The RANZCP has left competent and dedicated trainees in despair while the nation cries out for more mental health workforce.
The Royal Australian and New Zealand College of Psychiatrists’ August 2024 essay exam results dropped last week, and as an experienced exam coach and mentor to many psychiatry trainees and international medical graduates, I am floored.
The 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 far more pressing to do: begin a discussion around the devastation and distress many candidates are feeling after some of the worst pass rates we have ever seen, and the consequences for our understaffed mental health system.
Two years ago it was decided to allow candidates to sit the two written exams at different times. The modified essay question (MEQ) pass rate was around 56% and the critical essay question (CEQ) was 61%.
Three hundred and thirty-four candidates sat the MEQ this time, and 228 sat the CEQ, across Australia and New Zealand. They now need to wait until March 2025 to re-sit, and wait until May 2025 for their results. Fees for each attempt at each exam are around $2000.
I have always been one to highlight these issues that occur within my profession, recognising I am relatively safe from backlash as my years of training are long behind me.
I can speak up for those still caught up in their training systems and pathways, who are fearful of repercussions if they do challenge the status quo. I do it this time because my fear about where my profession is heading has never been stronger.
It may surprise lay people to know that in Australia and many other countries, to be a medical specialist such as a psychiatrist you must receive accreditation from a single governing accrediting organisation, which decides who is fit and able to join the psychiatry club. It administers the training program and sets high-stakes exams that trainees must pass to become a Fellow of the RANZCP in Australia and New Zealand.
It may surprise even other doctors to learn that these fellowship exams no longer include a clinical assessment.
The CEQ is like a Year 12 English exam, in which candidates must discuss a quote often derived from a poem or a book.
The MEQ attempts to examine different situations that a candidate may face, but they must answer based on what they would do if they were already a consultant. Sometimes the question is posed as if 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.
I have been involved in exam coaching since 2007 when I was going through exams myself as a psychiatry registrar in Victoria. Back then we sat mini clinical exams and interviewed patients under supervision. We were assessed on our ability to perform our role with safety and competency.
Since then, 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. They were last held during the covid lockdowns and failed badly due to technical problems, leaving hundreds of candidates in exam limbo and facing delays in progressing to fellowship.
The transition to written exams is a result of this, not because they’re a better way of assessing who should make the cut.
I have now coached hundreds of trainees and IMGs and I can say that these latest results speak more to flaws with the exam process than to the ability and competency of our training workforce.
Our psychiatry registrars and IMGs are the workhorses of mental health in Australia and New Zealand. They are propping up the system. 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 stuck in a holding pattern waiting for the next chance to sit their exams. For some that’s because English is not their first language and they are disadvantaged by having to write an English essay. Some of these doctors are qualified expert psychiatrists in their country of origin and have now dedicated their lives to working in ours.
At an individual level, for a cohort of ultra-high achievers who are intolerant of failure, failing an exam is crushing and leaves real scars. Having to sit an exam more than twice 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. The actual feedback they receive after failing an exam is often generic and unhelpful.
I am acutely aware of how such setbacks can impair and cause harm, having been shocked by the loss of three psychiatry registrars to suicide in one month back in 2015.
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 is likely to now find themselves paying ridiculous amounts of money to be assessed over a telehealth site.
And our society which 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 lead to a deficit of specialist doctors.
I am all for ensuring that our graduates are the best and most qualified that they can be. But this 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, an exam coach for the RANZCP examinations and a mentor and advocate for doctors in training. This is an edited version of a piece originally published at medium.com.