Achieving equal standards in medical student education: is a national exit examination the answer?

To the Editor: We read with interest the article by Koczwara and colleagues proposing a national exit examination for all Australian medical school graduates.1 It is refreshing to see interest in educational outcomes, a distinctly different trend from earlier reforms that shifted curricular focus from content to the learning process, exemplified by problem-based learning (PBL). Although the early process-focused programs were based on sound pedagogy current at their time, their educational outcomes have been relatively disappointing, with marginal or no demonstrable improvements in knowledge structures, clinical skills, or generic capabilities such as self-direction.2 Rather than an indictment of PBL, the results may reflect what was missing in those programs: explicit focus on educational outcomes, alignment of assessments with outcomes, and attention to the learning environment.

There is widespread agreement on the outcomes desired by medical schools. They include teamwork, effective communication, critical evaluation and reflective practice, as well as more traditional outcomes.3 Unfortunately, assessment methods have been slow to match curricular reforms, as these outcomes require new approaches, such as group and assignment work, peer assessment and portfolio examination, which are only now emerging in Australia.4 A national exit examination for Australian graduates is unlikely to adequately measure this range of outcomes.

While Koczwara and colleagues recognise that a national examination “might need to include a clinical component” and “would necessarily entail the explicit statement of professional values and expectations”, they support a multiple-choice question examination, suggesting such performance “can correlate well with clinical skills and future performance in multiple disciplines”.1 While this might “complement rather than replace” other medical school assessments, the message sent by its failure to address personal and professional attributes would be invidious.

In recognition of the limitations of multiple-choice questions, national examinations in North America now include a clinical component.5 This has major resource implications and, like all high-stakes assessments, uses relatively reliable, but much less valid measures — standardised or simulated clinical encounters. This is at odds with current initiatives in medical schools, which are moving to clinical assessments with higher face validity, such as the mini-CEX (mini-clinical examination exercise).6 It would be near impossible to adequately measure generic outcomes, such as teamwork, communication and reflection, in a single national examination. Koczwara et al recognise that insufficient attention has been paid to ensuring that achievement of educational outcomes is embedded in reform of medical curricula. Their solution is overly simple for a highly complex set of issues.