John Headley Ward: Sign-off based medicine—who wins?

The use of workplace based assessments on clinical placements risks making these experiences more about getting signatures than learning, says John Ward

We’ve all been there. You’ve just finished clerking a patient with pneumonia, a case which you’re fairly confident you could shoehorn as a “geriatric case based discussion.” You scuttle to the doctors’ office to find anyone willing to discuss “activities of daily living” (which you can’t remember asking about in hindsight, but you may have seen a walking stick somewhere in the bay). As you enter the office, sign-off forms in hand, the doctors start ducking for cover. Suddenly they all have newly discovered outliers that need reviewing or the sudden urge to bleep microbiology. There you are, stood like a Taylor Swift fan at the stage door after she’s already been smuggled out: alone, abandoned, and still obsessed about a “Blank Space.”

It’s those moments that make me think, if students don’t want to do workplace based assessments (WPBAs) any more than doctors want to actually sign them, then what do they actually achieve?

I understand why WPBAs came about. Using WPBAs is a good way to standardise assessments, with standardisation promoting patient safety and ensuring best practice is upheld. The introduction of the new Medical Licensing Assessment in the UK represents a further push for standardisation in undergraduate medical training.

Yet sometimes WPBAs become the sole purpose of placements, rather than a helpful addendum. Instead of trying to immerse yourself in cardiology, you’re running into theatres hoping a patient will consent to you placing a catheter. Placements become more about getting signatures than experience; if there are no tick boxes for documenting on ward rounds or assisting in theatres, then why spend your limited time on these activities? This view is supported by a survey of psychiatric trainees, which found that trainees felt WPBAs were time consuming and detracted from the clinical experience. While we may become adept at foisting our logbooks on doctors, we waste whole days of placement in the process, having to do the actual learning when we get home on

Furthermore, doctors seem to think that students gain some sadistic pleasure from WPBAs. I once asked an F1 to listen to my presentation, for him to retort “all you students care about is signatures.” Of course, how foolish of me to not adequately revere Andrew, the aforementioned F1, a patron saint of medicine who completed a qualifying MBBS degree without ever asking for signatures. However, he is correct. Students do care a lot about signatures because without them we fail placements. This culture alienates students from the clinical team, with doctors cynically viewing students as vultures on the job-list Serengeti, further preventing students from doing any actual learning.

The obvious solution here is to ask your consultant, given that they are your educational supervisor and therefore may take a passing interest in WPBAs. But consultants are rarely present and students often feel that WPBAs are an annoyance. Furthermore, research has shown that consultants are more likely than juniors to give generic feedback to students. Of the many consultant appraisals I’ve had, I can only remember a handful that didn’t just involve me reviewing myself while a consultant nodded. If even consultants, who have a vested interest in students being safe on their ward, loathe WPBAs, why would junior doctors want to sign them?

By forcing quotas and targets on students, it also means that patients get perpetually badgered by students who feel like they have no choice. I recall an incident when a patient was examined so frequently by students that she said she cried, stating that she simply couldn’t cope with being examined again. Considering the principle of beneficence, is it really ethical to have students endlessly examine convalescing patients for the sake of signatures?

For medical schools, WPBAs provide a practical way of making students aware of educational outcomes, and have incidentally been used in lieu of objective structured clinical examinations (OSCEs) in the current pandemic by some medical schools. Hamed Khan, chief examiner at St George’s, University of London, wrote in support of WPBAs, arguing that OSCEs perpetuate the idea that medical school is to pass exams and that they fail to prepare future doctors for frontline medicine. However, WBPAs similarly perpetuate the “jumping through hoops” nature of studying medicine, blinding students to actual learning opportunities, and furthermore minimising students’ judgment in how to develop their own clinical practice. 

WPBAs were implemented to improve medical education, however they have quickly become a cumbersome distraction from the privilege of learning medicine on the frontline. Maybe it’s time that we view WPBAs on clinical placements in the same way as a medical student at an aortic bypass; in the vicinity, vaguely helpful, but potentially catastrophic if overly trusted.

John Headley Ward is a final year medical student at St George’s University of London. Twitter @jseriousw

Competing interests: None declared.