Sir: I read with great interest the article by Tyrer et al (Psychiatric Bulletin, July 2002, 26, 257-263) on the MRCPsych examination.

The major findings of their study were: (1) doctors from the UK/Ireland fare much better than their counterparts from the rest of the world; and (2) the older the candidate, the lower the likelihood of success.

I would like to focus on the first point. In addition to the putative explanatory factors put forward by the authors to account for this finding, I would like to consider a few more. Compared to UK/Ireland graduates, overseas doctors are more likely to work in non-teaching hospitals for the whole of their basic specialist training. This will obviously impact on the quality of training they receive and, therefore, their level of preparedness to face the MRCPsych examination. Also, a not insignificant number of overseas trainees are forced by circumstances to take up non-career grade posts for visa purposes: permit-free training (PFT) visas for senior house officers (SHOs) are usually given by the Home Office for a total of 4 years. Understandably, for some, this period is insufficient to pass the examination. The overseas doctor, who sits his subsequent attempts at the MRCPsych examination as a staff grade, will obviously not have the same access to exam-related training as an SHO.

A study that controls for these potential confounding factors (Hospital of training: teaching v non-teaching, and post of the candidate: training v non-career grade) may be able to provide a more accurate picture.

From Table 1, in the Part I examination, 74% (305/410) of UK/Ireland graduates passed the multiple choice question (MCQ) examination compared with 57% (408/718) of overseas graduates, an absolute difference between the two groups of 17%. Among those successful in the MCQ component, 85% (206/305) in the UK/Ireland group and 54% (219/408) in the overseas group were also successful in the clinical component, an absolute difference of 31%. Why does the gulf between the two groups widen from 17-31% in just a few weeks between the written and clinical examinations? Is the clinical examination unintentionally biased against the overseas trainee?

Another striking statistic in the study is the relative percentage of overseas candidates appearing in the Part I and Part II examinations. Although in Part I, 64% (718/1128) are foreign graduates, in Part II this drops sharply to just 47% (357/763) with a corresponding increase in the UK/Ireland group from 36-53%. There may be several reasons for this, for example inability to pass Part I, dropping out of psychiatry or moving to non-training posts. Perhaps this is an area for further investigation?

It should not be forgotten that the Professional and Linguistics Assessment Board (PLAB) test, which most overseas doctors have to pass to work in the UK, is comprehensive and recognised to be of a high standard.

Finally, the College needs to be appreciated for its transparency in publishing the details relating to the MRCPsych examination. Also, it is encouraging to learn that there is going to be greater standardisation of the examination with the introduction of more reliable sections.