In defence of the long case

Benning & Broadhurst (Psychiatric Bulletin, December 2007, 31, 441–442) argued that the abandonment of the long case from the Member of the Royal College of Psychiatrists (MRCPsych) exam threatens the holistic approach in psychiatry and ignores the importance of the subjective dimension of the experience/behaviour and the role of the patient's biography in aiding understanding. We share their concern.

An online survey of trainee psychiatrists working in the North Trent Rotation Scheme with a response rate of 46% (n=43; ST1–3 and trust grade doctors n=26, ST4 and specialist registrars n=17) showed that the majority of trainees (62.8%) did not agree with abandoning the long case. Those who have passed the MRCPsych (i.e. ST4 grade and specialist registrars) opposed it more strongly than junior trainees (94% v. 42%, P=0.01). Similarly, senior trainees were more likely to disagree that Observed Standardised Clinical Examination (OSCE) is a fair alternative than junior trainees (76.5% v. 34.6%, P=0.01), but is not capable of testing from the bio-psychosocial perspective (82% v. 50%, P=0.05). Unsurprisingly, more senior trainees (58.8%) than junior trainees (30.8%) felt that the exam would be easier.

The majority of responders were concerned that passing the long case depends largely on one encounter. This could be addressed by incorporating one or two long cases per year as part of workplace-based assessments, which would ensure the appropriate choice of patients and possibly more time allocated for each case, as it has been shown to increase reliability from 0.60 to 0.90 (Waas & Jolly, 2001).

Finally, although we agree that OSCE could test different specific competencies, we should not forget that ‘the whole is more than the sum of its parts’ as one of our responders commented.