BMA calls for urgent review of online exam for medical students
BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n253 (Published 27 January 2021) Cite this as: BMJ 2021;372:n253Linked Opinion
We need to move towards a student-centred application process for foundation training
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Dear Editor,
The Doctors’ Association UK (DAUK) is an advocacy group campaigning for the working rights of doctors and medical students. In the last six months, the DAUK Medical Student Committee have witnessed the distress and frustration of many medical students due to poor communication, technical errors, and a lack of empathy from the UK Foundation Programme Office (UKFPO). After responding to concerns and speaking out on behalf of students, we ask one important question: do the UKFPO care about student welfare?
In December 2020, a number of students reported that their SJT examinations had been prematurely and unfairly terminated due to ‘technical difficulties’. One candidate received a call from their invigilator during the exam, but their phone was not within reach (as instructed by the exam regulations) and the exam was terminated. Other students were told that toilet breaks were not permitted, creating intolerable working conditions.
It is unacceptable that technical difficulties and unclear guidance resulted in early termination of this exam. Affected candidates immediately contacted the UKFPO and Pearson Vue to discuss their situation, but subsequent communication was delayed, dismissive and unclear. One candidate described this as "the most demoralising thing that has ever happened to me in medical school".
In January 2021, the UKFPO announced that candidates would be offered resit examinations. Although the U-turn was welcomed by many, the short notice and limited flexibility as to when the resits could take place, only created further stress and anxiety for students.
As current medical students, we are concerned about how the UKFPO will manage future examinations and foundation applications. Should we accept the inevitability of technical errors and poor communication as standard? Pearson Vue hosts several postgraduate examinations, including those for medical colleges such as RCOG (1). Unless action is taken, it is likely that similar issues will continue to cause emotional turmoil for candidates.
In a time where the mental health of doctors is worsening and the rate of burnout is increasing (2), student wellbeing must be a priority. Can, at a time like this, the UKFPO afford to be treating medical students poorly? As such, the DAUK will continue to campaign for effective and visible medical student representation within the UKFPO, to improve communication and place student wellbeing at the forefront of future decision-making.
1 - The RCOG membership exam [Internet] Available from: https://home.pearsonvue.com/Clients/Royal-College-of-Obstetricians-and-G...
2 - General Medical Council. Caring for doctors, caring for patients. GMC, 2019.
Competing interests: No competing interests
Dear Editor,
Thank you to the author for bringing attention to an issue that has caused pain and distress to the final year cohort in an already stressful time. What we have learnt from the situational judgment test (SJT) process this year is that organisations like UKFPO seem to choose to make themselves unavailable to the individuals they claim to be helping. When they only give updates from social media accounts like Twitter and Facebook, that is also a choice. When they make their only contact detail an email address/address(1), that, is also a choice.
Shall we start from the beginning? When I submitted my application on Oriel an error occurred where my first name ended up being listed as a single letter “A” instead of “Amy”. I obediently contacted UKFPO via their automated email three times, then four. I was responded to twice, with replies meagre in both word count and comprehension of my issue – the conclusion was that it was fine, and that Pearson Vue would have received my correct name. I chose to believe them. Closer to the SJT I decided this trust was misplaced, and I checked with Pearson Vue themselves – the response: “You need to get that name changed. Not through us though, through them”.
Did you know that no matter how hard you look there just isn’t a phone number for UKFPO? Many students learn this when desperately trying to get in contact with them. What followed for me was an email chain that involved my medical school and members of the foundation programme team before someone finally, thankfully, added the two letters to my forename two weeks later.
Five days on, armed with my correct full name of five letters and a matching ID card I sat down and connected with a Pearson Vue proctor, who promptly refused to let me go to the bathroom for (nearly) the next three hours. This was surprising only in that the no-bathroom period began from when the proctor could see me on-screen and not when the exam had started, leaving me and others ill-prepared. Worth highlighting in this is that these restrictions disproportionately affected both those who menstruate and individuals with disabilities or special requirements. When you consider that individuals with extra time were also not allowed to go to the bathroom, the reality simply becomes not only farcical but also discriminatory. The issues with the lack of availability both with online-proctored exams and at in-person test centres is especially difficult to comprehend considering how, the Prescribing Safety Examination allowed itself to be invigilated in person on university campuses even in March 2020(2) which continued in 2021. The decision from UKFPO to choose Pearson Vue to run the SJT instead of seasoned university staff is a perplexing one and should be challenged.
Medical students are appreciative of the developing culture of wellbeing support(3). There is however, only so much “looking after ourselves” and “asking for help” we can do; it becomes very difficult when important organisations like UKFPO are uncommunicative to pleas for help and make decisions that seem completely unfair. To many medical students the UKFPO continues to be an inaccessible group with no student or junior doctor representation. This and more needs to change in order to overhaul a group who seem to feel no compassion for medical students or future doctors. What has taken place in the last few months will not be easily forgotten by these soon-to-be foundation doctors.
References:
1. UKFPO. Contact us - UK Foundation Programme [Internet]. UK Foundation Programme. 2021 Available from: https://foundationprogramme.nhs.uk/contact-us/
2. Hope D, Davids V, Bollington L, Maxwell S. Candidates undertaking (invigilated) assessment online show no differences in performance compared to those undertaking assessment offline. Medical Teacher [Internet]. 2021 [cited 12 March 2021];:1-14. Available from: https://www.tandfonline.com/doi/full/10.1080/0142159X.2021.1887467
3. British Medical Association. BMA statement of expectations: Medical student wellbeing support during COVID-19 [Internet]. 2020. Available from: https://www.bma.org.uk/media/2559/bma-statement-of-expectations-medical-...
Competing interests: No competing interests
Dear Editor
This article highlights the concerns the BMA have on the impact of final year medical students. This has indeed been a year of uncertainty for medical students across the UK and reading this article has made me reflect on how COVID has shaped our last 12 months in full-time education before starting as junior doctors. The issues surrounding the SJT (Situational Judgement Test) were not in isolation, as many other incidents this year have been a source of apprehension and stress. Although this is just one exam, the cumulative effect should be considered.
As final year medical students, the SJT counts for half of our final EPM (Educational Performance Measure) which dictates the deanery and job we will be allocated after graduating (1). To see 20 students wrongly disqualified from such a seminal exam is both unnerving and shocking. To read the justification given that these 20 students equated to a very small percentage overall I feel takes away from the gravity it will have on each individual. No matter how few, no-one should have been subjected to this experience.
Last year, at the peak of the first wave, thousands of almost qualified final year medical students were fast-tracked through graduation to commence their role as FY1 doctors (2). As a 4th year student, the first wave bought my placement completely to a halt as we were shifted to self-directed, online learning. Almost a whole year later, our education had gone through several transformations- from volunteering in HCA roles and in COVID testing centres to returning to placement with the new PPE guidance and adapting to a constantly changing exam platforms (3). We are constantly balancing the risk from exposing ourselves at placement in hospital environments with the need to prepare ourselves for clinical practice in less than 6 months’ time (4). Exams setups have been unreliable, with last-minute changes and a plethora of problems due to new reliance on technology and Wi-Fi. Some exams have even been cancelled all together. All the uncertainty and changes have added both physical and mental challenges to students already navigating their way through a global pandemic (5).
With many more exams to undertake before graduating, it is not only the immediate logistical challenges that could affect us, but the long term implications to our confidence as newly-qualified clinicians (6). One study from June 2020 reported cancelled OSCEs, postponed placements and cancelled electives each had a significant effect on student’s preparedness starting work last August (7). Retrospectively, the students who graduated summer 2020 experienced less disruption than the current students, suggesting even greater effects for this years’ graduating cohort. Many studies have found FY1 doctors felt underprepared pre-COVID, but with the augmentation of a disruptive final year and the high-pressure environment we will be entering, I feel more support is needed for students (8).
I think it is important to pinpoint ways in which students can be supported during this time and this article, highlighting the issues with how the SJT was ran, shows there is more work to be done. With further exams this year it is increasing important that welfare of medical students is a priority.
References:
1. UK Foundation Programme. 2021. How is the SJT scored? - UK Foundation Programme. [online] Available at:
2. Iacobucci, G., 2020. Covid-19: medical schools are urged to fast-track final year students. BMJ, p.m1064.
3. Wang, J., Tan, S. and Raubenheimer, K., 2020. Rethinking the role of senior medical students in the COVID ‐19 response. Medical Journal of Australia, 212(10), p.490.
4. Gill, D., Whitehead, C. and Wondimagegn, D., 2020. Challenges to medical education at a time of physical distancing. The Lancet, 396(10244), pp.77-79.
5. Chandratre, S., 2020. Medical Students and COVID-19: Challenges and Supportive Strategies. Journal of Medical Education and Curricular Development, 7, p.238212052093505.
6. Choi, B., Jegatheeswaran, L., Minocha, A., Alhilani, M., Nakhoul, M. and Mutengesa, E., 2020. The impact of the COVID-19 pandemic on final year medical students in the United Kingdom: a national survey. BMC Medical Education, 20(1).
7. Rainbow, S. and Dorji, T., 2020. Impact of COVID-19 on medical students in the United Kingdom. Germs, 10(3), pp.240-243.
8. Monrouxe, L., Bullock, A., Gormley, G., Kaufhold, K., Kelly, N., Roberts, C., Mattick, K. and Rees, C., 2018. New graduate doctors’ preparedness for practice: a multistakeholder, multicentre narrative study. BMJ Open, 8(8), p.e023146.
Competing interests: No competing interests
Re: BMA calls for urgent review of online exam for medical students
Dear Editor
Prospective doctors have had an early introduction to the sad reality of the strained NHS postgraduate recruitment and training programme. This year brought complex and nuanced problems which will continue to influence and impact on future doctors in years to come. With the benefit of hindsight, starting the year with a deanery changing its interview criteria after the close of applications was a canary in the coalmine of how the system was going to fail our final years, and one only needs a brief foray into #MedStudentTwitter to see the damage that has been done to the psychological relationship between employer and future employee. The principle “nothing about us without us “ was disregarded to the detriment of students and the professional standing of national recruitment organisations.
EAs
Throughout discussions on the removal of educational achievement points (EAs) from the Foundation Programme Application Score (FPAS), we at the BMA consistently highlighted the need for any such change to be made with significant lead time due to the significant commitment students make a good number of years before graduation (in some cases, choosing a 6 year course before even entering medicine). At the time of the announcement, our understanding was that removal had been postponed pending review - hence the announcement not being made in February. We were not informed that the change was going to happen regardless, and the sudden announcement in Autumn 2020, when thousands of students in the affected graduating year had already begun their intercalation journey, was completely inappropriate. This became part of a pattern of wanton miscommunication and one has to question the rationale of reform like this at a time of acute stress. The initial decision to take on the aforementioned significant time and financial commitment had been made on the understanding of a benefit in an application process which can otherwise feel outside of many medical students’ control. While undertaking further qualifications and experiencing academia in the context of clinical practice is of course beneficial to personal development and patient care, the personal benefits of intercalating become less immediate.
The delay in the removal of EAs to the 2023 cohort has been presented as a condescending allowance granted to the national medical student body but the context for this suggests otherwise. Inconsistent rationale has been presented: for example, the letter to medical schools from the UKFPO Co-chairs (as referenced in the BMJ (1)) presents EAs as no longer being “a useful way of distinguishing candidates”, however on multiple occasions we have been told it is the impact on widening participation students that necessitates an urgent change. It is easier to convince people of change if you bring them with you rather than pulling the rug from under them; as an organisation we are actively working to improve access to medicine and know our members care deeply about this issue, however despite continuous requests from the BMA and other stakeholders, no data or evidence has been available to review outside of the anecdotal, which is why we have continued to advocate for at minimum a delay in removal.
SJT booking
The 2021 SJT cycle and delivery by Pearson Vue was seriously mishandled, with poor exam conditions, inordinate pressure on students and technical and procedural errors from open to close. Firstly, the technical error in allocating approved reasonable adjustments to students’ profiles ahead of the booking window forced disabled students to make unreasonable travel arrangements or settle for inconvenient booking slots, whether in location or time. This was amplified by the requirement for many students with adjustments to telephone to adjust their bookings, where students without could book online as soon as a preferable slot became available. This inequity was a completely unacceptable oversight for an international company in this sector. Students with disabilities and learning differences face enough challenges without the addition of structural barriers which could have been easily foreseen, and of which Pearson Vue were forewarned. Secondly, whilst several thousands students successfully sat the test in person or via remote proctoring, the experiences of innumerable students who faced inconsistencies in in-person and online delivery cannot be ignored. The decision to allow note-taking at test centres but not remotely presents clear variance in test conditions in and of itself, but the fact the latter was not communicated to students, who then had their tests terminated, was abhorrent. Refusal of comfort breaks remotely effectively meant that the Pearson Vue proctors were mandating inhumane conditions; no person should have to choose between soiling themselves and the termination of a life-changing test. Adding to this the reports of students having their tests terminated without warning or reason, and it is clear this cycle was not a success but rather an abject failure. The attempts to blame the pandemic were frankly insulting; remote proctoring was planned long before COVID-19 even came into being, and throughout the changeover to the new provider we have been firm in the need to ensure that students with access needs were sufficiently supported, and all received the same opportunity to succeed. COVID-19 only meant that travelling further to mask these errors was not appropriate or ethical.
Summary
This year has been a grossly incompetent failure and our members showed how much this had impacted them at our April conference, threatening a vote of no confidence in the UKFPO. Delivering national medical recruitment is a challenging feat, but the system and those leading on the decision-making must still centre those participating in it: despite being present within the room, the voices of students across our four nations have been repeatedly ignored and disregarded. The complexity demands enthusiastic collaboration with trainees, via their trade union, because seemingly small changes to systems can have a significant impact on our lives. When viewed in the context of wider issues in NHS postgraduate training, alongside the exceptionally high number of UK graduates on the reserve list this year who are yet to be allocated to foundation posts, we see a flawed system which demonstrates little regard for us. We are hopeful that the BMA medical students committee will be able use the issues raised by this challenging year to shape a system which will benefit all and showcase the wide range of abilities and experience necessary within the NHS. These challenges will impact students for years to come, and it is essential that leaders of training programmes recognise the stress, hurt feeling and detriment to medical students in this time of global uncertainty. With other health system challenges occurring, restraint, flexibility, and above all regular engagement and communication are vital.
Engagement with, and completion of, FY1 is of course necessary to achieve full GMC registration, and we hope that our future doctors will be able to overcome the loss of trust in their soon-to-be-employers resulting from this year. The BMA look forward to supporting them in their working lives as their trade union.
Yours sincerely,
Rebecca S Bates
Co-chair, BMA Medical Students Committee (2020/21)
Tinaye Mapako
Co-chair, BMA Medical Students Committee (2020/21)
Vassili Crispi
Deputy Chair (Education), BMA Medical Students Committee (2020/21)
(1) Nabavi N. BMA strongly opposes changes to foundation programme applications BMJ 2020; 371 :m4837 doi:10.1136/bmj.m4837
Competing interests: RS Bates and T Mapako are the 2020/21 Co-chairs of the BMA Medical Students Committee. V Crispi is the 2020/21 Deputy Chair (Education) of the BMA Medical Students Committee