The Members of the Council

Royal College of Psychiatrists

17 Belgrave Square

London

SW1 7PZ

Dear Members of the Council

Ref: Expiry of MRCPsych part 1 and the plight of the affected trainees

I wish to apprise you of the plight of the candidates who are going to be adversely affected by the expiry of MRCPsych part 1 ON 31ST July 2010.

I attended a meeting on this matter in the College convened to listen to the views of these candidates on 9th July 2010, attended by the President, the Chief Executive and Mr Palekar from the Exams department.

In brief, I believe this matter deserves immediate attention of the College Council, as current deadline for expiry of MRCPsych part 1 of 31st of July is adversely affecting the careers and lives of more than two hundred candidates, who are predominantly psychiatric trainees and some SAS doctors.

On the surface it may appear to an onlooker (as it happened to me initially) that this is a grievance from a group of disgruntled trainees, who are unable to clear the exam in time given by the College. But a closer examination reveals that the matter is much more complex and that there is an inherent unfairness in this matter, disproportionately so towards female candidates.

I had a chance to consider the issues raised by the candidates at some depth. I will give the summary of the issues and then explain those in some detail below based on the facts and opinions gathered from the delegation, which met the President, and the Chief Executive on 9th July 2010. I have also attached three case examples of the affected trainess. I am thus bringing to your attention a profoundly serious matter that requires your urgent intervention.

Summary of the main issues

  • The MRCPsych part 1 pass letter does not state any reference to an expiry date of the exam. This is in contrast to the current paper 3-result letter, which clearly states the expiry date.
  • The current Paper 1 and 2 are going to remain permanently banked in contrast to the College’s decision to invalidate of part 1, which was also presented to the trainees at its inception as valid forever.
  • The College had extended the validity of its own previous examinations up to a period of 8 years. The 8-year period is based on evidence for validity of examinations from America.
  • The specific aspects of discrimination towards female trainees and flexible trainees should be taken in to account.
  • The contents of paper 1 and paper 2 are not significantly different from the old part 1.
  • MRCPsych part 1 expiry period, although considered by many college committees, did not involve the stakeholders i.e. Part 1 holder directly.
  • The patients and their families should be more reassured as the college in the old system tested clinical skills at an early stage of psychiatric training by an Objective Structured Clinical Examination (OSCE).
  • The College should not discriminate trainees who passed their exams at different times to set up a common invalidity period.

As I understand the matters, under the old system, Royal College of Psychiatrists’ exams were divided into Parts 1 and 2. Each part had a written and a clinical component. But, in 2008, College changed the exams to three written papers followed by a Clinical Assessment of Skills and Competencies examination (CASC). In this system, a pass in paper 1 and 2 will be banked forever. However, after passing paper 3 of the examination a candidate had four chances at CASC. If the candidate failed to pass the examination within an allocated timeframe, she or he was expected to re-sit paper 3 and then repeat the cycle.

In the changed or revised examination process the College announced validity period retrospectively, for those who held a pass in Part I of the previous format. The College decided that a pass in Part I would expire and not count towards completing the membership exams, after July 2010. The trainees were not informed that this could be the case when they originally sat for their Part 1 and OSCE examination. The regulations of the previous format of the examination did not state a number of attempts or period of validity.

Those candidates who had passed Part 1 then took OSCE exam, which obviously needed a lot of preparation and competence. It seems to me that as this is now discarded the above candidates were seriously disadvantaged by the above decision. Ironically, the examination committee decided that in the future a pass in the current papers 1 and 2 would remain permanent in the new system.

The trainees have told me that they feel ‘cheated and abused at the hands of their own college’. They lamented that they have been made to feel that they have wasted their time and money. The manner in which the change is being managed has been making the trainees feel less valued as their hard earned part 1 examination results are totally discredited by the same organisation, which awarded it without any prospective conditions. Indeed, there is a growing anger and feelings of dejection and hopelessness in these trainees. Many of them may give up training or change the speciality, which will seriously deprive not only the workforce of trained psychiatrists but would be a waste of energy and financial investment done both by the NHS and trainees. The College must not underestimate their anger and sense of dejection among this group. It seems to me that this is a grave injustice and against the College’s own principles of fairness and inclusiveness.

The College rests its case on two issues - firstly the matter of different curriculums and methods of assessment for the part 1 and paper 1 & 2 and secondly the issue of public safety due to ‘poorly’ or ‘incompletely’ trained doctors slipping through the net.

My response to the first issue is that the EMI, ISQ & OSCE type methods for assessments are very well established. These methods were used to assess candidates for Part 1. The College’s curriculum for part 1 is essentially the same as paper 1 and paper 2 with notable exception of the part on genetics, which was not formally tested in old part 1 and the fact that OSCEs are not currently used in the new paper 1 & 2 format. The college reserves the right to vary the proportion of areas in which to assess the candidates and I believe that genetics was not a major contributor to paper 2 exams recently as well. Secondly, the reason to change the exam structure to the current modular format was not due to the ‘invalid and unreliable’ methods of assessment of the old part 1, but it was the non standardized mode of assessment through PMP, Essay writing and in particular the long case, which was a major source of concern for the College and the PMETB and eventually led to the scrapping of this method of assessment.

Regarding the College’s second point, I agree with trainees that various agencies including the GMC, PMETB and the employers themselves have the responsibility to ensure that doctors have the knowledge and competencies to practice safely. Besides the trainees and SAS psychiatrists are expected to undertake and demonstrate their continued professional development (supervised by the College) to ensure not only to be trusted by the public but also to gain the eligibility to sit for the exams. The College does have a role in the in contributing to patient safety but not the sole responsibility and that too not entirely through exams. Besides these are well establishes supervision processes in the NHS aimed at safety of the patients. Liking patient safety to the issue of Part 1 expiry does not have a convincing basis. Also where does this logic stand when you apply the same analogy to the indefinite validity of a pass in the current Paper 1 and Paper 2.

If the College does not handle this issue sensitively it is likely to have adverse impact on the recruitment and retention problems in psychiatry. The NHS Trusts are spending huge amounts of money on appointing locums to run the services at the moment and at the same time trainees willing to be trained further are inappropriately ignored in the name of ‘maintaining standards for the public safety’.

No doubt there are always two interpretations of these decisions, but I cannot fail to appreciate the concerns of these young doctors who feel contradictions in College's position in dealing with the part 1. They highlight the fact that they were not told at the time when they took part 1 that it could be invalid one day. They have told me that it makes no sense that when Paper 1 & 2, which are part 1 equivalent in the new system can be banked 'permanently''; but it is not right the other way round. It does not make sense to them as to how the changes after the 31st July 2010, given the above arguments, will lead to more competent and safe doctors. I can sympathize with them when all they want is College respecting its regulations when the trainees took their exams.

As I gather the trainees do not want any deadlock and are happy for the College to look at the previous precedents set up by its own committees whilst dealing with issues in the past. These include reversing the decision on a permanent fail in the preliminary examination in the late 80s.The College continued to allow people to take part 2 even if they had passed their part 1 up to 20 years ago, e.g. a person who had passed part 1 in 1987 (following the change in permanent fail system) could have continued to attempt part 2 until 2007. How can one justify the current decision to disqualify Part 1 exam with in 4 years of passing it (at least in some cases)? I was also been told that most of the affected candidates passed their part 1 between 2006 and 2008. I believe the College should not discriminate trainees who passed their exams at different times to set up a common invalidity period. This is particularly true for people who had by the start of 2008, after having passed their part 1 in 2006, not achieved the recommended 30 months training period to have taken part 2; particularly so when the College started to publicise the change in system only in March 2007. In the past the College had extended the validity of its own previous examinations up to a period of eight years[1].

They also want that a common invalidity period is not placed on all the candidates and they believe that in the past College has shown flexibility and pragmatism on matters like these. It seems they are right in pleading to the College that consideration is shown about part time trainees and people who took breaks to raise a family and other valid personal commitments. This hardly gave only one attempt to sit for the exam in some cases. It appears this invalidity period also coincided with upheavals in many trainees’ lives due to the MMC and MTAS fiascos.

It may be worth comparing with the practice of our sister Royal Colleges in similar situations. The Royal College of Surgeons expect people to pass all the exams within 3.5 years from the date of pass of the first exam. But they ran two parallel systems of exams to allow the smooth transition from the old system to the new system. Candidates can chose either system and can also switch between systems. This has been happening since 2004 and is due to end in 2010.

I believe this group of trainees are turning in to victims of the change on which they have little control. The College should take a more sympathetic approach in helping them through these tough times by giving them adequate opportunity to further their careers in psychiatry. I am not making a case for compromising on the standards but a case for the College being, fair and flexible in the light of the unforeseen consequences of its decisions. This matter which may appear narrow on the surface concerning a couple of hundred trainees, but there are wider issues of responsiveness and justice inherent in it, which are linked to the long term reputation of the College as a supporting and enabling body.

Dr Seshagiri Rao Nimmagadda

Elected Member of the College Council

Former Chair of Collegiate Trainees’ Committee

Enc: 3 Case Examples

Case - 1

“I am an ST3 trainee.

While I passedallmy previous exams at first attempt, I was given only one chance in taking the CASC due to the previously mentioned expiry statement. This is solely a result of my one-year maternity leave in 2008 and returning to work as part-time trainee.

Please find below a brief description of my situation:

I took Part I and passed in October 2007 (first attempt) while I was pregnant with my child.

I went on Maternity leave for one year from January 2008.The changes in the exam regulations were introduced in March 2008, while I was already on maternity leave with my son. At this stage I did not have any opportunity to make an informed decision about my future training.

I returned as flexible trainee in February 2009, and I have worked as part-time trainee since then (50% of full-time, 5 sessions per week).Although I initially wanted to do 7 sessions a week, this was not possible at the time as I could only job-share with another part-time trainee. This meant that the 30 months full-time equivalent training needed to sit the CASC was only completed by February 2010.

Itook Paper 3 in August 2009 and passed at first attempt. I thenapplied for the CASC, and I put a lot effort and time into preparing for it, as I knew that my future training depended onone single chance.Unfortunately I did not pass on this occasion. Currently I am facing the prospect of having to re-start all my exams. Even if I take Paper 1 and 2 this year I will have to re-sit Paper 3, too, due to its 635 days expiry period and given that my second baby is due on 26th January. That is the date for the CASC, too. It is a hopeless vicious circle when I will not have even a single chance to take the CASC. It seems a massive penalty for the only 'sin' of having a baby. However, in current UK law applying this regulation in its current form constitutes a case of Indirect Sex Discrimination.”

Case Scenario - 2

“I started my training in 2005 and passed my MRCPsych part 1 in 2006. Around this time I had to undergo infertility treatment and finally had twins in November 2008. The pregnancy and the delivery were complicated; the twin were born premature and had to be nursed in SCBU for a month. Most of my attempts at paper 3 were during times when I was either pregnant with the twins or on maternity leave. This was a very difficult period for me because of the complications during the pregnancy and bearing the fact that my twins were premature and needed much extra help. Although I was doing the exams under immense pressure it was bearing in mind that the Part 1 was going to be expiring in July 2010. I have also had the added pressure of being on the Run Through Scheme but the Deanery has kindly extended my training period for an extra six months and given me a chance to give my exams again. The time when I passed my Paper 3, which was in January 2010, was the time when I was extremely calm and off maternity leave. I have given my CASC in March 2010 but unfortunately did not pass the exam. I passed 11 stations and I don’t think it could be any closer

I am a very committed trainee and would like to have a long-term career in psychiatry. Giving my Paper 1 and Paper 2 again means I spend very little time with my family and both my twins being only 18 months old it seems a very exhausting task. The pregnancy and the maternity have been a very difficult time for me personally and I think that has impacted upon my examination results and also the amount effort that I have put in
during the exams. I would be extremely disheartened if I had to come out of training and start with exams all over again. I have full faith in the Royal College and the training system and I would be obliged if my case could be considered empathetically and if my personal circumstances could be borne in mind whilst making the decision.

Case Scenario - 3

“I passed my part 1 in first attempt after becoming qualified to take it in November 2006. I have never failed any exam before. I have completed my MSc and studying for Masters in medical education. I have been awarded a prestigious prize for academic excellence in psychiatry. I have numerous publications in high impact journals. I was not qualified to sit paper 2 until February 2008. I had to endure the loss of both of my parents in a matter of 18 months. I had health problems. I went through MTAS and MMC fiascos. I feel cheated by the College for its intent to strip me of my right to progress to obtain MRCPsych.”

1

[1]18) CANDIDATES SITTING OR RE-SITTING THE MRCPSYCH PART II EXAMINATION

i) Number of attempts