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MOVES towards nationwide benchmarking of medical students’ learning outcomes, rather than a national exit exam, are gaining a foothold in Australian medical schools, say several stakeholders.
A review of the current assessment models for medical education, published in the MJA, covers a selection of collaborative projects which appear to have won the support of the Australian Medical Council (AMC), the Medical Deans Australia and New Zealand (MDANZ), the AMA and medical students themselves. (1)
Unlike the US, where students must pass a national licensing exam before they can practise as doctors, Australian medical schools design, develop and deliver their own exams with little external moderation or comparison with students from other schools, the review authors wrote.
They said accreditation by the AMC provided some reassurance that assessment practices were appropriate in medical schools.
“However, very limited data are available for benchmarking performance against any national standard, or between medical schools in Australia.”
Professor Judy Searle, chief executive officer of MDANZ, told MJA InSight the “endgame” for medical schools was to reassure the public that their doctor was “well trained and well rounded”.
Professor Searle said medical schools had been considering a more collaborative approach with benchmarking for some time.
“[It’s not that the system is broken], I think it’s part of us being better at building the confidence of the public and demonstrating that what we’ve got is good. We can’t just sit back and say it — we have to show it as well.”
Professor David Ellwood, chair of the AMC’s Medical School Accreditation Committee, told MJA InSight that a collaborative approach rather than a national exit exam allowed Australian medical schools to retain their “own flavour”.
“We recognise the diversity of medical education in Australia”, Professor Ellwood said. “There are 19 medical schools and, particularly in the case of the newer ones, there are a lot of different settings represented, including rural and remote medicine. All schools have got their own flavour.
“Given the nature of Australian schools, with their very different approaches, it is difficult to say a single approach will work.
“The first question I would ask [about a national exit exam] as a medical educator is what is the argument for doing it? Will it increase public safety? I’m not sure we have any evidence for that.”
The collaborative approach is being tried in a number of projects including: common clinical assessment instruments; common assessment of clinical sciences and clinical student outcomes; benchmarking performance of schools via a common set of assessment items in the biomedical sciences; and generating databanks of summative and formative assessment items.
Dr Will Milford, co-chair of the AMA’s Council of Doctors-in-Training, told MJA InSight that a collaborative approach was far preferable to an exit exam.
“The fundamental question is one of what they are trying to achieve”, Dr Milford said. “It is unfair to let the individual student be the sole point of assessment and the bearer of the responsibility if the standards are not reached.
“The student is the product of the school’s program, and the school and program should bear responsibility.”
Ben Veness, president of the Australian Medical Students’ Association, said an external exit exam would fundamentally “change the way medical students study”.
“They will work towards the exam rather than focusing on becoming good junior doctors. What type of teaching are we trying to incentivise? Is it more important to spend time in clinical settings learning the practical skills of being a good junior doctor, or memorising [facts and figures]?
“If it isn’t broken, why fix it?”
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An exit exam would be a great political tool for any government wanting to limit Australian medical graduates.
If the academics doing either benchmarking or designing exit exams are the same academics who have designed the entry examinations to medical schools, (discriminating against rural/ remote schooled students and students who played sport/music rather than practised trial UMATS for years) , removed chemistry and physics as prerequisites, invented PBL ( problem-based learning- for example -problem-you are called to a person lying motionless touching an electrical wire beside his fire -fighting pump, the ambulance are out of town transporting , the RFS and SES are fighting fires, -do you commence CPR, or look up electrical physics on your IPAD?) ) , and removed human anatomy from the medical curriculum, (how do you palpate a pulse if you do not know what and where arteries are-can the IPAD be fitted with a doppler?), or designed the examinations for overseas medical graduates, (some of whom cannot understand nor be understood by Australian patients yet are deemed to be suitable for Areas of Need, again mostly rural/remote areas, few voters, who mostly only produce food and export dollars) then I suggest a better use of taxpayers dollars would be to sack all the academics and recruit older part-time and retired clinical medical and surgical doctors to train our students in clinical medical practice.
I agree with bemused’s perspective and his pen-and ultimate sentences. I have never passed an exam that i didn’t sit (study) for. What i learnt i now know. Every time i see a patient i undertake an examination and the results of that determine what i do and how well the patient does. Being on the spot also means being where the action is and being able to competently deal with the issues that present to us. Preparation for examinations helps prepare us for further examinations. We never stop learning nor must we become complacent. Challenges are fair game. In the world of medicine today, we can still rely on collegiate support. Examinations prepare us, inform us, strengthen and charge us and equip us with what makes ours the honourable profession we are, based on knowledge and accountability for our actions, for which we need to have “grit”. I stand by the above and the following: “non illegitemas carbarundum est” – “don’t let the bastards grind you down”; (do) “Good noW!”®.
At the risk of being labelled old-fashioned, my experience was that studying for the exams ensured a minimum level of fundamental knowledge. A number of my colleagues have expressed concerns about the level of basic knowledge displayed by some of our recent graduates. One colleague rang an intern to have a collegial chat about the mis-diagnosis of her son and was taken aback by the casual indifference about missing the obvious signs of Lobar pneumonia, and merely responded by asking if her son had enjoyed the interaction! It’s good to having caring and sharing doctors, but some solid clinical acumen is useful as well. I think a bit of quality assurance in the form of standarised questions, if not whole exams, would be a positive step. Provided these questions assessed fundamental knowledge and not esoterica , then studying for the exam would be a good thing.
The bane of the Australian experience is pandering to mediocrity and or to isolation and lack of objectivity or accountability, partisan views and bureaucratic intervention or with the exception of individual high achievers and Institutions, who in spite of the Australian creed do succeed in meeting the standards, ethical or scientific, of the international community and the world. Australian doctors need to be able to be creditworthy, as judged by academics, clinicians and objective assessment, not by bureaucrats and regulatory Boards, to meet the basic knowledge requirement anywhere in the world and be able to add to this with specific local knowledge and experience. Not one system of assessment but internal and external assessment tools could be used – or step up the program to meet the professional as well as patient need – to ensure the time of our best candidates and eager students is fully utilised to achieve recognisable and valid outcomes, in spite of the bureaucratic and mediocre and shirking of accountability that is the common creed.
Sitting the AMC exam makes sense, however even the AMC have no faith in their examination process. I was denied sitting it on some peculiar grounds. If It was a useful exam, it would have either passed or failed me. But to deny sitting it ? Were they afraid I’d fail, or that I’d pass? The students bring sufficient individuality to Medicine without duplicated costs of exam making etc. The US have had this right for a long time, ensuring standards are met across the nation and for internationals entering their system. Why are we so stuck on “all being individuals”, it’s Pythonesque so stuck on “all being individuals”. If we want rural schools to have different endpoints then you will need a system that keeps city trained doctors from practising in the bush due to a lack of ‘rural’ skills, is that what we want.
Overseas trained doctors are required to sit and pass an examination in what is considered a nationwide level of knowledge and expertise – if that level actually exists surely Australian graduates could sit & pass the same exam? If it doesn’t exist is it appropriate to create one only for foreign docs?