How to Pass MRCPsych Exam – by Dr Marium Mansoor

(Please note this blog was written in Nov 2020 and the MRCPsych exam regulation and format may change with time. For up to date exam format refer to RCPsych website https://www.rcpsych.ac.uk/training/exams)

My name is Dr. Marium Mansoor, 28 years old, married, and mum to a lovely daughter. I am from Karachi, Pakistan, and have lived my entire life here. I am a graduate of Dow medical college (2014) and did my residency/ training in Psychiatry from Aga Khan University hospital, Karachi. My first language is Urdu, but I was taught and trained in English. Like many of you, I once dreamt to be an MRCPsych and once upon a time, it looked like an impossible dream.

I am one of the fortunate ones to pass all three MRCPsych exams in the first attempts. I became a member in October 2020. I would like to share my journey with all of you with the hope to be of some help for all the IMGs aspiring for MRCPsych.

I started thinking of MRCPsych back in 2016, as soon as I started my Psychiatry training. The initial bit was to do homework on the core syllabus and structure of the exam and the eligibility criteria. I was mindful from the beginning that if I plan for MRCPsych during my training I will have to ensure I fulfil my primary training requirements, goals, and objectives; one of which was to give my local postgraduate exams timely (FCPS psychiatry).

The MRCPsych Exam:

The exam consists of 3 parts:

• Paper A (MCQ Paper)
• Paper B (MCQ Paper)
• CASC (Practical Exam)

I will share my preparation journey for all three exams. Please note that I have taken the syllabus topics and eligibility criteria from the RCPSYCH website (https://www.rcpsych.ac.uk/ )

Please note that the eligibility criteria can be updated. You can check you the criteria from https://www.rcpsych.ac.uk/training/exams/can-i-take-an-exam

Paper A:

I gave my paper A in December 2017, in the second year of my psychiatry training. I started my preparation around 6 months ahead of the exam date, but in my opinion, the duration can vary according to your usual study style. Some of my colleagues passed with 2 months’ preparation. My advice would be to go with your natural style, but make sure you are well prepared by the exam date.

Remember! It’s an expensive exam and includes planning about traveling as well (The Royal college took exams on online platforms in 2020 due to COVID. The college might stick to the online format of theory exams for good, which is certainly a plus point for international candidates).

Topics for Paper A:

Paper A covers the following sections of the syllabus:

1. Behavioural Science and Sociocultural Psychiatry
2. Human Development
3. Basic Neurosciences
4. Clinical Psychopharmacology
5. Classification and Assessment in Psychiatry

Further details of syllabus, scoring, and sample questions can be found on:

https://www.rcpsych.ac.uk/docs/default-source/training/examinations/exams-syllabic-curriculum-mrcpsych-december-2013.pdf?sfvrsn=20c35fdb_6

Eligibility Criteria (as of Nov 2020):

You are eligible to take Paper A if you are a fully registered medical practitioner. You do not need GMC registration to sit the Paper A of MRCPsych. As long as you are registered with a medical council, you can sit the exam.

Exam pattern and duration:

Paper A is a three-hour exam worth 150 marks, comprised of 150 questions.

It is made up of approximately:

1. Two-thirds multiple-choice questions (MCQ) and
2. One-third extended matching item questions (EMI).

Course materials I used:

• SPMM high yield (notes and MCQs)
• Fisch’s psychopathology
• Stahls psychopharmacology
• Atkinson & Hilgard’s Introduction to Psychology

I would recommend doing SPMM mock as well, it will give you a good idea of the real exam. Spend more time with EMIs, time yourself while doing mocks. Despite all the preparation, I struggled with times.

The number of questions has come down to 150 in 3 hours so I believe it should be easier to manage time now.

How I prepared:

• A printout of the syllabus and orientation of the SPMM notes.
• I kept both a hard copy and soft copy of SPMM notes, hence I was able to prepare with whatever suited me with my work schedule.
• I started with 1-2 hours a day on weekdays initially and gradually increased it to 3-4 hours every day in the last 3 months of exam preparation. 15 days before the exam I took leaves and studied up to 8 hours a day.
• I initially started SPMM notes and did MCQs and EMI given with every topic. After reading through notes I used to skim through the syllabus to ensure I have covered every topic.
• SPMM notes will only cover the syllabus, a very helpful tool. The flip side is it doesn’t help develop concepts, if you cant rote learn and given an exam without concept, just doing SPMM will be insufficient.
• If you have core concepts of the syllabus or if you give exams with rote learning, SPMM alone will work fine.
• I did SPMM notes cover to cover, I gave four reads to the notes.

Travelling and exam day:

(You may not have to travel as the exam has gone online since Covid-19 crisis and can be taken from you own house)

• In case you have to travel for more than 3 hours before the exam, make sure you reach your destination at least 36-48 hours before the exam. You can’t afford jet lag on exam day.
• Get a good night’s sleep. It will help you get through the day swiftly.
• The exam starts at 0900 Hours UK time, so please convert it to the exam venue time. I gave my exam in Singapore and my exam started at 1700hours.
• There will be other candidates, some might be discussing things enthusiastically. Avoid overhearing them, avoid studying or learning something new at the last minute.
• Don’t get intimidated by the huge number of candidates, it’s pointless and won’t affect your results.
• Grab a coffee and a light meal before the exam, make sure you take a water bottle along.
• Take your time in solving your exam, don’t follow the group dynamics of the room to leave early. They have given you 3 hours, use them wisely.
• After the exam, don’t waste your energy on how you did the exam. It’s done, no amount of stress and energy invested worrying for the result will change your results.

Paper B

I wrote my paper B in September 2018, Singapore center again. I was in my third year of psychiatry training at that time. Duration and style of preparation were more or less like paper A.

Topics covered in Paper B:

Paper B will cover the following sections of the syllabus:

• Organization and Delivery of Psychiatric Services
• General Adult Psychiatry
• Old Age Psychiatry
• Psychotherapy
• Child and Adolescent Psychiatry
• Substance Misuse/Addictions
• Forensic Psychiatry
• Psychiatry of Learning Disability
• Critical Review

Further details of syllabus, scoring, and sample questions can be found on:

https://www.rcpsych.ac.uk/docs/default-source/training/examinations/exams-syllabic-curriculum-mrcpsych-december-2013.pdf?sfvrsn=20c35fdb_6

Please note: There are two files for the psychiatry and critical appraisal syllabus.

Eligibility criteria (as of Nov 2020):

You are eligible to take Paper B if:

• you’re on an approved training programme. We recommend you have 12 months’ experience in psychiatry before attempting Paper B.

OR

• you are in a post recognized by your hospital or trust as having contracted time and funding for educational training. Your job plan must include dedicated time for academic and educational activities such as attending journal clubs, grand rounds, attending an MRCPsych course of equivalent, study leave, and weekly educational supervision

Exam pattern and duration:

Paper B is a three-hour exam worth 150 marks, comprised of 150 questions. It is made up of approximately two-thirds multiple-choice questions (MCQ) and one-third extended matching item questions (EMI).

• One-third of the paper covers critical reviews.

Two-thirds of the paper covers clinical topics

Course materials I used:

• SPMM high yield (notes and MCQs)
• SPMM mock (It’s very close to real exam)
• Superego café critical appraisal course (online one I did the videos and the book they provide)
• SPMM critical appraisal videos
• Shorter Oxford Textbook of Psychiatry
• ICD-10 (very superficially for criteria)
• Maudsley prescribing guidelines 13^th edition

How I prepared:

• It was the roughly same number of hours as paper A
• The only change was I divided my study time equally between critical appraisal and psychiatry syllabus.
• I kept watching the critical appraisal videos and studied the same topics from the books as well.
• As I mentioned, I can’t study without concepts, so I gave a selective read (covering syllabus topics only) of The Oxford handbook of psychiatry, ICD-10,  and Maudsley prescribing guidelines.
• In paper B you are allowed a calculator (simple one). Make sure you use the same you plan to use in your exam so your hands are all set on it. I am not sure about the online exam guidelines which were implemented in 2020, so make sure you go through them.

CASC (Clinical Assessment of Skills and Competencies)

I attempted my CASC in Sept 2020. At that time I was working as a faculty at AKUH Karachi. Like my previous exams, I started early, I.e. 5-6 months before exam day. I gave my CASC online due to COVID. The college, however, plans to continue the exam in person after COVID.

Eligibility criteria (as of Nov 2020):

You are eligible to take CASC if:

1. You have 24 months’ whole time equivalent post foundation/internship experience in psychiatry.

AND

• A pass in Papers A and B, OR you comply with transitional arrangements (this requirement has been waived for the 2020 exams)

AND

• You have sponsorship in place, and can demonstrate one of the following:
  
  • If your post is within a programme of approved training, you have successfully completed the Annual Review of Competence Progression by the time you apply for CASC.
  • for all other posts, you must have successfully completed an Assessment Portfolio, showing achievement of equivalent competencies to those defined in the ARCP, to include competencies in Psychotherapy AND Child and Adolescent Psychiatry, or Learning Disability. 

The format for the CASC?

The CASC format is like an OSCE (Objective Structured Clinical Examination).

The CASC is made up of two circuits of eight individual stations in each circuit which will test your clinical skills:

• The morning circuit will allow you 4 minutes to read the instructions and 7 minutes to complete the consultation task.
• The afternoon circuit will allow you 90 seconds to read the instructions and 7 minutes to complete the consultation task.

The sixteen CASC station exam is made up of:

• Five stations focused on History Taking, including risk assessment
• Five stations focused on Examination – both physical and mental state, including capacity assessment
• Six stations focused on patient Management.

Circuit 1

• 6 stations focused on Management
• 1 x station focused on Examination
• 1 x station focused on History Taking
• 4 minutes reading time prior to entering each station
• 7 minutes to perform the task

Circuit 2

• 4 x stations focused on Examination
• 4 x stations focused on History Taking
• 90 seconds reading time prior to entering each station
• 7 minutes to perform the task

Course material I used:

• SPMM notes
• SPMM and Birmingham videos
• Oxford weekend course
• SPMM mock.

Challenges and Myths about CASC:

Before I began preparation, I searched for blogs and posts from those who have casc experience (both successful and unsuccessful ones). The challenges I faced were lack of immediate senior guidance and I didn’t know where and how to start. On top of that, you will find a good amount of candidates/ex-candidates who will narrate horror stories of CASC. Retrospectively, I can safely say that there are a lot of myths around the exam, far from reality. I would like to clarify these myths:

• Your theoretical knowledge has been checked in paper A and B
• In CASC they want to see your clinical judgment and decision making skills (0n spot, like in real life)
• They want to see how you communicate and here:
  • It’s not an English language exam, it’s a clinical exam.
  • You are not at a disadvantage if your English isn’t too great, trust me I passed the exam. One of my biggest fears, before I started the preparation, was spoken English and the British accent (I will share a tip for that shortly).
  • You can pass the exam even if you haven’t worked in the UK/Ireland setup.
  • There are these to pass you, but to pass you they expect a certain competency level.

How I prepared:

• I started more than 5 months ahead of the exam because there is no shortcut to CASC. I repeat! There is no shortcut to CASC.
• I looked out for candidates planning to sit their exams in the same attempt. There are Facebook and WhatsApp groups for CASC where I found 4 international candidates and started my practice. I later found some local (within Pakistan candidates and started practicing with them as well at a separate time.
• I would recommend making a group of no more than 6, preferably 3 candidates so you can practice more.
• I reached out to seniors who have done MRCPsych and I was lucky enough to get 4-5 ST4 trainees and a generous faculty member who supervised my group’s practice regularly.
• Go through the CASC mark sheets to get an idea of the marking style. (the mark sheets are available on https://www.rcpsych.ac.uk/training/exams/preparing-for-exams )
• I started practicing on weekends for 2-3 hours (including reading time) for about a month.
• Later I increased it to daily for about 2-4 hours a day (duration of practice varied due to work commitments so you have to be very flexible). 15 days before the exam I took my leaves from work and practiced up to 8 hours a day.
• I started by watching past stations, videos, and collected experiences from those who had attempted CASC already. For the first two months, I focused on understanding the expectations from candidates and I realized that:
  • Clinical knowledge is just a small aspect of your exam
  • They want to see how you communicate the knowledge you have, and how you make decisions on the spot if something is challenging.
  • Empathy, regular pauses, checking to understand (just like you do clinically) is very important.
  • Managing time and sticking to tasks strictly is the key to pass.
• If you have no exposure to UK practice, I would strongly recommend you take mock. I took the SPMM mock and found it very close to the exam. It helped me add some finishing touches to my CASC preparation.
• Watch the CASC example videos on the RCPsych website, it will help you understand what they are expecting.

The day before the exam:

• Get an idea of what kind of stations have come up so far.
• Only work on new stations. There is no point in studying more than a few hours a day before the exam.
• Relax and try getting a good night’s sleep.

Some preparation tips:

• Record yourself to see what you do good and what needs improvement.
• Never take feedback from peers personally and always give feedback honestly.
• Ensure you work on body posture. The exam is anxiety-provoking so train yourself during practice to consciously relax your shoulders when taut, and your tone should have situational fluctuations.
• Use your 90 seconds/ 4 minutes wisely, work on the structure of stations, think of an opening sentence for your station because in the exam you will be in autopilot mode.
• Tip for communication skills: see a few British dramas. See how they interact and try incorporating that in your style. It will also help you get used to the accent.
• Do not copy anyone’s style, it looks fake. The practice is to help you enhance your approach, not your style.
• The majority of stations, up to 13 stations will repeat with slight modifications. So go with an open mind and expect subtle changes. Practice the common stations at least 4-5 times at intervals.
• Make a notebook, for each station you practice, make a structure, note feedback so you can recall it the next time you practice a particular station.

Tips for online exam:

• Record yourself and focus on your body language and posture, your tone, and expression.
• Try looking at yourself from an examiners’ perspective. See if you look like a confident ST4, that’s the level of competency college expects from you.
• Choose a place for your exam, it should have a neutral background. Ensure the background is clean, uncluttered area, free of distractions. Send your kids and pets away for the exam day. Make sure you have a stable internet connection.
• Try and practice at the same place where you plan to give your online exam form. This will help you stay calm as it will feel like a daily CASC practice rather than an exam.
• Make a habit of resting your back on the back of the chair you are sitting on, and intermittently lean forward when there is some concern, and while you are showing empathy. If you are leaning at the screen for whole 7 minutes, it gives an impression of an anxious candidate.
• Dress professionally, in a clinical attire, even if you are giving the exam from home.
• Keep a note pad and pen, along with a water bottle.
• Expect delays between stations, don’t panic if there is a delay.
• Despite a stable internet, you might face technical errors. The college is very mindful of them and you will get a call from them if they can’t connect to you online.
• If your connection drops, you might get a chance to resume the station from where you left, or they will offer you to re-run the station. The college tried hard that all candidates get to do all 16 stations and the majority were able to do so successfully.
• If you hear echo, audio difficulty from actor or invigilators end, SAY IT! They will not know unless you tell them what issue you are facing. These technical issues might affect your performance, so if they are aware of this they will assist you.

Tips for stations:

• Make your style of starting stations, preferable as you do in your daily routine. Stick to it for all your stations, it will come naturally.
• Set the scene. The first 30 seconds of your station will give a direction to your station and you can go back and forth on it when you feel the need. I will share my approach here:
  I used to start my stations with: ‘Hello! My name is Dr. Mansoor, I am one of the psychiatrists here. How are you today?’ the reason for asking how they are has two benefits:
  
  • It will make the actor feel that you are treating them as humans. You aren’t jumping to the task straight away, you value how they feel.
  • They might say I am good. In this case, you can build on the information given in the scenario, ‘I gather you have been referred to me by your GP…’
  • They might respond that ‘I am not so well/ I feel bit upset/ I am a bit anxious’ that is a lead you get in the first 30 seconds of your station. Bingo! Pick up their words, for example, what do you mean when you say you aren’t well?/ can you help me understand what you mean when you say you feel anxious? ( this is helpful in MSE and history stations, it gives a direction to your station quite early in the station.
• Always start with open sentences, narrow down to closed ended questions halfway through.
• Let the actor speak. Stop them only and when you feel they are either going off track or you have got the gist of their conversation. Always apologize whenever you cut them.
• Once the actor has given you a good amount of information, summarize it in a few words and check if that’s what they meant. It makes them feel heard.
• Make a habit of clarifying, paraphrasing, summarizing, and checking their understanding. It will take you a long way.
• For history stations:
  • Read the task carefully and never assume a diagnosis based on a hint given in the scenario.
  • Go with an open mind.
  • If the task says to reach a diagnosis, ensure you say the diagnosis in the end. If you aren’t sure of the diagnosis, say that as well (it looks like you a probably suffering from ______ but I would like to see you at a later time to get more understanding of the concerns you have just shared.
  • Ask all symptoms in a go(cluster all the symptoms). For example, if the actor reports feeling low, rule out all mood symptoms then and there. Here, you must always stay mindful not to sound like reading out of a checklist. So, paraphrase and reflect on symptoms as you go.
  • Always come up with a contingency plan. For example, if giving a diagnosis, briefly say in the end that ‘I would like to set up a time to talk to you in further detail about it, to see how we can help you from here onwards. Thank you for coming to see me today!’
• For management stations, divide the station mentally into three bits, check their understanding, build on their understanding, and deliver them information about the illness and lastly come to a management plan.
• For MSE stations, you don’t have to go into history bits. Like a past psychiatric history or family history. Clinically, history and MSE go together but not in CASC or you will run out of time.
• In difficult conversations like substance use, depression, abuse etc. appreciate the actor for their honestly, acknowledge that you understand it’s not an easy conversation, but it’s needed to get an understanding of what they have been going through so you can help them in the best possible way.
• In risk stations, don’t shy away from saying if the risk is high. Say that you are very concerned, even if the concern is about others and not the patient, be mindful that despite any of the above concern, you still have to mention that you are there to help them.
• NEVER be judgment. Be very cautious of your expressions, tone, and body language. They matter a lot more than we think.
• In CASC you can still pass if you fail four stations. A bad station doesn’t mean you have failed the exam already. Leave the station mentally the minute you leave it physically. If you ruminate on a bad station you will lose the current one as well. I know people who failed because their 1^st station went bad and that led to a chain of anxiety and negative cognitions. Please be gentle with yourself.

CASC+ Full-time job + family commitments:

As you might have noticed I had a two-year gap between my paper B and CASC. The reason was my family commitments and managing a newborn and of course COVID.

A few things that helped me to manage all of these were:

• There is no denial of the importance of family support.
• Acceptance that it’s a hard journey, and there are ways that you can achieve it helps you stay motivated.
• You need to be persistent and dedicated, dreams don’t become reality so easily or nobody would dream for them.
• Career breaks are important, but make sure you resume your career after a break.
• You have to be organized and manage time very effectively.
• I used to reach work an hour early and practice before starting work. During my clinical work, I minimized my breaks and utilized that time to finish work on time. Even in half-hour gaps (e.g. patient canceled in clinics) I used to study or practice.
• In expected free times I used to schedule practice ahead of time.
• I am guilty of watching SPMM/Birmingham videos while doing household chores like doing dishes and laundry, and on my commute to work (in case you don’t drive).
• There were days I couldn’t practice, it took me a while to accept that IT IS OK! I just have to be persistent.
• After work, I maintained a strict bedtime routine for my daughter and I used to practice 1.5 hours after putting her to bed. There were times she was sleeping right next to me while I practiced, times when I had a crying baby in my lap.
• Take regular breaks otherwise, it is going to be emotionally taxing.

Concluding words:

Exams are never easy, but they are doable. You don’t have to be a genius to achieve your goals. All you need is dedication and persistence. Balance your work/ study with some hobbies, set up regular schedules, and follow them. Life doesn’t stop for training and exams, everything has to be done in balance.

It’s not easy to strike that balance, but the constant effort will pay off your efforts for sure. A failure after effort doesn’t mean you aren’t a good doctor or not competent enough. No exam can determine that.

Good luck!

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Dr. Marium Mansoor – mariumansoor@hotmail.com

Tags: How to pass CASCHow to pass MRCPsychMRCPSYCHMRCPsych CASC