CASC candidates need better preparation

Kashyap & Sule are right to express outrage at the low pass rates for the Royal College of Psychiatrists Clinical Assessment of Skills and Competencies (CASC), and concern over the difference between UK-trained candidates and those trained elsewhere. ¹ They offer good suggestions for improvement. However, by focusing on the examination itself rather than the quality of CASC preparation in UK postgraduate training programmes, their outrage may be misdirected.

The validity and reliability of multistation Objective Structured Clinical Examinations (OSCEs) has been tentatively established. ² Despite the appeal of the long-case examination, it has poor interrater and test-retest reliability when system-atically evaluated; ³ its continued use in high-stakes professional examinations is difficult to justify. However, it is very concerning that many candidates are surprised when failing a supposedly objective examination after 3 years of practising psychiatry. Can it be that so many intelligent and diligent psychiatry residents have a severe lack of insight into their own abilities? This seems implausible. It is more likely that postgraduate training programmes are failing to equip residents with the skills they need to pass the CASC. Given that these are predominantly consultation and interpersonal skills, it is difficult to escape the conclusion that residents receive inadequate feedback on clinical skills in their initial years of practice, even before commencing formal preparation for the CASC.

The College dropping the Part 1 OSCE shifted responsibility for evaluating first-year residents’ core clinical skills to postgraduate training programmes by means of the workplace-based assessment (WPBA) system. This approach is not effective: there are multiple flaws in the current WPBA system ⁴ and its suitability for assessing and developing core clinical skills is even more questionable than the long-case examination. ⁵ These observations are supported by our own experience of delivering CASC training: many candidates are surprised to receive in-depth feedback on difficulties in interpersonal and consultation style. After 3 years of practising psychiatry to their best of their ability with little criticism or coaching, it is no wonder that they are disappointed when the first piece of negative feedback they receive is failing the CASC. This affects UK-trained and non-UK-trained candidates alike and to focus on discrepancies detracts from the issue that the current pass rate is too low for all candidates.

This leads us to the conclusion that a substantial share of responsibility for low CASC pass rates lies not with the Royal College of Psychiatrists, but with the postgraduate training programmes. It is of course important that the CASC is continuously evaluated and improved, but there are more pressing issues. First, we suggest that training programme directors collect and publish data on CASC pass rates and urgently improve support and training for residents at risk of failing. Second, preparation for the CASC must start in the first year of psychiatric practice, in the form of in-depth consultation skills training beyond the WPBA system. Finally, we recommend that current and prospective psychiatry residents use all available information regarding the quality of clinical skills and CASC training when choosing a postgraduate training programme.