Nationally assessed

Earlier this year, a General Medical Council conference debated national assessments to ensure consistency in standards between medical schools. Katie Fletcher argues against this

Having recently completed my final examinations, I feel thoroughly and rigorously assessed. I face continuous assessment within the Foundation Programmes and ever after until retirement. I may well, in fact, be assessed "from cradle to grave." And yet an apparent lack of consistency between the assessment methods used at different medical schools has led to calls for a further national assessment process.

UK medical schools vary enormously in their teaching methods and assessments. Their curriculums and assessments must be developed in accordance with the GMC's document Tomorrow's Doctors,^w1 and some consistency in standards is ensured by the Quality Assurance of Basic Medical Education (QABME) as well as the system of external examiners. Within this loose framework, however, very differing styles of teaching and assessment have developed.^w2

Diversity and innovation are key attributes of the current system of UK medical student assessment. Content and style of assessment drives learning,^w3 and so a variation in assessments allows valuable variety in teaching methods.

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Suggestions of national assessment risk stifling this diversity of, and innovation in, undergraduate medical education. National assessment risks dictating the direction of teaching and course structure. It could also be vulnerable to the influence of short term political agendas and public pressure groups, unbalancing the content of examination or curriculum and in turn skewing undergraduate teaching.

To ensure competence

One proposed purpose of national assessment is to ensure the competence of all graduating students. If this is the case, resources would surely be better directed at identifying struggling students at an earlier stage of training, through formative assessments and regular monitoring and feedback, and offering them appropriate educational and careers support. The question that a national assessment purports to answer seems to be better answered by other means.

Public accountability is another commonly stated aim of national assessment. At present, no objective evidence shows that students from one medical school achieve the same standards as students from another. In an increasingly litigious society, this is perhaps an untenable position. But again, other measures could be equally effective, for example, the tighter guidelines on how medical schools must prove the rigour of their exams. The QABME is also still in its infancy and should go a long way toward responding to the criticism levelled at medical schools for their inconsistency. Full registration with the General Medical Council is also contingent upon the trainee acquiring core competences through assessment of on the job performance within Foundation Programmes. Here, then, already in existence, is the public accountability sought by advocates of a national assessment.

So could the purpose of a national assessment be to make selection for specialty training or Foundation Programmes placements easier? Certainly, a neat number would make ranking easy. But the use of such a system destroys any diversity within the profession. This would be a hugely retrograde step, leading to a cohort of doctors selected not on the basis of their all round intellectual ability, specialty specific skills, aptitudes, or motivation but on their past ability to pass exams.

Fundamentally flawed

The plans for national assessment are, then, fundamentally flawed. They fail to fulfil the intended purposes and certainly do not justify the huge expenditure needed.

The arguments about national assessment in a way miss the point. The key determinant of patient safety, and the key challenge facing undergraduate assessment, will be to ensure a seamless transition between undergraduate education and work in the NHS. Studies have shown that newly qualified post registration house officers feel ill-equipped to perform their duties competently and that medical school has neither furnished them with relevant skills nor facilitated progression into the medical workplace.w5 w6 Easing this transition would ensure the competence of doctors in the NHS.

One key to smoothing the jump from medical school to practice as a doctor is creating a continuum between education, assessment, and postgraduate practice and to end the focus on the final examination. As Sir William Osler said, in 1913, we are too often guilty of making "the exam the end of education, not an accessory in its acquisition."^w7 Simple measures, such as incorporating feedback in assessments,^w8 can achieve this congruence between education and assessment. This would also be welcomed by students.^w9 Scope also exists for innovation in assessment to build on innovation in teaching-for example, making greater use of self direction. This would be an obvious driver to link education, assessment, and continuing training, and strategies such as peer and self assessment have been suggested.^{w8 w10} But their implementation necessitates flexibility in assessment procedures and innovation on the part of medical schools.

The questions facing undergraduate education have many potential answers. But national assessment is a flawed solution. It risks unbalancing curriculums, stifling diversity and innovation, and diverting attention away from the real need for change in undergraduate medical education. Reform is undoubtedly needed, but it is vital that educational continuity is not lost in the rush to be seen to be doing something. Patient safety is the central tenet of the NHS. Supporting medical schools in delivering an educational continuum with postgraduate training in programmes that are comprehensive, cohesive, and inspiring will do more to ensure patient safety than the empty gesture of a national assessment ever could.

1. General Medical Council. Tomorrow’s doctors. London: GMC 2002.
2. SL Fowell, G Maudsley, P Maguire, SJ Leinster, J Bligh. Student assessment in undergraduate medical education in the United Kingdom 1998. Med Educ 2000;34(suppl):S1-49.
3. Frederiksen N. The real test bias: influences of testing on teaching and learning. Am Psychol 1984;39:193-202.
4. Lempp H, Seabrook M, Cochrane M, Rees J. The transition from medical student to doctor: perceptions of final year students and preregistration house officers related to expected learning outcomes. Int J Clin Pract 2005;59:324-9.
5. Wood DF. Evaluating the outcomes of undergraduate medical education. Med Educ 2003;37:580-1.
6. Osler W. Lancet 1913;2:1047-50.
7. Michael Eraut. A wider perspective on assessment. Med Educ 2004;38:800-4.
8. Duffield KE, Spencer JA. A survey of medical students’ views about the purposes and fairness of assessment. Med Educ 2002;36:879-86.
9. Schuwirth LWT, Van der Vleuten CPM. Changing education, changing assessment, changing research? Med Educ 2004;38:805-812.

   

           

	EDITORIALS Nationally assessed       Katie Fletcher (July 2005)
	Sreenadh Gella (July 20, 2005)       SHO in Orthopaedics, Pinderfields general Hospital, Wakefield mrgella@hotmail.co.uk
	I have gone through the article written by the editor Katie Fletcher. There are some interesting points that provoked me to write this response. I think whatever GMC is doing, it is for establishing highest standards in medical practice by keeping an eye on the practices in the profession and assessing them. In medicine, there is a lot of scope for diversity and personal preference. Unless there are standardised practices and a body to monitor them it is very difficult to give the patients the best treatment modalities that are available. For the sake of patients I feel that medical professionals and their practices need to be assessed and standardised. Assessment and keeping update with the latest developments in medical education go hand in hand. These assessments need to be of the highest and unified standards through out the country and should start from undergraduate level. This is only possible by creating some sort of centralized assessment with potential to deliver confident, competent, safe doctors. Local assessments can not point out the deficits in local training and educational procedures unless they are coupled with national centralized assessments. Diversity and innovation are very important for development of a faculty but I do not think the national assessments will kill them as the local assessments can still take place along with the final national assessments. I feel the fears raised by the author in this letter regarding the political short gains and political influence of the curriculum for undergraduates may be unnecessary, as these decisions are usually made by the bodies with good experience and knowledge in medical education. National assessment need not only be by a written examination but there are other well known modes of assessment which can be utilized properly to get the best. No one likes to be assessed through out the life, but in our profession for keeping the profession up and for delivering the best for the patient, every doctor needs some sort of standardized assessment from step one. It involves a lot of expenditure but if that money can improve the standards in medicine, I think that money is well spent. These assessments if they are properly planned and structured can also improve the confidence of the medical students in performing the ward duties when they become doctors. There is no doubt that patient safety is the central tenet of NHS and I am sure the policy makers will use national assessment for improving the patient care and safety.

	EDITORIALS Nationally assessed       Katie Fletcher (July 2005)
	Dr Shyamala Hande (August 22, 2005)       Associate Professor of Biology, Melaka Manipal Medical College, Manipal-576104 shyamalahande@yahoo.com
	Think globally act locally The inconsistency in teaching methods and assessment in medical schools is a problem world over. Pressure to change the organization, content and delivery of both undergraduate and postgraduate medical education has greatly increased(1) in recent times. There is substantial variability in the content of medical school curricula, and the process of curriculum change is becoming more challenging because of intense competition for time and space in the course(2); and the assessment processes change accordingly. The emphasis should be on the need to reform medical education to bring it into harmony with society's needs and expectations(3). Continuous assessment of medical students at the university or institution level is required; a national assessment may not be the probable solution. It may not be advisable for medical schools to blindly follow guidelines framed by national or international bodies in a different part of the country or the globe. One should keep in mind that "The training at the medical school gives man his direction, points him the way, and furnishes him with a chart, fairly incomplete, for the voyage, but nothing more"(4) . With the help of guidelines and feedback from accreditation committees every medical school should be able to train medical students in knowledge, skills and attitude domains keeping in mind the patient and the local community. References: Parsell GJ, Bligh J. The changing context of undergraduate medical education.Postgrad Med J. 1995 Jul;71(837):397-403. Koczwara B, Tattersall MH, Barton MB, Coventry BJ, Dewar JM, Millar JL, Olver IN, Schwarz MA, Starmer DL, Turner DR, Stockler MR. Achieving equal standards in medical student education: is a national exit examination the answer?Med J Aust. 2005 Mar 7;182(5):228-30 Maudsley RF. Content in context: medical education and society's needs. Acad Med. 1999 Feb;74(2):143-5. Bean RB, Bean WB. Sir William Osler: Aphorisms from His Bedside Teachings and Writings. 1961 Springfield, Ill., Charles C. Thomas Company.