Skip to main content

The long case: a case for revival?

  • Albert Michael (a1), Ranga Rao (a2) and Vishaal Goel (a3)

Until 2003 the long case was the clinical component of the two summative examinations for the Membership of the Royal College of Psychiatrists (MRCPsych). This changed to an Objective Structured Clinical Examination (OSCE) format, initially for the Part I examination, and more recently to the Clinical Assessment of Skills and Competencies (CASC) at the end of 3 years of basic training. Although there are distinct advantages to the objective, competency-based assessment, questions remain on its validity. The expectation that formative workplace-based assessments would fill in the void left by the loss of the long case has not materialised. The options for retaining the advantages of the long case within the CASC framework while minimising the shortcomings of the CASC are suggested as a way forward.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      The long case: a case for revival?
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      The long case: a case for revival?
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      The long case: a case for revival?
      Available formats
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Ranga Rao (
Hide All

See commentary, pp. 382–383, this issue.

Declaration of interest

A.M. is a College Examiner and Training Programme Director, General Adult Psychiatry, East of England Deanery. R.R. is a College Examiner and was a member of the Examinations Subcommittee until 2012.

Hide All
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. Psychiatr Bull 2007; 31: 441–2.
2 Ponnamperuma, GG, Karunathilake, IM, McAleer, S, Davis, MH. The long case and its modifications: a literature review. Med Educ 2009; 43: 936–41.
3 Wilson, GM, Lever, R, Harden, RM, Robertson, JIL. Examination of clinical examiners. Lancet 1969; 1: 3740.
4 Maxim, BR, Dielman, TE. Dimensionality, internal consistency and inter rater reliability of clinical performance ratings. Med Educ 1987; 21: 130–7.
5 Hubbard, JP, Levitt, EJ, Schumacher, CF, Schnabel, TG. An objective evaluation of clinical competence. N Engl J Med 1965; 272: 1321–8.
6 Leichner, P, Sisler, GC, Harper, D. A study of the reliability of clinical oral examination in psychiatry. Can J Psychiatry 1984; 29: 394–7.
7 Gleeson, F. Assessment of clinical competence using the Objective, Structured Long Examination Record (OSLER). AMEE Medical Education Guide No. 9. Med Teach 1997; 19: 714.
8 van der Vleuten, CPM. Making the best of the ‘long case’. Lancet 1996; 347: 704–5.
9 Wass, V, Jolly, B. Does observation add to the validity of the long case? Med Educ 2001; 35: 729–34.
10 Eva, KW. On the generality of specificity. Med Educ 2003; 37: 587–8.
11 Wilkinson, TJ, Campbell, PJ, Judd, SJ. Reliability of the long case. Med Educ 2008; 42: 887–93.
12 Badger, LW, deGruy, F, Hartman, J, Plant, MA, Leeper, J, Ficken, R, et al. Stability of standardised patients' performance in a study of clinical decision making. Fam Med 1995; 27: 126–33.
13 Vu, NV, Steward, DE, Marcy, M. An assessment of the consistency and accuracy of standardized patients' simulations. J Med Educ 1987; 62: 1000–2.
14 Vu, NV, Barrows, HS. Use of standardized patients in clinical assessments: recent developments and measurement findings. Educ Res 1994; 23: 2330.
15 Hodges, B, Regehr, G, Hanson, M, McNaughton, N. An objective structured clinical examination for psychiatric clinical clerks. Acad Med 1997; 72: 715–21.
16 Hodges, B, Regehr, G, Hanson, M, McNaughton, N. Validation of an objective structured clinical examination in psychiatry. Acad Med 1998; 73: 910–2.
17 Thompson, CM. Will the CASC stand the test? A review and critical evaluation of the new MRCPsych clinical examination. Psychiatr Bull 2009; 33: 145–8.
18 Hodges, B, Regehr, G, McNaughton, N, Tiberius, R, Hanson, M. OSCE checklists do not capture increasing levels of expertise. Acad Med 1999; 74: 1129–34.
19 Regehr, G, MacRae, H, Reznik, R, Szalay, D. Comparing the psychometric properties of checklists and rating scales for assessing performance on an OSCE-format examination. Acad Med 1998; 73: 993–7.
20 Hodges, B, Hanson, M, McNaughton, N, Regehr, G. What do psychiatry residents think of an Objective Structured Clinical Examination? Acad Med 1999; 23: 198204.
21 Hodges, B. Variations of a theme by Harden. Med Educ 2003; 37: 1134–40.
22 Marwaha, S. Objective Structured Clinical Examinations, psychiatry and the Clinical Assessment of Skills and Competencies; same evidence, different judgement. BMC Psychiatry 2011; 11: 85.
23 van der Vleuten, CPM, Schuwirth, LW. Assessing professional competence: from methods to programmes. Med Educ 2005; 39: 309–17.
24 Wass, V, Jones, R, van der Vleuten, CPM. Standardised or real patients to test clinical competence? The long case revisited. Med Educ 2001; 35: 321–5.
25 Norman, G. The long case versus objective structured clinical examinations. BMJ 2002; 324: 748–9.
26 Fish, D, de Cossart, L. Developing the Wise Doctor: A Resource Book for Trainers and Trainees in MMC. RSM Press, 2007.
27 Fitch, C, Malik, A, Lelliott, P, Bhugra, D, Andiappan, M. Assessing psychiatric competencies: what does the literature tell us about methods of workplace-based assessment? Adv Psychiatr Treat 2008; 14: 122–30.
28 Bateman, A. MRCPsych Examinations Cumulative Results 2008–2010. Royal College of Psychiatrists, 2011.
29 Menon, S, Winston, M, Sullivan, G. Workplace-based assessment: survey of psychiatric trainees in Wales. Psychiatr Bull 2009; 33: 468–74.
30 Noel, GL, Herbers, JE, Capow, MP, Cooper, GS, Pangaro, LN, Harvey, J. How well do internal medicine faculty members evaluate the clinical skills of residents? Ann Intern Med 1992; 117: 757–65.
31 Babu, KS, Htike, MM, Cleak, VE. Workplace-based assessments in Wessex: the first 6 months. Psychiatr Bull 2009; 33: 474–8.
32 McKinley, RK, Fraser, RC, van der Vleuten, C, Hastings, AM. Formative assessment of the consultation performance of medical students in the setting of general practice using a modified version of the Leicester Assessment Package. Med Educ 2000; 34: 573–9.
33 Hamdy, H, Prasad, K, Williams, R, Salih, FA. Reliability and validity of the direct observation clinical encounter examination (DOCEE). Med Educ 2003; 37: 205–12.
34 Norcini, JJ, Blank, LL, Duffy, D, Fortna, GS. The mini-CEX: a method for assessing clinical skills. Ann Intern Med 2003; 138: 476–81.
35 Olsen, LG, Coughlan, J, Rolfe, I, Hensley, MJ. The effect of a Structured Question Grid on the validity and perceived fairness of a medical long case assessment. Med Educ 2000; 34: 4652.
36 Royal Australian and New Zealand College of Psychiatrists. Regulations: Basic Training and Advanced Training for Fellowship. RANZCP, 2003 (
37 Royal College of Physicians and Surgeons of Canada. Specific information regarding the Royal College oral and clinical component examination in psychiatry. RCPSC, 2013 (∼edisp/tztest3rcpsced002222.pdf).
38 Royal College of Physicians and Surgeons of Canada. Structured Assessment of Clinical Evaluation Report (STACER): Psychiatry Clinical Evaluation for Senior Residents (PGY-4 and PGY-5). RCPSC, 2011 (∼edisp/tztest3rcpsced000734.pdf).
39 Gleeson, F. Defects in postgraduate clinical skills as revealed by the objective structured long examination record (OSLER). Ir Med J 1992; 85: 11–4.
40 Pavlakis, N, Laurent, R. Role of the observed long case in postgraduate medical training. Intern Med J 2001; 31: 523–8.
41 Norcini, JJ. The validity of long cases. Med Educ 2001; 35: 720–11.
42 Norcini, JJ. The death of the long case? BMJ 2002; 324: 408–9.
43 Abouna, GM, Hamdy, H. The integrated direct observation clinical encounter examination (IDOCEE) – an objective assessment of students' clinical competence in a problem-based learning curriculum. Med Teach 1999; 21: 6772.
44 Luiz, EAT, Roberto, OD, Fernando, CF, Eduardo, F, Lio, CM, Ana, LCM, et al. A standardised, structured long case examination of clinical competence of senior medical students. Med Teach 2000; 22: 380–5.
45 Kroboth, FJ, Hanusa, BH, Parker, S, Coulehan, JL, Kapoor, WN, Brown, FH, et al. The inter-rater reliability and internal consistency of a clinical evaluation exercise. J Gen Intern Med 1992; 7: 174–9.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
  • URL: /core/journals/bjpsych-bulletin
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Full text views

Total number of HTML views: 0
Total number of PDF views: 16 *
Loading metrics...

Abstract views

Total abstract views: 54 *
Loading metrics...

* Views captured on Cambridge Core between 2nd January 2018 - 22nd July 2018. This data will be updated every 24 hours.

The long case: a case for revival?

  • Albert Michael (a1), Ranga Rao (a2) and Vishaal Goel (a3)
Submit a response


Work Place Based Assessments

Yasmine A. Nasr, CT1 Psychiatry
22 January 2014

Despite their many criticisms, I am in favour of work place basedassessments (WPBAs). They do, in theory, assess a range of important skills and do this outside of stressful examination conditions, thereby allowing trainees to perform to their greatest ability. The Assessment of Clinical Expertise (ACE) in particular covers many of the same skills assessed in the long case but avoids the snap shot examinationoften criticised of the latter. The ACE overcomes this by assessing patients across multiple specialties with varying patient groups and attempts to minimise examiner bias by requiring completion from a number of different trainers. It also supersedes the long case by allowing full observation of the patient encounter and so in addition to assessing diagnostic and management skills, provides a more reliable means of assessment of communication skills and the ability of the trainee to develop a rapport with their patient.

As a trainee, however, I can clearly see that WPBAs are not without their problems. The main concern for myself and many trainees alike is notwith their format or the skills they assess, but rather the rating and feedback. There is lack of consistency amongst trainers in completing these forms with no standards of reference to work to and so there is great subjectivity in their completion. Perhaps the introduction of external assessors who have received further training could be a step forward in overcoming such inconsistencies.

... More

Conflict of interest: None declared

Write a reply


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *