This article is adapted from a post in Dr Koshy Jacob's "Building Revise Radiology in Public" series on LinkedIn.

I didn't pass my FRCR 2B the first time I sat it.

I have not written that sentence in public before, and I notice a small reluctance in myself even now, which is precisely why it seems worth writing. Because if you have recently opened a set of results and found the wrong outcome there, the thing you most need to know is not a technique or a study plan. It is that the people you assume sailed through often did not, and that what happened to you is not the verdict on your ability that it currently feels like.

For most of my life, examinations had gone reasonably well. That changed at MRCP, after which I seemed to sit everything twice, and then in radiology the pattern broke again and I passed each stage as it came until I reached 2B. I went in expecting the same. I did not get it.

What I actually lacked

I have had years to be honest with myself about why, and the answer is unglamorous. I was not properly prepared. I did not have the technique the examination demands, which is a distinct skill from knowing radiology and has to be practised deliberately rather than absorbed by hoping. And underneath both of those, I simply did not know enough radiology yet.

What strikes me most, looking back, is that this was true even of my second attempt, the one I passed. I got through, and I was relieved, and I still could not have told you with any confidence that I had seen everything I needed to see. There was no way to know. The material available then was scattered across textbooks, courses, borrowed notes and whatever cases happened to come through your department that year, and nowhere in that arrangement was there anything that let a candidate say, with justification, that nothing important had been left out. You worked hard, you sat the exam, and you found out.

That gap between working hard and knowing you had covered the ground is, I think, the single most exhausting thing about preparing for this examination, and it has very little to do with intelligence or effort.

What the evidence says about failing

Here is where it becomes more interesting than consolation, because the science of learning has quite a lot to say about the value of getting things wrong, and almost none of it supports the idea that a first-time pass is the mark of the better doctor.

Robert Bjork's work on what he termed desirable difficulties established a distinction that ought to be far better known than it is: the conditions that produce the best performance during learning are frequently not the conditions that produce the best learning. Spacing, interleaving, retrieval practice and generation all feel worse at the time and all win on the delayed test. Difficulty that a learner can eventually overcome is not the price of learning. In a real sense it is the learning.

Manu Kapur took this further with a body of work on what he calls productive failure. In his studies, learners who were given demanding problems and allowed to struggle unsuccessfully before receiving proper instruction went on to outperform learners who were taught the efficient method first, particularly on measures of conceptual understanding and transfer, which is to say the ability to apply knowledge to something they had not seen before. A later meta-analysis across many such comparisons found the advantage held. The struggle was not wasted time preceding the real learning. It was what made the subsequent instruction land.

Then there is my favourite finding in this whole literature, and the one I suspect every radiologist will recognise instantly. It is called the hypercorrection effect, first demonstrated by Butterfield and Metcalfe, and it holds that errors made with high confidence are more likely to be corrected after feedback, and better remembered afterwards, than errors made tentatively. The mechanism appears to be surprise. When you were certain and you were wrong, the correction arrives with a force that a hesitant guess never generates, and it stays.

Every radiologist I know has a case like this. The diagnosis they were sure about and got wrong. They can usually recall it in detail years later, including the room they were in when they found out. That case is now the one thing in their practice they will never miss again. Janet Metcalfe's review of this field concludes, reasonably, that if the goal is performance in high-stakes situations, it may be worth allowing and even encouraging errors in low-stakes ones rather than avoiding them at all costs.

The thing a first-time pass cannot give you

There is one more asymmetry worth naming, and it is the one that changed how I think about all of this.

Dunlosky and colleagues, in their major review of study techniques, found that re-reading and highlighting reliably produce an illusion of mastery. The material feels familiar, so the learner concludes they know it, and they are frequently wrong. The examination is the instrument that punctures this illusion, and it only punctures it for the people it stops.

A candidate who passes first time is rarely told where their coverage was thin. They receive a result, they feel the relief, and they move into practice carrying whatever gaps they carried into the exam hall, unexamined and now invisible. A candidate who fails has been handed something genuinely valuable and thoroughly unwelcome: specific information about where they were weaker than they believed. It is a horrible gift. It is still a gift, and what someone does with it in the following months can leave them a more thoroughly prepared radiologist than the version of themselves who might have scraped through the first time.

Let me be careful here, because this argument has an edge I do not want to fall off. I am not saying that failing is better than passing. It plainly is not. It costs money, time, confidence and often a great deal of quiet suffering that colleagues never see, and nobody should reframe that as a blessing. Many first-time passers are outstanding radiologists who were also thoroughly prepared, and they deserve no asterisk against their names. The claim is narrower and, I think, sturdier: a failed attempt is not evidence that you are not capable of this work, and the road through a second attempt can produce a depth that the shorter road does not require.

Why this matters beyond the exam

Our MSK Programme Director, Dr Ramy Mansour, wrote recently that radiology is best understood as a language, and that mistakes are the teacher nobody invites. He made a point in that piece which sits underneath everything I have written here: that discrepancy meetings and peer review are not exercises in identifying failure but opportunities for collective learning, and that a culture encouraging reflective discussion rather than blame produces expertise, resilience and safer patients.

This is the part that lifts the argument out of reassurance. A radiologist who has learned to examine their own errors without being destroyed by them, who can sit with uncertainty rather than resolving it prematurely, who treats being wrong as information rather than humiliation, is a safer radiologist. Those capacities are not taught in any curriculum. They are usually acquired the hard way, and a failed examination is one of the few experiences early in a career that demands them.

I would rather work alongside someone who has been wrong, felt the full weight of it, and built a practice of honest self-scrutiny out of the wreckage, than someone who has never yet had cause to develop one.

What we took from it

The thing I could not get in my own preparation, and the thing I still could not honestly claim even after passing, was any way to know that I had seen what I needed to see. That is the gap our low-cost Core subscription exists to close, and I will leave it at that, because this article is not really about what we sell.

It is about what I learned about myself in the months between those two attempts, which is that I was not, as I had briefly suspected, someone who had reached the limit of their ability. I was someone who had not yet done enough of the right kind of work, which is an entirely different and much more hopeful problem. Almost everyone who fails this examination is in the second category rather than the first, and almost everyone believes, in the first few days, that they are in the first.

If that is where you are this week, I am not going to tell you it does not matter, because it does. I will tell you that it is a roadblock and not a verdict, that the people you look up to have more of these in their history than they mention, and that what you build in the next few months may end up being the most valuable part of your training. Mine was.

References

Bjork RA. Memory and metamemory considerations in the training of human beings. In: Metcalfe J, Shimamura AP, eds. Metacognition: Knowing about Knowing. Cambridge, MA: MIT Press; 1994:185-205.

Kapur M. Productive failure. Cognition and Instruction 2008;26(3):379-424.

Kapur M. Examining productive failure, productive success, unproductive failure, and unproductive success in learning. Educational Psychologist 2016;51(2):289-299.

Sinha T, Kapur M. When problem solving followed by instruction works: evidence for productive failure. Review of Educational Research 2021. doi:10.3102/00346543211019105

Butterfield B, Metcalfe J. Errors committed with high confidence are hypercorrected. Journal of Experimental Psychology: Learning, Memory, and Cognition 2001;27:1491-1494.

Metcalfe J. Learning from errors. Annual Review of Psychology 2017;68:465-489.

Fazio LK, Marsh EJ. Surprising feedback improves later memory. Psychonomic Bulletin & Review 2009;16(1):88-92.

Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Willingham DT. Improving students' learning with effective learning techniques. Psychological Science in the Public Interest 2013;14(1):4-58.

Originally shared by Dr Koshy Jacob on LinkedIn. Follow the series there