Friday, 7 December 2012

Examinations for doctors - time to think differently

I wrote the article below in 2006. I was not blogging at that time so it just lived in my computer. When you read it please be in a 2006 frame of mind. The article 14, the new rules for surgical exit exam, the impeding new contracts for doctors especially for SAS doctors and so on.

Once you have read it, cross reference it to the recent GP exam results.

We need an end to the monopoly of examination providers for post-graduate doctors. We need a plurality of avenues to demonstrate knowledge.  Why should every university in UK not have a knowledge test for specialist doctors?

The link to the intercollegiate website cited in the article will not work, you may want to search their website for the current link or otherwise check with them.



The surgical royal colleges have decided to allow any candidate who is able to muster the references of two consultant surgeons to take the intercollegiate exit examination. The colleges would see this as a response to the changes in the rules that have happened due the PMETB to allow a fair opportunity to anyone who wants to demonstrate their proficiency in surgical knowledge. The General and Specialist Medical Practise Order that created the PMETB was passed in April 2003 and there have been wide consultations before and since. It has taken three years to arrange a new format which is likely to change again very soon, in view of the MMC reforms.

While it is clear that the 'standard of knowledge' should be the same for surgeons entering the specialist register one has to question if the actual examination should also be the same. Whether different formats for differing groups/sub-specialties were considered is not known. Whether any surgeons who are not in training were consulted before these changes is not known. If any of the 'mediated entry' candidates who have taken these examinations in the past were consulted is not known. A close look seems to reveal the need to have some radical, new and different thinking about who should take which examinations and who should offer them.


The point about consulting the past candidates is rather important. The evidence for the importance lies in the figures available in the Intercollegiate Speciality Boards website ( where between 1998 and 2001 the overall pass rates in the intercollegiate surgical exit examinations was 70% for mediated entry candidates, 76% for type two trainees and 96% for type one trainees. We should keep aside the issue of mediated entry candidates for just a moment and look at the glaring difference of pass rate between type 1 and type 2 trainees. Most type two trainees worked to similar rotas in similar hospitals with similar consultants and mostly for similar number of years. Some differences do exist in their pathways such as type one trainees spending more time in teaching hospitals and type one trainees having experience in some research, while many type 2 trainees also have such exposure not all of them do. Opportunities for courses, learning etc are all similar. However, when it comes to examinations type 2 trainees did not do well. It begs many obvious questions, the foremost of which is why trainees with such similar pathways did not fare similarly at the examinations. If type 2 surgical trainees had equivalent training to type 1 trainees, as an admission to the examination implied till recently, why did they not do well? If we accept that the examination was a true reflection of their training and knowledge then was the process that selected them was wrong? If we accept that their pathways were not as similar as described here then why were they allowed into the examination on the basis of ‘end of training’ ‘exit’ examination? Knowing that type 2 candidates fared badly what changes were made to address that situation? If they were genuinely poor why were they selected into specialist registrar posts, if they continued to be poor why were they not stopped from progressing through their training which enabled them to take the examination?

When so many questions exist in the issue of type 2 registrars, there are even more for mediated entry candidates of the past and especially possibly for non-training post holding candidates of the future.


The debate is not simply about the present UK based SAS doctors, FTTA, LAT and LAS posts who intend to take these examinations under the new regulations. The future also demands some answers. Some of the colleges have taken upon themselves to hold these examinations in many parts of the world. The demand for such examinations exists. Would the colleges allow non-training doctors from abroad to sit the intercollegiate exit examinations? This opens an even wider debate whether surgeons not in non-training posts from anywhere in the world would be allowed entry in to the specialist register partly on the basis of a test of knowledge that UK Royal Colleges offered. That is not to say that such surgeons should not be allowed but to wonder if the GMC, PMETB and royal colleges have the resources to probe the credentials of such candidates so thoroughly that the British public can be assured of quality in real time practise and not success in a paper work exercise. Perhaps the easy way out is to ‘rule’ on application, that the applicant is in need of further training, which is in reality will be difficult and expensive to challenge by overseas applicants.


The law in the form of the PMETB rules allows for various types of demonstration of knowledge, specifically to enable a variety of suitable candidates to enter the specialist register. The surgical colleges instead of taking the cue and innovating, have changed the entry criteria and the format to allow non-training surgeons to sit the same examination. Instead of exploring and enabling diversity that the law demanded the situation is now quite simply similar to tying the hands of a challenger and then putting him into the boxing ring. The example of an SAS doing excellent breast work for years taking the exit examination as an opportunity and achieving a predictable failure can be foreseen very clearly. To state that it is the responsibility of the candidate to ready themselves in all aspects before appearing for the examination sounds very reasonable but in reality very cynical. To then retrain the candidate due to a PMETB refusal or an examination failure and on the successful completion of 'training' and/or 'examination' only to be employed to the same job but possibly a higher title seems bad logic and an extreme waste of resources.

There is also a general perception that the current format of the new examination could be interpreted as being that of a different standard than the recently expired one. There is a suspicion that the goal posts are set differently in preparation for the MMC changes.


In the UK there is only one form of test of knowledge. There is only one body that provides it. This situation may be appreciated as offering uniformity. On the other hand it could also be considered as a monopoly of provision. The general view of monopolistic provision is that it is unhealthy. The intercollegiate format could also be perceived as cartelisation of sorts. The reality of a very small number of people involved in taking these examinations may prevent such a thought stream from developing into meaningful progress.

Surely the royal colleges have huge experience in designing examinations and though a challenge could devise a range of 'fit for purpose' examinations which would be of equivalent standards to enter the specialist register. The law allows it though does not require the colleges to do so. Coming from a different angle would it not be logical to wonder why a breast specialist has not taken a specific exit examination in breast surgery and so on? The urologist does.

More and more of assessments are being delegated and devolved to local deaneries who then sub-delegate to individual trusts and consultants in the form of in the work place assessments. As a logical futuristic extension some consideration may be given to decentralising the test of knowledge to be provided by a range of alternative providers. This may be not only a great market opportunity but also an opportunity to demonstrate leadership and vision, for universities and private educational systems to device such tailored high standard tests of knowledge as they have already done in the CME/CPD areas.


No one argues the need for good knowledge before entering the specialist register; it is no doubt a must. The entire debate is about the demonstration of that knowledge. The intercollegiate surgical exit examination is one of them but it is probably suited only for the current type one trainees. That examination's suitability for others including type 2 trainees and their derivatives, the future MMC defined ST post holders, SAS surgeons, MMC generated non-training post holding surgeons, overseas non-training post holding surgeons is unclear, though many will take it due to lack of alternatives. There may also be reluctance on the part of the ‘higher’ authorities to accept alternatives.

It is time to realise that 'similar' and 'equivalent' do not have to mean doing the same things or taking the same examinations. It is possibly the time to wonder about the paucity of alternatives to demonstrate knowledge. With the large increase in the number of medical students and the possibility of expansion of ‘consultant’ numbers, it is time for the good and great of the medical profession, though the surgical example is illustrated here, to lead in thinking, policy and practise rather than to react and respond as shown repeatedly with some of the glowing examples such as Calman, EWTD, PMETB and MMC amongst many others, with many issues arising from them still remaining unresolved.


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