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FIRST EXAMINATION FOR THE FELLOWSHIP IN CLINICAL RADIOLOGY

Curriculum and Information: General


1 INTRODUCTION

1.1 The First Examination for the Fellowship in Clinical Radiology comprises two
modules: Physics and Anatomy.

1.2 The purpose of the curriculum is to provide those undertaking specialty training in
clinical radiology with appropriate knowledge of the physical principles that
underpin diagnostic medical imaging and of the anatomy needed to perform and
interpret radiological studies. When linked with other training in clinical radiology,
this will lead to the safe and effective application of diagnostic imaging for the
benefit of patients.

1.3 It is intended that the curriculum should be delivered during the first year of
specialty training. This is expected to take about 40-45 hours of formal physics
teaching and 30 hours of focussed anatomy teaching, over a period of about six
months. This should be supplemented by practical training and private study of
material recommended by trainers.

1.4 Assessment is in the form of the First FRCR Examination, which is held three
times a year. The format of the assessment is different for each of the two
modules and details of each are given in the relevant syllabus component later in
this document. The two modules will be scheduled so that both may be
attempted at the same sitting, although not necessarily at the same venue.

1.5 The curriculum has been developed by the Physics Working Group and Anatomy
Working Group, and agreed by the Fellowship Examining Board and the
Education Board of the Faculty of Clinical Radiology of the Royal College of
Radiologists. It has been approved by the Postgraduate Medical Education and
Training Board (PMETB) as an integral and mandatory component of specialty
training in clinical radiology. It is kept under review and will be revised as
appropriate.

1.6 The curriculum is presented in two separate syllabus components, one for each
of Physics and Anatomy. These are laid out later in this document, along with
the aims and learning objectives for each, and details of the assessment for each
of the modules.


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2 EXAMINATION STRUCTURE

2.1 The First FRCR Examination is held three times a year: normally in March, J une
and September. Each of the two modules is held at each sitting.

2.2 There is no limit on the number of times that a candidate may attempt either the
examination overall or either of the modules. A candidate may attempt the
modules at the same sitting or at separate sittings and may pass them either
together or separately in any order. Once a pass has been obtained in a module
there is no requirement to resit it. A candidate will be deemed to have achieved
overall success at the First FRCR Examination once both modules have been
passed.

2.3 No minimum period of clinical experience or clinical radiology training needs to
have been completed in order to enter the examination. No confirmation of
course attendance is required. Candidates undergoing specialty training in the
UK require the signature of their training programme director on their application
form each time they attempt the examination in order to confirm that the number
and combination of modules to be taken are appropriate.

2.4 Candidates who attempted the First FRCR Examination in any of its previous
formats without achieving success but without reaching the attempt limit (ie fewer
than four attempts prior to the Winter 2002 sitting and/or fewer than three
attempts between the Winter 2002 and Spring 2009 sittings) are permitted to
enter the current format examination.

2.5 Candidates who reached the attempt limit for a previous format of the
examination without achieving success (ie four attempts prior to the Winter 2002
sitting or three attempts between the Winter 2002 and Spring 2009 sittings) are
not permitted to enter the current format examination.

2.6 In considering the eligibility of candidates who attempted the First FRCR
Examination prior to the Winter 2002 sitting, attempts made at examinations that
granted exemption from it will be taken into account.

2.7 No exemption is granted from the First FRCR Examination on the basis of
success in any other examination.

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FIRST EXAMINATION FOR THE FELLOWSHIP IN CLINICAL RADIOLOGY


Curriculum and Information: Physics


3 INTRODUCTION

3.1 The purpose of the curriculum is to provide those undertaking specialty training in
clinical radiology with appropriate knowledge of the physical principles that
underpin diagnostic medical imaging. When linked with other training in clinical
radiology, this should lead to the safe and effective application of diagnostic
imaging for the benefit of patients.

3.2 It is intended that the curriculum should be delivered during the first year of
specialty training. This is expected to take about 40-45 hours of formal physics
teaching, during the early months of specialty training, supplemented by practical
training and private study of material recommended by trainers. Basic
knowledge of physics and mathematics is assumed.

3.3 Assessment is in the form of a written multiple choice question (MCQ) paper.
Further detail is given in Section 7 of this document and in the "Guidance Notes
for Candidates", which are published on the College's website: www.rcr.ac.uk.


4 AIMS OF THE CURRICULUM

4.1 Provide appropriate knowledge of the physical principles that underpin the
following diagnostic medical imaging modalities: planar (projection)
x-radiography, x-ray fluoroscopy, x-ray computed tomography (CT), ultrasound
imaging, magnetic resonance imaging (MRI), planar (projection) radionuclide
imaging, single photon emission computed tomography (SPECT) and positron
emission tomography (PET).

4.2 Describe how the concepts of risk, safety and quality apply in these imaging
modalities including the responsibilities of individuals and organisations.

4.3 Provide sufficient understanding of the principles underlying each imaging
modality to enable selection of the most appropriate modality for a particular
clinical situation, to select the optimal operating factors, to interpret the images
produced, to communicate the results and to discuss the complete imaging
process with professional colleagues.

4.4 Assist trainees to satisfy the requirements for adequate training in order to carry
out professional roles in medical diagnostic imaging as specified by UK
legislation and guidance.


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5 LEARNING OBJECTIVES

Those who have followed the curriculum should be able to:

5.1 Describe the structure and properties of matter, the phenomena of radioactivity
and magnetism, the nature of ionising radiation, radiofrequency radiation and
ultrasound and how they interact with matter.

5.2 Distinguish between different types of diagnostic medical image and understand
how such images are created, reconstructed, processed, transmitted, stored and
displayed.

5.3 Describe the construction and function of medical imaging equipment including
the radiation or ultrasound source, image-forming components and image or
signal receptor.

5.4 Indicate how imaging equipment is operated and describe the imaging
techniques that are performed with such equipment.

5.5 Identify the type of information contained in images from different modalities.

5.6 Distinguish between different indices of image quality, explain how they are
inter-related and indicate how they are affected by changing the operating factors
of imaging equipment.

5.7 Identify agents that are used to enhance image contrast and explain their action.

5.8 Explain how the performance of imaging equipment is measured and expressed.

5.9 Describe the principles of quality assurance and outline how quality control tests
of imaging equipment are performed and interpreted.

5.10 Recognise artefacts in medical images and identify how they are removed or
their impact is reduced.

5.11 Recognise the hazards and risks to patients, members of staff and members of
the public associated with medical imaging and describe how their impact is
reduced without compromising diagnostic image quality.

5.12 Identify the major pieces of UK legislation and guidance that affect the practice of
medical imaging and interpret their requirements.


6 EXAMINATION SYLLABUS

The syllabus is intended as a guide and general indication to the breadth of the topics
that may appear in the examination questions. It is not a teaching plan and the bullet
points do not relate to equal amounts of study time. The syllabus should be studied to
a depth sufficient to allow the learning objectives in Section 5 above to be achieved.

6.1 Principles of medical diagnostic imaging
Projection (planar) and tomographic images
Analogue and digital images
Structure of digital images
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Digital image processing, fusion, transmission and storage
Display and viewing of analogue and digital images
Picture Archiving and Communications Systems (PACS)
Quality assurance

6.2 Common themes for all imaging modalities
Image formation
Image quality - contrast, noise, contrast resolution and spatial resolution
Contrast agents
Image processing and analysis
Equipment performance measurement, test objects and quality control
Image artefacts
Hazards, risks and safety

6.3 Matter and radiation
Structure of matter, the atom and the nucleus
Nature and properties of charged particle and electromagnetic radiation
Interaction of electrons with matter
Production of x-rays
Interaction of high energy photons with matter
Filtration of x-ray beams
Electron energy in solids
Luminescence

6.4 Ionising radiation dose
Absorbed dose and kinetic energy released to matter
Effects of ionising radiation on living tissue
Equivalent dose and effective dose
Radiation risk
Population dose from natural and artificial sources

6.5 Radiography with x-rays
Construction, function and operation of computed and digital radiographic
systems
X-ray tube and x-ray beam
Image receptors for computed and digital radiography
Scatter rejection
Contrast media iodine, barium and air
Dual energy radiography
Film-screen radiography
Mammography
Radiographic tomography and tomosynthesis

6.6 Fluoroscopy with x-rays
Construction, function and operation of a fluoroscopy system
Image receptor image intensifier and flat panel detector
Scatter rejection
Automatic brightness control
Image digitisation
Angiography with contrast media, including digital subtraction techniques

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6.7 Safety in radiography and fluoroscopy with x-rays
Radiation detectors and dose meters
Measurement of absorbed dose and dose rate in air
Estimation of patient absorbed dose
Typical dose-area products, entrance surface doses and effective doses in
radiography and fluoroscopy
Detector dose indicators
Factors affecting radiation dose
Time, distance and shielding for dose reduction
Children and pregnant patients
Estimation and control of radiation dose to staff and members of the public
Operational dose quantities
Personal dosimetry
Pregnant staff

6.8 Radioactivity
Nuclear stability
Mechanisms of radioactive transformation
Nuclear energy states and gamma emission
Activity and radioactive decay
Natural radioactivity
Artificial radionuclides and their production
Radiopharmaceuticals and their production

6.9 Planar radionuclide imaging
Construction, function and operation of a digital gamma camera
Imaging collimators
Image receptor scintillation detector
Scatter rejection
Static, whole-body, dynamic and gated imaging

6.10 Safety in planar radionuclide imaging
Activity measurement with radionuclide calibrator
Estimation of patient absorbed dose
Typical activities and effective doses
Factors affecting radiation dose
Time, distance and shielding for dose reduction
Children and conception, pregnancy and breast-feeding in patients
Estimation and control of radiation dose to staff and members of the public
Pregnant staff
Contamination and environmental dose rate monitoring
Storage, handling and transportation of radioactive substances
Storage and disposal of radioactive waste

6.11 UK framework for ionising radiation protection
Hierarchy of recommendations, legislation and guidance
J ustification, optimisation and dose limitation
Ionising Radiations Regulations 1999 and Approved Code of Practice
Risk assessment, restriction of exposure and dose monitoring
Radiation Protection Adviser and Radiation Protection Supervisor
Local Rules and work procedures
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Designation of working areas and classification of workers
Dose limits and dose constraints
Comforters and carers
Ionising Radiation (Medical Exposure) Regulations 2000, Notes on Good
Practice and 2006 amendment
Duty holders and their training and responsibilities
Employers procedures
Diagnostic reference levels
Exposures for research, health screening and medico-legal purposes
Medicines (Administration of Radioactive Substances) Regulations 1978 and
1995 and 2006 amendments
Administration of Radioactive Substances Advisory Committee and Notes for
Guidance
Radioactive Substances Act 1993
Registration to hold radioactive substances
Authorisation to store and dispose of radioactive waste
Medical and Dental Guidance Notes
Notification and reporting of radiation incidents

6.12 Tomographic reconstruction
Angular and linear sampling of projection data
Filtered back-projection and reconstruction filters
Iterative reconstruction

6.13 X-ray computed tomography
Construction, function and operation of a CT scanner
Helical and multi-slice scanners
Image reconstruction
CT angiography, CT fluoroscopy and gated imaging
Radiation dose to patients, staff and the public
Radiation safety and factors affecting radiation dose

6.14 Single photon emission computed tomography
Construction, function and operation of a rotating multi-head gamma camera
Image reconstruction
SPECT/CT
Radiation safety and factors affecting radiation dose
Typical activities and effective doses to patients, staff and the public

6.15 Positron emission tomography
Construction, function and operation of a multi-detector ring system
2D and 3D acquisition
Image reconstruction
PET/CT
Radiation safety and factors affecting radiation dose
Typical activities and effective doses to patients, staff and the public

6.16 Nuclear magnetic resonance
Nuclear spin angular momentum and nuclear magnetic moment
Bulk magnetisation and the effect of magnetic field strength
Precession in a magnetic field and the Larmor equation
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Resonance with radiofrequency pulses
Relaxation mechanisms and relaxation times
Free induction decay signal

6.17 Magnetic resonance imaging
Construction, function and operation of a superconducting MRI scanner
Permanent and resistive magnets
Radiofrequency receiver coils
Spin-echo pulse sequence
Spatial localisation of the signal
K-space, image acquisition and image reconstruction
Multi-echo, fast spin-echo and single shot techniques
Gradient echo imaging basic spoiled and non-spoiled techniques
Tissue suppression methods short TI inversion recovery (STIR), fluid
attenuated inversion recovery (FLAIR) and fat saturation
Basic principles of diffusion techniques
Standard gadolinium extracellular space contrast agents
MR angiography
Spatial misregistration, chemical shift, susceptibility, motion, flow and other
artefacts

6.18 Safety in magnetic resonance imaging
Static magnetic field projectiles, induced voltage, implants
Fringe field and controlled area
Time-varying gradient fields eddy currents, stimulation, implanted devices,
acoustic noise
Radiofrequency fields specific absorption rate, heating
Safety of patients, staff and members of the public
Pregnant patients
Shielding and imaging room design
Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use

6.19 Physics of ultrasound
Nature and properties of ultrasound
Propagation and interaction of ultrasound in matter
Scattering of ultrasound waves
Piezoelectric effect
Design and construction of ultrasound transducers
Continuous and pulsed wave ultrasound
Beam shape from a single transducer and an annular array
The Doppler effect

6.20 Ultrasound imaging
A-mode and B-mode imaging
Time-gain compensation
Construction, function and operation of a real-time B-mode scanner
Image acquisition and reconstruction
M-mode
Microbubble and particle suspension contrast agents
Harmonic imaging
Measurement of flow with continuous and pulsed Doppler ultrasound
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Duplex scanners
Colour-flow and power Doppler imaging

6.21 Safety in ultrasound imaging
Physical effects - heating, streaming, cavitation and mechanical damage
Intensity and energy limits
Thermal and mechanical indices
Measurement of power output
Safety of patients, staff and members of the public
Safety guidance


7 ASSESSMENT

7.1 The examination for the Physics module comprises a single paper of 40 multiple
choice questions (MCQs) and is of two hours in duration.

7.2 The examination is held at five UK venues (Birmingham, Bristol, Edinburgh,
London and Manchester) and three non-UK venues (Dublin, Hong Kong and
Singapore).

7.3 The standard for success is determined at each sitting of the examination based
on the difficulty of the questions used and so may vary between sittings.

7.4 Further details about the examination can be found in the "Guidance Notes for
Candidates", which are published on the College's website (www.rcr.ac.uk) and
sent to all candidates when their application is accepted.
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FIRST EXAMINATION FOR THE FELLOWSHIP IN CLINICAL RADIOLOGY


Curriculum and Information: Anatomy


8 INTRODUCTION

8.1 The purpose of the curriculum is to provide those undertaking specialty training in
clinical radiology with appropriate knowledge of the anatomy needed to perform
and interpret radiological studies. When linked to other training in clinical
radiology, this will lead to the safe and effective application of diagnostic imaging
for the benefit of patients.

8.2 It is intended that the curriculum should be delivered during the first year of
specialty training. This is expected to take about 30 hours of focused anatomy
teaching, over a period of about 6 months, supplemented by practical training
and private study of material recommended by teachers. Basic knowledge of
anatomy is assumed.

8.3 Assessment is in the form of an electronic image viewing session. Further detail
is given in Section 12 of this document and in the "Guidance Notes for
Candidates", which are published on the College's website: www.rcr.ac.uk.

8.4 A knowledge of radiological anatomy is fundamental to the study of radiology. It
is intended that the First FRCR Examination is taken after only six months of
clinical radiology training and the standard and level of anatomical knowledge
tested and expected reflect this. The assessment is of knowledge of radiological
anatomy not surgical anatomy, surface anatomy or cadaveric anatomy but
applied anatomy that is relevant to clinical radiology.


9 AIMS OF THE CURRICULUM

9.1 Provide appropriate knowledge of the anatomy that underpins all radiological
imaging including radiography, fluoroscopy, computed tomography (CT),
ultrasound imaging and magnetic resonance imaging (MRI).

9.2 Provide sufficient understanding of the radiological anatomy that is visible on
each imaging modality to perform and interpret studies including communicating
the results and discussion with clinical colleagues.


10 LEARNING OBJECTIVES

Those who have followed the curriculum should be able to:

10.1 Describe and recognise the bony and soft tissue anatomy visible on radiographs,
including common normal variants. This will include children of all ages.

10.2 Describe and recognise the radiological anatomy visible on CT, including
multiplanar reformats. This will include solid organs such as the heart and lungs,
bones, vessels and muscles.

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10.3 Describe and recognise the radiological anatomy visible on ultrasound imaging,
including first trimester antenatal ultrasound. This will include solid viscera such
as the liver and spleen, bones, vessels, major ligaments and tendons.
Endocavity ultrasound, such as transvaginal, transrectal and endoscopic
ultrasound, will be excluded.

10.4 Describe and recognise the radiological anatomy of MRI, including solid viscera
such as the brain and abdominal organs, bones, joints, muscles and vessels.

10.5 Describe and recognise the radiological anatomy of fluoroscopic studies of the
gastro-intestinal, biliary, genito-urinary and vascular systems.

NB: Nuclear medicine, including positron emission tomography, is excluded from the
anatomy curriculum.


11 EXAMINATION SYLLABUS

This syllabus is intended as a guide and general indication to the breadth of the topics
that may appear in the examination questions. It is not a teaching plan and the bullet
points do not relate to equal amounts of study time. The syllabus should be read in
conjunction with the learning objectives in Section 10 above.

1 Head & Neck

1.1 Brain
Ventricles and CSF spaces
Arteries and venous sinuses
Basal nuclei and major white matter tracts
Cerebrum and cerebellum
Cranial nerves
Pituitary and juxtasellar structures

1.2 Skull
Calvaria and base of skull

1.3 Face and neck
Arteries and veins
Sinuses
Orbit and contents
Facial skeleton
Tongue and oral cavity
Lymph node groups
Larynx and pharynx
Thyroid and parathyroid
Salivary glands

2 Thorax

2.1 Cardiac
Mediastinum, pericardium and lymph node groups
Cardiac chambers, valves, arteries and veins
Great vessels and azygos/hemi-azygos system
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2.2 Bronchopulmonary
Trachea and major bronchi
Pulmonary vasculature
Pleura and fissures

2.3 Chest wall and diaphragm

2.4 Breast and axilla

3 Abdomen and Pelvis

3.1 Bowel
Oesophagus and stomach
Duodenum, small bowel and appendix
Colon, rectum and anus

3.2 Upper Abdominal Viscera
Liver segments and blood vessels
Biliary tree and gall bladder
Pancreas, adrenals and spleen

3.3 Abdominal wall

3.4 Spaces and planes
Perirenal and pararenal spaces and fasciae
Peritoneal reflections and spaces

3.5 Genitourinary tract
Kidneys and pelvicalyceal systems
Ureters and bladder
Prostate, seminal vesicles and urethra
Testes and epididymides

3.6 Gynaecology
Ovaries and fallopian tubes
Uterus and cervix
Vagina

3.7 Vascular supply
Portal venous system
Aorta and major branches
IVC and tributaries

3.8 Lymph node groups

4 Musculoskeletal system

4.1 Spine
Vertebrae, sacrum and joints
Paraspinal muscles and ligaments
Spinal cord, cauda equina and nerve roots
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4.2 Upper Limb
Bones and joints, including shoulder
Muscles and nerves
Blood vessels

4.3 Lower Limb
Bones and joints, including pelvis
Muscles and nerves
Blood vessels


12 ASSESSMENT

12.1 The examination for the Anatomy module comprises an electronic image viewing
session of 100 questions (20 images and five questions on each) and is of
1 hours in duration.

12.2 Initially, ie for the three sittings in 2010, the examination will only be held in
London.

12.3 Additionally, for the three sittings in 2010, the examination will be available in
Hong Kong and Singapore in paper format.

12.4 The introduction of additional UK venues and the adoption of an electronic format
examination in Hong Kong and Singapore at a later stage are being explored.

12.5 The standard for success is determined at each sitting of the examination based
on the difficulty of the questions used and so may vary between sittings. It is
likely that more than one set of images and questions will be utilised at each
sitting and the standard required for success may also vary between the sets of
images and questions.

12.6 Further details about the examination can be found in the "Guidance Notes for
Candidates", which are published on the College's website (www.rcr.ac.uk) and
sent to all candidates when their application is accepted.





August 2009