The Clinical Assessment of Skills and Competencies (CASC) is the final hurdle in the MRCPsych examination. Unlike Paper A and Paper B, which test knowledge and reasoning, CASC tests whether you can perform as a psychiatrist in real clinical scenarios. It is an OSCE-style examination with 16 stations, each lasting 10 minutes.
CASC has the lowest pass rate of the three components. First-attempt pass rates are approximately 60–65%, and many candidates who passed Papers A and B on their first attempt find themselves retaking CASC. The reason is simple: CASC tests skills that cannot be learned from a question bank. They must be practised.
CASC Station Types
The 16 stations fall into four categories:
- History taking (4–5 stations): Psychiatric history, risk assessment, collateral history, developmental history, mental state examination. The examiner is looking for structure, rapport, and elicitation of key clinical features.
- Management (4–5 stations): Acute management (agitation, overdose, catatonia), medication initiation/monitoring, electroconvulsive therapy (ECT) consent, capacity assessment. These require you to think on your feet and demonstrate clinical reasoning aloud.
- Communication (4–5 stations): Breaking bad news, dealing with relatives, explaining a diagnosis, negotiating treatment with a reluctant patient, handling a complaint. These are the stations that separate passing from distinction.
- Consultation (2–3 stations): Liaison psychiatry referrals, GP referrals, multidisciplinary team consultations. These test your ability to formulate and communicate a management plan concisely.
Marking Criteria
Each station is marked by a single examiner using a global rating scale. The domains assessed are:
- Interpersonal skills (30%): Rapport, empathy, listening, non-verbal communication. The examiner assesses whether the patient (actor) would trust you.
- Information gathering (25%): Structure, coverage of relevant domains, appropriate use of open and closed questions. Failure to ask about suicide risk is an automatic fail in any history station.
- Information giving (25%): Clarity, appropriate language level, checking understanding. You must avoid jargon unless you explain it.
- Management (20%): Appropriate plan, safety netting, justification of decisions. The plan must be specific, not generic.
Candidates must pass a minimum number of stations (typically 10–12 out of 16) and cannot fail both communication stations. A single catastrophic failure (e.g., missing suicide risk, being rude to a patient) can result in an overall fail regardless of other station scores.
12-Week CASC Preparation Plan
Weeks 1–4: Concept Familiarisation
- Learn the station format and marking criteria thoroughly. Knowing what the examiner wants is half the preparation.
- For each station type, write a structured template. For history stations: introduction → open question → history of presenting complaint → past psychiatric history → medication → social → forensic → risk → ICE (ideas, concerns, expectations) → summary → plan.
- Watch example CASC performances (available from the Royal College website and training schemes). Identify what the passing candidates do differently from the failing ones.
Weeks 5–8: Paired Practice
- Find a CASC partner. This is essential. You cannot prepare for CASC alone because the interactive element is the core skill being tested.
- Practise 2–3 stations per session, 3 sessions per week. One partner plays the patient, the other the candidate. The third person (if available) times and observes.
- Record your sessions on your phone. Watch them back. You will notice things you miss in the moment — rushing, interrupting, using jargon, poor eye contact.
Weeks 9–12: High-Fidelity Simulation
- Full mock CASC circuits (8–16 stations in one sitting). Your local training scheme usually runs these. Attend every one available.
- Focus on your weak station types. Most candidates struggle with communication stations because they prepare for clinical knowledge stations only.
- Practise the first 30 seconds of every station type. The first impression often determines the overall score. A confident, structured opening sets the tone.
Common Pitfalls
- Talking at the patient rather than with them. CASC is not a viva. You must demonstrate two-way communication. Pause, listen, respond.
- Information dumps. When asked for a management plan, candidates often list every option they can think of. A focused, justified plan is better than a comprehensive but unfocused one.
- Ignoring the actor’s cues. The patient actor is trained to give specific cues. If they say “I’m worried about the side effects,” address that concern directly. Candidates who ignore cues and continue with their pre-planned script score poorly.
- Running out of time. Ten minutes passes quickly. Practise with a timer. If you spend 4 minutes on history, you have 6 minutes for the rest. Allocate your time consciously.
CASC for Text-Based Practice
PsychStar is developing a CASC preparation module with text-based simulated patient interactions. Each scenario presents a clinical situation, you choose your response, and the platform shows the consequences of your choice with examiner-style feedback. This allows you to practise clinical reasoning and communication strategy outside of paired role-play sessions. Try 5 free questions at psychstar.io/try.