CASC guide for candidates

The aim of the CASC is to assess the clinical skills at which candidates at a defined point of training should be competent.

The CASC is based on a format that should be familiar to anyone who has ever been involved in OSCEs. Specifically, the examination consists of two circuits which must be completed on the same day.

Stations consist of several elements. There is a construct that is used by the examiner to assess candidates’ performance, instructions to candidates, instructions to the role player and marksheets.

The purpose of the construct is to define what the station is set out to assess in such a way that the examiner is clear as to what constitutes a competent performance.

These have a standardised format with elements in common between stations of a similar type. For example, a history taking station may include directions such as:

The candidate can be expected to

  • take a history

The candidate should

  • explore the duration and extent of the problem
  • elicit features of the presenting problem
  • explore with the patient the effects of his or her problem
  • obtain a comprehensive and relevant physical history
  • explore how the patient’s work, family life, marriage and social life have been affected

There will be guidance about what particular areas of the history a competent candidate would cover followed by some general comments about interview/ communication skills that differ little between stations e.g.

The candidate should

  • show an appropriate mix of open and closed questioning
  • demonstrate advanced listening skills
  • elicit information in a structured, focused, fluent manner
  • demonstrate empathy with the patient’s experience
  • avoid the use of jargon”

In some stations the, focus of the task may centre around interview/ communication skills.

The instructions to candidates

Outside each booth the candidates will, in the preparation time, be given access to a series of instructions that detail what is expected of them in the station.

These will consist of some information required to set the scene followed by explicit instructions as to what candidates are expected to carry out.

These specific instructions will be in bold and bullet point format to assist clarity. Sometimes, negative instructions will be included e.g. “The candidate is not expected to obtain a risk history.”

This is to assist the candidate in establishing the focus of the station.

The instructions to role players

All role players are professional role-players and have been thoroughly trained in the specifications of their roles.

Please note that following successful piloting of stations involving learning disabilities played by role-players with a learning disability, such stations are active and may appear as part of the examination.

The instructions for role players are designed to give role players sufficient information to play the required role and also to deal with eventualities when candidates stray from the defined tasks.

They are set up in such a way that the response to candidates will vary according to the degree of skill elicited by candidates.

An example would be that a candidate who is rude or abrupt may be met by irritability and/ or hostility just as would be the case in a real clinical setting.

Feedback

For overall failing grades, examiners will also mark against a number of detailed feedback statements to enable useful feedback to be given to candidates.

These are not part of a marking checklist and are to be used for feedback only.

Examiners can also mark against a number of detailed feedback statements during their examination of a station, if they are applicable.

These do not form part of the marking checklist, but purely to enable candidates to reflect on their performance in the station.

Please note, the CASC is designed for purposes of accreditation and not training, and as such, the feedback statements will inevitably be limited in informing this.

Only those candidates who were unsuccessful at the CASC will be sent this formative feedback, so it may assist them in preparing for the next attempt.

Classification of diseases

Candidates are reminded that they are expected to know the principles of classification and to have a working knowledge of both ICD-10 and DSM-IV.

Use of alcohol gel

Health services, the public, patients and role players are increasingly aware of hygiene and infection control issues.

Therefore, there should be an expectation that candidates will cleanse their hands properly using the alcohol gel provided before and after physical examination of the simulated patient.

The gel will be placed in a prominent position within the station.

The candidate should take care not to splash gel on the role players’ skin or examine sensitive areas, such as the eyes, before the gel has dried.

Failure to use the gel will not in itself lead to the examiner failing a candidate but will result in the mark being one grade lower than performance of their physical examination would otherwise achieve.

Candidates do not need to remove ties or roll up sleeves.

This Guide forms part of the Eligibility Criteria and Regulations for the MRCPsych Examinations.

To meet the minimum standard required in the CASC exam, you must meet or exceed the total borderline regression score and achieve the passing score in a minimum of 12 stations. You must meet both criteria to be successful.

The reason candidates have to meet both criteria is to make sure that they have demonstrated an acceptable level of performance across a broad range of stations that reflect the breadth of core training.

Candidates who score highly in some stations cannot use this to compensate for low performance in other stations.

How is it marked?

The Borderline Regression Method is considered to be the most objective way of setting the standard for practical exams.

Each CASC station is marked by an appropriately-trained examiner, who provides two sets of scores: (1) 5 point ‘analytic’ global domain scores ranging from 1 (Poor) to 5 (Excellent) for between three and five domains and (2) One 6-point overall global judgement which comprises Excellent Pass, Pass, Borderline Pass, Borderline Fail, Fail, or Severe Fail (refer to Grade Descriptors).

The total weighted domain scores are regressed onto their global scores to produce a linear equation for each station for all candidates.

The total domain score for borderline candidates, determined through this line of best fit becomes the pass mark for that station.

The pass mark for the whole exam is the average of the station pass marks for that day.It is important for reasons of policy and patient safety only to pass candidates who are clearly competent.

All examinations are therefore subject to a ‘standard error of measurement’ (SEM). So, for the CASC exam, the initial indication of a standard is raised by an estimate of measurement error. Passing a station is dependent on the station score.

Station pass marks

Overall judgements for each station are used only to set the pass mark via the regression equation e.g. an examiner can give an overall judgement of Borderline Fail but a candidate can still pass the station.

Therefore, the secondary passing criteria of 12 stations is based on station cut scores and not the overall judgement of examiners.

The minimum of 12 stations has been set on the basis that the five history taking and five examination stations cover basic clinical skills (information gathering, mental state examination, communication, etc) and that a borderline candidate should be expected to pass eight out of these ten stations.

The six management stations are intended to test higher level clinical management skills (clinical analysis, reasoning, decision making, etc) and that a borderline candidate should be expected to pass four out of six stations.

Stations in both circuits are not all of equal difficulty. In recognition of this the Examinations Sub Committee has set a minimum total number of stations to pass across the whole exam rather than separate thresholds for history, examination and management stations.

Reviews by the sub-committee

In addition, any candidate who receives two or more marks that indicate a severe fail in a station will have their overall performance reviewed by the Examinations Sub Committee (ESC) and may fail the examination, irrespective of their total test score or whether they have achieved the passing score in a minimum of 12 stations.

The ESC sets the final pass/fail criteria based on due consideration and analysis after the examination, taking account of station difficulty, candidate and examiner performance and other relevant considerations.

Examination results will need to be ratified by the Education and Training Committee (ETC) prior to publication. The MRCPsych Exam Regulations and exam standard settings are subject to change from time to time and candidates are advised to check the Examination pages of the College website for up to date information.

The CASC exam is a clinical assessment of skill and applied knowledge.

The exam tests your skills and applied knowledge in: consultation management; clinical assessment and management – including for risk; and effective communication.

Each CASC station will focus on more than one area of skill and /or applied knowledge.

You are reminded that your day to day clinical activities are excellent preparation for the CASC exam and an excellent opportunity to refine and hone clinical skills.

You should make full use of educational supervision to make sure you have effective clinical techniques and skills and that you're not reinforcing poor habits.

Observing more experienced clinicians, using video, and encouraging feedback are useful ways to improve clinical skills.

The CASC exam is also a test of applied knowledge so you should make sure you maintain up to date clinical knowledge.

Criteria for assessment

Professional attitude and behaviour

  • Behave in a professional manner

    The doctor should always behave in a professional manner, showing respect and behaving in a manner that does not exacerbate any emotional or physical distress.

    The doctor can be assertive but must not be rude, arrogant, flippant or dismissive of the role player’s concerns.

  • Develop an appropriate professional relationship

    The doctor should develop an appropriate professional relationship with the patient. The doctor should be aware of the patient’s feelings when taking a history, collecting information or conducting an examination.

    The doctor be aware of the patient’s agenda, health beliefs and preferences. The doctor should use this understanding to guide their interaction. This lies at the heart of patient-centred consulting.

Consultation management

  • Have a systematic approach to consultation

    Consultations should be organised, focused and follow a logical structure demonstrating a clear and systematic way of thinking.

    Any relevant issues should be followed through to their logical endpoint while issues irrelevant to the task should not be pursued further.

    This requires active listening when taking a history, starting by asking open questions to explore the issues before focussing on specific details with closed questions.

    Explaining what is happening or the purpose of the consultation/ interaction is a useful way of structuring the consultation and clarifying the issues.

  • Manage time effectively

    Consultations should be conducted fluently without excessive interruptions or allowing the pace of the consultation to be inappropriately dictated by the role player.

    The doctor needs to be sensitive to the role players needs while taking responsibility for managing the pace and sequence of the consultation effectively.

  • Prioritise tasks effectively

    The doctor should recognise the focus of the CASC station and prioritise questioning and other tasks appropriately and to an appropriate depth.

    They need to be able to recognise verbal and non verbal cues from the role player and follow these through appropriately.

    The doctor should recognise whether there are any ethical issues (for example issues of confidentiality and consent) and deal with these in a professional manner.

    The doctor should ensure that the role player has understood any issues raised in the consultation. Summarising can be a useful way of demonstrating that the doctor has collated and processed the information gained during the consultation.

Communication skills

  • Be fluent, reactive and demonstrate active listening skills.

    The doctor should use effective verbal and non-verbal communication during the interaction. They should demonstrate effective and active listening skills, being structured and logical but reactive and responsive to verbal and non verbal cues.

    The doctor should be able to use communicating strategies for example summarizing, clarifying or rephrasing questions appropriately. Avoid in-appropriate use of stock phrases.

  • Demonstrate an effective questioning style:

    The doctor should use an effective communication style using open and closed questions appropriately. The level of complexity of the questions should be tailored appropriately.

  • Demonstrate effective use of language and/or explanations:

    The doctor should communicate relevant information using language that is appropriate to the person with whom they are communicating. They should be able to recognise when simpler or more technical language and explanations are required. Jargon should not be used.

Applied clinical knowledge

The doctor should demonstrate an ability to apply clinical knowledge effectively and appropriately: identifying and recognising significant findings in the history, examination or data from information provided; interpreting these correctly; acting upon them appropriately; ensuring all the essential issues are identified and that there are no significant omissions.

The doctor should demonstrate an appropriate range and depth of knowledge appropriate to the task.

Clinical assessment skills

  • Explore symptoms and signs competently:

    The doctor should be fluent and systematic when communicating, using the appropriate questions, techniques and / or instruments in a way that does not distress patients.

    The doctor should recognise which of their findings are relevant and/ or significant and prioritise these areas for further and more detailed questioning or investigation.

    The doctor should tailor his or her systematic approach to the specific task or tasks in questions rather than undertake a superficial one size fits all assessment process.

  • Demonstrate skills in risk assessment:

    The doctor should be able to identify potential high risk issues. The doctor should be able to explore risk in a systematic way and with sufficient depth so that an adequate management plan can be developed.

    In certain clinical scenarios, the risk may be unclear, in this situation the doctor will be expected to develop a clear formulation that recognises this uncertainty and the reason for it.

  • Recognise the importance of physical health issues:

    The doctor should be able to recognise the interaction between physical and mental health and understand the effects medication they prescribe can have on physical health.

    The doctor’s knowledge and skill base needs to be up to date and in line with current UK best practice.

  • Identify and use appropriate psychological or social information relating to the problem:

    The doctor should recognise how a patient’s psychological state and social circumstances can effect their physiological and biological functioning when undertaking an assessment.

    They should recognise the influence that for example social networks, occupation, gender, age, ethnicity, sexuality, religion, culture and other issues of diversity can have on their presentation and mental state.

  • Develop an appropriate formulation of the problem and/ or make the correct working diagnosis:

    The doctor should use be able to use information available to her or him to undertake the appropriate questions or examination to come to an evidence based opinion on diagnosis and /or to be able to formulate the issues in a structured and clear manner with the appropriate level of detail identifying where appropriate those findings that support the diagnosis and those that may support a different diagnosis.

    In certain clinical scenarios, the diagnosis may be unclear, in this situation the doctor will be expected to develop a clear formulation that recognises this uncertainty and the reason for it.

    The doctor should reach appropriate differential diagnoses and most likely diagnosis based on their findings being aware that common conditions occur commonly.

    This requires the doctor to have a good knowledge base and to be able to apply that knowledge to a specific clinical situation.

    In certain clinical scenarios, the diagnosis may be unclear in this situation the doctor will be expected to develop a clear formulation that recognises this uncertainty and the reason for it.

Clinical management skills

  • Develop a management plan reflecting knowledge of current best practice:

    The doctor should be able to demonstrate that she or he has developed an adequate evidence based management plan that is safe, coherent and feasible and in line with current UK best practice.

    The doctor should be aware of up to date national guidelines such as those published by NICE (National Institute of Clinical Excellence) and SIGN (Scottish Intercollegiate Guidelines Network)

    The management plan should reflect the natural history of the condition, and be appropriate to the level of risk.

    The management plan should take into account possible risks and benefits of different approaches including medication and other physical treatments, psychological approaches and social interventions.

  • Demonstrate an awareness of risk management:

    The doctor should be able to demonstrate that she or he has developed an adequate evidence based risk management plan that is safe, coherent and feasible and in line with current UK best practice.

    The management plan should reflect the nature, severity, frequency, likelihood and immanency of the risk.

    This requires the doctor to have a good knowledge base and to be able to apply that knowledge to the specific clinical situation.

The following grade descriptors are intended to give examiners a guide about what to look for in a candidate’s performance when selecting the appropriate grade in the ‘Overall Judgement’ section.

They should be used in conjunction with each station’s specific construct.  Should a significant element of the candidate’s performance fall into a ‘failing’ grade then that is the appropriate grade to award.

Excellent Pass

The candidate demonstrates an excellent level of competence expected of a newly appointed ST4 with a clinical approach that is entirely justifiable, very well communicated and technically proficient.

The candidate shows a logical approach that covers most of the key areas identified in the construct.  Any minor omissions do not detract from the overall performance.

Pass

The candidate demonstrates a clear level of competence expected of a newly appointed ST4 displaying a clinical approach, which whilst it may not always be fluent, is reasonably systematic, clinically justifiable, well communicated and technically proficient.

The candidate covers all essential areas of skill identified in the construct but may omit a few relevant but less important points.

Borderline Pass

The candidate demonstrates a level of competence expected of a newly appointed ST4, displaying a clinical approach, while not necessarily fluent, is clinically justifiable and technically proficient.

Communication must be appropriate. The candidate adequately covers essential areas of skill in the construct, but some desirable ones may be omitted.

Borderline Fail

The candidate fails to demonstrate an adequate level of competence displaying a clinical approach that at times is unsystematic or inconsistent with practice at the ST4 level. Technical proficiency may be a concern.

The candidate fails to adequately cover the essential issues or makes too many omissions of less important factors.

Fail

The candidate clearly fails to demonstrate an adequate level of competence displaying a clinical approach that is frequently unsystematic or inconsistent.

Their approach lacks fluency and focus. Many essential and desirable components are omitted, not achieved, or inaccurate.

Severe Fail

The candidate fails to demonstrate competence, with a clinical approach that is incompatible with accepted practice.

Their performance may show inadequate reasoning and/or technical incompetence. The candidate may show lack of respect, attention or empathy for the patient, carer or other individual involved in the clinical interaction.

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