Time to Rethink The Physician Exam

I keep hearing the works never waste a crisis. The COVID-19 pandemic certainly fits the bill for the RACP Physicians Exam. In Australia the barrier for junior doctors to progress from basic physician trainees to advanced vocation trainees consists of a multiple choice examination and then for those that pass, a clinical examination consisting of short cases that assess examination skill and long cases designed to assess capacity to manage patients from a problem-based perspective. This year the clinical examination may not be able to be run. Normally held across July/August it could be postponed until October. The problem with this is that the practising for the exam takes months and is not possible to do with the infection control required during the pandemic. This is not to mention that the registrars themselves will be on the frontline and also will be emotionally and physically fatigued even if they don’t catch the virus. October is after the usual recruitment period for the subsequent year so there will be flow on effects. 2020 will be remembered as a lost year or 20/21.

The questions we should ask as a profession include: (1) does the exam ritual actually ascertain competence as a future physician, (2) is it really a good discriminator between those who can do the job and those that can work to the test, (3) does it really assess the knowledge-base, (4) does it assess ‘soft’ skills such as communication and team work, and (5) does it really assess readiness for vocational training.

It should be said that there are other assessments in play such as log-books, structured activities such as mini-CEX and case-based discussion, as well as supervisor reports. However, these assessments, in particular the supervisor reports, may not be very objective, and trainees not performing up-to-scratch can slip through the system. Ultimately the exam is the arbiter of progression.

The college should think of different approaches to assessment that spread out across training. These should address core competencies but with sufficient breadth to cover the key specialties including cardiology, respiratory, neurology, gastroenterology, geriatrics and endocrinology. Haematology, oncology and immunology are important but have boutique aspects that are not always necessary for the general physician to know. Viva exams that focus just on knowledge without necessarily having patient examination could be considered. (Video) observed practice and clinical audit could also be considered. Reduced emphasis on assessments that can be biased due to candidate performance anxiety is desirable. Additional focus on other contributions outside routine ward care should also be considered – for example leading innovation through RMO Associations or quality improvement activities. Alignment with the approaches to CPD that the college has implemented is desirable.

After the plague year we shouldn’t return to business as usual.

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