Abstract
Objective:
To describe an approach to support Royal Australian and New Zealand College of Psychiatrists (RANZCP) trainees achieve success in the Modified Essay Question (MEQ) examination.
Method:
Synthesis of the opinion of the authorship encompassing a range of relevant stakeholders, supported by a qualitative content analysis of published examination feedback from the RANZCP Committee for Examinations.
Results:
In approaching the MEQs, candidates are encouraged to (1) read the scenario and questions carefully, (2) answer questions broadly and with justification, (3) manage time effectively, (4) undertake deliberate practice in preparation, and (5) ‘check your own pulse’ (i.e. limit the detrimental impact of anxiety on performance).
Conclusion:
Preparing for the MEQ examination through deliberate practice will help candidates become competent psychiatrists. The ability to critically think in clinical practice, a key focus of this assessment, is an essential skill all psychiatrists need to develop and maintain.
Completing the Royal Australian and New Zealand College of Psychiatrists (RANZCP) competency-based fellowship programme (CBFP) can be challenging. 1 The essay-style examination has often been perceived as one of the most demanding requirements to pass. Reasons for this may include trainees’ readiness and the timing of their attempts, 2 and difficulties balancing training demands with life outside of psychiatry and service delivery needs. 3 Following recommendations arising from an external review of RANZCP assessments, the Critical Essay Question (CEQ) and Modified Essay Question (MEQ) components of this exam have been decoupled in 2021. Trainees are now required to independently sit and pass the MEQ and CEQ components.
The new ‘Modified Essay Question Exam’ requires trainees provide written responses to four to six MEQs over 150 min. Extensive information about this exam is provided to trainees on the College website (https://www.ranzcp.org). Candidates are expected to demonstrate high levels of competence (i.e. the ability to integrate and apply knowledge and complex real-world clinical settings). 2 The examination challenges candidates to apply critical thoughts to clinical scenarios and develop reflective capacity using a broad approach guided by the CANMeds framework. It tests their ability to integrate their clinical experience with ‘textbook’ knowledge, to write and communicate clearly, and to justify one’s opinion with evidence. There have been several ‘how-to’ articles published that aim to help trainees pass the CEQ component,4-6 but none focusing on the MEQ. In the current paper, we describe an approach to MEQs that may help trainees working towards examination success.
Methods
The guidance is based on the consensus of the authorship which covers a range of relevant stakeholders: successful candidates (EG, KF, SS), Directors of Training (JC, SP), examination markers (JC, SP), and people with experience in question writing and standard setting (JC, SP). The guidance was also informed by a qualitative content analysis 7 of the ‘post-examination reports’ for the essay-style examination that had been published on the RANZCP website between May 2018 and May 2021. This analysis was completed inductively by SP and facilitated using NVIVO-12. The other members of the authorship reviewed the initial outcomes of the analysis to achieve consensus on the coding.
Results
The synthesis arising from the qualitative content analysis of the guidance provided in post-examination reports is depicted in Figure 1 and Table 1. Figure 1 illustrates the scenario content foci. The key message drawn from this is that the MEQ requires a comprehensive understanding of psychiatric practice across a broad range of real-world contexts. Table 1 summarises the principles and guidance provided to past candidates based upon their examination performance. The consistency of these overarching principles over successive reports suggests several longstanding issues impacting candidate performance.
Scenario content areas identified through analysis of post-examination reports for the essay-style exam – Modified Essay Question component (2016–2020).
Principles and guidance relevant to the Modified Essay Question feedback identified through content analysis of post-examination reports
Sources: Published RANZCP Essay-style exam reports 02/2016 to 03/2020 (9 reports).
Representativeness: aPresent across all sources (n = 9/9), bPresent across most sources (n = 5–8/9), cPresent across some sources (n = 1–4/9).
Content appearing under ‘Elaboration’ is illustrative and does not exhaustively cover content relating to the relevant guidance.
The consensus guidance of the authorship was informed by this content analysis and organised under the following themes: (1) read the scenario and questions carefully, (2) answer questions broadly and with justification, (3) manage time effectively, (4) undertake deliberate practice and (5) ‘check your own pulse’ (i.e. limit the detrimental impact of anxiety on performance). Table 2 summarises these findings.
Summary of advice to candidates sitting modified essay questions
Read the scenario and question carefully
Considering all the information in the vignette and reading the questions carefully is critical to answering them adequately. Candidates need to understand the context of the question, e.g., Where is this interaction occurring (setting); Who is providing the information (e.g. patient, carer, other health practitioners); What resources are likely to be available and challenges may emerge; and, How do the patient’s characteristics (e.g. age, gender, culture, diagnosis) necessitate tailoring the response? Reflecting on this information will allow candidates to focus their response to the details of the scenario.
Every detail in the scenario is included for a reason. Marking criteria are weighted towards responding to the vignette content rather than requiring inferences and abstraction. The additional vignette information provided before each successive question should critically focus each successive answer. Providing a specific answer to each question is critical, as no marks are allocated for answers going beyond that question (including answers relevant to previous and subsequent questions). Remember, each question will be marked by a different person (i.e. answer to question 1.1 is marked by examiner A, answer to question 1.2 is marked by examiner B, so on).
Answer questions broadly and with justification
Candidates need to be mindful that markers are not allowed to draw inferences about what they think the candidate is trying to. Candidates should help the markers by making their reasoning explicit. Headings and sub-headings can help to structure the answers, reduce the burden of explanation and reasoning, and make it easier for markers to see the reasoning. Paying attention to the question type is also important. For the rare ‘list’ questions, keywords and phrases without elaboration and justification are sufficient. The ‘outline’ questions require a list with some justification or detail for marks to be awarded. The ‘describe’ questions require a comprehensive answer that addresses several relevant elements with associated justification/reasoning. ‘Discuss’ questions require additional description and explanation, while ‘Debate’ questions are often well responded to by considering the pros and cons or risks and benefits or a range of relevant actions or considerations.
In practical terms, the following formula may assist candidates to make their reasoning explicit to markers:
‘[Indicated action] … because… [Scenario information] + [Supporting evidence]’
The word ‘because’ in the formula may take different forms (e.g. due to, to support/address/enhance, to avoid/limit/prevent/minimise, in order to).
Time management
Even with the recent change in the number of questions in the essay-style examination, timing remains critical to success and candidates should stick to one mark per minute. Running out of time will affect the total score, and candidates can always return to elaborate their answers if they have any spare time at the end. Perfect is the enemy of the good, especially when answering MEQs. It is more strategic to get 50% for two questions than aim for 100% in one question. Candidates should actively practice ‘moving on’ or leaving questions when they have reached the time limit for marks allocated. Candidates should also consider the role of double spacing or leaving space between dot points to allow for further elaboration if time allows to return to the question. This may also assist in improving the legibility of their writing.
Deliberate practice
Having sufficient depth and breadth of relevant content and experimental knowledge will reduce the cognitive demands associated with MEQs. Research examining the development of expertise emphases deliberate effort across a prolonged period of time with a focus on quality of performance in specific domains. 8 In addition to focused preparation and practice in responding to MEQ questions, we suggest candidates deliberately practice psychiatry throughout their training through:
i. Understanding the fundamentals – i.e. obtaining a broad and detailed knowledge through reading textbooks, clinical practice guidelines and academic (and non-academic) papers.
ii. Repeated practice in applying fundamental knowledge in clinical encounters to develop comprehensive and realistic plans to support an individual’s recovery. Management plans should justify specific actions, as well as consider the relevant issues broadly. Careful consideration should be given to the acute, medium- and longer-term time frames, and the foreseeable challenges. Biological, psychological and sociocultural (including the role of families and carers, and issues of stigma) factors should all be considered. Furthermore, plans need to be realistic with consideration of local resources, external supports, governance, legal and ethical issues. Similarly, risks should be considered broadly including not just aggression and self-harm, but also vulnerability, physical health, substance use, non-adherence/engagement, relapse, stigma, reputation, finances and accommodation. It is critical to not just identify risks but also tailor the management plan to address these. The plan also needs to consider the needs and roles of a broad range of stakeholders beyond the designated patient including families, NGOs, GPs, the multidisciplinary team and the broader mental health service.
iii. Reflecting on their practice, the limits of their knowledge and the limits of the profession of psychiatry. This includes actively developing an understanding of the junior consultant role as a clinical leader and manager within a multidisciplinary team. One way to achieve this is open a dialogue with their supervisors by demonstrating curiosity about how and why they do what they do in their everyday decision-making. Actively observe a junior consultant getting a handover from a clinician about a patient: What questions do they ask to help synthesise and formulate the case? How do they address safety through appropriate care settings?
iv. Seeking and giving feedback. Identify a group of peers to form a study group with. Come up with practice clinical scenarios, practice reading and reflecting on each other’s answers. Always do these questions to time. Determine if the justification or elaboration was detailed or specific enough.
Take your own pulse
Anxiety and time pressure significantly impact how candidates process information. In exam situations, candidates risk misreading the questions, thinking rigidly, prematurely foreclosing without considering all the available information, and overthinking the underlying intentions of the questions. To paraphrase the third law of the House of God: when attempting the MEQ examination, the first procedure is to take your own pulse. Getting ready takes time and effort. Before the exam, optimise the fitness – both physical and mental. This may mean getting used to handwriting for several hours at a time or seeking expert assistance for performance anxiety. Anxiety management is a lot easier if one is cognitively competent enough to sit the examination.
Conclusion
MEQs, as with any assessment in the CBFP, are not just a hurdle one needs to jump over to become a psychiatrist. The process of preparing for these assessments is much more important than the outcome for each attempt. The skills that one obtains while preparing for them – the ability to critically think in clinical practice, being able to manage time and anxiety, and learning the art of deliberate practice – are essential skills of being a competent psychiatrist that need to be practised and maintained long after completing training.
Footnotes
Acknowledgements
JC, SP and SS acknowledge the many trainees whose experiences have informed their understanding of this examination component. KF, EG and SS acknowledge their peers and supervisors who supported them towards success in the Modified Essay Question component of the RANZCP examinations.
Disclosure
JC and SP are employed in Director of Training roles by the MSAMHS. In the last 5 years: SP has received honoraria from Johnson & Johnson and Qld Psychotherapy Training, and grant funding from Suicide Prevention Australia, the Mental Health Alcohol and Other Drugs Branch (Qld), the RANZCP, and TPCH Foundation; SS has received honoraria from Seqirus and received funding from the RANZCP.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sector.
