How to Run a Mock CASC

Heather Welsh

Introduction

The CASC (Clinical Assessment of Skills and Competencies) has been running since 2008 and is the final membership examination for the Royal College of Psychiatrists (MRCPsych).¹ It is a clinical examination and follows an OSCE format (Objective Structured Clinical Examination), where candidates move through 16 short stations.^2,3 We have been running a mock CASC in the West of Scotland for the last few years and have received consistently good feedback from candidates. This article describes our experience of organising the mock exam.

Step 1: Practicalities

The organising committee

Our mock CASC is arranged by the organising committee for the local core psychiatry education programme (MRCPsych course). This committee is comprised of a consultant chair, higher trainee chair and one or two trainee representatives from each higher subspecialty and each core training level. The higher trainee chair takes the lead with organising the mock, with the support of other committee members. This works well, as the trainees have recent experience of sitting or preparing for the exam and are enthusiastic about medical education.

Support from our postgraduate operations manager is invaluable. She works closely with the committee to book the venue and actors, and order equipment such as screens and a bell. She also has a key role in advertising the mock exam to trainees, booking places and being a point of contact for candidates. She assists with set up on the day of the exam and prints station instructions, marking schemes and labels for candidates.

Venue

Our mock exam is held in the same venue as our core trainee educational programme. We have 2 rooms to use for stations and a waiting area for candidates. Screens are borrowed from Glasgow University Medical School to create separate stations.

Timing

The mock exam takes place around 2 weeks before the CASC. This enables candidates to have prepared for the exam and leaves some time to work on any issues identified by the mock. Planning usually starts 4-5 months in advance of this, with increasing intensity and time commitment as the exam approaches.

Step 2: Mock Exam Format

CASC format and blueprint

The CASC itself includes morning and afternoon circuits, which all candidates will move through. There are 16 stations in total, with 90 seconds between each to read the task instructions. The morning session comprises 4 pairs of ‘linked’ stations, lasting 10 minutes each. In these paired stations, the second station is connected to the first in some way, such as taking a history in the first part then discussing with a family member in the second. Each station is marked independently. The afternoon consists of 8 single stations, lasting 7 minutes each. A passing list is posted online after a few weeks, with specific feedback made available to unsuccessful candidates.²

Mock CASC format

Our mock CASC is run in one afternoon session from 1.30-5pm. We have been able to include 16 stations by running the 2 circuits simultaneously. To make this possible, each station is 7 minutes in duration, with 90 seconds between stations. 4 candidates start after a delay, as it is not possible to start on part 2 of a linked station. Trainees are allocated candidate numbers and starting stations for both circuits to coordinate this effectively (figure 1). 16 candidates can take part in the mock exam.

Figure 1. Candidate numbers

At least 3 other higher trainee helpers are recruited to assist the coordinator on the day of the exam. The same marking scheme is used for each station, covering domains common to all stations, such as building rapport and range and depth of questioning. There is also space for specific feedback, which examiners are encouraged to provide, though they do not interact with candidates directly during the exam. Forms are completed contemporaneously and distributed to candidates immediately after the mock exam.

Step 3: Writing the Stations

The content of the CASC follows a blueprint, which is available through the RCPsych website. A variety of skills are tested during the 16 stations of the exam, including history-taking, mental state examination, risk assessment, cognitive examination, physical examination, case discussion and difficult communication.³ We refer to the blueprint when selecting which stations to include in the mock. Each year, recent CASC candidates are asked to suggest stations and we combine these with previous stations to construct the mock exam. New stations are written by the trainee who suggested them, including candidate instructions and actor’s notes. The higher trainee organiser formats these to maintain consistency across the mock exam.

Role-play actors

For our most recent mock CASC, we employed paid actors for every station. These actors are part of a local agency which has experience in working as simulated patients for Glasgow University exams and communication skills sessions. In previous years, we have recruited a combination of core/higher trainees and actors. We have found pros and cons to each approach. The use of paid actors was more realistic for trainees but writing scripts proved more challenging as instructions required greater detailed in relation to specific psychiatric information, such as how a person with mania may present.

Step 4: Recruiting Examiners

There are a number of local consultant psychiatrists who are actively involved in teaching. They are supportive of the mock CASC and enthusiastic about examining stations. After the stations have been devised, consultants are invited to examine based on their areas of expertise. Higher trainees with particular interest in education are then asked to examine any remaining stations. Candidate instructions and actor’s notes are circulated to examiners in advance (figure 2). A simple guide to the mock exam is also sent to any new examiners. As we use the same marking scheme for each station, it is down to the experience of the examiner to consider whether the candidate has addressed the specific tasks appropriately.

Figure 2. Station template

Step 5: The Day of the Mock Exam

The higher trainee coordinators arrive at least 1.5 hours prior to the start time to set up the venue. Examiners, actors and candidates are asked to arrive 15-30 minutes before the scheduled start time. Each group is briefed on the exam format and given the opportunity to ask questions. Actors and examiners are shown to their stations and allowed time to discuss them. Candidates are provided with numbered labels to wear, for examiners to record on their marking sheets. The 4 candidates who will be starting later are asked to wait, while the others are shown to the examination rooms. They are shown which station they will be starting at, then queue in order at the door.

The mock exam coordinator stands where they can be heard by both rooms. There are 1 or 2 helpers in each room to guide the candidates around the circuit. The bell is rung to signify the start of the exam, the end of the 90 second preparation time (the start of each station), 1 minute warning and the end of each station. The candidates who were allocated to start later are brought into the circuit and shown to their station as the ‘end of station’ bell is rung, as this also signifies the start of the 90 second preparation time for the next station.

Marking schemes are collected and sorted during the break. Candidates are not kept separate from examiners, actors or each other. They are advised that they will get the most out of the afternoon if they don’t discuss the stations but this is ultimately their choice.

Examiners and actors return to their stations following the short break and candidates swap between circuits. Following the second round, there is another short break. Actors are excused at this point and most examiners remain for a feedback session. Marking schemes are collected, sorted and distributed to candidates. One room is re-set for group feedback. Examiners are thanked for their time and each is asked in turn for general feedback, hints and tips on their station (figure 3).

Figure 3. Mock CASC timing

Overcoming Potential Problems

Examiners

Our examiners are all either higher trainee or consultant psychiatrists. It is therefore possible that unforeseen circumstances mean that they may have to cancel at very short notice, attend late or not at all, or be called away during the mock exam. Each of these has happened over the past few years but has been easily managed by the extra higher trainee helpers stepping in to examine a station.

Actors

All of our actors have attended as planned. If a paid actor has to cancel at short notice, the agency will find a replacement. If a trainee actor did not attend, one of the higher trainee helpers could step in. Another potential problem which we have encountered is actors not performing as intended. This can be minimised by preparing clear instructions for actors, with examiners providing some direction if needed.

Quality control of stations

It is difficult to know how a station will work until it is used in the mock exam. To minimise the risk of problems, stations are checked and formatted before the exam. They are circulated to actors and examiners in advance to allow time for them to raise any concerns and clarify any uncertainties. Despite following these processes, there are some stations which appear unclear or do not run smoothly on the day of the mock exam. It is helpful to receive feedback from examiners, so that stations can be amended or avoided in future.

Timing

Our mock exam follows a very tight schedule. If the mock exam itself overruns, then fewer examiners may be able to remain to provide feedback. The higher trainee coordinator should keep time carefully during the day of the mock exam, particularly during break times, which are very brief. Support from other higher trainee helpers is essential for this, in working together to collect and organise marking sheets and guiding examiners, actors and candidates to stations. Late arriving examiners remain a potential problem due to their other commitments. We provide a sandwich lunch to our examiners prior to the exam, which helps with prompt attendance.

Venue

The venue we use is quite cramped and can become noisy. We have access to only 14 screens to divide the 16 stations so they are close together and those at the ends of the room are not fully enclosed. The screens are thin so only muffle the noise from neighbouring stations. These issues of space and noise are difficult to overcome. Trainees are warned in advance and aim to focus on their own station as much as possible.

Recruiting actors, examiners and candidates

To date, we have not experienced any problems in recruiting actors, examiners or trainee helpers. We have been able to fill all candidate places and often have a waiting list. If necessary, the mock exam could be run with fewer stations and still provide helpful practice for trainees. If resources were tight, trainees could be role-play actors for some or all of the stations.

Conclusion

We run a local mock exam annually due to continued demand from trainees. It takes significant time and effort to arrange but is good experience for the organiser and local trainees and consultants remain enthusiastic. The mock CASC in the West of Scotland puts a strong emphasis on providing feedback for trainees to work on. The provision of completed marking sheets on the day of the exam and the group feedback session help with this ethos. Our experience has shown that a mock CASC can be delivered locally, at a low cost, while still providing trainees with a realistic exam experience.

References

1. Hussain A, Husni M. Preparing for the MRCPsych CASC - an insight based on experience. BJMP; 2010; 3(2): 55-58
2. Royal College of Psychiatrists. Candidate guide for clinical assessment of skills and competencies (CASC). Available from: www.rcpsych.ac.uk/traininpsychiatry/examinations/examinationstab/mrcpsychcasc/casccandidateguide.aspx [Accessed 16th May 2016].
3. Royal College of Psychiatrists. MRCPsych CASC blueprint.Available from: www.rcpsych.ac.uk/pdf/MRCPsych%20CASC%20Blueprint%20March%202011.pdf [Accessed 16^th May 2016].

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