Membership of the Royal College of Physicians

Membership of the Royal College of Physicians (MRCP) is a professional qualification in the United Kingdom obtained via a postgraduate medical exam involving both written and clinical examinations. The examination is run by the Federation of the Medical Royal Colleges of the UK (the Royal College of Physicians of London, the Royal College of Physicians of Edinburgh, and the Royal College of Physicians and Surgeons of Glasgow). It is perhaps similar to the board exams required in the United States and is notorious for its difficulty. The fail rate for the Part 2 PACES alone is around 60% per attempt.

The three Royal Colleges of Physicians of the United Kingdom share a common membership examination in general medicine: this is the examination for the Diploma of Membership of the Royal Colleges of Physicians of the United Kingdom. Successful candidates are eligible to apply for the award of the MRCP(UK) Diploma. A similar exam organised by the Royal College of Physicians of Ireland is termed MRCPI.

Holders of the MRCP(UK) can subscribe as "collegiate members" to any or all of the three UK Royal Colleges of Physicians. That qualification should not be confused with the individual college memberships - MRCP Edin, MRCP Glas and MCRP Lond - which are still awarded, in small numbers, always without examination and sometimes as a step towards a fellowship (FRCP) of one of the colleges, which is also awarded without examination.

There are three centres for the MRCP(UK) - London, Glasgow and Edinburgh. Examinations are however held throughout the UK and in overseas centres.

History
The three Royal Colleges of Physicians have been holding membership examinations for many years. In the London College the Censors, helped by other examiners, had the duty to carry out the assessment of candidates and advise the College. The MRCP(London) examination began in 1859 with a numerical marking system devised in 1893. In the late 1960s the need to have a single recognised membership examination throughout the United Kingdom was recognised. Such an examination made it unnecessary for junior doctors to enter several membership examinations and removed the suggestion that the standards of the examination at the three Colleges were different. In October 1968 the three UK Colleges set up a common Part 1 examination. The common Part 2 examination was divided into general medicine and paediatric options. In 1993 Part 1 was also divided into these two options. From 2004 the paediatric option has been transferred entirely to the Royal College of Paediatrics and Child Health. When there were distinct examinations in medicine and paediatrics, the diploma used not to specify which speciality the candidate had taken.

The examination for the MRCP(Edin) entailed taking a special subject: the options included cardiology, haematology, neurology, pathology and psychiatry. Since the demise of the separate medical memberships there has been no replacement national examination in any medical speciality. New Royal Colleges have arisen in London for pathology and psychiatry. The MRCP (Ireland) survives and retains options in non-medical specialities.

Aims and content
The exam incorporates both examination of the candidate's knowledge of basic medical sciences as well as testing the clinical skills required for the diagnosis and management of disease. Changes to the exam in recent years have put more emphasis on communication skills and professionalism. Obtaining the "MRCP(UK)" is a prerequisite to anyone wishing to go on to a specialist training post as a Physician in the United Kingdom. Recently the college has also started approving overseas training as valid for the purposes of part 2 of this exam.

Various companies, including the Royal Colleges themselves, have developed preparatory courses that focus on the nature of the questions and the required background knowledge.

Status
The status of the MRCP examinations seems to have changed over the years. Up to the second world war it seems to have been more difficult than the postgraduate MD then offered by some British universities to their own graduates, which involved taking a clinical examination as well as submitting a thesis: not necessarily of PhD standard. The MRCP is portrayed as a supreme hurdle in A. J. Cronin's 1937 novel The Citadel.

In the postwar era it came to be taken, along with similar examinations in other specialties, by large numbers of foreign medical graduates, mainly from Asia and Africa. The pass rates were notoriously lower for this group, who became much more numerous and with repeated exam attempts would have contributed significantly to the colleges' finances, while they supported the National Health Service in "training" posts.

The MRCP came to mark an undefined middle point in postgraduate training, which needed latterly to continue for a number of years at a higher grade before a "Consultant" post could be obtained in the NHS. The various UK Royal Colleges made it clear that a membership or fellowship does not itself constitute a complete specialist qualification for practice in the UK. The medical colleges have resisted converting the Fellowship to a final specialist qualification, as has happened in surgery, and in medicine elsewhere.

There is also a tension between examinations, where the candidate is assessed on performance in front of strangers on one or a few occasions, and the kind of continuous assessment by immediate superiors that increasingly characterises medical training. Consequently the future of the MRCP and similar qualifications is in doubt.

As important as changes in educational practice may be the 2006 changes in British immigration rules. Non-European Union graduates who come to train in medicine are now to be regarded as workers, rather than students, and will be granted work permits only if no suitable EU candidates are available. Already EU speciality qualifications are legally equivalent to the British ones, and EU nationals with one may not be required to take any extra British test. It is likely that the non-EU candidates, who currently form the great majority, will become far less numerous, and will not be replaced by a similar number of EU candidates.

The alternative for the Royal Colleges may be to export their product, by holding more examinations abroad, as the surgeons have been doing for some years: mainly so far to the Gulf states, Singapore and Hong Kong. Effective marketing requires product placement by granting diplomas without examination to opinion leaders in major hospitals and Ministries of Health.

Parts
The MRCP exam has three parts: MRCP Part 1 (written paper); MRCP Part 2 (written paper); and MRCP Part 2 PACES (clinical).

The MRCP part 1 examination consists of multiple choice questions in the best of five format.

The MRCP part 2 examination consists of multiple choice questions in the best of five format and n from many format.

The MRCP PACES examination consists of a carousel with 5 stations. Station one tests the candidates ability to examine the respiratory system and abdomen. Station 2 tests the candidates history taking ability. Station 3 tests the candidates ability to examine the cardiovascular system and perform a neurological examination. Station 4 tests the candidates communication skill and the ability to deal with issues of medical ethics. Station 5 consists tests the candidates ability to examine the eyes, the endocrine system, the locomotor system and the skin.

The MRCP is a mandatory requirement for entry into a specialist training scheme for all medical specialties such as internal medicine and advantageous in other specialities such as radiology, anaesthetics and accident and emergency medicine.

Fees
As well as difficult, the examinations are notoriously expensive - at present costing the candidate £1250 from start to finish - assuming each examination is passed in a single attempt. Candidates may elect to participate in any of a number of training courses to improve the chances of passing but none outwith the Royal College itself are endorsed by MRCP(UK).