (skin grafts and flaps)Principles of safe anastomosisTechnical skills and proceduresPreparation of the surgeon for surgery Effective and safe hand washing, gloving and gowningPreparation of a patient for surgery Creation of a sterile field Antisepsis DrapingAdministration of local anaesthesia Accurate and safe administration of local anaesthetic agentIncision of skin and subcutaneous tissue Ability to use scalpel, diathermy and scissorsClosure of skin and subcutaneous tissue Accurate and tension-free apposition of wound edgesKnot tying Single handed Double handed Instrument Superficial DeepPage 12
Haemostasis Control of bleeding vessel (superficial) Diathermy Suture ligation Tie ligation Clip application Transfixion sutureTissue retraction Use of tissue forceps Placement of wound retractorsUse of drains Insertion Fixation RemovalTissue handling Appropriate application of instruments and respect for tissues Biopsy techniquesSkill as assistant Anticipation of needs of surgeon when assistingModule 4 The assessment of the surgical patientObjectiveTo demonstrate the relevant knowledge, skills and attitudes in assessing thesurgicalpatient.Clinical skills Surgical history and examination (elective and emergency) Constructing a differential diagnosis Planning and interpreting investigations Clinical decision making Team working and planning Case work-up and evaluation Taking consent for intermediate-level intervention, emergency and elective Interactive clinical communication skills: patients Interactive clinical communication skills: colleagues Principles of obtaining consent from vulnerable and non-competent adultsModule 5 Perioperative managementObjectives Preoperative assessment and management. Intraoperative care, including managing patient care in the perioperative periodand conducting safe surgery in the operating theatre environment. Postoperative care including the assessment of common complications. Assessment and management of bleeding including the use of blood products. Coagulation, deep venous thrombosis and embolism. Use of antibiotics. Assessment and planning of perioperative nutritional management. Metabolic and endocrine disorders in relation to perioperative management.Knowledge and clinical skillsPreoperative assessment and management Cardiorespiratory physiology Diabetes mellitus and other relevant endocrine disorders Fluid balance and homeostasis Renal failurePage 13
Pathophysiology of sepsis – prevention and prophylaxisThromboprophylaxisLaboratory testing and imagingRisk factors for surgery and scoring systemsPre-medication and other preoperative prescribingImmunisation protocols for surgeons and patientsIntraoperative care Safety in theatre including patient positioning and avoidance of nerve injuries Sharps safety Diathermy, laser use Infection risks Radiation use and risks Tourniquet use including indications, effects and complications Principles of local, regional and general anaesthesia Principles of invasive and non-invasive monitoring Methods of prevention of venous thrombosis Surgery in hepatitis and HIV carriers Fluid balance and homeostasis Temperature regulation Principles of cardiopulmonary bypassPerioperative care Principles of enhanced recovery following complex surgery to include basicprotocols and potential clinical benefitsPostoperative care Postoperative monitoring Cardiorespiratory physiology Fluid balance and homeostasis Diabetes mellitus and other relevant endocrine disorders Renal failure Ileus Pathophysiology of blood loss Pathophysiology of sepsis including SIRS and shock Multiorgan dysfunction syndrome Postoperative complications in general Methods of postoperative analgesiaNutritional management Methods of screening and assessm
the MRCS Module 1 Basic sciences Objective To acquire and demonstrate sufficient knowledge of the basic scientific principles within the six categories listed below to understand, investigate and manage the common surgical conditions specified in module 2: 1 applied surgical anatomy 2 applied surgical physiology
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