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The Royal College of Psychiatrists Improving the lives of people with mental illness


Reflections of an overseas CASC candidate

On passing paper-I, II & III of MRCPsych. I thought I had the approval for having the potential for becoming a psychopathologist, a neuroscientist, or a reviewer, but to be a clinician is a different thing. This is where my exam results took a slightly different direction.

I am a veteran overseas candidate  - if the term applies - of the clinical assessment of skills and competencies exam (CASC exam), I was repeatedly unsuccessful till my validity period expired, which is something that I am not particularly proud of, but equally unashamed of 'only recently'.  I would like to reflect on this journey, hoping it might help someone else. I hope I do not indulge into projecting my shortcomings unto other factors, or indulge in self-condolence, self-pity or other defensive mechanisms that I learned about in paper-I.  I also would like to explore the psychosocial aspect of the journey.

One of the things that I learned is that on recurrent travel to Sheffield, packing is not limited to clothes, study materials and to-do list only, it involves dreams, hopes, worries, home-sickness and jet-lag at times. Money issues seem to be a commonly discussed theme among overseas candidates. The role these factors play may vary from increasing motivation to pass, to a burden depending on various factors that would probably boil into a Gaussian bell-shaped curve. I discovered that travelling by plane, train, and underground can be a good opportunity to study and meet with candidates.

... Support came from many people in variable shapes, with some who tend to minimise the whole thing, giving examples from the lives of  Bill Gates, Steve Jobs, and Mark Zuckerberg as successful drop-outs...

Candidates and colleagues were helpful as actors; it seems like psychiatrists can mimic the inner world of their patients to a good depth. During mock exam, courses and hotel stay in the night prior to the exam, I came to appreciate that we 'candidates' are all the same human being, sharing thoughts, emotions and worry about exams, reading books when we can, having nervous laughter, suffering the same anxiety, nightmares, tearful when stressed, and sleepless prior to exam. Just before the exam, a queue is formed of hopes, and a march starts, where each takes his/her position. As the bell rings to start the station, one could here the voice of many trainees echoing synchronously 'Hello, I'm doctor ….'

Each station is seven minutes, having a structure did not look like a luxury in the exam; setting an agenda makes life easier. Understanding the problem, prior to analysis and finding a solution is indispensable. One of the commonly expressed worries during the exam is cultural difference between overseas and patients (actors). Cultural differences and variations seemed eventually over-rated. A worried mother about her son who just received a psychiatric diagnosis or a father who is terrified to learn that his son has NMS seem like a universal theme; apart from costumes, interpersonal distance and language, we have a person in trouble who needs empathy, support, and explanation. The lamentations over under utilised medical skills, expressed by residents of psychiatry seems irrelevant in stations of ECG, physical examination, fundoscopy, laboratory tests' interpretations.

Back to home, I have to face the question of 'How did it go?'. Throughout papers, and CASC, I think I am particularly unable to answer this question. I cannot be a student and an examiner. Unless, one did marvellously well, one cannot tell what will happen exactly. The count-down timer can be met with an eagerness to go behind this blank page, or beg the clock to tick slowly.

On receiving the feedback form, one would wish to learn as much as possible from it for the next time. Some even expressed their wish to have an audio or video recording of themselves. 

Hong Kong
In one re-sitting, I decided once to sit for the exam in Hong Kong (fig. 1) hoping to change or abolish the environmental factors of the exam. After waiting for approval - the priority is given for candidates from Far East - to sit in the exam. After crossing about half of the globe in a long journey, experiencing jet-lag and managing the expenses, I can safely dare to say that the problem was not in the exam site and that learning can be a bit costly at  times.

Failing an exam can provoke grief reaction. I tend to agree with the late Christopher Hitchens in his book 'Mortality', that the Kübler-Ross criteria may not go in a linear fashion, some stages can get prolonged, some missed, and one can move to and fro between them for a while. It is often difficult to explain to a spouse, a friend or a family member, how does it feel, or to explain how psychiatry is not like mathematics. The transparency of the cumulative pass rate report on the RCPsych website may render itself tempting to misinterpret, and many seem to get trapped in adding irrelevant meanings to numbers. On re-sitting the exam I came to understand the mounting anxiety in terms of Pavlovian theories on learning.

At the end of an unsuccessful journey, once again met with bereavement, guilt, and a tendency to blame oneself, equally opposed by an inclination to unjustifiably project the whole package on anything including weather (fig. 2), place, time and noise. Reaching a resolution is not an automatic process but it is quite likely to occur.

My family taught me what does the Rogerian 'unconditional positive regard' mean in real life situation. Support came from many people in variable shapes, with some who tend to minimise the whole thing giving examples from the lives of  Bill Gates, Steve Jobs, and Mark Zuckerberg as successful drop-outs (though I failed to find the link between computer and psychiatry). Some advised to take a vacation, and others said 'it was not meant to be' whatever this meant. There seemed to be an urge to make meaning out of it or to find out a lesson or take-home message. I came to recognise that some people would hint even overtly that I ought to think this way, which reminded me of Dr Viktor Frankl when he put his logotherapy theory into a mathematical equation saying that despair is suffering without meaning (D=S-M). This urge to find 'The meaning' may have a protective value. Some argued that I should not 'take no for an answer', this varied from recommending an appeal, to re-sitting the exam. The structure of the story of a 'hero' as described by Joseph Campbell, can be haunting to many people who tend to think of candidates as heroes who travel for call, and will eventually reach their goal, with invariably no other alternative resolution.

The topic that became disturbing to others, was me talking about this journey till its end; where some would subtly point out that one should not talk about failures, or something within the lines of 'exposing a wound'. Though it is part of life, and it is hard to find someone who never had one. May by talking about it is not a pleasant topic, may be it evokes a sense of an 'unfinished business' in Perls' terminology. The culture that is success-based, and achievement-directed seems to either squeeze success out of failure, make meaning out of it, or abolish it from its existence. Acceptance of it as is; seems to be the hardest endeavour with no make-up, no lamentation, no lessons learned, no analysis of gains and losses for the next round.

Dr Emad Sidhom



I wish other candidates a better chance, I feel happy for the many successful candidates, and I guess I became able to understand some of the evoked feelings that unsuccessful ones might experience. I can say that failing to receive the title of MRCPsych should not be 'the end of the world', unless one fails to go beyond a loss.



Re: Reflections of an overseas
I also share similar experience with this Dr Sidhom although I am a UK trainee but from Egypt. I have done the old system and passes part one after 4 attempts. Then I have done part two theory twice then failed the clinical part in 2006. Shortly after the examination system changed which was massive shock and triggered a lot of anxiety as it required to be familiar with the new system and adapt to the new ways of the exam. I had to do paper three in the new system to be eligible for the clinical part CASC.

In my struggle Ihad to repeat part one 4 times, each time missed by a fraction. I kept reminding myself that “Our greatest glory is not in never falling, but in rising every time we fall” Confuciusit,.I was asking myself every day what else I could do to get to the other side?. I started to doubt myself and my ability to whether I would ever pass this exam in my life time. My life was on a holt, I could not think or do anything else because all my energy and focus was to overcome this hurdle. I was on an emotional roller-coaster preparing for the exam for 2 moths then waiting very anxiously for one then having to recover for another 2 months which was extremely devastating. The worst part is the depression and the big vacuum in my confidence at the time as I never had to repeat any exam in my life. i was looking at different roots to become a consultant and to avoid this exam and article 14.

However I decided to step back and take time off to reassess my situation and give my brain a break to recover and to restore my mental and physical energy in order to cope with this daunting challenge. I did not do any exam, study or preparation for one year. I joined the gym and gone on holiday. This seemed to have improved my thinking and my brain ability to absorb information and able to process it in a better and effective way. Fortunately this seemed to work very well and i managed to pass paper 3 from 1st attempt and CASC first attempt.

I feel the most important part is never to loose hope as this is very crucial to continue and keep morals up. Also encouragement and support from family and friends was very important. I believe although this is a very difficult exam for overseas doctors due to cultural and system difference, it is by all means not impossible. Knowledge could be increased and skills could be enhanced to pass it once you have the fighting mentality to keep going.

Dr Mohamed Mansour
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        About this blog

Dr Emad Sidhom


Dr Emad Sidhom, is a psychiatrist working in an old age psychiatry department in a private hospital in Cairo, Egypt. He is board certified by the Arab Board of Psychiatry.