Intended for healthcare professionals

Career Focus

Failing postgraduate exams

BMJ 2007; 335 doi: (Published 01 December 2007) Cite this as: BMJ 2007;335:s200
  1. Vanessa Harry, clinical research fellow in gynaecological oncology (v.harry{at},
  2. Averell Bethelmy, SpR anaesthetics
  1. Aberdeen Royal Infirmary


Vanessa Harry and Averell Bethelmy describe recovering from the depths of despair

Most doctors do not pass postgraduate examinations on the first attempt. This is undoubtedly reason for disappointment, but with repeated unsuccessful attempts, these feelings become multiplied, resulting in an overwhelming sense of frustration, lack of confidence, and ultimately, demoralisation. Many unfortunate candidates have training delays despite being clinically sound.

Falling at the first hurdle

Postgraduate medical exams are a stumbling block for many people, who despite having passed many exams during undergraduate training, find them particularly challenging. Although lack of preparation may play a role, a stressful, demanding job that leaves little time and energy for study, as well as in some cases, simultaneously coping with family life, can contribute to this struggle.

Career brakes

The mental burden placed on people who have not passed postgraduate medical exams can be considerable. Because career progression is currently determined by success in these exams, and because several colleges allow a finite number of attempts, it increases the usual stress associated with exams, and the eventual build up of tension can adversely affect performance. In these cases, exams cease being just another test, and become a high stakes hurdle, which can ultimately affect finances and employment opportunities.

Many candidates who are repeatedly unsuccessful will attest to the fact that an exam can become the central aspect of their lives, around which everything else revolves, and they are unable to make any long term plans for the future until that hurdle is cleared.

Examination information

Examining bodies are committed to provide a fair and rigorous assessment of people in specialist careers, and so maintain an appropriate standard of medical education and ultimately, patient care. The extent to which this is achieved is still questioned. It is well known that not all trainees who pass exams are clinically competent, and similarly, failure does not necessarily equate with clinical incompetence.

Evidence based exams

There are variations in pass rates from one college to another. The reliability of an exam deals with how accurate the assessment is, and its validity is concerned with the appropriateness of the assessment, and whether the test has lived up to its intended purpose. Holsgrove noted that a potentially reliable test may leave much to be desired in terms of validity.1 He cited pitfalls in the ability of medical postgraduate exams to test essential abilities such as communication skills, technical competence, and formulating a diagnosis and treatment plan. In a systematic review investigating the validity of medical postgraduate certification, Hutchinson and colleagues also concluded that there was a general lack of published evidence on validation of these tests especially considering the impact they have on doctors' lives.2

Room for improvement

Many colleges have attempted to improve their exams, making them more relevant and practical. Most exams consist of two or three parts, done at different stages of training. The aim of the first part is to build up a foundation of basic sciences specific to the specialty, and subsequent parts are geared toward testing clinical acumen and practical skills.

Rock bottom

Failing an exam can feel like reaching ground zero, and the low morale and lack of confidence can even hinder further study. Rebounding from this is difficult, but not impossible.

Change your outlook

An exam, although important, does not entirely determine how good a doctor you are. Reassure yourself that you are committed to your job, and strive to perform to the best of your ability. Remind yourself that your original intention in pursuing your career was to contribute to improving the care and overall treatment of patients.

Deep learning

Learning by rote can be difficult, time consuming, and rarely useful. Deep learning involves relating different facts to each other, so that information is used insightfully and intellectually, as in problem solving.3 This is more permanent and requires less time and memory. Relating what you read to the clinical situations that you encounter develops a greater understanding of what is being studied.

Learn (and teach) on the job

Studying is rarely effective after a hard day of on-call duties. Use your job as an opportunity to challenge the knowledge you have acquired so far. For any condition you encounter, remind yourself of the aetiology, differential diagnosis, or alternative forms of management, and question your seniors as well. Take the opportunity to teach medical students or discuss the topics you are reading at the moment with colleagues on the ward, which will further increase your confidence and knowledge. Exam preparation courses also allow for discussion with others in a similar position. Instead of reading only books and journals, practice numerous questions and essays. Be familiar with your college's website and published guidelines.

Be aware (not beware) of exams

Take care to find out about the various components of the exam, the numbers of questions, the use of negative marking, and the proportion of marks given for different sections. Obtaining a syllabus will not only guide you on what is required for the overall exam, but will also give an indication of how much time to devote to revising individual topics.

Knowing beforehand how much time will be allocated for different components will allow good time management. Be strict with how long you allow yourself for each question.

Help, I need somebody

Your own consultants, educational supervisors, and regional advisers should be available for support and advice. The onus, however, is on you to seek out this help.

Take advantage of the counselling services and guidance interviews that are provided for unsuccessful candidates by most colleges.

Especially for those who have repeatedly failed, exams can become a debilitating psychological hindrance. Hypnotherapy, as well as behavioural therapy, has been shown to have favourable results in reducing anxiety in these cases and may be worth exploring.45

Persistence pays off

With the recent changes to training, postgraduate exams may become part of a more integrated assessment involving workplace based evaluation. Remember, those struggling with upcoming membership or fellowship exams are not alone. Developing better learning skills and exam techniques as well as seeking support can go a long way toward success, and in most cases, persistence pays off.

Change of specialty

Changing life circumstances, or the increasing demands of a particular specialty, may lead to the recognition that your originally chosen field is not for you. In these circumstances, feel free to explore opportunities that suit you better and which may ultimately give you greater satisfaction.


  • Acknowledgments

    Thanks to Maggie Cruickshank, Gordon Narayansingh, and David Parkin, consultants at Aberdeen Royal Infirmary.


View Abstract