Towards decolonising medical education assessments

Despite Australia's consistently high global ranking in life expectancy, the gap of approximately 8–10 years between First Nations peoples and non-Indigenous Australians represents one of the most persistent and clinically significant health inequities in the developed world. The Productivity Commission’s latest Closing the Gap report (2025) found only five of 19 targets are on track with several outcomes remaining stagnant.

Barriers to timely, high-quality, and culturally appropriate care remain a major driver of health inequity. This is compounded by the ongoing underrepresentation of First Nations healthcare professionals, with Indigenous doctors making up less than 1% of the workforce. The Australian Medical Council (AMC) now requires medical schools to actively support Aboriginal and Torres Strait Islander and Māori health equity, and to increase their participation as students, staff, and leaders. In response, the Australian Government’s recent decision to uncap Indigenous medical places has been welcomed by Group of Eight universities as a significant step forward, removing a key barrier to entry for First Nations students.

While widening access to medical programs is necessary, equally there needs to be equitable pathways to succeed once admitted. Medical school-specific attrition data for Indigenous status remains notably absent from the literature. In broader higher education settings, attrition rate for Indigenous students stands at 35% compared to 23% for non-Indigenous students.

A range of institutional supports have improved First Nations student retention, including financial and accommodation assistance, tutoring, and faculty training in cultural safety and anti-racism. These are important advances at structural and relational levels. However, less attention has been given to teaching approaches and assessment practices that directly affect learning, progression, and fitness to practise. Many First Nations students who experience academic difficulty still go on to fail and leave medical programs.

Opening the door, closing the path

Following the Commonwealth Government’s decision to uncap Indigenous medical places, and the Australian Medical Council’s (AMC) focus on increasing Indigenous student numbers, many Australian medical schools now offer alternative entry pathways. In these pathways, standardised tests such as the GAMSAT (Graduate Medical School Admissions Test) are optional or not required. For undergraduate programs, entry thresholds have also been lowered for ATAR (Australian Tertiary Admission Rank) and UCAT (University Clinical Aptitude Test) scores.

Removing exams such as the GAMSAT aims to improve equity, particularly for students from disadvantaged backgrounds who may lack the time, money, and resources needed to prepare. However, this creates an important tension. The same factors that make these tests difficult to access may continue to disadvantage Indigenous students once they enter medical school.

The GAMSAT includes three components: Biological and Physical Sciences (75 multiple choice questions (MCQ)), Humanities and Social Sciences (62 MCQs), and Written Communication (2 essays). Success in the MCQ sections requires not only knowledge, but also specific study skills and test-taking strategies, often developed through structured preparation and coaching. Evidence shows weak or no association between standardised entry tests such as GAMSAT and UCAT and key clinical capabilities, including clinical reasoning and fitness to practise. This calls into question whether these tests are justified. 

Students who have bypassed entry tests may have had fewer opportunities to develop familiarity with MCQ formats compared with peers who have been extensively coached. As a result, a barrier removed at entry can reappear during the medical program. In effect, the system shifts disadvantage rather than removing it. If the entry test is a weak proxy for entry into a medical program, and the internal assessment system shares the same structural and educational shortcomings, then Indigenous students are facing inequity at every stage of their medical training.

Once in medical school, students encounter MCQs that remain the most prevalent form of assessment to test medical and clinical sciences knowledge. Their dominance is sustained largely by practical efficiency. MCQs can assess breadth of knowledge across a wide range of content for large cohorts in a standardised and easily markable format. In general, MCQs are useful in testing the ‘knows and knows how’ domains of clinical competence. Their utility, however, in assessing higher cognitive functions such as clinical reasoning, diagnostic thinking and professional judgement has long been questioned (here, here, here). Furthermore, the MCQ-based testing, by its very nature of item generation, can be culturally biased and misaligned with the diverse ways of knowing, seeing and being our First Nations students are accustomed to. The deeper issue lies in the dominance and over-reliance on MCQ-based assessment throughout medical programs, including in the later years, rather than issues around their validity alone.

The move away from MCQ dominance is not simply a procedural adjustment based on pragmatics, it is an epistemological one. The dominant epistemology in Western medical education privileges one form of ‘truth’ expressed in decontextualised, verifiable, single-correct-answer form. Clinical competence, from this perspective, is atomised into discrete facts assumed to be best tested via MCQs. Contemporary and futuristic clinical practice is culturally situated, complex, and operates on multiple ways of seeing, knowing, and being. First Nations epistemologies are particularly relational, experiential, and embodied ways of knowing that are clinically essential in the contexts where First Nations doctors will practise. An assessment system dominated by MCQs not only disadvantages First Nations students culturally, it actively misrepresents what clinical competence requires. 

Way forward: pluralistic ways of knowing

Medicine and healthcare are inherently complex, and so too is the process of preparing competent and capable clinicians. Addressing complexity requires ‘systems thinking’ that provides a framework to tackle complexity using interconnections between people, knowledge, environment, and practice. In this regard, we are privileged to draw upon First Nations ways of knowing, being, and doing, which offer holistic, long-term, and sustainable frameworks for navigating precisely the kinds of complex challenges that modern medical education faces.

Through this lens, we propose a principle of pluralism — the recognition and affirmation that diversity exists across what we assess, who we assess, and what we ultimately seek to achieve. Framed this way, the challenge of Indigenous medical student selection and progression is not simply a problem to be solved by waiving requirements or lowering thresholds. These are compensatory measures applied to a system that was never designed with diversity in mind. 

We know from the assessment literature that core clinical capabilities are complex, situated, and developmental in nature. No single test, taken at a single point in time, can adequately capture the breadth of attributes required of a future clinician. A good assessment system, whether for selection or for academic progression, must therefore be built on multiple observations, multiple tools, and multiple opportunities for a student to demonstrate competence and capability across diverse contexts. Selection and progression frameworks should be redesigned around the full spectrum of capabilities that current and future medicine demands: complex clinical reasoning and decision-making, patient-centred communication, relational care; ethical judgement, and cultural capabilities.

The argument here is not for a separate or lesser standard for Indigenous students, but a better standard for all students. Advances in artificial intelligence now make this vision not only desirable but feasible. Personalised, adaptive approaches to selection and academic progression are possible moving towards longitudinally aggregated, diverse assessment modalities underpinned by culturally responsive educational design. Aggregating evidence of clinical capabilities across time and context is both more equitable and more valid than any snapshot measure. This can be achieved via an interlinked program of educational support, assessment of core competencies using multiple formats and early identification of and customised support for learning needs. 

Addressing MCQ over-reliance, however, requires more than substituting one assessment format for another. It demands a fundamental rethinking of how medical curricula are designed. Traditional body-system and block-based structures, in which disciplines are taught and assessed in isolation, create conditions that naturally favour MCQ-based decontextualised fact-recall testing. Moving beyond this requires curricula that are integrated and interconnected within which clinical knowledge is built and assessed progressively in relation to real-world application.

To conclude, decolonisation of traditional assessment system is imperative if we want to address the chronic underrepresentation of First Nations doctors. In this reimagined system, First Nations students are not passive recipients of accommodation but active architects of a strengths-based transformation. The holistic, relational, and community-centred capabilities they bring are not an add-on, but they add the very value it has long been missing, and long overdue for recognition within our selection and assessment frameworks.

Way forward: pluralistic ways of knowing

Medicine and healthcare are inherently complex, and so too is the process of preparing competent and capable clinicians. Addressing complexity requires ‘systems thinking’ that provides a framework to tackle complexity using interconnections between people, knowledge, environment, and practice. In this regard, we are privileged to draw upon First Nations ways of knowing, being, and doing, which offer holistic, long-term, and sustainable frameworks for navigating precisely the kinds of complex challenges that modern medical education faces.

Through this lens, we propose a principle of pluralism — the recognition and affirmation that diversity exists across what we assess, who we assess, and what we ultimately seek to achieve. Framed this way, the challenge of Indigenous medical student selection and progression is not simply a problem to be solved by waiving requirements or lowering thresholds. These are compensatory measures applied to a system that was never designed with diversity in mind. 

We know from the assessment literature that core clinical capabilities are complex, situated, and developmental in nature. No single test, taken at a single point in time, can adequately capture the breadth of attributes required of a future clinician. A good assessment system, whether for selection or for academic progression, must therefore be built on multiple observations, multiple tools, and multiple opportunities for a student to demonstrate competence and capability across diverse contexts. Selection and progression frameworks should be redesigned around the full spectrum of capabilities that current and future medicine demands: complex clinical reasoning and decision-making, patient-centred communication, relational care; ethical judgement, and cultural capabilities.

The argument here is not for a separate or lesser standard for Indigenous students, but a better standard for all students. Advances in artificial intelligence now make this vision not only desirable but feasible. Personalised, adaptive approaches to selection and academic progression are possible moving towards longitudinally aggregated, diverse assessment modalities underpinned by culturally responsive educational design. Aggregating evidence of clinical capabilities across time and context is both more equitable and more valid than any snapshot measure. This can be achieved via an interlinked program of educational support, assessment of core competencies using multiple formats and early identification of and customised support for learning needs. 

Addressing MCQ over-reliance, however, requires more than substituting one assessment format for another. It demands a fundamental rethinking of how medical curricula are designed. Traditional body-system and block-based structures, in which disciplines are taught and assessed in isolation, create conditions that naturally favour MCQ-based decontextualised fact-recall testing. Moving beyond this requires curricula that are integrated and interconnected within which clinical knowledge is built and assessed progressively in relation to real-world application.

To conclude, decolonisation of traditional assessment system is imperative if we want to address the chronic underrepresentation of First Nations doctors. In this reimagined system, First Nations students are not passive recipients of accommodation but active architects of a strengths-based transformation. The holistic, relational, and community-centred capabilities they bring are not an add-on, but they add the very value it has long been missing, and long overdue for recognition within our selection and assessment frameworks.

Associate Professor Emma Walke  is a Ngyangbul Bundjalung woman and the Head of Indigenous Health Sydney Medical School and Academic Lead, Aboriginal Health Education University Centre for Rural Health Lismore NSW. Her background is in Aboriginal Health Management, curriculum development, teaching and research. 

Priya Khanna is an academic in Sydney Medical School with a background in medical education and educational research and evaluation. Her work focuses on faculty-wide and program-level curriculum and assessment redesigns, particularly in Indigenous health and healthcare education programs.

Professor Jane Bleasel is a rheumatologist and medical educator who has led major medical curriculum reforms and improved healthcare access in metropolitan, rural, and First Nations communities. She has held senior leadership roles across Australian universities and is currently the Head of School and Dean of Sydney Medical School.

Jane Stanley, a proud Wiradjuri woman with ties to her family’s Country in Wellington and currently Director of the Gadigal Centre at the University of Sydney, has played a vital role in shaping the Gadigal Centre into a hub of community and support for Aboriginal and Torres Strait Islander students and staff.