Kieran Walsh: Are medical school assessments becoming a tick box exercise?

“You teach a child to read, and he or her will be able to pass a literacy test.”

One of the most enjoyable things about listening to George W Bush torturing the English language is that no matter how confused his sentences get you can still understand almost exactly what he means. Widely derided as one of the worst presidents in US history, the constant malapropisms often reveal quite clear underlying goals. Many might say teach a child to read and you will set them off on one of life’s great journeys—starting perhaps with Paddington Bear and ending with Finnegan’s Wake—but for the former president the goal is a tick box—passing a literacy test. Is there a danger that assessment systems in medical schools will end with the same outcome?

Certainly thought leaders in assessment processes should take note. It is worth returning to first principles—the idea behind a good assessment process is that it will help to produce competent doctors with the necessary knowledge, skills, and behaviours to care for patients in their community. An assessment process may be good at producing medical students who can pass undergraduate exams in their preclinical years: this may or may not be a predictor of success later on, but it is certainly necessary to proceed to become a doctor. Some would say that the purpose of assessment should be to widen participation in medicine—but that is a moot point. Certainly no one should be discriminated against in assessments, but it is an interesting subject for debate as to whether we should specifically design assessment systems that will widen participation. When working in clinical medicine I was from a different background to most of my patients and yet none of them ever complained or asked to see someone from the same background as themselves. I wonder how I should have reacted if they had done so.

Is there a danger that such systems designed to widen participation will produce doctors whose competence is not what it should be? In 10 years time, will we, like George W, “wake up at the high school level and find out that the illiteracy level of our children are appalling?” Having waterboarded grammar for eight years, George W has now left the stage—leaving as one of his many legacies a mangled English language that is at its most telling when it is most unclear. Will we learn from his legacy?

Kieran Walsh is clinical director of BMJ Learning—the education service of the BMJ Group. He is responsible for the editorial direction of BMJ Online Learning, BMJ Masterclasses, and BMJ onExamination. He has written two books—the first on cost and value in medical education and the second a dictionary of medical education quotations. He has worked in the past as a hospital doctor – specialising in care of the elderly medicine and neurology.

  • Omsafiaa

    As a current medical student my question would be – what kind of assessments should we have? I infer from your article that you believe standards are falling but in my experience some of the clinical practices of experienced physicians would not be acceptable were they put forward as a demonstration of competence in current clinical examinations. It is rather difficult to assess what needs to be committed to memory when “the way you should do it” so drastically differs from “the way it is done in practice”. Furthermore, as a mother whose child has required medical care on more than one occasion I have found it very difficult to refrain from asking if these (often rather surly/arrogant) experienced clinicians will be carrying out a detailed history and examination or whether their gut instinct has a higher sensitivity and specificity for correct diagnoses. In fact on one occasion when I challenged a physician’s provision of care, the full force of the medical school was brought to bear in a question of my own professionalism. Perhaps the pendulum has swung a little too far from basic anatomy and physiology and I certainly believe that the transition from medical student to F1 should be much less of a drop off the end of a cliff but the haphazard and somewhat careless way much of our training is provided means that simply surviving medical school is most students’ main goal!! If consistency and excellence were available to look up to our aspirations might be a little higher.