What more proof do you need?

Some hospitals in the United Kingdom have started testing their own candidates who apply for foundation year posts. Neel Sharma investigates

Working towards a medical degree is not easy, and it wasn't long after joining medical school that I understood the phenomenal workload. The didactic "spoon feeding" method with which we became intimate in our school days was a thing of the past. In my clinical years there was an obvious decline in the number of lectures, and with that the added benefit of specialist training sessions at the bedside. They were interactive, of course: often so interactive as to put individual students in the spotlight and have them questioned to the point of humiliation.

In the United Kingdom, the clinical years also involve taking student selected components, as part of which the student will compile a case report or discussion of a particular disease in detail. At Manchester, where I study, evaluations come in two forms-firstly, the ubiquitous multiple choice questions, and secondly the objective structured clinical examination. Our final exams also include a gruelling paper of extended matching questions on themes such as symptoms, management, and diagnoses, intended to assess the ability of the candidate to process and evaluate information. Other medical schools also test their candidates using objective structured clinical examinations, but the format of knowledge based papers may differ.

I'm not criticising these methods of assessment. It is hard to imagine other ways to test our knowledge. Day to day quizzing in ward rounds, course work reports, and end of year exams have become commonplace.

Some hospitals, however, think that these are not enough. Recently, a competency assessment has been introduced to test students who have applied for foundation posts. Yes: even qualified students, who satisfied tough examiners to get their bachelor of medicine and surgery degree, must sit the exam, which currently includes a 20 minute discussion of a hypothetical acute medical scenario.

How can such tests be representative of candidates' knowledge and skills. After all, objective structured clinical examinations, with their multiple stations, were introduced to test students' understanding of different clinical scenarios. These tests have been used by medical schools for years since it was realised that there had been too much emphasis on factual knowledge as opposed to clinical skills and attitudes.¹

Modernising Medical Careers (MMC) is responsible for the current reform of postgraduate education (figure)². In the foundation programme, MMC is piloting four tests (multi source feedback, mini clinical evaluation exercise, direct observation of procedural skills, and case based discussion), which newly qualified doctors will have to sit³. According to the organisation, the purpose of these tests is to "help doctors be better doctors." In addition, it states that "patients need to be assured that when a doctor is registered he/she has demonstrated the ability to practise in accordance with particular published standards."

The Modernising Medical Careers framework

I understand the importance of on the job training measures. Firstly, practising medicine demands continual learning. Secondly, it is important that astute clinicians can show their grasp of the clinical case in question and the associated procedural scenarios. But to test candidates before they start may serve, in my view at least, to dishearten them by implying that their medical degrees are not important enough. I am appalled and think it unjust for hospitals to set their own appraisals, particularly if candidates have shown their worth throughout medical school, and the General Medical Council has yet to implement this nationwide.

1. Dornan T, O'Neill P. Core clinical skills for OSCEs in medicine. 3rd ed. London: Churchill Livingstone, 2003.
2. Modernising Medical Careers. Career framework explained. London: MMC. www.mmc.nhs.uk/pages/specialities/specialityframework (accessed 30 Sep 2006).
3. Modernising Medical Careers. Assessment. www.mmc.nhs.uk/pages/assessment (accessed 30 Sep 2006).