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

While a national examination would appeal to those wishing to ensure
that the core components of the medial education have been understood and
achieved by every medial student, irrespective of medical school, the
introduction of such a system would merely make students “learn the exam”.
The sole concern would be on ensuring that the syllabus for the exam was
learned at the expense of taking advantage of clinical experiences as and
when they occur. Students would try and limit their time on the wards as
they would prioritise work towards the exam. In addition, surely medical
students are already burdened with enough assessment, both before and
during their time at medical school.

Students fear exams and those from lower economic backgrounds already
feel they are battling against all odds to succeed. The exam would
undermine diversity in medical schools and all efforts to widen access to
medical schools.

The exit exam could prove to be the straw that breaks the camels
back. The foundation programme application system and it’s predecessor
MTAS has undergone change beyond sense in recent times. Students and
junior doctors are becoming disillusioned by the uncertainty in medical
education and training. Surely stability is what is called for now. I
believe that face to face interviews will allow consultants to assess a
potential doctors capabilities far more that any examination.

Are those advocating a national exit exam suggesting that the current
assessment system is not up to the standard required to accurately reflect
ability and achievement? If so, then they are also making an indirect
accusation that the vigorous GMC monitoring and inspection system of
medical schools is not up to the mark. Their visits ensure that students
are being taught and assessed in an appropriate manner.

The quoted study suggesting that post graduate examinations show that
certain medical schools perform better overlooks the fact that students
move after qualifying! Surely post graduate examination analysis should
look at what hospital you work at to reflect their postgraduate training
standards?

I also fear that a ranking system based on academic scores may also
jeopardise the career prospects of those who are excellent practical,
clinical based doctors but may not be as good at passing the exams. I have
heard several clinicians comment that some of the best doctors they know
actually were modest performers at best during their medical school years.

Competing interests:
Past BMA MSC Deputy Chairperson

This is a difficult issue which has been a long way down the medical
education agenda for decades. The fact that it is now much more topical is
entirely due to the current system of appointing to F1 posts. This ranks
students in quartiles and is based on the assumption that quartiles at one
medical school are equivalent to those in any other. What eveidence there
is, much of it from the work of Chris McManus at UCL, suggests that this
is very far from true.We therefore have a national recruitment system but
one not based on a truly national assessment, a typically British fudge.

Ian Noble in fact acknowledges this with the fashionable "diversity"
argument, which naturally applies just as much to post-graduate exams if
we accept it: should we abolish these since they do not take into account
the great diversity of experience of the candidates?As the accompanying
article points out there are certainly problems with any national test but
it seems rather odd to argue against it on the grounds that it would be
less fair than the mess we have at the moment.Of course as the academic
component of applications is further down-graded perhaps we should just
encourage our students to do creative writing courses rather than
bothering about dreary stuff like diagnosis and treatment.

Competing interests:
None declared

While I remain unconvinced of the benefit of a national exam, I would
argue that the viewpoint of this article is too idealistic for the current
climate of selection processes within the medical career ladder. While I
agree that a system should be proven to be “fair, valid and reliable”
prior to use to distinguish between trainees, this is not the story of
MTAS (as was discussed by Parashkev Nachev, BMJ 2007;335:615 doi:
10.1136/bmj.39342.515961.59 ). As a profession, working with a clear
evidence base is now our comfort zone. So, who wants to volunteer for a
RCT of whether a national exam works or not to decide their future? Fiona
Patterson was involved in the development of the MTAS, (BMJ 2007;335:802
(20 October), doi:10.1136/bmj.39360.727535.59) and in her article last
year described the difficulties of the multi-niche aspect of the all-
encompassing career that is ‘medicine’ when it comes to applying one
standard application procedure. Surely this then also applies to the
concept of a national exam. While there is certainly a benchmark
requirement for foundation doctor skills and knowledge base, if the
individual medical schools cannot be trusted to deliver this then it
undermines the system and I agree that focus could be in danger of
changing from producing doctors with a well-rounded medical education to
producing clones that can pass the national exam.

Competing interests:
None declared