Published 22 August 2008, doi:10.1136/bmj.a1279
Cite this as: BMJ 2008;337:a1279

Head to Head

Are national qualifying examinations a fair way to rank medical students? No

¹ University of Sheffield Medical School, Sheffield S10 2RX

Chris Ricketts and Julian Archer (doi: 10.1136/bmj.a1282) argue that a national test is the only fair way to compare medical students, but Ian Noble believes that it will reduce the quality of education

Much has been made of the lack of standardisation within UK medical schools as a result of a recent research paper.¹ The authors called for a national licensing examination after they found that medical schools had significantly different pass rates for the Royal College of Physicians postgraduate examinations. However, these exams are for progression in higher training and not a test of the accepted level of competence to practise as a foundation doctor. There is no evidence that UK medical schools are not currently fulfilling their responsibilities of ensuring that students who reach the required standard to qualify as doctors are fit to practise. Indeed, in a 2005 survey of postgraduate deans, only three UK graduates out of 5833 first year doctors caused concern relating to clinical competence.²

Ranking and diversity

Whether a national qualifying examination is a fair way to rank medical students is less important than the actual desirability of ranking medical students. Traditionally, medical degrees in the UK have not been classified. Medical students graduate having achieved the level required to practise medicine. There has been no better or worse graded doctor at the initial stage of postgraduate training, and rightly so. Ranking students across the country would result in the higher ranked, and therefore perceived "better" doctors, going to the most desirable parts of the country and the lower ranked, or "worse," doctors being sent to the less desirable parts. Perversely, this distribution is likely to be indirectly proportional to the health needs of the relevant communities. The more affluent, and therefore more healthy, parts of the UK would be more competitive in the job market than the less affluent areas.³

If it is decided that ranking of newly graduating doctors is desirable for their allocation into a generic training programme, a national qualifying examination is not the appropriate way to do it. Medical schools’ curriculums and delivery of the undergraduate programme are quality assured and controlled by the General Medical Council through its Quality Assurance of Basic Medical Education process.⁴ The standards for undergraduate medical education leading to a UK recognised primary medical qualification are set out in the GMC document Tomorrow’s Doctors.⁵ The standards for the first year of the foundation programme are outlined in The New Doctor.⁶

A national examination would ruin the current diversity in assessment of medical education and, because assessment has been shown to drive learning,⁷ would probably ruin the diversity in education. All schools would be likely to amend their curriculum to teach students how to pass the exam. Undergraduate medical education should be about learning how to be a good doctor and not merely about how to pass an exam. Indeed, a national exam would make it likely that schools would be reticent to innovate new curriculums. Yet surveys of several thousand first year graduates have shown that curricular change may have contributed to trainees feeling better prepared for work.⁸

Knowledge is not all

Until a system of examination can be demonstrated to be fair, valid, and reliable it would not be appropriate to use it for ranking. There is currently no single method of assessment in medicine that fulfils these criteria. Although multiple choice questions may be reliable, they can assess only knowledge and do not offer a valid assessment of the clinical skills required to practise as a junior doctor. Objective structured clinical examinations may be more valid but are not absolutely reliable⁹ and therefore not absolutely fair.

A national ranking examination is likely to be based on an assessment of pure knowledge and not on performance. Medicine is a performance and practical discipline, and although knowledge is important, it is not what makes the difference between a good doctor and a less good doctor. Selection into specialty training should be based on ability and aptitude within that specialty, not merely pure knowledge from a breadth of other specialties.

Performance on the day for such a high stakes assessment is likely to play an important part for candidates. There is a drive away from high stakes single point assessments in medical education. Muijtjens and colleagues strongly advised against the use of such assessments in making qualitative comparisons between medical schools.¹⁰ Their study of around 5000 students in three medical schools over four years showed that single assessments have a higher potential for error than multipoint testing.

The British Medical Association has clear policy in opposition to a national qualifying examination that has been voted on and set by representative conferences of both medical students and the full profession. The Medical Schools Council, which represents all the UK medical schools, is also opposed to a national qualifying examination (J Tooke, personal communication). The case has not been made for one, and even if it were made there is no valid and reliable method to introduce it. Such an assessment in the UK could badly affect the diversity, methods, and therefore quality of medical education in the UK. There is no requirement, need, or will for such an examination, and it is highly unlikely that it would ever be truly fair.

Cite this as: BMJ 2008;337:a1279

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Competing interests: ISGN chairs the BMA Medical Students’ Committee.

References

1. McManus IC, Elder AT, Champlain A, 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 Medicine 2008;6:5.[CrossRef][Medline]
2. General Medical Council. Strategic proposals for assessment. London: GMC, 2006.
3. UK Foundation Programme Office. Competition ratios for 2007 applications. London: FPO, 2008.
4. General Medical Council. Quality assurance of undergraduate education. 2008. www.gmc-uk.org/education/undergraduate/undergraduate_qa.asp.
5. General Medical Council. Tomorrow’s doctors. London: GMC, 2003.
6. General Medical Council. The new doctor. London: GMC, 2005.
7. Swanson D, Case S. Assessment in basic health science instruction: directions for practice and research. Adv Health Sci Educ 1997;2:71-84.[CrossRef]
8. Cave J, Goldacre M, Lambert T, Woolf K, Jones A, Dacre J. Newly qualified doctors’ views about whether medical school had trained them well: questionnaire surveys. BMC Med Educ 2007;7:38.[CrossRef][Medline]
9. Newble D. Techniques for measuring clinical competence: objective structured clinical examinations. Med Educ 2004;38:199-203.[CrossRef][Web of Science][Medline]
10. Muijtjens AMM, Schuwirth LW, Cohen-Schotanus J, Thoben AJ, van der Vleuten CP. Benchmarking by cross institutional comparisons of student achievement in a progress test. Med Educ 2008;42:82-8.[Web of Science][Medline]

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