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The long case is dead – long live the long case: Loss of the MRCPsych long case and holism in psychiatry

  • Tony Benning (a1) and Mark Broadhurst (a2)
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Hodges, B., Regehr, G., Hanson, M., et al (1998) Validation of an objective structured clinical examination in psychiatry. Academic Medicine, 73, 910912.
Hodges, B., Regehr, G., McNaughton, N., et al (1999) OSCE checklists do not capture increasing levels of expertise. Academic Medicine, 74, 11291134.
Martin, P. & Ashcroft, R. (2005) Neuroscience, Ethics and Society: A Review of the Field. http://www.wellcome.ac.uk/assets/wtx027876.pdf
Pies, R. (2005) Why psychiatry and neurology cannot simply merge. Journal of Neuropsychiatry and Clinical Neuroscience, 17, 304309.
Pilgrim, R. (2002) The biopsychosocial model in Anglo-American psychiatry: past, present and future. Journal of Mental Health, 11, 585594.
Royal College of Psychiatrists (2006) A Competency Based Curriculum for Specialist Training in Psychiatry. Royal College of Psychiatrists.
Tyrer, S. & Oyebode, F. (2004) Why does the MRCPsych examination need to change? British Journal of Psychiatry, 184, 197199.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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The long case is dead – long live the long case: Loss of the MRCPsych long case and holism in psychiatry

  • Tony Benning (a1) and Mark Broadhurst (a2)
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eLetters

Trainees welcome new pattern of MRCPsych

Vijay Natarajan, psychiatrist, staff grade
18 January 2008

I would like to congratulate the Royal College for leaving out “ the long case” and changing the whole pattern of conducting MRCPsych. The longcase was not able to differentiate between good and poor candidates and had a lot of subjectivity in it.The whole pattern of examination needed an overhaul and though it has comea bit late, the trainee doctors welcome this much needed change. Not only was the pattern unfair but biased and made passing the exam a lottery. Some candidates who had done their postgraduate degrees abroad and had been practising psychiatry for more 5 years were failing not once but repeatedly in the old pattern. They were getting extremely frustrated, because one could not get a proper feedback as to why they were not passing their exams, this despite being sufficiently competent and knowledgeable enough to work as Consultants.When the whole pattern of practising psychiatry is changing with electronic records, new ways of working, numerous teams (Home treatment team, early onset psychosis etc) one need not stick to an old pattern of examining candidates. Electronic records esp. RIO in London has made life much easier for everyone. One can sit in their office and know how their patients are. The junior doctor no longer has to wait for notes to be brought from medical records or redo details of past psychiatric history, family history etc every time they see /discharge a patient.Change is important in every sphere of life because unless and until we try new things we cannot make improvements in our system.‘The long case is integral to the bio-psychosocial approach ’.I do not agree with authors on this statement. Bio psychosocial model can still be tested in OSCE’s.

The authors feel that subjective data will not be tested in the new format. I believe acquisition of subjective data should not be tested in exams because each individual practises psychiatry in a different way. Psychiatry is a very subjective field; some people are eager to work with personality disorders and substance misuse, while others find working withthem extremely difficult and unrewarding.

The culture of psychiatry is changing like everything around us and probably its time we adapt to changing times.
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Conflict of interest: None Declared

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Changes in MRCPsych examination regulations not in tune with Sir. Tooke�s report.

Siraj Salahudeen, Staff Grade Psychiatrist
16 January 2008

We all appreciate changes if it is for good reasons. However, in caseof MRCPsych membership examinations, it needs to be seen how dropping of long case and essay will affect the overall objective of the exam. Nevertheless, the changes in the examination regulations are not far sighted as far as the SAS (Staff and Associate Specialist) grade doctors are concerned.

Apart from the actual changes in the MRCPsych examination, the Royal College of Psychiatrists also published new regulations for the new style examinations. It says that after 31st December 2008 all trainees must be in a PMETB/Deanery approved run through training or FTSTA post to re-sit any part of the examination. However, this is in sharp contrast to Sir John Tooke’s final report and recommendations on medical training. Sir Tooke in his report recommends that SAS doctors should have access to training overseen by Postgraduate Deaneries and CPD opportunities and theyshould be able to make a reasonable limited number of applications to Higher Specialist Training positions according to the normal mechanisms and also to acquisition of CESR (Certificate confirming Eligibility for Specialist Registration) through the Article 14 route. The new MRCPsych regulations will have serious implication on the SAS grade doctors who arestill in pursuit of examinations and their aspiration to get the MRCPsych membership. Doctors take up SAS grades for a variety of reasons. I think the Royal College of Psychiatrists should amend their above decision to restrict SAS grades in taking up the MRCPsych examinations from 2009.

Declaration of Interest : Passed MRCPsych whilst working as a Staff Grade

Siraj Salahudeen, MBBS, DCPsych, MRCPsych, Staff Grade Psychiatrist, Derbyshire Mental Health Services Trust, Psychiatric Unit, DCGH, Derby, DE22 3NE

References

http://www.rcpsych.ac.uk/pdf/Regulations2008%20Final%2013-12-07(2).pdf

http://www.mmcinquiry.org.uk/MMC_FINAL_REPORT_REVD_4jan.pdf

http://www.pmetb.org.uk
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Conflict of interest: None Declared

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The art of Psychiatry

Jon Van Niekerk, ST4 (General Adult Psychiatry)
07 January 2008

To the Editor

The art of psychiatry.

I read with interest the article by Benning and Broadhurst (Psychiatric Bulletin (2007) 31: 441-442). Holism in psychiatry has become a cliché in psychiatry. It is sad that at a time when specialitiesoutside psychiatry are embracing the humanities, psychiatry seems to have started to neglect it.

Psychiatry has made a lot of progress over the last few decades. Paging through psychiatric journals that are filled with imaging studies and genetic breakthroughs show these remarkable discoveries. In response to these advances in psychiatry Dr David J. Hellerstein argues that: “In exploring these new universes, we need not be only technicians and scientists, but also artists!”

The pressures on seeing patients within specified targets and this affair with all things biological is impacting on our patient care. This reductionist psychiatry with quick consultations and quick fixes fits in with the consumer society of “just add water and stir”. It is unfair to expect a pill to fix complex psychosocial problems.

It’s all well and good to have holistic training, but when you have done the training you need the support and resources to implement them. In the proposed New Ways of Working we are expected as doctors to only seethe most complicated cases. Hopefully in this new scheme there will be more time to spend with patients and provide them with a more holistic treatment. Teaching will provide the foundation to build from but withoutthe resources to implement holism, they will become forgotten poems.

word count: 246

Reference:

1.BENNING T, BROADHURST M, The long case is dead — long live the long case. Loss of the MRCPsych long case and holism in psychiatry. Psychiatric Bulletin (2007) 31: 441-442

2.HELLERSTIEN, D (2007) The disappearing patient. Posted on Medscape 08/10/2007 Best wishes

Dr Jon van NiekerkSpecialist Registrar in General Adult Psychiatry, Rawnsley building, Manchester Royal Infirmary, Oxford Road, M13 9WL, email: vzvanniekerk@hotmail.com
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Conflict of interest: None Declared

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An elegy to essay writing

Lena Palaniyappan, Academic Clinical Fellow
07 January 2008

Benning & Broadhurst (2007) raise an important issue with regard to the change in MRCPsych exam format. In addition to the loss of long case, the new exam discards essays and critical appraisal in theory assessment. The loss of essay, in my opinion, needs significant mourning.

Essays have traditionally been the only mode of testing logical arguing skills. This is an essential skill for any clinician in psychiatrygiven the intangible nature of certain domains of our clinical work. In the absence of a well constructed arguing ability, team working and teaching cannot flourish.

Essays tested contemporary contents unlike MCQs, which were obtained from a bank of questions. The creativity and reasoning abilities of a candidate are largely untested in the new format exam. This means we mightget many qualified members in the future who managed to read the specifiedsyllabus and managed their time well at CASCs (new OSCE exams), though they never had a chance to prove that they are up to date with the developments in the field or that they could think critically about a controversial issue in the field. This is a great loss; the aforementionedare important and distinguishing skills for any psychiatrist.

I am a candidate who sat the last of old pattern MRCPsych part 2 exams. I, like most of my peers, spent a substantial amount of time in researching British Journal of Psychiatry, Advances in Psychiatric treatment and Psychiatric Bulletin apart from other journals, when preparing for my exams. Journal reading habit was cultivated strongly by essay paper in MRCPsych. This is not the case with MCQs. Factual recall istested equivalently by both MCQs and essays (Palmer & Devitt, 2007). But higher order cognitive skills including problem solving cannot be easily tested by a set of MCQs (Schuwirth et al, 1996). It is everyone’s secret that College employs a bank of questions with high repetition rate for subsequent exams.

One argument against essay writing is standard of assessment, which could vary widely when an essay is evaluated. Standardisation of assessment could be attempted by structured essay evaluation tools. Removing essay writing completely and replacing it with MCQs is a costly trade off between assessment standards and the abilities tested.

Fast food may be easy and appealing, but cannot solve all nutritionalrequirements. MCQs may be an easy option if one considers online delivery of exam modules in future, but whether we need to give up on essay papers is a matter of serious debate.

Declaration of interest:

LP was awarded Laughlin prize for outstanding performance in old format MRCPsych exam - Autumn 2007. He is also involved in writing a MCQ book for the new format MRCPsych.

References:

Benning, T., Broadhurst, M. (2007) The long case is dead — long live the long case: Loss of the MRCPsych long case and holism in psychiatry. Psychiatric Bulletin, 31, 441-442

Palmer, E.J., Devitt, P.G. (2007) Assessment of higher order cognitive skills in undergraduate education: modified essay or multiple choice questions? Research paper. BMC Medical Education, 7, 49.

Schuwirth, L.W.T., van der Vleuten, C.P.M., Donkers, H.H.L.M. (1996) A closerlook at cueing effects in multiple-choice questions. Medical Education, 30, 44-49.
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Conflict of interest: None Declared

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The long case is dead

Simon Wilson, Consultant Forensic Psychiatrist
18 December 2007

I very much enjoyed Benning & Broadhurst's editorial and share their concern. I think the cultural shift they warn against has already begun to happen in many of the clinical settings I come across. Perhaps the changes to the exam reflect this?

Several unrelated upheavals in British psychiatry have had the unintended consequence of bringing about the death of the long case in routine clinical practice. New Ways of Working, "functionalised" mental health teams, the NHS's soviet interpretation of multi-disciplinary working (nurse = doctor = social worker = psychologist), electronic records that are not fit for purpose, and the prevailing view that in-patient admissions simply represent a failure of community care and a financial pressure to be managed at all costs together mean that patient histories are just not taken any longer. New Ways of Working has removed psychiatrists from seeing their patients. The dogma that all are equal means that psychiatrists are not allowed to say that actually there are some aspects of our work (like taking histories and formulating cases) that we do better than other disciplines. Functionalised teams mean that only Assessment teams (i.e. a nurse or social worker) are meant to do any "clerking". Poorly functioning electronic records have replaced paper notes, and have relegated the latter to dusty store cupboards, if they canbe found at all. There seems to be no sense that they may contain valuableinformation. The current mental state seems to be all that is of any concern. Familiarising oneself with a patient's history (perhaps containing important data about risk, for example) might make them harder to discharge from hospital.

The changes to the MRCPsych examination are in danger of consolidating this situation. The "Part 1 summary" seems to be on the verge of extinction. Are we training a generation of psychiatrists who will place no value on listening to their patients? Or on putting togetheran understanding of their stories based on all the relevant data?
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Conflict of interest: None Declared

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