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The MRCPsych Examination Reborn

Dr Ben Green

The MRCPsych Examination is Dead, Long Live the MRCPsych Examination

The old style MRCPsych Examination will cease in Autumn 2007.

The new examination from Spring 2008 onwards loses various standard elements that many UK consultant psychiatrists will have experienced during their own examinations. No patients will be seen – gone are clinical examinations using real patients, any essay option, any research option, Patient Management Problems (indeed gone is the concept of examiners questioning candidates in any way) short note questions, and any variety of old favourites.

In comes an examination that is ‘standardised’ with reliability and validity data and designed to satisfy the requirements of educationalists, PMETB and MMC (both the latter organisations being somewhat battered and discredited though after the 2007 junior doctors jobs debacle).

The new examination includes a portfolio of assessments of candidates performed in the workplace, three papers of MCQs and extended matching questions, and a souped up OSCE.

The examination is primarily designed for trainee psychiatrists (although portions may be sat by some other trainees, for instance general practitioners). The College does not intend non-training grade psychiatrists to be allowed to sit it as this would not conform to the concepts of PMETB/MMC.

The exam is designed to be completed by the end of the ST3 year and to mark a transition to the more senior ST4, ST5 and ST6 years.

The examined portions are designed to be accompanied by assessments in the workplace, conducted by local consultant trainers, local senior nurses and more senior trainees and psychologists. These workplace assessments are to be arranged by the trainee themselves and should build up into a portfolio of training. In pilot area the individual pass rate for each assessment is acknowledged to be very high. The figure quoted is 98%. Not surprisingly there is some concern that the assessments may not be entirely suited to ‘discriminate’ between acceptable and non-acceptable candidates.

Royal College Examiners are therefore to visit training centres to monitor the standard of these assessments, but this system may not be fully in operation until 2010.

The College is therefore aware of a tendency or bias towards these assessments showing the candidates in a positive light. In some ways this is deemed acceptable because the assessments are meant to be spread through the training and reflect the expected standards at the stage the trainee is at, and also that they are supposed to be formative assessments (i.e. designed to feedback and improve further performances) rather than summative or final.

What can workplace assessments focus on?

They may for instance focus on a trainee’s ability to take the history of a presenting complaint. The assessor will watch the trainee’s performance throughout the task, then complete a form and give constructive feedback to the trainee. Other example elements that could be assessed might be ‘discussing treatment with a relative’ or ‘administering ECT’. In other words these are tasks performed in day-to-day practice. A variety of assessment instruments have been devised and a confusing crop of acronyms such as ACE, min-ACE, DOP and so on have sprung up. Do not be alarmed, the concepts behind these jargonistic instruments themselves are simple and those who seek to baffle rather than illuminate others should not put you off.

Examples of Workplace based Assessments: Assessment of Clinical Expertise (ACE), Mini-Assessed Clinical episode (Mini-ACE), case based discussion (CbD), Directly Observes Procedural Skills (DOPS), Case Presentation (CP), Journal Club Presentation (JCP), and the Mini-Peer Assessment tool (Mini-PAT). The introduction of a Patient Satisfaction Questionnaire (PSQ) and Team Assessment of Benaviour (TAB) or things like them are likely to be introduced.

The point is to assess a variety of competencies according to the College’s own ‘Competency Based Curriculum for Specialist Training in Psychiatry’. It is for and for the candidate to build up a comprehensive portfolio of their competencies that will foreshadow future consultant appraisals and revalidation.

The task for the College will be to see that this is not a meaningless paper exercise and that the correct assessment tools are used, that enough competencies are assessed and that they are sufficiently varied (e.g. not exclusively assessments of mental state in depressed outpatients) and by senior enough assessors. Consultant trainers are more stringent in pilot studies than trainees or staff grade nurses.

Educationalists have also focused somewhat on Competencies (which require knowledge and skill) rather than attitudes or ethics. It will perhaps be for some of the elements incorporating 360-degree feedback to capture these vital nuances. Otherwise assessments that only evaluate skills (vital though these may be) are likely to reduce a profession to a skills-based trade.

These workplace skills can be developed from being performed ‘under supervision’, at a level of ‘competency’ or at a level of ‘mastery’ with ‘mastery’ levels attained during later training years.

Pilot studies have indicated that trainees are enthusiastic as they like positive feedback that values their development and offers constructive ways of developing their skills. Assessors though probably need to be more discriminating as the pass rate is excessively high (over 90%). The high pas rate may be due to conflicts of interest i.e. emotional bonds between assessor and trainee, a lack of precision as to what constitutes good performance – so assessors need to think ahead and think what a good candidate should be capable of in a specific situation before assessing it. Discussing such assessments with consultant peers may help generate acceptable standards e.g. what would you and your consultant colleagues expect an ST3 trainee to look for in assessing a patient with morbid jealousy?

Discussion of the feedback specifying exactly what was done well and exactly what could be improved and precisely how that can be achieved is particularly useful.

The assessments are meant to be spread across the training period before the exams.

Completion of an adequate number of workplace based assessments is an eligibility requirement for the clinical portion of the exam (OSCE).

Written papers

The new MRCPsych examination contains three papers. These incorporate multiple-choice questions (one correct choice from 5) and extended matching questions. Each paper will last there hours. Papers One and Two may be taken individually or together around the same time.

Paper One examines basics such as history taking, mental state examination and descriptive psychopathology, aetiology, cognitive assessment, diagnosis and classification, basic psychopharmacology, developmental psychology, social psychology, psychological measurement, basic psychological treatments, dynamic psychopathology, the history of psychiatry, basic ethics and philosophy, stigma and culture.

Paper Two examines principles of psychopharmacology such as pharmacodynamics and pharmacokinetics, psychotropic drugs, adverse reactions, evaluation of treatments, neuropsychiatry – physiology, endocrinology, chemistry, anatomy, and pathology, genetics, statistics and research methods, epidemiology, advances psychological processes and treatments.

Paper Three examines research methods, evidence based practice, statistics, critical appraisal of research and clinical topics. Subspeciality knowledge from liaison psychiatry, forensic psychiatry, addiction, child and adolescent psychiatry, psychotherapy, learning disability, rehabilitation and old age psychiatry will also be covered.

In order to sit Paper One the candidate must have completed 4 mini assessed clinical encounters (4 mini-ACEs) and two case based discussions (CbDs) and had 12-24 months or specialist training verified by a college tutor or training school. Paper Two’s eligibility requirements are similar.

To sit Paper Three the candidate must have been eligible to site Papers One and Two and in addition have undertaken 8 verified mini-Aces and 4 verified CbDs.

Paper Three’s pass result may be held on to for 18 months until the OSCE is completed. If the OSCE isn’t completed in the 18 month period then the exam must be repeated.

Clinical Examination

To sit this the candidate must have passed all three written papers and have a number of additional ACEs in various specialties including psychotherapy, developmental psychiatry and general adult psychiatry amongst others. College Examiners will eventually evaluate some of these externally.

The re-vamped OSCE will include a variety of eight-minute stations and some longer linked stations. An example of a linked station might be two stations: the first where a candidate evaluates risks in a patient with morbid jealousy and the second station where those risks and management of them are discussed with the patient’s partner.

First Published September 2007

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