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There must be a better approach to measuring a junior doctors’ skills, commitment and knowledge than the current battery of examinations, writes a trainee who obtained the highest clinical examination score at their training hospital.
I thought it was time we talked about the exams through which we put every doctor who wants to specialise. I have failed once, and quite easily may have failed again. As my long term personal relationship crumbled, partly from the impacts of my study, I was told by my partner that I did not study enough. And yet I have spent almost my entire undergraduate, postgraduate and working life studying. I was tired of studying.
Part of me wondered if they were right, but, if that’s the case, it was due to the overwhelming anxiety of career success relying on a single day, which is enough to stifle anyone’s efforts.
I have been asked if I feel better and more relaxed after finally having sat the clinical exam for the second time, after a year of waiting. Instead, I struggle to suppress flashbacks of the exam and ruminations about things I should have known or done on the day. I worry mostly about whether I passed but also cannot help but think about the unknown of what job I will do next year either way. I know I am not alone in feeling this way. I have read anonymous posts on Facebook groups where fellow doctors endure ongoing feelings of anxiety, stress and trauma due to these exams. Extremes I have felt and am still feeling.
Let us first talk about trying to study around full-time work as a doctor. It is hard to be motivated to study when full-time work involves 13-hour shifts on a hospital ward, frequent night shifts, and relentless exposure to illness and dying. The juggling of long hours, necessary chores and sleep with study does not leave much room for anything else, particularly activities to sustain mental health. The last thing I would want to do after a shift, while feeling both mentally and physically exhausted, was listen to lectures or read dense paragraphs on UpToDate.
Despite this, I would practise multiple-choice questions before a shift, during a much-needed meal break, or as I finally drifted off to sleep. My weekends would be filled with studying with a group of similarly suffering friends. We would cram medical minutiae based on infuriatingly obscure past questions. All this preparation was for the written exam, which on its own requires a year of dedicated study, affecting hobbies and friendships and consuming any time I was not at work.
I will forever remember sitting on a beach alone shortly after having sat the written multiple-choice exam for adult basic physician training, waiting for an email to tell me if I had passed or failed, wondering if my career would be able to progress or not that year. Somehow, I made it through that first hurdle of the computer-based exam to the reward of preparing for the final clinical exam. This time, study took the form of months of repetitive, sometimes humiliating, case presentations in front of respected seniors, including those responsible for my career and rehiring.
My weekends and days off were still not my own, spent at the hospital searching the wards of the unwell, hoping that a few would consent to being examined as we practised learning disease manifestations. My fellow doctors would joke about their parents bringing them meals or taking away their washing, as daily existence became a burden for us all. The only release was the occasional coffee break at the hospital cafe or in our shared office where I sat with colleagues, crying and expressing the same distress that I was feeling, all of us wondering whether this was worth it.
I failed the clinical exam last year. As I write this, I am waiting for the results of my second attempt and, for all I know, I may have just failed again. After I failed the first time, I could not adequately verbalise the emotional impact on me. Seniors and colleagues told me it was not a reflection of my abilities as a doctor or on me as a person. But when you see the clear, unambiguous words “fail” on an online intranet tracking your medical training, the feeling of pure inadequacy is inescapable. At times medical training feels like playing an extended, life-determining game of snakes and ladders and I landed on a very long snake. I felt like a failure as a doctor but also in life. My career that I had effectively been working towards since graduating high school had just hit a massive roadblock. Even now these exams still feel like an insurmountable obstacle. The idea of facing a repeat period of preparation was excruciatingly painful, let alone the thought of being in those exam rooms again, not knowing the answer and simultaneously knowing what that meant for my life and career.
I think about colleagues that were resitting with me this year and I feel a surge of respect. Some are resitting for the third and final permitted attempt and I am in awe of their courage and resilience. The commitment to try again is a chance to pass, but also something far scarier: a chance to fail again. After I failed, my personal life disintegrated. A neglected relationship eventually dissolved, my landlord gave notice, and health issues arose causing discomfort and difficulty sleeping. These exams are never the only stressor in a person’s life and I have discovered they can easily push someone over the threshold of what is bearable.
There was a fridge magnet in my grandparent’s old house with the quote “Be kind, for everyone you meet is fighting a hidden battle”. The question I ask, though, is, why do these medical exams have to be such an additional painful life battle for so many doctors? Why is it accepted and allowed that one day, one performance, is how years of skills, development and learning are assessed?
Presumably, those who make it through have the trauma reduced with time and seemingly begin to accept that it is a necessary evil or a right of passage for every physician to battle. Yet, I have met many consultants who can still clearly recall some painful detail from their exams decades ago. Doctors who do not ultimately make it through slink away in despair trying to redefine their life’s direction. They must start again to pursue an alternate fellowship or become a career medical officer. However, it must not be an easy transition, as they will never become a physician specialist, their goalpost for so many years. Perhaps some leave clinical medicine all together because a new path often means more study, more arduous exams, and the long hours of a trainee with little control over rostering.
Surely there is a better approach that uses the accumulation of years of skill development and commitment to assess a doctor instead of one single torturous day.
This article was written by an Australian doctor.
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I’ve completed the MRCP UK and RACP exams.
I completely agree that the RACP written exam, ironically, has very poorly written questions, particularly when compared to the MRCP exams. In part 2 of the MRCP exam (which goes over. 1.5 days and is the equivalent of the clinical applications paper) if I remember correctly every single question had a clinical vignette followed by investigations and then a question. These questions genuinely felt like they were trying to assess clinical knowledge. The questions in the clinical applications paper of the RACP written exam would often test knowledge of niche areas of medicine and may not even contain a clinical vignette.
However, I also think exams are necessary. In fact, I actually think more exams are necessary (please don’t put a hit out on me!). Firstly, there needs to be more opportunities to sit the RACP exam per year. Part of the stress comes from knowing you have to wait an entire year to have another attempt. Wheras there are mutliple opportunities per year to sit other exams such as the MRCP or USMLE.
I still do not understand why there are not exit exams in Australia. It seems there is a compensatory need to make the RACP an exit level exam when it should be assessing whether a BPT has a sound foundation in general and to a lesser extent subspecialty medicine to enter advanced training.
Pilots have to pass a theory and practical test on a regular basis to demonstrate their ongoing competence. Doctors should have to do the same. So I also believe exit exams need to be sat repeatedly e.g. every 3 to 5 years. The key thing with that process is that the exams should not be designed to be hard or to allow boasting of a high failure rate. They should be written to ensure a doctor has the most basic knowledge required to practice safely.
You need a heart of stone to not feel a least some sympathy for trainees like the one who has written this article. But strangely, I think the answer to Australia’s issues is more exams of much better quality and relevance, rather than no exams.
Are you suggesting that we should eliminate the exams simply because they are challenging? That might not be the right approach. Medicine is a demanding field that necessitates both innate aptitude and a strong work ethic, which includes the ability to study for extended periods (I’ll admit, I struggled with the last part myself). Dumbing down the standards doesn’t appear to be a viable solution. Additionally, using only 360-degree assessments have their own set of issues and biases.
Nonetheless, I do concur that clinical examinations pose a significant problem. Regardless of the efforts made by medical colleges to introduce objective criteria for assessing clinical competence, these exams are still performative and can be susceptible to individual examiner bias. Addressing this issue will require further research based on evidence. One potential solution could involve recording the clinical exams to allow for detailed analysis, rather than relying solely on snap judgments made on the day.
I can vividly recall a situation where I excelled in written exams but inexplicably failed a clinical exam. One of the reasons given was that I didn’t “command the room” like Dr. X, a tall man with a deep voice. After three speech and drama from an experienced television and stage actor on how to “act like a doctor”, I passed the following year. Interestingly this gifted actor, who was pursuing teaching after the roles had dried up after a long career, landed a major role in an international motion picture soon after, a lesson in perseverance perhaps.
On a personal note, some of my confidence issues stemmed from a disadvantaged background. During my time as a medical student and junior doctor, most of my peers came from elite private schools or selective school systems and had a sense of entitlement. It was a challenge to pursue an undergraduate medical course while living in a rented flat with a single parent who was colloquially known as a “heavy drinker.” In those days, there were no extra credits for coming from a less privileged background.
Interestingly, after providing my own offspring with all the advantages I lacked, they were diagnosed as highly gifted and subsequently joined a high IQ society. I recently decided to try joining the same society and found that I easily met their criteria. This experience did wonders for my confidence.
I am extremely thankful I passed my FRACGP exams the first time, or I would not have had enough fuel in the tank so to speak to repeat them. I may well have left the profession. That said, I sat the written exams whilst 34 weeks pregnant with baby #1, then the OSCE 2 years later whilst 35 weeks pregnant with baby #2. It was a struggle- I simply crammed for 2 weeks before. There’s no way I could have coped mentally (or financially) if I had to repeat them and I feel so very sympathetic to those who do. I know of some very clinically sound doctors who have failed multiple times, and it is emotionally devastating for them and puts a huge strain on them and their families to have to pay for and repeat these exams multiple times. Ironically, only 5 years on, I’m now desperately trying to find an exit from medicine altogether. But that’s another story.
As an examiner i am constantly battling with the RACP to have fair exams.
It should be an exam to assess competence to be a physician not to discriminate on who will perform best in an exam
Having been given questions by the examination committee to ask in the Clinical exam that no consultant examiners present on the day could answer is unfair and I felt embarrassed having to ask the candidates such unreasonable esoteric questions
I also for many years had a recurring nightmare about not having prepared for the exam or having to sit again with no notice
Many contributors have maintained the „we have to maintain standards“ position without addressing the fact that the evidence that performance on exams such as the RACP examination has any value in determining one‘s subsequent performance as a clinician. THere are studies which show that long cas/short case exams predict performance on similar tasks in the future ( surprise !) but few if any which convincingly show that they predict performance as a clinician, which is what it is supposed to be about.
THere is also an element of macho/bastardry in it, as well as the „I had to go through it , so you should too „, with a high failure rate being seen as a badge of honour by the College. I remember when involved in an accreditation battle about an OTD the College types maintained that this person ( who had practised as a consultant in country of origin ) should be sent back to the start because their exit exam had a 90% plus pass rate while RACP pass rate was ~50% and therefore gold standard. What they had chosen to ignore was a) the difference between an exit exam and an intermediate exam. And b) the fact that one was not allowed to sit the exit exam until one‘s prof was confident that one was ready. The blind assumption that the way we do things is the only way is dangerous, not least because of the talent it wastes.
We should perhaps ask ourselves not „what is wrong with the trainees in that that 50% struggle to pass?“ but perhaps ask „why is our training so crap that we can‘t get 90% plus up to speed?“
I am an accredited supervisor and watch/support trainees going through this. It is destructive and it is often the normal, sane ones who have the most trouble, not least because they can see outside the box in a way that I couldn‘t when I was on the hamster wheel.
We are dealing with extraordinarily talented people who are much smarter than I ever was, however low this may set the bar. If we can‘t get them up to speed either the test is wrong ( almost certainly the case) or our training is inadequate ( highly likley alos to be a contributor )
There comes a time in professional development when the trainee is likely to know more than the examiner. That time has come with training for a medical specialty. High stress exams are no longer valid at this level as it is clear to all that the exam results do not measure clinical competence of the would be specialist. Far more weight should be given to the opinions of those who supervise and work with specialist trainees as to their competence. Exams at that time of professional development are illogical, immoral, invalid, obsolete and unnecessary. It is high time for all the specialist colleges to grow up.
There is no doubt that the preparation for the exams is stressful and prolonged, more so for some than others. As a last minute study crammer of details but also a long term observer and sponge for knowledge I didn’t find it so confronting and perhaps approached the exams with a different attitude. That may have been influenced by taking 2 years to travel and get real life experience after my resident year before committing to specialty training.
It was apparent to me that the higher level you go the harder it would be and I was more likely to find my limitations. Most of you would have friends and family who were unable to reach their academic goal, which may have been just getting to university, let alone completing the course. What makes medical doctors so special they should always be granted their aspirations?
Perhaps you should consider the years of hard work and dedication/deprivation endured by those who choose to follow the career path of elite sports/athletics. All those years of training and cost potentially undone by a minor training accident or untimely influenza infection destroying their chance to compete at the Olympics, let alone win, with the chance of winning the 100m sprint being about 1% even if you get to the event! They are special people to try so hard with such a tiny chance of “success”.
People who are not so blessed could be working harder than you to achieve at a much lower level. If they wanted 10,000 physicians a year then you would be assured of passing the exam. It’s not personal, it’s a numbers game with the resources to train and employ people. Popularity inherently leads to greater competition for limited spaces, but perhaps it would be kinder to cut candidates out at the beginning rather than have them study for years first, however, that may exclude people who improve with maturity and experience which would otherwise be denied. I don’t see any methods which can be totally fair and efficient.
Lastly, character is what you develop after you have experienced serious adversity and got on with working for your best future, not cherishing bitterness about the past. Best thing I ever did was to learn to accept the past traumas and just focus on making the future as good as I can manage. It’s worth a try!
This is a great article. It’s so refreshing that the challenges of the specialist exam journey are now being prominently discussed.
There are so many challenges, ranging from debilitating stress and anxiety, lack of confidence in demonstrating consultant-level performance, and the significant impact that all this can have on a doctor’s personal life.
This is a great article. It’s so refreshing that the challenges of the specialist exam journey are now being prominently discussed.
I work with doctors going through this process. There are so many challenges, ranging from debilitating stress and anxiety, lack of confidence in demonstrating consultant-level performance, and the significant impact that all this can have on a doctor’s personal life.
Please reach out if you feel you need help.
Please stop conflating trauma and exam pressure and consequences. That’s the easy bit.
As for the exams as they currently stand. First question: shall we lower the standards? If so, by how much?
If you are not bright enough or enthused enough to pass the exams without excessive suffering, and you chose to suffer excessively, then who are you to complain except to yourself.
I have had a career and children. If I had to choose between the wellbeing of my career and the wellbeing of my children, I would have chosen my children. I hope I would have, anyway.
It is widely accepted that the exam process is imperfect in terms of being a benchmark for a level of knowledge, and skill that is required to practice as a consultant. However to date, it remains the best that there is. It is notable in the article that there is no alternative offered. The statement that ‘there must be a better way’, is worthless without attempting to provide a superior alternative. Are you suggesting that you can become a consultant based on merit alone?
Many colleges have evolved their assessment pathways to include work place based assessments along during the course of training, but the primary and fellowship exams remain. The exam process is hard, it requires dedication and sacrifice. If you were not expecting this then I think you are naive. The public have a right to expect high standards from their medical professionals.
And then we can talk about the “do or die” interviews to get on to training programs in the first place…
Most often the examiners are biased even they say they are evaluating on multiple metrics .Many Good excellent doctors fall victim to this.Need a better system to evaluate practitioners.
An important essay highlighting some of the hidden challenges and trauma doctors in training face.
Spare a thought for those who never get the opportunity to sit the specialty exams of their choice – those that never make it on to their chosen training program, despite the insurmountable need for growth in numbers of specialists with regards to our growing and older population. A huge bottleneck in surgical specialties particularly is acceptance onto the training program which is often limited to few attempts, all the while the public hospitals can’t ever survive without unaccredited registrars to do the bulk of the work.
I truly empathise with the original author and so many comments. I had 2 primary school children who I loved with my heart and soul and yet had to spend hours and hours and hours studying, working, preparing for both physician exams. I am a dam fine mother and physician and have treasured my career and given so much to my patients, profession and colleagues. Thankfully my adult children are happy but I will always live with the shame and consequences of my marriage disintegrating during the training process. I am exhausted and now we are so often feeling as if there are battles to keep funding for systems that work for our patients and healthcare staff; and too frequent unfriendly fire on our profession in general.
My motivation is unchanged- is my family ok? Are my patients ok? Are my colleagues at all levels ok?
How to end this soliloquy- please let’s look after each other and speak up through the groups that support us as the AMA does – bless them.
In all honesty, if I had not passed the exams the first time around, I don’t think I would have tried again.
The effect they have had on my life, my mental health, and the detriment to my and my peers overall wellbeing cannot be understated. My peers who were not so lucky (yes, luck does have a big part in this) are struggling to pick up the pieces,
Now, months after the exam, I find myself burnt out, apathetic and unmotivated with now further demands to get into any subspecialty making the slog relentless and seeming un-ending. My Hospital reluctantly approved leave 6 months after the exams, and requests to have 2 months of contiguous leave in 2024 or work part time have been denied (noting that in the interview I was asked how I will manage my burn out as a trainee, yet they will not help me to do this).
Now, as I stare down 3 – 6 more years of training and possible further exams, the longer this training lasts the less it all seems worth it. We are selecting those who will tolerate the most, not those who will thrive the most and that is a shame for patients and the profession.
As the author describes, exams with high failure rates are a brutal system of limiting entry to a specialty. I deeply sympathise.
There may well be a better system that shifts some of the emphasis onto other factors (continuous assessment, 360-degree feedback, interview, references from seniors etc).
Every one of those alternatives has its own limitations, such as being prone to bias, gaming or “It’s who you know”.
Unfortunately every solution does need to face at some point the unpleasant reality that a large number of people who want to follow a particular career path will have to be excluded from that path. This exclusion can occur before, during or at the last hurdle down that path.
Medical school selection does most of the ‘culling’ before entry, rejecting most of those who want to consider medicine as a career, and passing most of those who successfully enter the system.
The current specialty system does a variable amount at the start (limited registrar posts) and the rest right near the end.
If 1000 people want to do a job where the health system optimally requires 500, any fair system still has to figure out how best to identify each of the 500 who need to be given the unpalatable news, sooner or later, that they have dipped out.
Another downfall regarding the clinical exam is the lack of standardisation. I know of one candidate that got two renal transplant long cases and both an interstitial lung disease and a scleroderma in their short cases. Meanwhile a candidate that was sent to a different state ended up with Familial eosinophilia, short gut syndrome and two cranial nerve short cases with no hand or respiratory short case. Obviously the cases were entirety different and not at all standardised. Furthermore certain states have discussed removing the hand exam from the clinical exam completely as it is felt to be “too easy”, whilst in other states these patients with hand signs are frequently asked to participate. They subjectiveness of this exam is too ambiguous and not fair for the trainees. I have been told by various local and national examiners that the “moderation” session they are all supposed to attend often results in significant discrepancies in marks, with some examiners giving a “mock candidate” a 6 (the highest mark), whilst other examiners score this exact same candidate a 2 (a clear fail). Based of this the RACP candidates ability to pass on the day is largely dependent on the generosity of the examiner and the types of cases they get on the day.
Lastly the RACP is the only college that continuous to use actual patients whilst ICU, ED and anaesthetics have converted their clinical exam to a viva exam with actors used if patients are required. In some ways perhaps this is a more ethical approach, as in the RACP long cases the patients are repeatedly asked about their end of life plans, depression and suicidality all which of course can be triggering for these patients and lead to flow on consequences. In certain cases these patients have ended up crying in the exam which causes distress to both the RACP trainee and of course the patient themselves. There definitely needs to be a better way to conduct these exams, and one that better reflects actual clinical practise rather than the current archaic, outdated and non- standardized model that currently exists.
As the partner of someone who is going through this currently, it absolutely tears me apart seeing the hell he puts himself through to meet some obscure marking criteria that is supposed to define whether or not you are capable. Nevermind the decades long training and practical application of it all – no, but how you present your answer, how you carry yourself in 30 minutes is supposed to define your appropriateness in becoming that fellow. It needs to change. In a world so focused on mental health and well-being, it boggles the mind that this industry is the last to put this as a priority for their employees.
Why is it ‘normal’ for specialty/final exams in ANZ to have 50-60% pass rates, but the same specialty board exams in US/Canada are 90+%? Are trainees here simply inadequate compared to NA, and not practising at ‘minimum expected level of a safe consultant’? Or are North American standards inherently much lower to patient detriment?
Or is it the exams?
I feel you.
I felt like my whole world crumbled when I got the result.
I don’t know if I could try again- I don’t feel like doing so – wasting my life away on such exam.
I’m still waiting..
Post grad examinations have always been difficult and they have nearly always had a significant failure rate. This combination has lead to very high standards generally but even with these high standards we continue to see practitioners practice in an aberrant manor eg over servicing and also the use of procedures that are unproven. Do our contributors want a 100% pass rate?
The additional issue is the financial burden imposed by these examinations. Why does sitting and exam need to cost in excess of 5k. The colleges need to be transparent with the associated costs and not use these already stressful events as a source of additional revenue.
Dear RACP trainee,
I empathise with you. I passed my psych registrar exams after having to repeat most of the numerous exam components a second time. Each time I flunked and had to re-sit, it felt like I was intrinsically a failure and not good enough. I had to watch my lucky-enough peers celebrate their passing and progress onwards, while I languished and had to grieve the loss of what could have been. I took solace in knowing that many of my then senior colleagues and respected consultants had to go through a similar experience and failing exams was not uncommon.
The exams are currently in a state of major review and flux, with an aim to make the exams more preparatory for real-life consultant practice. Only time and a good amount of feedback and data collection will tell if it succeeds in doing so.
Perhaps the board of examiners at the RACP could talk to the examinations board at the RANZCP about their exam processes and the recent changes by the RANZCP as well as challenges and lessons learnt with the RANZCP exams overhaul.
Another option is for an independent review of the validity and value towards future consultant preparedness of the current RACP exams. The review should not include any past or present RACP trainees or fellows in order to be independent.
On the one hand, one might argue if it ain’t broke there’s nothing to fix, on the other hand being stuck in tradition could hold many deserving trainees back.
Ultimately, the vast majority of us will try our best, pick ourselves up and demonstrate our resilience by passing those failed exams and moving on. Along the way, some trauma may have been accrued. And so the cycle goes on, the rite-of-passage goes on, and on….
Cycles of trauma are not ok….
Same story for this lost puppy unable to conquer the Part 1 anaesthesia exam yet hospitals are happy to pay me peanuts (ie CMO rate) to undertake work normally assigned to a Fellow or newly minted consultant albeit with cursory level 3 or 4 “supervision”.
This editorial makes for excellent reading. 30 years ago I spent a bit over two years of my life trying to pass THE EXAM needed to gain my FRACP. I think the PTSD of seeing a list of passing candidates on the college noticeboard and not being able to find my name will NEVER leave me.
I have been working a mixture of clinical work and University work since then and there is no doubt that having a scientific method to establish a “cut score” in an exam is an academic task that is taken very seriously in Medical School in 2023. At medical school on average about 2-5% of the cohort “fails” an assessment- we remediate and eventually 1-2% do not make the grade.
Fast forward a few years and those same students who graduated medical school( As physician trainees mostly from the top half of their respective class) and have a proven track record earned through 4-6 years of tough undergraduate exams, following excelling at school or during their first degrees ,are somehow lining up to do exams which usually carry a failure rate of 30-50%. There is no academic justification for where the cut score is placed. The trainee faces the possibility that after two to three years of eat, sleep, work and study of facing about a 10% chance they will never make it and need to “rethink” their career choice after an investment of 12 years of hard work. About 60% of FRACP graduates have experienced failing one or more times whilst gaining their letters and then there is a lucky few who manage to escape the process without ever failing.
It is nothing short of ‘bastardisation” and there must be a better and fairer way forward!
I’m not sure corruption is part of the peroblem. ItIn some specialties training is stilll focused on ‘ passing the exam’ rather than ensuring a broad range of experience I worked at one aged care hospital where we had some patients with predominantly psychiatric conditions- doing ward rounds and discussing management was enormously helpful- there is a lot if medicine in psychiatry too which may not be a major concern in training or exams, but certainly is in clinical practice- I think the government reviews’the system’ from time to time. Maybe post graduate training could be university based – there is a significant amount of research about whether exams are fit for purpose- I know this was looked at very seriously in setting up the postgraduate medical course at the University of Wollongong- I still wake during the night with nightmares but not so often now. I think the system of exam focus year after year is a major factor in the continuanc of a long outdated system- maybe competency assessment during training will be better-good luck – it’s up to those who pass the exams to work towards reviewing the system.
Twenty years down the track now as a practising physician must agree with the author of this piece . All my fellow colleagues and I experienced trauma. Had I not succeeded first time I really wondered if I had the mental strength to face this process a second time. I’m not sure that I did .Not sure what the solution is but there is a problem . As a female of 28 having just passed the exam and having put my life on hold to study I remember thinking – my real life needs to start now as this is no way to live .
I can identify with the pain expressed and life wasted. When I was a trainee specialist, the college to which I aspired to become a member had no formal (or informal) training program. It had a three part exam. I failed Part 1 on first attempt. Part 2 twice, and Part 3 twice, before finally succeeding. By then I was 35, and had spent most of my life studying. I deferred having children until success was finally achieved, only to find my fertility had declined, and I required assisted conception. There is an upside to all this. I now have two lovely boys. I became a good specialist, and thrived on the daily challenges. I learned to believe in my own abilities. I am now retired, but loved my work so much that I stayed on for a few more years. I still have nightmares about not being prepared for an exam, and being unable to put pen to paper. The trauma is indeed lifelong, only mitigated by my own sense of achievement.
This article is great, but also doesn’t highlight some of the important issues with exams. There is a story not told by the colleges. While multiple choice exams have been rigorously validated as being able to detect the presence or absence of conceptual knowledge, the clinical exams have never been validated against a gold standard (there have been some thinly veiled attempts, but none rigorous evaluations). One of those metrics, would be that persons sitting clinical exams with greater clinical experience, should, in general, have better pass rates.
This is the opposite of what occurs in many clinical exams, where the pass rates of re-sitters (persons sitting the exam after one or more failures), is far lower than first time sitters, despite having at least one year extra of training/study. For example, the ACRRM training program used to release these numbers, with first time sitter pass rates of 50-70%, with persons sitting for their second attempt or more, having pass rates below 30%. This highlights, that such exams selects out people good at that form of evaluation, rather than persons that are practicing safely and appropriately for specialty practice.
Differently, high failure rates in clinical exams should be viewed by colleges as alarming, rather than a badge of honor. High failure rates is a poor reflection on the college itself, as it means one of three things. Either, the college is failing to select trainees appropriately, is failing to train them, or has a faulty test/examination system.
The data regarding resitting pass rates, and an absence of rigorous validation and evaluation, suggests that clinical exams are likely to to be faulty evaluation tools. Why have we not rigorously validated our examination methods against a gold standard (I.e. putting practicing senior consultants through the exams without studying, to measure their applied standard practice knowledge)?
Colleges often state that they evaluate the trainee on a variety of metrics. But since exams are an all or nothing exercise (if you fail, the other evaluation methods are worthless in allowing you to progress), the college assumes that test is perfect in its evaluation method and does not take into account other metrics when evaluating if a trainee can progress. Composite scoring (scoring all evaluations together with weighting for each) would fix this problem, and allow for the fact that individual evaluations (tests) are imperfect.
Overall, it appears like our senior doctors apply a different standard of evaluation to its trainees than they apply to their patients. An analogy would be like saying that a raised CRP is an absolute indicator of the presence of infection, when we know very well that there are a hundred other causes of raised CRP’s.
The first comment highlights this well, something I have also heard many times: “ Seniors and colleagues told me it was not a reflection of my abilities as a doctor or on me as a person.”
As a diagnostic radiologist, now long retired, my favourite nightmare for many years, particularly at any time of unrelated stress, was to dream it was the night before an exam, particularly a written paper. I found myself unable to find my text books. I was asking myself why I hadn’t been studying. These nightmares occurred for years after all my exams were behind me, and some even involved me asking myself, in my dream, why was I stupidly presenting myself to sit the same exam again, when I knew I had already previously passed it.
Others have told me of suffering similar recurrent nightmares.
“ Seniors and colleagues told me it was not a reflection of my abilities as a doctor or on me as a person.”
I too have been told this, and I find it slightly infuriating, everyone knows that the clinical exam doesn’t actually correlate with how good a doctor you are, but for some reason it’s still the yardstick we use. There must surely be a better method.
Fellow trainee who’s passed the equivalent MRCP exams in the UK but these are not recognised by the Australian college for basic physician trainees (RACP). Extending my pain further. I too have watched my relationships crumble around me as the strain has taken its toll. This is before the endless geographical moving every 3 months in the BPT network, with hospitals spread much further, upto 8 hours, from our mother hospital. I don’t mind, but my family sure does! The long case presentation absolutely bares no clinical relevance to being a good clinician. Much that’s wrong with this system, and when I have raised this, the senior people in the system with a FRACP (consultants, presumably they have a vote or a voice) know that the people managing RACP are a careerists, not interested in change. The feedback from the written exam in Feb 2023 was how random and non-relevant to clinical practice the exam was (there were many psychiatry questions, and even one obstetric psych question (!))… In an internal Physician exam). Yet there is no recourse. When asking RACP directly, the feedback was “it’s in the curriculum, under point so and so” (it says you should have some basic understanding that a physician would be expected to have). The exams are much less useful than international equivalents and the whole corrupt system needs an overhaul