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Whatever NEXT?

Exit Exam in Medical Education

​Sambit Dash (sambit.dash@manipal.edu) teaches biochemistry at the Melaka Manipal Medical College, Manipal Academy of Higher Education, and comments on public policy. Anant Bhan (anantbhan@gmail.com) is a researcher in global health and bioethics, and is an adjunct professor at Yenepoya (Deemed to be University), Mangaluru.

The proposal of a National Exit Test as an exit examination for MBBS graduates to ensure a minimum quality standard is desirable in a country with large gaps in healthcare. However, in its current form it could be reduced to just another examination that can be gamed and one that does not ensure basic skills. Sound designing, increased investment in testing infrastructure, and phased planning and implementation are needed to ensure that NEXT serves as a panacea to the lack of standardised medical graduate output in the country.

The Medical Council of India (MCI), which currently regulates medical education in India, has put forth a proposal to the Ministry of Health and Family Welfare (MoHFW) to conduct an exit examination, the National Exit Test (NEXT), targeted at all medical undergraduates who pass the MBBS course. The NEXT is primarily aimed at ensuring a minimum quality standard for the 61,000 odd graduating MBBS doctors that the approximately 479 medical colleges in India produce (MCI 2017). The proposed examination that intends to bring uniformity in the quality of the MBBS graduates across the country, however, has inherent design flaws, which risks reducing it to just another examination that does not deliver on what it aims to do.

What the Proposal Says

The NEXT was mooted as a proposal to add Section 10E to the Indian Medical Council Act (1956) in December 2016 (PRS Legislative Research 2016a, 2016b). Similar proposals were made earlier in 2010 and 2013, but have gained ground in 2017. There is a possibility of the MCI itself being dissolved and replaced by the Niti Aayog proposed National Medical Commission (NMC). The draft NMC Bill had suggested a National Licentiate Examination (NLE) as an exit examination for MBBS, and to serve as an entrance examination for postgraduate courses. However, the NLE seems to have given way to the proposed NEXT, while retaining its original purpose of serving as an entrance examination for postgraduate courses. However, no further notification has been issued in this regard, and the National Eligibility cum Entrance Test for Post Graduation (NEET PG) continues to be the entrance examination for postgraduate courses in the country.

What Does India Need?

A basic doctor is expected to exhibit empathetic care, be capable of assuming healthcare team leadership, have the knowledge and skills to examine patients appropriately, take history, and be able to perform a certain minimum set of clinical procedures as an independent medical practitioner, like treating non-complicated disease conditions, conducting a vaginal delivery on their own, being able to read and diagnose based on ECG, being able to treat diarrhoea in a child, etc.

There are many ills that plague medical education in India; from design flaws in the medical curriculum, to outdated syllabi, corruption in admissions and conduct of examinations, and lack of a social orientation. These lead, in some cases, to the production of a substandard quality of graduates who lack basic clinical skills (Chakrabarty 2016). The MBBS course, which is designed to produce an independent physician, is subject to wide variations in quality, a lot depending on the medical college from which one graduates. India produces nearly 65,000 MBBS graduates each year, which is an undersupply situation given the current abysmal doctor to population ratio of 1: 1,674 in the country.

Problems in NEXT Proposal

Apprehensions have been expressed regarding the utility of the NEXT, including the possibility that the already understaffed healthcare sector would be further left bereft of the large number of graduates who might fail to qualify in the NEXT and would not be allowed to practise till they are able to do so. However, this is not too different from the current scenario where a lot of fresh MBBS graduates do not join the clinical workforce immediately after graduating with a MBBS, but spend months (and, sometimes, years) preparing for postgraduate entrance examinations.

It has been earlier reported (India Today 2015) that a proposed Indian MBBS exit examination and the current NEXT too models itself on the Foreign Medical Graduates Examination (FMGE) screening test. The FMGE was introduced through the MCI Screening Test Regulations, 2002 and is conducted by the National Board of Examinations twice every year. It serves as a screening test for candidates who have obtained an MBBS or an equivalent degree from a foreign country and desire to register with the MCI or any state medical council in order to be able to practise medicine in India.

The FMGE, however, is just another multiple-choice question (MCQ)-based test that requires a candidate to get half the answers right out of 300 questions in order to qualify. While the pre- and para-clinical subjects carry a weight of 100 marks, the clinical subjects carry 200. Unfortunately, the FMGE does not test any higher order of learning or clinical skills, and is thus not an ideal template on which to design an exit examination. That only 19% of graduates from foreign countries passed this test from 2012–15 (Dubbudu 2016) is a reflection of either the substandard medical education that these foreign graduates received, or on the misalignment of foreign MBBS curriculum and Indian curriculum requirements, or on the FMGE itself.

A pertinent question that has arisen with the mooting of the exit examination is whether it will replace the MBBS final year examination. In the past, the Indian Medical Association (IMA), a representative and influential voluntary body of Indian doctors, had opposed the exit examination as they fear it would render the final year examination worthless (Times of India 2015). It is unclear at this stage as to what the status of the final year MBBS examination, a test that has both a written component and a clinical examination, will be. In the scenario of the NEXT becoming the primary exam of importance post the MBBS course, what happens to the final year MBBS examination is also under question (Hindu 2017). Would the degree awarded by the university lose its meaning and stop reflecting the quality of the MBBS graduate? Would the four-and-a-half-year long (five-and-a-half including compulsory internship) MBBS become a coaching programme of sorts aimed at having students qualifying the NEXT to move further ahead in their medical career?

Global Models of Exit Exams

There are various models of exit examinations in foreign countries. In the United States, the United States Medical Licensing Examination (USMLE), came into effect from 1992, prior to which there was an examination by the National Board of Medical Examiners (NBME) at the end of the second year of studying medicine. The USMLE, over the years, has become more clinically applied. Since 2015, the USMLE in all its three steps has added components of patient safety and quality improvement.

In the United Kingdom (UK), the proposed UK Medical Licensing Assessment (UKMLA) aims to ensure that the graduate “has the skills and competence to practise,” and has been structured to be implemented over a few years in order to come out with a well-designed test (Gulland 2015). The UKMLA would replace the existing Professional and Linguistic Assessments Board (PLAB). The UKMLA was mooted in 2005, a model was devised in 2015, and it is proposed to be implemented for foreign graduates in 2019 and UK graduates in 2021. In keeping with the autonomy of various medical universities in the UK, the General Medical Council has announced that there is no one-size-fits-all policy that can be implemented.

In a seven-year follow-up study in Canada, it was shown that scores in medical licensure examinations correlated positively with the doctors’ performance in primary care. A study in 2001 to strengthen the Korean Medical Licensing Examination proposed having objective structured clinical examination (OSCE) stations and also delved into logistical constraints, like availability of adequate number of venues, trained examiners, simulation systems, etc. It concluded that it was crucial to develop an objective checklist and evaluation matrix (Lee et al 2001).

There is a lot to learn from global evidence in designing and implementing a better NEXT. Medical regulators should take the time to plan, design and implement an exit examination model which serves the purpose of assessing whether an MBBS graduate has been trained adequately to be able to serve as an independent skilled practitioner. Additionally, the testing model should integrate well with the internal mechanisms throughout the MBBS course for medical student assessment, so that there is also attention paid to ongoing comprehensive training throughout the course.

A Robust Exit Exam?

The philosophy and intent of an exit examination in medical training should be clear and simple. It should have both written and clinical components. The written examination would test the cognitive domain, or the knowledge and understanding of a student, while the clinical component would test for psychomotor skills and competence. In addition, the examination should be designed to test the affective domain as well. This is in line with the objectives of the MBBS curriculum An MCQ-only NEXT will not serve this required purpose. If it is to be structured as another MCQ-based examination, and given the high stakes of acquiring a prized postgraduate seat associated with it, it could lead merely to a further padding of the financial kitty of already mushroomed postgraduate entrance coaching centres in the country, which probably would start advertising and running classes for clearing the NEXT.

Vis-à-vis the final year MBBS examination, stripping it of its importance will result in a dip in motivation of students. In order to not reduce the final MBBS examination to another “internal examination,” which risks colleges “pushing” maximum students through it to write the exit examination, the NEXT needs to test all three domains of education: cognitive, psychomotor, affective. That will further strengthen the students’ need to take existing MBBS examinations seriously.

It is the responsibility of the government to ensure that quality is maintained in health professionals’ education and to ensure a basic minimum skill set in a physician. Towards this goal, the government and medical education regulators need to invest significantly and in a sustained manner in building facilities that can test the skills of MBBS graduates at the exit level. Establishing simulation labs, acquiring advanced and adequate mannequins, and training staff might take a few years, and it would only then be meaningful to execute the NEXT. In the past, many stopgap arrangements and sudden examination model changes have hurt the interests of students immensely, and hence it is prudent to take the designing of the NEXT slowly and with caution. We should learn from the phased implementation of the UKMLA. Furthermore, technology can be leveraged in developing the test protocols.

It is true that logistics play a major hindrance in the conduct of a good test. Among the nearly 472 medical colleges, many are premium institutions and have a long track record in excellence. In testing for competence in clinical skills, along with newer facilities, many of these institutions can provide logistical requirements and leadership/mentorship. These centres, along with observers from the apex medical regulatory body, can ensure fair conduct of the skills component of an exit examination. OSCE stations, patient models, simulations, and mannequins can address the intent of the NEXT.

Ensuring NEXT Is Meaningful

A test is as good as its intended purpose. While an entrance test is aimed at selecting from a pool of applicants, an exit examination serves to assess the knowledge, skill and attitude of each potential qualifying MBBS doctor. The entrance examination for MBBS in India exclusively tests the cognitive domain. In the examinations held during the course, the focus is primarily on knowledge, followed by skills, and attitude is usually neglected. Over the years, the MCI has made efforts to give attention to the affective domain. It is important that prior to granting a licence to practise, all the three domains are adequately tested.

The idea of an exit examination would find support among the public given the precarious state of healthcare in India. With rampant corruption in the MCI, frequent news of medical negligence, and rising trust deficit, a patient would want to be sure about the competence of their treating doctor.

With the idea of the NEXT, a window of opportunity has opened to rectify a few ills in medical education. Silos can be broken, and the concepts of competence-based learning, inter-professional education, etc, can be incorporated to achieve the aim of producing an MBBS graduate with the intended skills and training. It should not be frittered away by reducing it to just another imperfectly designed and hurriedly implemented examination.

The NEXT should not be reduced to a system that can be easily gamed. A truly meaningful and well-carved NEXT should be a gold standard test for the production of a stand-alone skilled physician, irrespective of wherever they studied undergraduate medicine in India, and not serve as just another gateway to medical postgraduate seats/courses.

References

Chakrabarty, Roshni (2016): “Problems Plaguing Medical Education: Why India Suffers a Severe Lack of Quality Doctors,” India Today, 6 July, http://indiatoday.intoday.in/education/story/medical-education-problems/....

Dubbudu, Rakesh (2016): “Only 19% of Indian Graduates with Foreign Medical Degrees Are Eligible to Practice,” Newslaundry, 21 December, https://www.newslaundry.com/2015/12/21/only-19-of-indian-graduates-with-....

Gulland, Anne (2015): “GMC Proposes Single Test for All Doctors Wishing to Work in UK,” BMJ Careers, 5 June, http://careers.bmj.com/careers/advice/GMC_proposes_single_test_for_all_d....

Hindu (2017): “IMA Flays New Qualifying Test for MBBS Graduates,” 3 January, http://www.thehindu.com/news/national/kerala/IMA-flays-new-qualifying-te....

India Today (2015). “MBBS Doctors to Face Exit Examination,” 1 June, http://indiatoday.intoday.in/education/story/mbbs-doctors-to-face-exit-e....

Lee, Y M, K Hwang, S H Baik, M H Hong, Y S Choi and S H Kim (2001): “An Experience of OSCE for Introducing Clinical Performance Assessment to Korean Medical Licensure Examination,” Korean Journal of Medical Education, Vol 13, No 1, pp 47–57.

MCI (2017): “List of Colleges Teaching MBBS,” Medical Council of India, New Delhi, https://www.mciindia.org/ActivitiWebClient/informationdesk/listofCollege....

PRS Legislative Research (2016a): “Draft IMC (Amendment) Bill, 2016,” http://www.prsindia.org/uploads/media/IMC,%202016/Draft%20IMC%20%28Amend....

— (2016b): “Draft-National Medical Commission Bill, 2016,” http://www.prsindia.org/uploads/media/draft/Draft-National%20Medical%20C....

Times of India (2015): “IMA Opposes MBBS Exit Exam,” 19 June, http://timesofindia.indiatimes.com/india/IMA-opposes-MBBS-exit-exam/arti....

[All website URLs viewed on 27 June 2017.]

Updated On : 3rd Jan, 2018

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