Student soapbox: national medical exams
Kinesh Patel believes a national standard is the way forward
It is not often that I can say that the USA does something better than Britain does, and it is even less often that I am seen to be a proponent of exams, but in the case of medical examinations, which I hope we all recognise as a necessary evil, I feel that the USA's system is superior.
In order to practise medicine in the USA all
medical students have to pass national exams,
the "United States Medical Licensing Exam."
(USMLE) These exams are taken in three steps:
Step 1 is taken after two years of medical school,
Step 2 in the final year, and Step 3 after qualification. They are intended as general exams, with the emphasis being more scientific in the
earlier stages and more clinical in the later
stages. The later stages include specialty specific questions as well, for example, on psychiatry,
dermatology, and ophthalmology. Students take
the exams on computers and are given a
numerical score, in a similar fashion to their
standard attainment test. The significance of the
score is that hospitals and other employers can
compare students from all over the country
against each other when sifting through the
hundreds of job applications they receive.
In my opinion, such a system would be most
welcome here, as many senior doctors find it
increasingly difficult to differentiate on paper
between many applicants when searching for
junior staff, especially as medical degrees are
not classified as other degrees are (first, upper
second, etc). It is unfair, I believe, to judge on
the infamous "publications" section of any
(every?) curriculum vitae. Many students are not
interested in writing, but are interested in and
very competent at medicine, and a USMLE-style examination would allow this sizeable proportion of students to be credited with their
achievement. Of course, the interview would
still form a major part of the assessment of suitability for a certain job, but the exam result would indubitably help in the shortlisting.
Medical schools would still be free to set any ancillary exams that they saw fit to test special and individual aspects of the course, but such a system would provide a nationwide framework by which all medical teaching would have to take place. The medical schools would also still have final say over which candidates graduated. The unpopular side of this, for the medical school deans at least, would be that medical schools could be compared against one another directly, on the basis of their results. However, I imagine that this would inspire those institutions performing less well to examine the reasons for this and that this would lead to an improved medical education. At the moment there is little scope for comparison of the efficacy of different curricula at instilling information into our somewhat unreceptive minds.
In addition, the introduction of such an exam would provide some extra motivation, although this may be unwanted, to do as well
as possible in exams - American students are
on the whole very motivated to score as highly as possible, knowing that to some extent their futures depend on how they perform.
The exams would have to be set by an external organisation not affiliated to any of the medical schools, and there should be little difficulty in ascertaining what is core knowledge for every medical student in order to lay down a curriculum on which the exam would be based. Some would argue that this would lead to an increased level of homogeneity between medical schools, and while this may be true, I would regard this as a positive step. In the increasingly litigious atmosphere of today, an atmosphere which will undoubtedly become worse, medical training needs to be uniform both at undergraduate and at postgraduate level. The public
is looking for accountability (and perhaps
blood) from the medical profession, and the
introduction of such an examination would no
doubt further the former of these wishes.
Whether acquiescence to public desires is desirable is an entirely different matter.
Foreign medical graduates have a notoriously difficult time when coming to Britain - again, competence is often not considered. In
the USA all doctors have to pass the same set
of exams, and again this favours direct and fair
competition. Studies have also shown that in
Britain that those doctors with foreign sounding names, even those qualifying here, are less likely to be shortlisted for interview.1,2 A standardised exam would contribute to the elimination of such practices - it is far harder to discriminate when comparing like with like.
To summarise, USMLE-style national medical undergraduate examinations would not bring an end to all the woes of medicine, but
I believe they would provide clear benefits to those who are most deserving, help eliminate unfair practices as well as adding transparency to job selection, and, perhaps best of all, infuriate deans all over the country.
Kinesh Patel, second year medical student, Imperial College School of Medicine, London
Email: kinesh@ulysees.freeserve.co.uk
studentBMJ 2000;08:303-346 September ISSN 0966-6494
- Esmail A, Everington S. Asian doctors are still being discriminated against. BMJ 1997;314:1619.
- Esmail A, Everington S. Racial discrimination against doctors from ethnic minorities. BMJ 1993;306:691-2.
