Validity of final examinations in undergraduate medical training

doi:10.1136/bmj.321.7270.1217

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Cees van der Vleuten (c.vandervleuten@educ.unimaas.nl), professor of education

Department of Educational Development and Research, University of Maastricht, PO Box 616, 6200 MD Maastricht, Netherlands

Accepted 18 July 2000

Most medical schools, particularly those in the United Kingdom, have a final examination at the end of undergraduate medical training. Although the format of these examinations has been changed recently by the introduction of newer types of assessment such as objective structured clinical examinations, medical educators are still questioning their validity and worth. I believe that there is a strong case for better continuous assessment during undergraduate training and less reliance on final examinations.

Summary points

Even with modern forms of assessment, final examinations are of questionable reliability and validity

They are of limited educational value to students because there is little opportunity for feedback and correction

The effort spent on running final examinations would be better invested in improved continuous assessment during training

Continuous assessment through “clinical work samples” is a promising new method of assessing medical students

Functions of the examination

The final examination has at least two functions—an accountability or selective function and an educational one. First and foremost, the final exam should provide a guarantee to society that the training programme delivers competent doctors. It should be able to identify any students who are unfit to practise, so that they can be prevented from doing harm, and to license competent students who are ready for further practice and training. With regard to the educational function, proponents claim that the requirement to sit a comprehensive examination at the end of training means that students revise and recapitulate what they have learned throughout the course, a process which leads to a more integrated understanding of the knowledge and skills they have acquired. Let me examine these functions in greater detail.

The selective function

The outcome of the final examination should predict whether a student will be competent. The process should prevent false negative results and, in particular, false positive ones. In other words, the final examination should …