The latest RANZCP written examination results mean failure for more than the candidates
The RANZCP August 2024 MEQ and CEQ essay exam results have just dropped, and as an experienced exam coach and mentor to many psychiatry trainees and IMG’s (international medical graduates), I have been floored. Exam results are released twice a year after the February and August rounds of written essay exams, and this is generally a time to hear from my clients who have passed or need to repeat their attempts. It is also a time to plan my next round of offerings for the upcoming exams.
But this time, I have found something way more pressing to do and that is to begin a discussion acknowledging the utter devastation and distress many candidates are feeling with pass rates that are some of the worst we have ever seen, and the consequences on our understaffed mental health system as a consequence.
Yesterday’s results were some of the worst ever, and this is in light of a decision two years ago to allow candidates to sit the two written exams at different times. The MEQ essay exam pass rate was around 56% and the CEQ essay exam (the creative writing piece) was 61%. 334 candidates sat the MEQ exam this time, and 228 sat the CEQ essay exam, across Australia and New Zealand. They now need to wait until March 2025 to re-sit, with results not being available until May 2025. Fees for each attempt at either of the essay exams are around $2000.
I have always been the person who highlights these issues that occur within my profession, and who recognises I am relatively safe from backlash as my years of training are long behind me. I can speak up for those still beholden to their training systems and pathways, fearful of repercussions if they do challenge the status quo. I do it this time because my concern and fear about where my profession is heading has never been more concerning.
It may be a surprise for many to know that in Australia and many other countries around the world, if you want to be a medical specialist such as a psychiatrist you must receive your accreditation from one governing accrediting organisation, and for us that is the Royal Australian and New Zealand College of Psychiatrists, RANZCP. It is completely different to medical school training where a student can study at numerous universities around the country. The RANZCP is our representative body and accreditation organisation, and they are the ones who decide which of us are fit and able to join their club. They also administer the training program and they set high-stakes exams that trainees must pass to become a Fellow of the RANZCP in Australia and New Zealand.
One of these high-stakes essay exams is the “CEQ” or critical essay question, which is actually a creative writing piece akin to a year 12 English exam essay. Candidates must discuss a quote often derived from a poem or a book. The other essay exam, the modified essay question, or MEQ attempts to examine different situations that a candidate may face, but the kicker is they must answer based on what they would do if they were already a consultant. Sometimes the question is posed that they are acting as a clinical director of a service, yet the candidate is attempting the exam in their third or fourth year of training. They are not examined on their learning, study, skills and experience to date. They therefore must somehow predict the future of how they would approach a situation when the whole point of doing the exams is to get to that place.
I have been involved in exam coaching since 2007 when I was going through exams as a psychiatry registrar in Victoria. Back then we sat mini clinical exams and interviewed patients under supervision and were assessed based on our ability to perform our role with safety and competency. Since this time, the clinical exams have fallen out of favour, and have been regarded as too expensive to run. It is my opinion and that of many of my colleagues that these exams were the best way to decide who had what it took to become a consultant psychiatrist. The contextual element that is missing in this argument is that they were last held during the COVID-19 lockdowns and failed bitterly due to technical problems that occurred while the exam was running, leaving hundreds of candidates in exam limbo, and facing delays in progressing to fellowship. The transition to making written exams the high-stakes exit exams that they currently are as a result of this, not for any reason that they were deemed a better way of assessing who should make the cut.
I have now coached hundreds of trainees and IMG’s and I can say that these latest results speak more to flaws with the exam process and not to the ability and competency of our training workforce. These doctors, like so many in our public health system are literally propping it up. Our psychiatry registrars and IMG’s are the current workhorses of our mental health system in Australia and New Zealand. They have worked through a pandemic and an ensuing mental health crisis that will last for years. At the same time, they have studied and prepared for their assessments and these exams. If they are deemed not good enough by way of their results in written exams, why are they able to work in their highly responsible and generally autonomous roles?
Because of these exam results we have hundreds of trainees waiting for the next chance to sit their exams and stuck in a holding pattern. Some because English is not their first language and their ability to write an English exam didn’t make the grade. Some of these doctors are expert psychiatrists in their country of origin and have now dedicated their lives to working in ours. But they have been held back from being able to work at the level they are already qualified for, by working in Australia and New Zealand.
At an individual level, failing an exam for a cohort of ultra-high achievers who are intolerant of failure is crushing and at times leaves real scars. Having to sit an exam for more than two attempts can be inexplicable. I am aware of a wave of dedicated trainees applying for breaks in training, some with no real intention to return, as they try and come to terms with feedback that they are not good enough. Often the feedback they receive after failing an exam is generic and unhelpful. I was shocked by the loss of three psychiatry registrars in one month to suicide back in 2015 and I am acutely aware of how such setbacks can impair and cause harm to human beings who have chosen to pursue a career in psychiatry. I fear that little has changed in almost 10 years, and in fact, despite all the talk about doctors mental health, we are all in a worse position. A better solution would be to train, educate and nurture our next generation of psychiatrists so they can experience longevity and satisfaction in their career pursuits, not grind them into the ground before they even make it.
At a systemic level, everybody needs to know about the impact of this. The GPs who are tearing their hair out trying to refer a patient to a psychiatrist. The vulnerable person needing help, who are more likely to now find themselves paying ridiculous amounts of money to be assessed over a Telehealth site. And our society who continues to ask why some people with mental illness go on to commit horrific crimes, hearing constantly about their failure to access timely and critical psychiatric care. It remains that despite the number of skilled mental health professionals in our system, psychiatrists possess certain skills and experience that nobody can replace.
The effects of failing to progress our next generation of psychiatrists through their training programs are cumulative, but ultimately leads to ensuring we don’t produce nearly as many specialist doctors as we could. I am all for ensuring that our graduates are the best and most qualified that they can be. However this current exam situation is very unfair, as there is no transparency around how success is determined or externally validated.
There are many factors that are contributing to our current mental health crisis, but this is one key factor that could be resolved to free up safe and competent trainees to fill urgent gaps that they have spent years preparing for. Doctors who are already working tirelessly in our mental health system. But like so many things, I believe the real impetus for change must come from those outside our profession, to begin asking questions and demanding answers about why we have the trainee bottlenecks that we do, and why so many of our next generation of psychiatrists are leaving before their work has truly begun.
Dr Helen Schultz is a consultant psychiatrist, and an exam coach for the RANZCP examinations, as well as a longstanding mentor and advocate for doctors in training. She is a professional writer and regular contributor of freelance articles and media appearances. www.drhelenschultz.com
