GMC will develop single exam for all medical graduates wishing to practise in UKBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5896 (Published 01 October 2014) Cite this as: BMJ 2014;349:g5896
All rapid responses
Before anybody can consider the merits or otherwise of imposing an additional assessment on already stretched final year medical students, they must first consider the nature of the assessment. Therefore, we need to be clear about what a National Exam means.
For example, is this an exit (from medical school), licensing or entrance (to the Foundation Programme) exam? Secondly, will it potentially absorb national assessments already in place, such as the Situational Judgement Test (SJT) (if a foundation programme entrance exam) or Prescribing Safety Assessment (PSA) (if a licensing exam)? These questions are important in determining the response.
One of the biggest concerns is that medical students will be learning to the test, not learning to practice. This is because any further examination, on top of an already rigorous examination schedule in final year will compromise the amount of time that medical students have on the wards.
Most concerning may be the amount of time that this will take from the usual Preparing for Professional Practice unit that all medical students take in their final year. Is a reduction in the exposure that medical students already have on the wards a price worth paying for additional didactic learning?
There are, of course, proposed merits to a National Licensing Exam (NLE). It may provide objective assurance of common standards and consistency of assessment of outcomes across all UK Medical Schools, including the new private ones. It will replace the PLAB thus becoming a standard condition for registration with the GMC, or at the very least, employment within the NHS. Failure in the NLE may be a significant driver for quality improvement. Failure would be clearer if all medical schools were bench-marked against each other. It would also align our system in the UK with systems elsewhere, such as the US and Canada, where national exams are already used.
However, there are problems with this proposal. In the case of the SJT and the PSA, the introduction of a national exam may become an unnecessary duplication. More concerning would be the impetus to duplicate one exam for which the validation process remains on-going; the SJT, and the other for which no psychometric analysis has been completed; the PSA. I.e exams that currently lack an evidence base.
Illing J, et al noted in a 2008 study that it was not the type of curriculum or cohort of medical students within a year that influenced the preparedness of medical graduates to work as newly-qualified Doctors. Instead, it was undergraduate clinical placements, shadowing, adequate induction and the support of those in the workplace and at home that were tangible drivers of quality. In addition, Paice et al concluded in a survey of Junior Doctors that practice gained in a real clinical setting helped preparedness. Thus, more time on the wards and a longer shadowing period were seen as potentially useful changes. This is counter to the threat of less clinical exposure if the NLE were to be launched.
There is a common theme running through this that people forget; there are already rigorous barriers in place to regulate the transition from medical undergraduate to Junior Doctor.
The way to promote the safety of patients and to protect the learning of medical undergraduates would be to ensure that clinical placements offer structured experiential learning across a range of specialties. This should be complemented by the development of student assistantships that allow students to carry out clinical competencies in a supervised manner and a period of shadowing where they are involved in day-to-day ward business with supervised direct patient contact.
1. Illing J, et al. How prepared are medical graduates to begin practice? A comparison of three diverse UK medical
schools Final Report for the GMC Education Committee. General Medical Council/Northern Deanery. April 2008
2. Paice, E. et al (2002b) Stressful incidents, stress and coping strategies in the pre-registration house officer years. Medical Education. 36(1): 56-65
Competing interests: Working on behalf of an organisation with expressed concern about a National Exam.
Some readers so far expressed doubt on the value of a national licensing exam for medical graduates, thinking there is already too much exams and study in the medical school curriculum and postgraduate education.
I beg to differ.
Over the last few years there is increasingly more accusation of discrimination on ground of ethnicity and cultural background in examinations to achieve qualifications in UK , principally the PLAB and the MRCGP. Some deemed the only 'obvious' reason of poor performance of candidates of certain classification is that the examination modules is somehow racially discriminatory, including the non face to face component like MCQs. This makes good tabloid headlines and unjustified onus on the examiners rather than the candidates, a situation I do not agree with.
I see that there is a need to draw a line somewhere when setting standards, and even though there are situations where English is spoken less (in various ethnic communities including Wales!), nevertheless the language of English is still spoken by at least 85 -90% of the population be it as a first or second language. A license to practice in UK is rarely given conditionally, even less on the basis of practice within regional ethnic communities. Furthermore, continuing medical education in UK is rarely, if ever, held in ethnic language other than English. Therefore it is inevitable that the exams will somehow slant towards academic level of English in reading, writing and speech. If you can't achieve that you can't be expected to take another 20 years to reach the standard while on probation for the similar period.
I am not sure about this, but I suspect that in UK just like in Australia there is a huge variation of quality of medical graduate between medical schools, between years and even within the same cohort of medical graduates within the school. I am sure some of us often wonder how certain house officers ever become doctors and often their incompetencies go under the radar in the pre-streaming years unchecked. Certainly a few rogue graduates can easily ruin an otherwise reasonable reputation of certain medical schools.
The introduction of a national license exam is a proclamation to medical students, medical schools, and society that there is a minimum standard to achieve similarly for local and overseas graduates, many will pass, some will not. Such an exam is not going to be perfect or fair, but we should NOT pretend it will be: certain competent candidates will have a bad day, but they will eventually pass, if they are demonstrate the required competency at the end of the day. Some will never do well in formal exams, but they will have to learn to do so, we cannot allow exceptions.
Harrison Carter, co-chair of the BMA’s Medical Students Committee, should be reminded that a barrier exam is not an excessive event; if this could allegedly distract students from essential medical training, then the school's curriculum needs an overhaul, since all postgraduate qualification in most professionals involves some form of exit examination.
Lastly, may I add that in Australia, there have been some attempt to look into a national licensing exam for local graduates and overseas trained doctors seeking entry to the workforce, via AMC certification. There is not unexpectedly significant resistance and lack of enthusiasm from both the students and their Australian medical schools.
The recent glut of new medical schools in Australia set up by universities who traditionally do not have a clinical science and health faculty, meant that there will follow a similar glut of medical graduates who are from a previously untested curriculum (AMC approves the content of the curriculum but does not publicly test or benchmark the graduates of each new school to national standard). As such we in Australia faces a challenge of potential oversupply of junior doctors in the next few years, with a vast difference in background and foundation, all competting for the few training positions for further qualifications. Some will take longer than other, and from interaction with some of them, I think there are a few who will never make it beyond their basic degree, unless there are some critical changes, either by candidates somehow seeing the light after all the failed attempts by well meaning mentors to help them, or lower the bar.
I cannot see that happening.
I hope that the UK system works quickly so that Australia can just simply adopt the changes from the UK experience like many other schemes
Competing interests: No competing interests
The reach of the GMC extends ever further. The graduate now faces a career of 45 years plus with the prospect of a licensing examination in addition to a degree that he or she has attained after studying hard for 4 or 5 years, including content that is overseen by the GMC. Also the graduate has the continual requirement to produce pages of self reflection for appraisal which is the main informant for 5 yearly revalidation. I am thoroughly fed up with paying for the privilege of being policed by this increasingly beauraucratic behemoth.
Competing interests: No competing interests
An exam to be sat prior to registration by all doctors is concerning. Is the implication that the GMC is no longer satisfied with the assessment and final examinations leading to the award of medical degrees in the UK?
Competing interests: No competing interests