What’s the right answer?

In medical school, no one tells you that 10 years later you’ll still be staring at anatomy and physiology flashcards while your normal, adult friends are out living their lives. The exam grind is almost unknowable for non-DITs. Medical students are safely wrapped up in unchallenged dreams of a brilliant future not knowing what horrors await. For friends and family outside of medicine it’s even harder to understand. There aren’t many industries where you have to sit the most difficult exam of your life in order to progress – or keep – your career, so understanding can be lacking. I’ve been asked more than once if I will “be a doctor” if or when I pass the physicians exam.

Are things really that bad? Not all exams are created equal and they vary across specialities. DITs know in general that surgical exams are encyclopaedic and must be studied for at midnight between appendectomies; ED exams are a DIY project and no one else in the department even realises you’re sitting until you’ve passed; anaesthetics trainees must pass the first time because the volume of candidates makes failure a logistical nightmare for admin; psychiatrists are only examined on five drugs but have to know the entire Diagnostic and Statistical Manual of Mental Disorders; physicians will act like their exam is a bigger deal than everyone else’s whilst insisting on calling it ‘the little quiz’; and all other specialties will forget that General Practitioners sat an exam to get there. I don’t know enough to comment on the paediatrics exam, but I assume it’s just the physicians exam on smaller paper. 

Common between specialties is expense, lack of work-life balance and pressure to pass. Do exams make us that much better as doctors that they warrant all this pain? Assessments of highly specialised skills are notoriously hard to validate and it is commonly accepted that sometimes talented doctors fail and people with obvious deficiencies still manage to do well in testing specific domains. The Australasian College of Emergency Medicine was recently criticised for anomalously low pass rates of candidates from non-English speaking backgrounds. Certain speciality associations, such as the Australian Orthopaedic Association are changing requirements around surgical exams as the common surgical clinical exam has become irrelevant to their subspecialty.

The knowledge that exams are imperfect makes the havoc they wreak on us that much harder to take. Two surgical registrars I am close with failed their surgical science written exam by 0.3%. I haven’t mistyped that, both failed by less than 1%, which equated to one multiple choice question over four separate papers. Both passed comfortably overall but all four sections must be passed individually to succeed. What downstream effect does this 0.3% have on their lives? Financially, a loss of six weeks wages, emotionally, a spectrum that started with ‘despondent’ and ended with ‘I’m a wreck; drinking port through a straw’ (their words), in terms of life-planning; a year added onto training and, they report,  the spectre of not being re-employed on their one-year contract because their departments have (as one registrar put it) “lost faith in them”. I’ve known more than a handful of excellent doctors who haven’t been able to progress with their careers because their exam technique was poor, rather than their clinical and interpersonal skills. This seems unfair as exam technique can be perfected. These individuals have had to move on to other areas, resulting in a loss to medicine. 

Whilst we need to ensure our speciality trainees have garnered adequate skill, making a perfect exam is an impossible proposition. The talented specialists we’ve lost to a single barrier exam and the personal cost of sitting exams argue for more balanced assessment. Colleges need to be changing and perfecting exams whenever possible or even getting rid of them if they’re not performing their intended function. Although progressing in speciality training will never be an unchallenging or stress-free activity, we need to bear in mind that the process of sitting exams and failing them too, bring personal, financial and emotional costs that are often not appreciated.