National finals - the way forward?
With another new application system to the Foundation Programme set to begin for applicants in their final year from 2012-13, Sanjeev Ramachandran belives it is time for a national qualifying exam.
There has always been one hot topic surrounding medical school finals: should the current system be replaced by a single national qualifying exam? It is an issue that has provoked strong debate, and with good reason. This article hopes to shed some light onto why national finals would be a step in the right direction.
What do finals mean for medical students? It is the culmination of five hard years of medical training and the first real test of our competency as future medical professionals. There is also the small matter of a job waiting at the other end of it all in August. The word ‘pressure’ sums it up.
Medical school finals, however, are unique. There is so much that rides on these exams, ranging from patient care to ranking students. Is the system in place the fairest and most effective way of assessing if medical students are ready to metamorphose into doctors?
Currently, each medical school has its own set of assessments for its finalists. Whilst the standard of the exams are reviewed and regulated by the GMC, the lack of national standardisation does create problems. Presently, what should be a national recruitment process is based on students’ rankings locally within their own medical school. This is bound to produce some inequality as each school’s set of candidates will have a different spread of abilities. It is also particularly strange as either end of the road in one’s medical training do involve nationally sat exams- admissions tests for UCAS on one and postgraduate exams such as the MRCP PACES on the other.
An immediate advantage of a national qualifying exam would be to establish a fair way of comparing students across the UK. With competition such an integral part of a career in modern medicine, it becomes increasingly important to base decisions for jobs only on the fairest and most rigorous methods. A national qualifying exam would particularly facilitate recruitment for our first postgraduate training posts, which attract applicants from a multitude of different medical schools. In addition, a national licensing exam will allow for fairer comparison between local doctors and those from abroad who wish to practice in the NHS.
So what about the people who matter the most- the patients? By standardising the minimum qualification level, the GMC can ensure that all newly qualified doctors have a core set of clinical competencies. As such, patients are much more likely to receive a basic standard of care. There is evidence that performance in a national licensing exam is a good predictor of both patient satisfaction and a doctor’s clinical ability. One study on Canadian physicians who completed a national clinical skills exam showed that those who performed better on it tended to receive fewer complaints from patients.
Any debate that affects the NHS in any way is inevitably going to involve a discussion on financial matters. This is another front where a national licensing exam can come into its own. Resources for assessing students are currently shared out between medical schools. Implementing a single nationally sat exam will help pool all these resources, thereby reducing costs.
So far we have established that national finals are fairer, cheaper and can help improve patient care. So is it really the Holy Grail the GMC have been looking for? The idea of a national qualifying exam is not without its imperfections. While it ensures that all would-be doctors possess a baseline level of skill and knowledge, this means that there must also be a push towards a common core curriculum. This could disadvantage medical schools with teaching styles that are incompatible with it. It might well force many to restructure their course and homogenise teaching styles to remain competitive. As one student puts it: “It’s like sucking the soul out of a medical school. It completely removes its individuality!” These are practical issues for medical schools to deal with, but it could in turn impact on individual students who might have thrived on alternative teaching methods.
Despite the drawbacks, many medical students are still strongly in favour of having national finals. A second year tells the Medical Student: “Whatever problems it may stir up, it is still the fairest way for employers to compare students across the nation. I definitely agree that we should have one set of exams that everybody has to sit.” Indeed, it will be a balancing act between the potential benefits and the hypothetical downsides of the new system. If, however, the GMC is committed to providing appropriate support to medical schools during the transition period, the balance may well tilt in the favour of national finals.
It is worth pointing out at this stage that this discussion about national exams is not completely academic. The Foundation Programme Application System (FPAS) is currently undergoing a massive overhaul. As of next year, finalists will have to negotiate a new application system where the previous “white space” questions have been replaced by - no prizes for guessing - a nationally sat exam called the Situational Judgement Test (SJT).
The SJT is a machine marked assessment lasting a little over 2 hours, and students’ performances in it will have a large say in whether or not they get their dream Foundation Programme job. It is designed to test a range of attributes outlined in the Foundation Programme job specification. Students sitting the SJT will be given a variety of scenarios they are likely to encounter as FY1s, and will be asked to choose the most appropriate actions to take.
The success or failure of the SJT will go a long way towards highlighting the potential positives and negatives of a national licensing exam. It will also give the GMC an indication of how compatible the entire idea is with the current set up. If a decision is reached to go forward with national finals, the SJT will at least ensure that they won’t be marching into it completely blind.
On the whole, national finals, while not necessarily the GMC’s knight in shining armour, is certainly a step in the right direction. Although it may have issues in the short term that will need to be addressed, it has the capacity to benefit us all greatly in the long run.
Example SJT questions
A 45 year old alcoholic is admitted in the afternoon with delirium tremens after stopping drinking two days previously. During the night you are called to see him as he has become very aggressive and is demanding to be allowed home. As you arrive on the ward he punches one of the nurses. He is confused, shouting and threatening other patients.
Choose the THREE most appropriate actions to take in this situation
A Prescribe extra sedation for the patient
B Ask the nursing staff to call hospital security
C Attempt to talk to the patient to try and calm him down
D Reassure the other patients in the ward that they are safe
E Ask the nursing staff to help you restrain the patient
F Ask the nursing staff to call the police
G Inform the patient that his behaviour is inappropriate and will not be tolerated
H Ensure that the nurse who was punched is not badly injured
Answer: B,C,H
You are looking after Mr Kucera who has previously been treated for prostate carcinoma. Preliminary investigations are strongly suggestive of a recurrence. As you finish taking blood from a neighbouring patient, Mr Kucera leans across and says “tell me honestly, is my cancer back?”
Rank in order the following actions in response to this situation.
A Explain to Mr Kucera that it is likely that his cancer has come back
B Reassure Mr Kucera that he will be fine
C Explain to Mr Kucera that you do not have all the test results, but you will speak to him as soon as you do
D Inform Mr Kucera that you will chase up the results of his tests and ask one of your senior colleagues to discuss them with him
E Invite Mr Kucera to join you and a senior nurse in a quiet room, get a colleague to hold your ‘bleep’ then explore his fears
Answer: DCEAB
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