Early days: 1518–1859

The Royal College of Physicians of London tested the knowledge and competence of those who wished to practice as physicians from the outset. Candidates would be tested on four subjects at three-month intervals – their knowledge of medical theory, signs used by physicians and the symptoms of disease, methods of treatment, and materia medica. The content of these examinations was based entirely upon the works of Galen, and candidates would have three months to build their knowledge of the 17 volumes of recommended reading. The president, together with five Fellows, would pick out at random three questions from three different places in the books. The candidate would be allowed several hours to consider the questions, before returning to read out to the assembled college his identification of the passages and his answers to the questions. The Fellows would judge whether he had found the right place, understood what he had read, and reasoned about it well. The result would be decided by a simple majority vote, although candidates who had failed to demonstrate their understanding of one of the three questions would have little chance of passing. A fifth, more practical examination, on the use and practice of medicine, did not involve knowledge of key texts, and candidates who were known to be highly skilled or of distinguished education would only be tested on this. The College ensured that the exam was robust and rigorous, to make it universally known that no one would become a Fellow unless learned in the theory and practice of medicine. Edinburgh and Glasgow used similar methods to test the knowledge and skills of prospective Fellows.

The examinations evolved over the years to reflect changes in knowledge and practice, but they were always regarded as a fair way to test the skills required of physicians. The rigorousness of the exam is reflected in the fact that only 80 people passed between 1691 and 1750. Some of the methods may seem odd to modern eyes, particularly the continued conduct of the examination in Latin until the beginning of the 19th century, but the Colleges included this to demonstrate beyond their own bounds that their Fellows were men of wide learning. However, by this time the examination was beginning to change to reflect the increasing professionalisation of society.

The Membership 1859–1969

The examination began to develop into its more familiar modern format in the middle of the 19th century. London ran the first membership exams in April 1859, while Edinburgh and Glasgow began exams to admit new members and fellows in 1861 and 1886 respectively.

As one of the historians of the RCPL puts it, the examination ‘remained unchanged in its essentials for over 70 years’. Candidates would sit papers on medical anatomy and the principles of medicine, the practice of medicine, and the principles of public health and psychiatric medicine. They would also have short extracts for translation from Latin, Greek, French and German. The latter were included so candidates could demonstrate that they had a sufficient level of general education and culture, and thus could maintain the dignity and honour of the College. A clinical examination and two oral examinations would follow. Candidates had to be a minimum age of 25, provide satisfactory testimonials of their character and their education, and not be engaged in trade. While the exam was run four times a year, the numbers passing remained small, e.g. only 20 in 1880. Edinburgh required its candidates to pass written examinations on similar subjects, but also to comment on a case from the local Royal Infirmary and answer questions on it, as well as pass an oral examination lasting an hour.

The London exam remained in this format until 1893, when the retiring Senior Censor (Censors are the senior officers of the RCPL) criticised the variable standard and leniency of the examination. Following his recommendations, a system of numerical marking was adopted. Women were first allowed to sit in 1908, and in 1909, Dr Ivy Evelyn Woodward became the first female candidate to pass the examination. Further changes were introduced over the years. As fewer candidates attempted the classical and modern language translations, less weight was given to these sections. However, they were not finally dropped until 1963. The numbers of candidates steadily increased, reflecting the increased numbers of students moving into the profession, with over 100 sitting for the first time in March 1935. As physicians demobilised following military service, huge numbers sat the membership examinations after 1945 (Edinburgh’s numbers increased from 37 in 1925 to over 1000 in 1959), and although pass rates remained low (e.g. averaging around 33% for the Glasgow exam in the 1950s), the examination continued to attract aspiring physicians and it was recognised that those who passed had reached a standard that justified entry into further training as a consultant.

Sample question from 1867 RCPL Paper – 'Describe the morbid anatomy of Typhus Fever, of Typhoid Fever, and of Scarlet fever; and point out in what particulars these diseases essentially differ from each other'.

MRCP(UK) 1969–2000

Minor tweaks to the examinations run by the Colleges continued throughout the 1950s and 60s, as they constantly considered ways to cement their qualifications in the new health system. Major changes soon followed: a multiple choice paper for the Part 1 examination was first introduced by London in 1963, while the new Part 2 would consist of written papers, clinical tests, and an oral examination. However, the most significant change came at the end of the decade, when the new MRCP(UK) Part 1 examination run by the three Colleges was introduced, meeting the need for a single membership examination valid across the country, and finally quashing persistent rumours about the varying standards of the examination. A new joint Examining Board with representatives from each of the Colleges was established. A common Part 2 exam, requiring candidates to demonstrate not just their grasp of clinical knowledge, but also problem solving abilities, clinical skills and attitudes, was introduced soon after. Candidates had to answer short questions instead of essays, but were also required to pass an oral examination where they discussed several topics as well as long and short cases. By 1982, the examination was run in 17 centres in the UK and 11 overseas (an innovation first introduced by necessity during the war, but discontinued thereafter until 1970 – RCPL had been reluctant to run its examination outside of the capital until 1964). By this stage, 4000 candidates a year were sitting Part 1, and the exam began to adopt a format more recognisable to modern candidates, thus continuing on its long journey to the global success story that it is today.

Further Reading:

G. Clark, A. Cooke & A. Briggs, A History of the Royal College of Physicians of London, Vols. I–IV (Clarendon Press, Oxford, 1964–2005)
W.S. Craig, History of the Royal College of Physicians of Edinburgh (Blackwell, Oxford, 1976)
J. Geyer-Kordesch & F. Macdonald, Physicians and Surgeons in Glasgow (Hambledon, London, 1999)
J. Geyer-Kordesch & A. Hull, The Shaping of the Medical Profession (Hambledon, London, 1999)

History of MRCP(UK) – a contextual timeline