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

In reply: We appreciate the insightful responses to our proposal.1 Lawson-Smith alludes to one of the most significant justifications for a national examination — fairness. One cannot expect foreign medical graduates to attain a standard comparable with that of Australian graduates if we do not measure this standard. We propose that we owe fairness not only to foreign graduates coming to Australia, but also to Australian medical students who have a right to confidently expect an education that will lead to similar knowledge, skills and attitudes, irrespective of which university they choose. And finally, we owe fairness to society, which would also expect the same standards of graduates irrespective of where they come from. Unless we consider what are acceptable standards, we operate within an environment where standards of outcome differ from place to place and as we do not measure outcomes uniformly, we do not know how they differ nor have a system to address potential deficiencies.

McNeil and Grimm point out that medical education has focused less on outcomes and more on process, and raise concerns that assessment methods lag in the sophistication necessary to assess outcomes. We wonder whether the reason for this lack of sophistication lies in the relative lack of interest in this field, and also in the lack of agreement on what constitutes acceptable outcomes. The process of outcome assessment is indeed complex, and the first step is national consensus on appropriate outcomes to be uniformly achieved.

McNeil and Grimm also point out that some of the desirable outcomes, such as teamwork, effective communication, critical evaluation and reflective practice, may be harder to test than medical knowledge. While this is certainly the case, reliable assessment methods do exist, such as the Moral Judgment Interview2 and Rest’s Defining Issues test.3 The mini-CEX (mini-clinical examination exercise) that McNeil and Grimm refer to, allows testing of judgement, professionalism, communication, organisation and efficiency.4

Cox questions whether a written examination can test the complex judgement and decision-making process that is better tested in the clinical setting by experienced clinicians. We propose that the national examination is not meant to replace clinician-based assessments and ongoing learning and feedback. Furthermore, a national examination does not need to be conducted only in the written form. Specialty exams already conducted nationally incorporate a clinical element and are conducted in multiple locations. The main objective of a national examination is to ensure the comparison of outcomes against agreed acceptable national standards. This objective should not impose specific limitations on the structure of the examination.

Cox warns of the risk of “reductionist standardisation” and asks whether oncology is taught consistently across different medical schools in Australia. We acknowledge that uncertainty is ever present in medical decision-making, but remain hopeful that there exist core knowledge, skills and attitudes that patients can expect and that can provide a foundation for national standards. Oncology is not taught consistently across different medical schools in Australia today. While its mode of delivery may differ, we propose that its outcomes should not. And we hope that agreement on national outcome standards and a national process of assessment of these outcomes will be a first step in achieving that objective.