The COVID-19 pandemic has thrown up unprecedented challenges and one of them in the medical field is reforming the undergraduate and postgraduate medical examination system in the country to suit a new normal. The authors, who are medical professionals closely involved with the process, propose innovations in both theory and practicals that can make examinations possible. COVID-19 has given us an opportunity to fast forward these changes which can work to benefit of the medical education system.
With over 542 medical colleges functioning in India and over 70,000 students entering medical colleges for undergraduate education alone and close to 30,000 doctors passing out every year under the National Medical Commission (NMC), the whole examination system for awarding diplomas and degrees during the COVID-19 pandemic has to be looked into critically and redefined.
As in developed countries, the graduate and post-graduate theory examinations should be implemented and follow a uniform pattern across the country. The authors, who have gone through the theory examination from 1styear MBBS to post-graduade degrees in both India and UK from 1970s to 1980’s have over the decades observed no significant changes in the examination pattern, both for theory and practicals.
While India adopted the British system of examination after independence, UK colleges have overhauled their examination systems many times, taking into account the advances made in medical sciences. The objective of any examination must be clearly defined and capable of measuring the training and competency the candidate has had over the years. To achieve this, revamping of the theoretical and practical components of medical examinations has to be addressed.
Role for Multiple Choice Questions (MCQ’s)
The theory examination should be able to test factual knowledge, application of that knowledge and the clinical reasoning behind a decision using the modified examination pattern.
The undergraduate degree MBBS seems to carry very little value in the current era. Is it because the patients want to see only a specialist? This may partly be the reason, but at the end of the undergraduate training, most doctors feel ill-equipped to take care of patients. This lack of confidence obviously becomes transparent to patients even at the first few consultations. A MBBS doctor should be well trained to become a good family physician as in most countries, but this concept or training is lacking in India.
The theory examination is made up of essays and short notes. Our current examination system meticulously explores the theoretical knowledge of the student in great detail. Examinations are designed to ascertain what the student knows about a particular condition in depth. The current examination pattern evaluates whether the student remembers all the basic sciences related to the field chosen and the knowledge base is assessed through a couple of essays and several short notes but ignores the other sections of the vast syllabus.
Technological advancements have made great strides in medical sciences and doctors apply these in day-to-day practice. But the aforementioned examination pattern largely remains unchanged. The metrics used remains the same for decades. The question papers are set by each university separately and lack uniformity in assessing the knowledge of the candidate, although the text books followed by the graduate and post-graduate medical students, rewritten with new editions both by national and international authors, have made significant changes, redefining platforms for learning and acquiring knowledge in all specialities.
Clearly, there is a need to evaluate the overall competency of the student in several domains. While theoretical assessment is important to identify the knowledge base, however, instead of asking students to write about 10 or 12 topics in the theoretical examination, the knowledge application over several topics can be tested. This can be achieved by implementing Multiple Choice Questions, Single Best Answers and/or Extended Matching Questions. Using these examination patterns, clinical reasoning and application of knowledge in several aspects of the curriculum can be easily tested.
Testing basic statistical facts should become an essential part of the curriculum and theory examination. It is this knowledge which helps in planning research projects and thesis hypothesis later in the career. This can become the first step in bridging the gap between the plethora of clinical cases in India and the paucity of research.
The introduction of the common examination system with time-bound multiple choice questions will sharpen the knowledge base of the candidate to choose the right answers testing in-depth their knowledge base.
For example, a question bank can be created with tens of thousands of questions with the correct answers, and these can serve as a common platform for setting up questions for future examinations. These question banks can be updated every year as per the new knowledge base from rapid advancements in medicine.
This pattern of selecting questions for each examination is practised in developed countries and in some neighbouring countries. The weightage of the questions and answers can be evaluated through digital systems and the level of difficulty for each question can be scored. The answers can be easily evaluated without the need for human intervention, using software and avoiding precious time of examiners being wasted at university centres where they sit in closed rooms evaluating the theory papers. The downside to the system of theory evaluation is the in-built variation in evaluation and possible bias, with no uniformity in the metric used and marks offered. There can be huge saving of expenses for the enormous quantity of papers used for theory examination and the examiners’ evaluation fees can easily be offset by digital evaluation of answers.
Answers for essay questions and short notes are often like a soap opera, in our opinion, as the first author had been an examiner in Medicine in the current Indian system for 24 years.
There are instances where the university or the examination body felt the incompetency of the examiner evaluating the theory and called for re-evaluation. The author did this a few times, thereby exposing the weakness and the downside to the essays-and-short-notes based theory examination. This practice leads to delay in the declaration of results, which is unheard of in developed countries.
To evaluate the potential of medical students, especially in final year undergraduate, post-graduate and sub-speciality examination, the primary objective is to assess the practical learning and ethics embedded in medical education. We should always remember the Hippocratic Oath stating the obligations and proper conduct of doctors, formerly taken by those beginning medical practice. The current examination system lacks in the primary objectives in many ways.
When the first author passed the MRCP UK medicine examination in 1981 at a London centre including Part I and Part II, it was time-bound multiple choice questions with negative marking for wrong answers. This practice of negative marking was abolished later as the examination reform committee felt that every examinee may tick some wrong answers and punishing the candidates by negative marking was inappropriate.
Practicals with mannequins
The practical examination should be conducted under secrecy with utmost security, with anonymity of patients, their medical condition and diagnosis a matter of privacy, enabling the candidate to examine with confidence, humility and politeness. This practical examination should be time-bound for each candidate to assess their competency, be it undergraduate, post-graduate or sub-speciality examinations.
Evaluation of professional skills and attitudes, communication skills and awareness of legal and ethical knowledge is needed. Communication skill should look at the ability of a student to communicate with the patient and the ability to liaise with the senior and junior colleagues, nursing and other paramedical staff.
What about post-graduates who specialise? Can their overall competency in the field they have chosen be assessed and the confidence needed instilled?
The capability to adapt that knowledge to a particular patient, identifying the possibilities in that patient and arriving at a treatment plan is important. Communicating the management plan, using terms the patient understands and with necessary empathy is the next task. In doing so, being aware of any ethical dilemmas or legal issues is important. If the speciality is a surgical field, the post-graduate days are spent in acquiring the skills needed for the practice. The current examination pattern, however, is not able to judge the competency of the surgical or procedural skills of the candidate. If a person is able to memorise the steps of a procedure and relay it during the examination, they are deemed to be competent. This cannot be the ideal way of assessment.
The authors, who are examiners for both Indian examination and UK examination systems, find that the downside to the Indian examination is exposed in terms of examiners mostly turning up late at examination wards, lack of application in time spent on each candidate, no guidance from universities/non-compliance by examiners on stipulated level of assessment of knowledge for each candidate, intimidation of the candidates through conversation by examiners which goes beyond the rule of examination, and the use of mobile phones by examiners during practical examination. These are some of the many illnesses of the practical examination system which require reformation. This is a less discussed subject among the medical education community but requires impassionate introspection to overcome the deficiencies.
The clinical competency relies on taking an appropriate history, conducting an examination and planning further tests and management. Clinical skills can be judged from the candidate performing the procedure in front of the examiners. Obviously, patients or volunteers cannot be subjected to this demonstration. Skills and simulation labs with well-equipped mannequins, simulators and box trainers in a skill training workstation can be the best resources in this regard.
Scripted scenarios, volunteers
Creating scenario-based questions on different aspects, with each scenario taking only 10-15 minutes for assessment is the next step. This process should ensure that there is no ambiguity in the questions or in the answer expected. Using scripted scenarios and volunteers trained to be role players, communication skills can be assessed. With the examination pattern standardised, containing questions for different components and a set of trained examiners, the whole examination can be conducted over two days in each centre.
The challenge in this multiple domain assessment is the time factor spent for each candidate and standardisation. Looking at medical examinations overseas, which have adapted to this model over the last few years, standardisation has been achieved through meticulous planning and training of examiners. Yes, training examiners is an important step in achieving standardisation.
These are COVID-19 times, which started in March 2020, and the end is not on the horizon, and with huge spread in India: nearly 50,000 to 60,000 people getting infected every day irrespective of age, gender, profession and socio-economic status. Over hundred doctors have succumbed to COVID-19 and other health care workers are also infected.
A webinar was conducted on May 20 under the aegis of Nitte University Mangalore, led by Vice-Chancellor Prof. Satheesh Kumar Bhandary. The panel included Prof. S. Sacchidanand Vice-Chancellor of Rajiv Gandhi University, Bangalore. Dr. Shiva Kumar Mishra Vice-President of the National Board of Medical Examination and Dr. Rajen Sharma, National President of the Indian Medical Association, besides the authors.
The changes to be made in the medical sciences examination pattern were discussed. Prof. P.V. Vijayaraghavan, Vice-Chancellor, SRIHER, Chennai strongly suggested distance based use of standardised patients and computer assisted mannequin based assessment for future practical examinations. National Board of Examinations has already introduced Objective Structured Clinical Examination (OSCE) as a path forward.
The advantage of MCQ based theory paper is that it does not require going to any medical college and can be taken from anywhere from a designated centre and to ensure that no one cheats, the questions set is shuffled, and is different for each candidate. As social distancing, masks and hand sanitisation are the primary preventive methods recommended by WHO and the Indian Council of Medical Research, it was felt that the practical examination in medical sciences requires revamping to prevent the spread of infection from different individuals who are asymptomatic carriers of COVID-19.
The health of the individual patient used in a hospital ward for practical examination, the examinees, other supportive staff and examiner are at risk of COVID-19 infection. The purpose of conducting a practical is to test the skills of individuals who are appearing for the examination to give a pass or fail. Thus close contact, non use of mask and compromise of hand hygiene, present a real world risk of infection for all stakeholders.
In summary, effective solutions are possible:
- Conduct practicals by virtual examination using digital technology/computer assisted mannequins.
- Time-bound practical examination to avoid lengthy questioning and assessment of examinees.
- Brief examiners prior to practical examination, strictly follow guidelines.
- Maintain the sanctity of examination.
- Multiple choice questions for theory examination; maintain uniformity nationally. Avoid essays and short notes to reduce university examination costs.
- Give weightage to internal assessment and give marks obtained by candidates as a platform for their performance in the practical examination.
COVID-19 has brought many changes including the notification of telemedicine guidelines for practice of medicine and this is a big step for access and affordability for healthcare in India. We require similar urgent changes to overhaul both our undergraduate and postgraduate medical examination system. Most students work extremely hard to get into the medical stream, we need to provide them with the best education and training as they deserve no less.
Prof. Georgi Abraham, MD, FRCP, Eminent Medical Teacher Awardee – National IMA 2017, Madras Medical Mission Hospital, Chennai, Email : abraham_georgi@yahoo.com
Dr. A.Tamilselvi FRCOG, Consultant Urogynaecologist, Madras Medical Mission Hospital, Chennai, Email: atamilselviurogyn@gmail.com
Dr. Sunil Shroff, MS, FRCS, D.Urol, Consultant Urologist, Madras Medical Mission Hospital, Chennai, President-elect, Indian Society of Organ Transplantation, shroffmed@gmail.com
