Obtaining the MRCP diploma - difficult Olympic hurdles or a straightforward triple jump?

Introduction

The Royal Colleges of Physicians of the United Kingdom have a common membership examination in general medicine and successful candidates are eligible for the award of the MRCP (UK) Diploma1. This important postgraduate qualification is achieved after passing three separate examinations typically known as MRCP Part 1, MRCP Part 2 and MRCP PACES. Attaining the MRCP (UK) Diploma or “full membership” has become a necessary prerequisite for successful completion of UK Core Medical Training (CMT). Attaining the MRCP (UK) Diploma is now essential prior to commencing training in any of the medical specialties at Specialist Trainee year 3 (ST3) level. For many doctors, acquiring this essential qualification proves to be a long, arduous and expensive process. Pass rates for trainees in the component MRCP examinations vary widely between UK postgraduate medical deaneries2. This variation in attainment of the MRCP, and other postgraduate medical examinations, reflects many factors including pre-medical school admission qualifications, UK medical school attended, gender, ethnicity, organisational skills of trainees and the different emphasis placed by deaneries on the optimal “timing” of examinations with respect to junior doctors within Foundation Year (FY) and Core Medical Trainee (CMT) programmes2–7. This article aims to provide FY and CMT doctors with some practical guidance on the optimal timing of taking MRCP examinations and pragmatic advice to UK and overseas medical graduates and their clinical supervisors on effective preparation for these important postgraduate career milestones.

Purpose of the MRCP

A popular misconception about the MRCP (UK) Diploma award is that memorising excessive amounts of obscure detail is needed to pass the written exams. This is not the case. The MRCP Part 1 examination tests an understanding of the important basic science principles that underpin day-to-day clinical practice. MRCP Part 2 is a more clinically oriented written examination with questions focused on clinical scenarios. The exam tests whether candidates can consider various clinical factors in deciding on the most appropriate investigation or treatment. The candidate answers “single best answer” multiple choice questions in the both the MRCP Part 1 and Part 2 examinations. The MRCP Practical Assessment of Clinical Examination Skills (PACES) explores the ability of trainees to integrate a number of clinical skills with the aim of demonstrating safe management of patients allied with appropriate communication to allay patient concerns. Passing these three MRCP examination components and appointment to an ST3 post following interview allows the trainee to enter higher specialty training in various medical specialties within the UK.

Cost of the MRCP

In 2012, the total cost of a UK-based trainee applying to sit each part of the MRCP (UK) Diploma would be £14561. This sum excludes any books, online question banks, exam preparation courses or travel expenses which are required by a candidate. The true cost of taking the MRCP examinations in the UK is arguably closer to £2500, none of which is tax deductible and relatively little of which can be reimbursed. A candidate who needs to resit MRCP examinations will spend even more money and unfortunately some trainees may eventually spend several thousand pounds negotiating PACES. For an overseas-based clinical trainee the cost of sitting each component of the MRCP (UK) Diploma is at least £23301. Clearly, having an efficient plan to get the “full membership” is vital to minimising costs associated with resitting component MRCP examinations.

Foundation Year Programme and MRCP

UK postgraduate deaneries have provided variable advice to candidates on when they should sit the MRCP examinations. Those deaneries that promoted preparation for MRCP during the Foundation Year Programme and encouraged an early attempt at MRCP Part 1 appeared to have higher pass rates than deaneries which have actively discouraged MRCP exam preparation during the Foundation Year 1 and Year 2 (FY1 and FY2) years. Part of this inter-deanery variation in MRCP examination success may stem from regulations in place from August 2007 to August 2009 when only MRCP Part 1 was required to be eligible for appointment to an ST3 post. These earlier regulations arguably had reduced the sense of urgency trainees had to progress through the component exams of the MRCP (UK) Diploma during the Foundation Year Programme and Core Medical Training years. For instance, for those trainees attempting the MRCP Part 1 examination during 2010-11 the pass rate was 77.4% (ranging from 57.7% to 95.0% in the sixteen UK postgraduate medical deaneries) by the end of year 1 of Core Medical Training (unpublished data from Royal College of Physicians examinations department and JRCTB, September 2011 Update) As outlined previously, success in MRCP examinations is associated with certain background factors including the medical school a candidate attended, gender, ethnicity and time management skills of trainees2–7. There are several other reasons for disparate MRCP pass rates. Firstly, those who delay attempting the MRCP examinations find, in the worst case, that they have 18 months or less in which to sit and pass all three parts. This generally leads to cramming revision, superficial learning, and often several examination resits with consequent delay in entering ST3 level medical specialty training.

Secondly, the FY1 period, immediately after graduation from medical school, may be viewed as a relatively quiet year in terms of academic endeavours whilst the graduate makes the transition from medical student to junior doctor. Some deaneries have emphasised the importance of the Foundation Years for obtaining curriculum competencies and sampling different clinical specialties rather than studying for postgraduate examinations. Nevertheless, studying for the basic science component during FY1 and passing the MRCP Part 1 examination in early FY2 actually enables the trainee to concentrate on learning the clinical material tested in the MRCP Part 2 and PACES exams from an earlier point in their career. This clinical learning is more readily integrated and reinforced when trainees are not dedicating their mental energy to revising basic science principles. As a greater proportion of their FY2 and core medical training experience is used to assist preparation for MRCP Part 2 and PACES exams then the likelihood of passing is increased.

Finally, due to specific local factors in each deanery some trainees may have different levels of commitment to their ultimate specialist career pathway and this may impact on when MRCP exams are attempted. A deanery encouraging attendance at high quality MRCP examination revision courses or the local organisation of focused clinical teaching for MRCP PACES are also likely to improve trainees’ preparation for these examinations.

Timing MRCP

The MRCP is a medical “triple jump” that needs to be carefully planned. A timeline of when these exams might be taken in relation to training grade is outlined in Figure 1. Presently, the full MRCP (UK) Diploma is required before an individual can take up an ST3 post in a medical specialty. The concern is that a candidate without PACES may be offered an ST3 post to begin in August pending a pass in PACES but may fail the June/July diet of exams and thus be ineligible to take up their ST3 post. Ideally junior doctors should attain the full MRCP (UK) Diploma award before applying for ST3 positions.

Fig 1

Linking the junior doctor training year with an optimal timetable for sitting MRCP examinations

A trainee appointed to a core medical training post from August 2009 onwards who does not pass the full MRCP (UK) Diploma award by the end of 24 months has not completed core medical training. There has been some variation in interpretation of this regulation at Annual Review of Competence Progression (ARCP) meetings but this may result in a trainee being given an ARCP outcome 3 (unsatisfactory outcome: inadequate progress by the trainee - additional training time required) and core medical training period extended by 6 months in the first instance. This may also impact upon the availability of entry points for core medical training for new trainees.

In order to maximise the chance of passing all the component MRCP examinations comfortably within the given timeframe, even allowing for resit exams, it seems prudent to consider taking the MRCP Part 1 exam in October or January of the FY2 year. The MRCP Part 2 examination could then be attempted in April or June of FY2. If both parts are passed then the whole Core Medical Trainee Year 1 (CT1) year can be used to prepare for MRCP PACES exam which could be taken in June of CT1 or September of CT2 with opportunity for a resit prior to the ST3 post applications. Having a full year or more to prepare for MRCP PACES allows active clinical skill development whilst allowing time to undertake audits, projects and teaching in order to improve the quality and competitiveness of an ST3 application.

What Candidates say is Needed to Pass MRCP

Passing MRCP Part 1 is highly dependent on both the number and quality of multiple choice questions attempted in revision texts or online question banks. Clinical experience per se was rated as relatively unimportant in whether one passed the MRCP Part 1 exam. In contrast, clinical experience plays a much more important role in dictating the outcomes of both MRCP Part 2 and MRCP PACES. The successful PACES candidate is likely to have spent a good deal of time in both outpatient and acute care settings and will have managed a variety of medical problems before a successful PACES attempt. Time is needed to not only integrate a broad base of clinical material but also to refine the communication and counselling skills which are usually critical determinants of success in PACES. It seems likely that there is a direct correlation between the volume and quality of clinical encounters a candidate has had and their subsequent success in the MRCP PACES examination

Taking MRCP examinations early versus Later in Training

The previous discussion outlines many of the benefits of taking MRCP examinations early in clinical training. However, there are some potential disadvantages of tackling these postgraduate examinations prematurely. Table 1 lists some of the pros and cons of sitting MRCP exams early in training. There are two major hurdles that doctors face in deciding to take MRCP early. The first is their own personal uncertainty regarding their future career path and the second is the perceived insurmountable difficulty of taking the MRCP examinations in the earlier stages of clinical training. Arguably career pathway indecision should not preclude consideration of studying for and attempting MRCP Part 1. Clinical therapeutics and the basic sciences (such as statistics, genetics and cell biology) together account for around 45 out of 200 multiple choice questions (22.5%). These are topics that are covered in the postgraduate exams of many other specialties and are themselves highly relevant to clinical work during the Foundation Years. Additionally, knowledge of the pathophysiology underlying common medical conditions that is tested in the MRCP Part 1 examination is highly desirable for all trainees regardless of later medical career specialism. Even if Core Medical Training is not pursued after FY2, the fact that a postgraduate exam has been attempted and passed demonstrates personal commitment, discipline and capability that will be often be rewarded at short listing and interviews, especially in those specialties in which exams can only be taken after appointment to a training post.

Table 1

Pros and Cons of studying for and sitting MRCP examinations early

Pros	Cons
More confidence in managing medical patients	Uncertainty regarding medicine or a medical specialty as a long term career pathway
More constructive input into ward rounds and daily ward reviews	Pressure of studying for postgraduate exams so early in career after starting work as a junior doctor
More competitive applications for clinical posts and at interview; demonstrates commitment to specialty, or in studying for a postgraduate exam	Potentially diverts focus from obtaining Foundation Year competencies
Reduces stress at the end of Core Medical Training when applying for ST3 posts in medical specialties.	Expensive to sit examinations if poorly prepared or motivated and therefore more likely to fail first attempt
Broader knowledge base augments the educational value of workplace based assessments.	Exam burnout
Improves quality of referrals made to other specialties
Sense of achievement and progression in career
Allows time for resitting examinations if needed or a break

The perceived difficulty of the MRCP Part 1 examination is arguably a “cultural” phenomenon. The content of the MRCP Part 1 may prove challenging because the basic science concepts tested were usually covered in medical school curricula during the earlier years of the medical course and inadequate time is dedicated by candidates to revising these areas. The changes in working patterns occasioned by the European Working Time Directive mean that the FY1 year is actually a very good time in which to prepare for the basic science components of not only the MRCP but also other postgraduate clinical exams, so long as sufficient time is given to refresh and integrate the material studied. For those that are clear on their intention to proceed to Core Medical Training they can ‘hit the ground running’ with MRCP Part 1 passed early in their FY2 year and continue preparation for MRCP Part 2 and PACES examinations during FY2, CT1 and CT2 years.

Concerns that studying for MRCP will compromise attainment of Foundation Year (FY) Programme competencies are unfounded. Instead of seeing MRCP preparation and FY competencies as mutually exclusive they should be viewed as opportunities to develop a richer FY programme experience. Having a broader knowledge base improves the quality and validity of workplace based assessments.

A Strategy for MRCP Success

Each individual brings their own learning style to studying for MRCP examinations but we suggest a number of practical “tips for success” as follows:

Studying vast blocks of exam-related material at a time is wearying. Focus on small specific areas, especially those in which you have no or limited experience. Test your own knowledge with multiple questions and concentrate on those subjects which you have found to be most challenging.

Ask Core Medical Trainee and Specialist Trainee colleagues which books and online question banks they used. Purchase a small number of good exam revision resources and set aside time every week to study them. This is especially helpful for MRCP Part 1 exam preparation.

Many Core Medical Trainees and Specialist Trainees will be more than happy to coach MRCP PACES candidates (especially if there's a nice meal at the end of it for them!)

Make sure, having encountered a new disease or concept; you can actually recall some salient facts about it the next day, and then the next week!

Make your studying part of your day-to-day job. Does this patient have an unusual disease, or taking an unfamiliar drug, or is he/she experiencing a complication of their condition? Not only will some targeted reading later that day or night (again, digest small chunks, not textbook chapters) consolidate what you've seen but will make you a better, safer and more interested doctor.

Be active in your learning. Consider what complications could develop; are there interactions with the drug you have just prescribed? How will you answer the patient if you are asked about their prognosis? Search out and use scoring systems, calculate the CURB65 and ABCD2 scores, assess the anion gap (smartphones leave most doctors without excuse for doing this) - practising what you have learnt is key to creating a longer term memory for the clinical context.

Studying for the MRCP examinations does not occur in a vacuum. You will encounter many patients with rare diseases. You will come across patients whose laboratory results or physical examination suggest a serious potentially treatable disease - you may be the first and perhaps only doctor that person has contact with. MRCP PACES examiners are not looking for virtuosic displays of diagnostic brilliance but safe, competent doctors who are ready to proceed to higher specialist training. What you study for MRCP will keep patients safe; on some occasions you will have learnt something that may save a life.

Conclusions

A junior doctor interested in a long term career in a medical specialty should consider sitting the written MRCP Part 1 (and if successful) Part 2 examinations during the Foundation Years Programme. Active studying from early on in the Foundation Years Programme allows integration of clinical material into daily patient care thus improving both safety and quality. A combination of careful planning and thorough preparation will maximise the chances of success in these expensive postgraduate examinations. Those applying for Core Medical Training should aim to have passed the MRCP Part 1 examination by that time and possess full MRCP (UK) Diploma by the time of medical specialty ST3 application. The MRCP examinations should be seen as a feasible medical “triple jump” rather than impossible Olympic hurdles.