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In order to progress in a medical career, such as getting onto a specialty training programme, you will need to pass further post-grad exams. It's really important to be aware of the demands PRIOR to starting your role as a doctor - as you can prepare to combine your full-time job with the level of study required to pass these exams. You will not be given time off to study (unsurprisingly) and you will be expected to pay for these exams yourself (although you can claim tax relief - keep reading)!
A brief recap of UK training:
All medical graduates must undertake and complete the 2-year Foundation programme of general medical training (in a variety of specialties) in order to practice as a doctor in the UK.
On successful completion of the foundation programme, doctors can continue training in either a specialist area of medicine or in General Practice.
There are around 60 different specialties to choose from and the length of training required before becoming a fully qualified doctor will depend on the specialty. For more about specialties, see my post on Choosing a Medical Specialty which includes the GMC list of them too.
Specialty training programmes
Run-through training programmes
Approx. 3 years for General Practice and 5-8 years for other specialties. After finishing your foundation years, you become an 'ST1' (Specialty Trainee Year 1) straight away. This means you only apply to your specialty once.
Some examples include Paediatrics, Obstetrics & Gynaecology, Ophthalmology, Radiology, Cardiothoracic surgery & Neurosurgery.
Uncoupled training (Core then higher specialty training programmes)
Uncoupled training is split into either 2 or 3 years of core training (where you become a CT1, CT2 etc.), before entering higher specialty training at ST3 level. With this path, entry to ST3 is a competitive process, which involves applying for a post, similar to what you did after completing your foundation years. Therefore, it is important to note that the application following core training is highly competitive and does not guarantee a specialty training post.
Some examples include: Dermatology, Endocrinology, Gastroenterology, Infectious Diseases and Tropical Medicine, Psychiatry & Rheumatology.
More of these specialties can be found here
ACCS (Acute Care Common Stem)
3-year training programme that follows F2. It is the only core training programme for trainees wishing to enter higher specialty training in EM (emergency medicine), and is an alternative core training programme for trainees wishing to enter higher specialty training in GIM (General Internal Medicine), AIM (Acute Internal Medicine) or Anaesthesia.
On successful completion of a run-through or higher specialty training programme, doctors are awarded a Certificate of Completion of Training (CCT) which allows them entry onto the General Medical Council (GMC) specialist or General Practice register.
The difference between medical and surgical specialties
Medical specialties focus on a defined group of patients, diseases, skills, or philosophy e.g. Paediatrics, Psychiatry, Neurology, Internal Medicine.
Surgical specialties focus on surgery and you will learn technical skills that are necessary to perform operations. e.g. Orthopaedics, Plastics, Neurosurgery.
There are also specialties that have a mix of medical and surgical aspects e.g. ENT, Ob/Gyn, Emergency Med and Anaesthesia.
What exams do I need to take as a doctor and how many?
Exams during foundation training
The Multi-Specialty Recruitment Assessment (MSRA)
This is a single computer-based exam that includes Professional Dilemmas (PD) and Clinical Problem Solving (CPS) questions. Once the application window has closed for your chosen specialty and successful candidates have been longlisted, you’ll be invited to register with Pearson VUE and book your MSRA, if you meet the eligibility criteria outlined during the application process.
You will need to take this exam in order to get an ST1 training place in specialties such as:
psychiatry (core, child and adolescent)
core surgical training (In October 2022, it was also announced that core surgical trainees i.e. anyone wanting to do surgery will also be invited to sit the MRSA). See the update here.
Each specialty will use your MSRA score in selection processes for specialty training slightly differently. For example, in 2022, GP and Core Psychiatry Trainees assessed and ranked candidates based solely on their MSRA performance, whilst, for Obstetrics and Gynaecology, the MSRA score was used as a differentiator between the lowest scoring applicants.*
Cost: £0 FREE
The Membership of Royal College of Physicians (UK) exam Part 1
All physicians who want to train in a medical specialty (ST3 and beyond) in the UK have to pass the Membership of Royal College of Physicians (UK) (MRCP UK) exams which have 3 parts. Passing all 3 parts of the MRCP(UK) examination is a requirement for entry into ST3 and above in the UK. Part 1 is usually taken at the end of F1 or F2.
The medical (or 'physician') specialties that require you to take the MRCP can be found here. Make sure you are quite sure about applying to one of these specialties before taking the exam. Not sure? Hold off from taking it.
MRCP(UK) Part 1 examination is a 1-day exam consisting of two 3-hour papers. Each paper has 100 Single Best Answer (best of 5) questions and is sat in an exam hall or online.
You are eligible to take the MRCP as soon as you have completed a minimum of 12 months of post-graduate training (i.e. completed your F1 year). The highest pass rates (70%) are achieved by those who first attempt Part 1 between 12 and 24 months after graduation (between F1 and F2).*
*According to the official website: https://www.mrcpuk.org/mrcpuk-examinations/part-1
Cost of exam: UK graduates £460, International graduates £616
OR
The Membership of Royal College of Surgeons (UK) exam Part 1
In order to enter into specialist surgical training (ST3 level), trainees must pass the MRCS (Membership of the Royal College of Surgeons) Examination. The recognised surgical specialties are as follows:
Neurosurgery
Obstetrics & Gynaecology
Cardiothoracic
General
Oral & Maxillofacial
ENT (Ear, Nose & Throat, also called Otolaryngology)
Paediatric surgery
Plastic surgery
Trauma & Orthopaedics
Urology
Vascular
Academic surgery
More info on surgical specialties can be found here
The MRCS has 2 parts: A (written paper) and B (OSCE).
The MRCS Part A is a 5-hour Single Best Answer exam consisting of 2 papers taken on the same day. The AM paper is 3 hours long focusing on Applied Basic Sciences (surgical anatomy, physiology, pathology, microbiology and pharmacology) followed by a PM paper which is 2 hours long that focuses on the Principles of Surgery (pre-, peri- and post-operative management, surgical care of children, organ and tissue transplantation etc.). The pdf for the syllabus of this exam can be downloaded here
Cost: £578*
Part 1 can be taken around the same time as someone taking the MRCP ~ end of F1/F2.
During specialty training (general exams)
MRCP Part 2 written examination
Part 2 written exam can be taken by trainee doctors who have passed the MRCP(UK) Part 1 exam. It builds on the knowledge assessed in Part 1 and again, consists of two 3-hour papers, each with 100 SBA questions. The exam tests the ability of candidates to apply clinical understanding, make clinical judgements and take responsibility for diagnoses, investigations, devising appropriate immediate and long-term management plans and treating patients.
The highest pass rates on the Part 2 Written Examination are achieved by candidates who make their first attempt within 3 years after graduation.* This period coincides with the end of the CT1 (core training 1) year or earlier in UK medical training.
*According to the official website: https://www.mrcpuk.org/mrcpuk-examinations/part-2
Cost of exam: UK £460, International £616
MRCP Part 2 clinical examination (PACES)
The Part 2 Clinical Examination (Practical Assessment of Clinical Examination Skills - PACES) is designed to test the clinical knowledge and skills of trainee doctors who hope to enter higher specialist training (ST3). The exam sets rigorous standards to ensure your competence across a range of skills and that you are ready to provide a high standard of care to patients.
There are 5 clinical stations where there are either patients with a real condition, or trained actors - like the OSCE format. At each station, there are two independent examiners who will observe and evaluate the candidates' performance.
The PACES is a half-day examination that takes place in a clinical setting (hospital or clinical skills centre). It assesses seven core skills and encompasses 5 stations. You will encounter 8 different patients.
Highest pass rates are seen in doctors who wait until between 3-4 years after graduation.*
*According to the official website: https://www.mrcpuk.org/mrcpuk-examinations/paces
Cost: UK grads £657, Internationals (varies between £1000-£2000)
Following completion of all 3 parts, successful candidates are invited to attend an MRCP(UK) new members ceremony at the Royal College of Physicians.
OR
MRCS Part B
The OSCE (Part B) will normally consist of 18 examined stations each of 9 minutes’ duration. These stations will be divided into broad content areas (BCAs) as follows:
Anatomy and surgical pathology (5 stations)
Applied surgical science and critical care (3 stations)
Clinical and Procedural Skills (6 stations)
Communication skills (4 stations)
Giving and receiving information
History Taking
Candidate notes and guidance on this OSCE can be downloaded here
Cost: £1047*
Once you have passed your MRCS, you will become a Member of the Royal College of Surgeons and can continue your higher specialty training!
During specialty training (specialty-specific exams)
General Practice
In order to begin your General Practice training, you will need to take the MSRA when you apply for General Practice after completing your F1 and F2 years and if successful, will become an ST1 (Year 1 Specialist GP trainee).
During your 3-year training (i.e. before the end of ST3), you must pass the MRCGP (Membership of the Royal College of GPs) exam in order to be awarded your Certificate of Completion of Training (CCT).
The MRCGP exam includes 3 components (MRCGP exam page here):
An Applied Knowledge Test (AKT): The AKT is a computer-based test, 3 hrs and 10 mins long comprising 200 questions. Approx. 80% of questions are on clinical medicine, 10% on evidence interpretation (including the critical appraisal skills needed to interpret research data) and 10% on primary care organisational issues (including administrative, ethical, regulatory and statutory frameworks). All questions address important issues relating to UK general practice and focus mainly on higher-order problem-solving rather than the simple recall of basic facts. (£470)
A Clinical Skills Assessment (CSA): The CSA is a skills assessment in an OSCE format. Patients are played by trained role players, and cases are written and assessed by working GPs. Each candidate is allocated a consulting room and has 13 ten-minute consultations. This has become the Recorded Consultation Assessment (RCA) conducted online due to COVID-19. (£1076)
Workplace-Based Assessment (WPBA): During all your placements you will complete workplace based assessments. You collect evidence related to 13 areas of professional capability and record it in your Trainee Portfolio. This evidence is used to inform six-monthly reviews and - at the end of training - to make a judgement about your readiness for independent practice. (£0)
Upon completion of these 3 components, you will become a registered GP! You will then need to apply for GMC GP registration (£466).
Your progress will then be monitored at least yearly by an Annual Review of Competence Progression (ARCP) Panel.
Minimum total to train as a GP: £2012 (this is the cheapest training possible - doesn't take into account resits, travel to exams, payment of study resource etc.)
Medical specialties
A Specialty Certificate Examination (SCE) is now a compulsory component of assessment for Certificate of Completion of Training (CCT) for all UK trainees whose specialist training began in or after August 2007 and is in one of the following specialties:
Acute Medicine
Dermatology
Endocrinology and Diabetes
Geriatric Medicine
Medical Oncology
Neurology
Palliative Medicine
Respiratory Medicine
Rheumatology
The Specialty Certificate examinations are a test of knowledge of key areas of the UK specialty training curriculum. The competencies tested by the SCE are clearly stated in the specialty curriculum (available on the JRCPTB website). Specialty trainees are required to pass the SCE in order to obtain their CCT.
Cost of exam: UK £700, International £875*
More info about the SCEs for specialties can be found here
Gastroenterology
The European Specialty Examination in Gastroenterology & Hepatology (ESEGH) has become the GMC-approved mandatory summative assessment of knowledge for UK trainees in Gastroenterology and Hepatology.
Cost: UK £700, EU €800, all other countries/territories £875
More info can be found here
Nephrology
From February 2020, specialist trainees in Nephrology will take a single examination called the European Specialty Examination in Nephrology (ESENeph).
Cost: UK £700, EU €800C, all other countries and territories £875
More info can be found here
Surgical specialties
Once you have completed your surgical training, you will be eligible to take the Fellowship of the Royal College of Surgeons (FRCS) exam. This exam is a mandatory requirement for the award of a Certificate of Completion of Training (CCT) or Certificate of Eligibility for Specialist Registration (CESR). The examinations are regulated by the Joint Committee on Intercollegiate Examinations (JCIE) for UK residents. The Joint Surgical Colleges’ Fellowship Examination (JSCFE) provide the exam for the international surgical community. The FRCS exam must be sat with the royal college of your choice.
Once a surgeon has attained CCT or CESR, they will be added to the GMC's specialist register and will be eligible to apply for a consultant post or a fellowship for further, more specialised training.
Most doctors who obtain their fellowship go on to become consultants in their respective specialties. More about surgical qualifications and abbreviations can be found here
ENT
The intercollegiate Diploma in Otolaryngology – Head and Neck Surgery (DO-HNS) tests the knowledge, clinical and communication skills and professional attributes expected of a doctor intending to join an otolaryngology department in a trainee position.
It is also relevant to doctors who wish to practise within another medical specialty that interacts with otolaryngology and for General Practitioners who wish to offer minor ENT surgery. More info can be found here.
Royal College exams
Finally, for any specialty you go into, you can take an exam to be a member of the Royal College of that specialty in order to progress throughout the final years of your training. These can demonstrate competencies in order to progress in your career.
Please be aware that these exams are NOT actually compulsory to progress through training. However, by passing them, you can use official abbreviations after your name which may give you an edge when applying for higher training positions, especially consultant positions.
The Royal College exams are also very helpful for international medical graduates who have emigrated to the UK to practice as a doctor in a specialty. By taking these exams, you will have a nationally recognised level of training.
The Royal College Exams for some specialties can be found below:
The Royal College of Paediatrics & Child Health (RCPCH)
To apply to ST3, applicants must hold two out of the three written MRCPCH examination papers (Foundation of Practice / FOP, Theory, and Science / TAS, Applied Knowledge in Practice / AKP). These can be taken any time from F1-ST1.
Cost: UK £725 (FOP and TAS) + £835 (AKP) = £1560
Diploma of Child Health (DCH) - 2 exams, 1 theory and 1 clinical (OSCE) exam. NOT compulsory but desirable.
The DCH recognises competence in the care of children in trainees in specialties allied to paediatrics. Candidates, including GPs and paediatricians, use this as an opportunity to up-skill and gain an internationally recognised postgraduate medical diploma.
The Royal College of Pathologists (RCPath)
Offers ~ 20 exams depending on the sub-specialty you want to go into. Find out more here
The Royal College of Obstetricians and Gynaecologists (RCOG)
Membership exam (MRCOG) - The MRCOG exam is internationally respected as the gold standard qualification for career progression in O&G. The Membership examination is intended for those who wish to specialise in obstetrics and gynaecology. The exam is a 3-part assessment:
Part 1 – Covers basic and applied clinical sciences relevant to Obstetrics & Gynaecology. Trainees must pass Part 1 before they can progress to ST3.
Assessment of training - can be done after Part 1. Is a form you fill out proving all of your training and skills thus far. Must be completed and approved before applying to take Part 3.
Part 2 – clinical scenarios with single best answers.
Part 3 – Practical exam (OSCEs) which assesses a doctor’s ability to apply core clinical skills in Obstetrics & Gynaecology
Residents must pass both Part 2 and 3 before they can progress to ST6.Membership exam (MRCPCH) - 4 exams, 3 theory and 1 clinical (OSCE) exam.
Diploma exam (DRCOG) - An exam that results in a diploma in women's health, especially for GPs and GP registrars who want to improve and demonstrate their knowledge and interest in women’s health. It is also suitable for Foundation Year Two Doctors (FY2), Core Training Doctors (CT) and GP Specialty Training Doctors (GPST) especially during their O&G placements; any medically-qualified practitioner who wishes to improve and demonstrate their knowledge and interest in women’s health; doctors working in O&G departments not intending to sit MRCOG; doctors working in private women’s health clinics and associate Members who wish to obtain an RCOG qualification in women’s health
The Royal College of Radiologists
Sets and runs exams in clinical oncology and clinical radiology
The Royal College of Psychiatrists
Membership exam - 2 theory papers and 1 clinical exam (CASC). A UK doctor would sit Paper A in FY2 then progress through the rest of the MRCPsych exams from CT1-3 (core psychiatric training).
Without a doubt, working and studying will be difficult but it is possible, especially if you're set on a specialty! It's also important to note that Royal College exams are not compulsory but may be desired.
All in all, it's vital that you start thinking ahead (i.e. in your F1 and 2 years) about what specialty you want to go into, if any, so you can map out the exams you need to take to get there!
How do doctors afford all of this?
When there is a will there is a way and actually, doctors shouldn't be footing all of these bills! Trainees can claim tax relief on professional fees (e.g. your GMC registration fees) and subscriptions (e.g., annual subscriptions you pay to approved professional bodies or learned societies if being a member of that body or society is relevant to your job), if you must pay these fees to be able to do your job.
You cannot claim tax relief on life membership subscriptions, or for professional membership fees or annual subscriptions you:
have not paid yourself (for example if your employer has paid for them)
have paid to professional organisations that are not approved by HMRC
Your organisation (NHS) can tell you how much tax you’re allowed to claim back.
Tax relief will raise an individual’s tax-free personal allowance by the amount that they have spent on the examination(s). This can lead to an effective saving of up to 40% of the examination cost (depending on whether the trainee is a higher-rate taxpayer). Historically however, this has not always been straightforward for trainees and HMRC has fought several cases on this issue.
HMRC declares that: 'A trainee doctor employed as a registrar on a training contract is required, as a stated contractual duty of the employment, to attend various external training courses. As part of the duties of the employment there is a mandatory requirement to maintain a national training number by attending a series of training courses and events. Failure to complete the course and obtain the qualification will mean that he can not proceed to the next stage of his chosen profession. Attendance at the training events is an intrinsic part of the employment and one of the duties of the employment. The costs of travel to the events, course fees and other associated costs met by the employee are deductible.’ Unfortunately, this has not been extended to jobs that are NOT training posts but which still require the holder to have a National Training Number and to any other posts such as Specialty Doctor jobs – i.e. only trainees are eligible for tax relief.
This seems illogical and unfair but is a function of the way the law is written (specifically Section 336 of the Income Tax (Earnings and Pensions Act) 2003) as the employee must be ‘obliged’ to pay something for it to be deductible. Being desirable simply isn’t enough e.g. most Royal College Membership exams - as they only test competence and do not of themselves improve an individual’s ability to be a doctor.
Links about tax relief:
MRCPUK — Are my examination fees tax deductible?
Royal College of Surgeons of England — Claiming Tax Relief on RCS Fees Royal
Medics Money — Website with free resources to help doctors claim back tax and find accountants
Sources & further reading:
