Should UK medical students sit a national qualifying exam?

YES Imagine if the best universities admitted only pupils who had been in the top 25% of ability in their particular school. This would pose a curious dilemma for parents—should they choose the best school with the highest academic standards but face the risk that their child may not be in the top quarter of ability, and so miss out on the best universities? Or should they send their children to the worst school possible where they have a better chance of being at the top of the class?

Clearly such university admissions policies would be nonsensical, but this is exactly what is happening in medical schools throughout the United Kingdom. Not only are standards set individually in each medical school, but the examinations are different and use different metrics to assess students.¹ The result is that it is easier to achieve a top academic score in a medical school with weaker academic competition, and it also fails to guarantee an objective consistent standard in graduates from different medical schools.²

The foundation programme was introduced in August 2005 to modernise the process by which junior doctors apply for training jobs.³ Students from each medical school are ranked by academic quartiles, which are used in combination with short answer questions⁴ to help determine the first jobs of each graduate. All schools are assumed to be academically identical: “Students ranked in the top 25% of any medical school will be regarded as equivalently ranked to those in the top 25% of all other medical schools.”⁵ This is intuitively wrong because average standards and distribution of students’ abilities vary between medical schools.^{6 7 8} A student at a top ranking university, competing against a high calibre class, will achieve a lower academic ranking than if they had attended a lower ranked university, competing against academically weaker peers. Consequently, it may be more difficult to obtain the foundation job in the specialty and location of choice.

A fairer assessment

A national qualifying exam would remove this inequality while ensuring a threshold of satisfactory competence for junior doctors. A standard written and clinical examination would finally permit legitimate comparisons to be made throughout the country, and medical graduates would know they had been assessed fairly and objectively. Patients could be assured that all junior doctors had achieved a satisfactory level of competency. Although the General Medical Council in the UK does run a rigorous quality assurance programme,⁹ its ability to objectively verify students’ competence is arguably limited in the absence of a national qualifying exam.

A national examination would also help identify medical schools and regions that are the best or worst at preparing students for a career in medicine. A recent study showed that only a third of newly qualified doctors agreed that they had been well prepared for their jobs, with significant variation between medical schools.⁶ Pass rates for membership exams of the Royal College of General Practitioners⁷ and the Royal College of Physicians⁸ have also been shown to vary enormously between graduates of different medical schools.

The UK could introduce a system similar to that currently used in the US medical licensing exam (USMLE; www.usmle.org) or the Medical Council of Canada qualifying examination (www.mcc.ca/english/examinations/qualifying_e1.html). Both are well established examinations that involve written and clinical components to assess students to a nationally standardised level of competence. The USMLE comprises several steps that cover core medical sciences, clinical medicine, and clinical skills using standardised simulated patients,¹⁰ with a final step to assess applied knowledge needed as a junior doctor. Test results are used by medical schools for curriculum and graduation decisions, contributing to the residency job selection process. This centralisation relieves the burden of final assessment from local medical schools, freeing up more time for clinical work, teaching, and research. The USMLE also ensures the quality of foreign doctors trained outside of the United States, while the UK’s assessment is inadequate in comparison.¹¹

Time for change

While assuring minimum competence it is also important that higher achievers are appropriately recognised and graded. The currently favoured objective structure clinical examination¹² is designed to assess a minimum “clinical competence,”¹³ with the emphasis on defining the correct pass-fail cut-off rather than distinction level.¹⁴ Modifications may therefore be needed to ensure that higher achievers are appropriately identified, perhaps extending higher tier competitions, such as the University of London gold medal (www.medical-student.co.uk/gold).

National assessment in the UK was discussed by GMC consultation in mid-2005 but “did not indicate a clear consensus.”¹⁵ Since then, the introduction of the foundation programme has reignited the debate, and I think that further consultation is essential.

A national exam should not damage medical school individualism or diversity, and it should not change the content of teaching in the course of a medical degree. Rather it should serve to standardise assessment at the end. Those who argue that such a system would disadvantage some medical schools may well be admitting that such schools currently set suboptimal standards. If a medical school is confident in its abilities there should be no problem in using a nationally validated assessment tool and matching students to jobs based on their objective ability rather than their geography.

1. Fowell SL, Maudsley G, Maguire P, Leinster SJ, Bligh J. Student assessment in undergraduate medical education in the United Kingdom, 1998. Med Educ 2000;34(Suppl 1):1-49.
2. Matheson NJ, Burns A, Henderson K. Foundation year for newly qualified doctors: GMC assessment of junior doctors’ competency is inadequate or inconsistent. BMJ 2005;331:697-8.
3. Hays R. Foundation programme for newly qualified doctors. BMJ 2005;331:465-6.
4. Hawkes N. Online selection of new doctors “grossly unfair.” Times 2006 Mar 4. www.timesonline.co.uk/tol/news/uk/article737241.ece.
5. Foundation Programme. Frequently asked questions. Cardiff: Foundation Programme, 2008. www.foundationprogramme.nhs.uk/pages/medical-students/faqs#how-is-my-application-scored.
6. Goldacre MJ, Lambert T, Evans J, Turner G. Preregistration house officers’ views on whether their experience at medical school prepared them well for their jobs: national questionnaire survey. BMJ 2003;326:1011-2.
7. Wakeford R, Foulkes J, McManus C, Southgate L. MRCGP pass rate by medical school and region of postgraduate training. Royal College of General Practitioners. BMJ 1993;307:542-3.
8. McManus IC, Elder AT, de CA, Dacre JE, Mollon J, Chis L. Graduates of different UK medical schools show substantial differences in performance on MRCP(UK) part 1, part 2 and PACES examinations. BMC Med 2008;6:5.
9. General Medical Council. Overview of the QABME process. London: GMC, 2007. www.gmc-uk.org/education/undergraduate/undergraduate_qa/qabme_process.asp.
10. Dillon GF, Boulet JR, Hawkins RE, Swanson DB. Simulations in the United States medical licensing examination (USMLETM). Qual Saf Health Care 2004;13(suppl 1):i41-5.
11. David Rose. Foreign doctors face competence inquiry. Times 2007www.timesonline.co.uk/tol/life_and_style/health/article2231550.ece
12. Harden RM, Gleeson FA. Assessment of clinical competence using an objective structured clinical examination (OSCE). Med Educ 1979;13:41-54.
13. Boursicot K. Setting standards in a professional higher education course: defining the concept of the minimally competent student in performance based assessment at the level of graduation from medical school. High Ed Q 2006;60:74-90.
14. Norcini JJ. Setting standards on educational tests. Med Educ 2003;37:464-9.
15. General Medical Council. Strategic options for undergraduate medical education. London: GMC, 2006. www.gmc-uk.org/education/documents/strategic_outcomes_final_report_jun_2006.pdf.

No The recent General Medical Council (GMC) report Strategic Options for Undergraduate Medical Education showed that the royal colleges, the GMC, and the BMA all thought that university based examinations ensure quality and safety in the assessment of medical students.¹ A national qualifying exam would not only add another level of bureaucracy to the process of qualification, it would also indicate poor trust in the ability of universities and examiners, most of whom are clinical practitioners, to exercise the basic ethical principles of beneficence and non-maleficence in assessing students.

A national exam would allow selectors to crassly categorise graduates on a directly comparable national scale. However, with controversy surrounding applications to the UK foundation programme, introducing such an exam plays into the hands of a flawed system for job allocation. Change the system by conducting interviews and allowing candidates to submit full CVs, not the method of examination, which has existed harmoniously with the job application process until now.

Fixated with grades

Despite widespread concern about the failure of the foundation programme to compare candidates fairly, academic achievement is relatively underweighted. Students above the top quartile ranking (45 marks) and below the bottom quartile (30 marks) would differ by only 15 out of a possible 100 marks.²

Many schools are choosing to include performance in student selected components in this academic weighting. These components are chosen and often designed by students themselves, so it would seem impossible to nationally standardise their assessment. Any attempt to do so would undermine the original ethos of exploring specific topics of personal interest. And why challenge yourself with a self designed component in something that stretches you, when you could easily score top marks by dusting off your school French exam, for example?

Arguably, it is more valuable to have demonstrable achievements in terms of leadership, teamwork, and professional integrity than it is to come above the top academic quartile. As such, in the foundation programme application, 55 marks are allocated based on the answers to key questions; it is here that greater differentiation can be achieved. The implementation of a national qualifying exam risks overemphasising academic achievement at the expense of the balanced range of skills required to be a good doctor and enjoy a long and prosperous future career.³

Sacrificing breadth and diversity

Such an exam would need to be conducted before the completion of undergraduate training because final year students currently apply for positions early in their final academic year. The need to prepare students for this exam would stretch throughout the undergraduate years, driving a process of curriculum standardisation rather than the current more flexible mentality of preparing doctors for practice.

The diversity of our country’s teaching hospitals and their associated medical schools should be a source of great pride to the profession in the United Kingdom. A full medical education involves students being taught by leaders of their disciplines who have associations with their medical schools. Such special interests and teaching diversity, which are often marginal and not part of the core medical curriculum, are the most enjoyable part of learning. If qualification becomes even more driven by assessment, it is undoubtedly these perhaps superfluous but highly inspirational and enthusiastically delivered aspects that would fall victim to time constraints imposed by further exam preparation.

More dangerous, perhaps, is the public perception of another system of ranking in the NHS. Whether it is hospital star ratings or league tables for consultants, people’s faith in local healthcare provision is undoubtedly affected by media coverage of rankings. Medical schools that provides relatively poorly performing graduates, albeit ones who perform at the level required by the GMC for qualification, may damage public confidence, but no evidence supports this danger. But implementation of such a grading system will inevitably lead to public pressure for individual doctors’ scores to be made available. And competent yet comparatively poorly performing doctors will be marginalised in terms of patients’ confidence.

Improve the existing system

The need for consistency in outcomes between medical schools and students is unquestionable, and this is monitored by the GMC’s quality assurance programme.⁴ The subjectivity of this assessment underlies the need for a rigorous external examiner system, whereby universities swap examiners to ensure comparability in the assessment standards at different schools. Greater support and structure in the external examiner system would allay fears about the standards between schools. Better training for examiners, particularly when assessing objective structured clinical examinations, allows doctors responsible for clinical supervision and teaching to be aware of the assessment criteria for such exams, bridging the gap between ward teaching, preparing for assessment, and life as a new doctor.

Ensuring that medical graduates are equipped with the skills and knowledge to practice safely and confidently is critical. However, passing finals must not become simply a case of rote learning a fixed knowledge base. Preparing for a career in medicine is more than just preparing for an exam; it is a process of professional enculturation, involving knowledge, personal skills, and probity⁵—tough assessment criteria for any exam.

1. General Medical Council. Strategic options for undergraduate medical education. London: GMC, 2006. www.gmc-uk.org/education/documents/strategic_outcomes_final_report_jun_2006.pdf.
2. F1 application procedure. NHS, 2007. www.foundationprogramme.nhs.uk/pages/home/about-the-foundation-programme.
3. Falder S. Balancing medicine with a life. BMJ 1998;317:2.
4. General Medical Council. Overview of the QABME process. London: GMC, 2007. www.gmc-uk.org/education/undergraduate/undergraduate_qa/qabme_process.asp.
5. General Medical Council. Tomorrow’s doctors. London: GMC, 2007. www.gmc-uk.org/education/undergraduate/GMC_tomorrows_doctors.pdf.

   

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