Failure in medicine: these exams need to change 

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.

If this opinion piece has triggered any discomfort, please make a long consultation with your independent and trusted general practitioner, seek support from the DRS4DRS program or the Doctors’ Health Alliance.

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