The personal cost of postgraduate medical exams: Are we asking too much of trainees?

Postgraduate exams take a psychological, social, and financial toll on trainees. Ricky Ellis, Duncan Scrimgeour, and Peter A Brennan ask whether the personal sacrifice required is appropriate

The successful completion of postgraduate medical exams is a professional achievement for all clinicians and a mandatory requirement for specialty trainees in the UK. These exams have been a tradition for over 150 years and have been sat by an almost incalculable number of doctors, many of whom have gone on to achieve great things in their careers. Medicine and surgery have changed beyond recognition over this time, during which assessment methodology and curricula have been adapted, but is it now time for the expectations of training programmes to change?

The personal impact of exams

Although the days of expecting junior doctors to work unsafe hours have gone with the introduction of the European working time directive, doctors’ workloads have become increasingly challenging. This is in part due to growing staff shortages, loss of continuity, increased demand, and fewer resources. The first casualty of the increasing amount of time that must be given to service delivery is often training. In addition, the covid-19 pandemic has resulted in clinicians working through a period of unimaginable uncertainty and worry. The loss of face-to-face teaching and meetings has limited the peer-to-peer comradery that has formed the backbone of doctors’ support networks for generations. The pandemic has also resulted in some junior doctors losing valuable clinical rotations that under normal circumstances would provide vital exposure to specialties in which they may later wish to pursue a career. However, trainees are still expected to pass postgraduate exams to progress in their training. 

It is easy to overlook and underappreciate the preparation these exams require. Failure rates are high, yet it is rare for trainees to be allocated time in their working day so that they can prepare. Consequently, revision mostly takes place in evenings and weekends around already busy and stressful work schedules, causing work-life imbalance, stress, and low morale. The importance of doctors’ wellbeing is increasingly recognised and supported, yet the prevalence of burnout among clinicians is worryingly high. This can have devastating consequences for the mental health of doctors and the care given to patients. Can the system truly express concern over burnout while simultaneously requiring clinicians to spend their off-duty time revising for exams?

Time spent revising away from friends and family can have a detrimental impact on doctors’ relationships and social support networks. Additionally, hobbies, exercise, and sport—which are all vital for health and wellbeing—are often sacrificed for revision. 

Preparation for postgraduate exams takes many months and sometimes years. Some specialties, such as surgery, require doctors to sit both entry and exit exams over the course of a training programme, with only a few years’ reprieve between them. The reality is that trainees often have to give up their work-life balance to pass these exams—a sacrifice which should not be overlooked.

Medical training is expensive when you take into account indemnity insurance, membership fees, courses, and conferences. The financial cost of sitting postgraduate exams is high, especially once you’ve factored in learning materials and revision courses. This added expense can put additional stress on trainees who will often have other financial obligations, including mortgages and dependants. 

Time for change?

Postgraduate exams take a psychological, social, and financial toll on trainees. We recognise that they are important summative markers of a trainee’s progression and competency, as well as safeguards for patient care, so we’re not suggesting that they should be scrapped. However, certain changes could be made to support the wellbeing of the trainees who are taking them. Dedicated study time would protect trainees’ personal, social, and family lives. This is provided in many other industries for mandatory learning and assessments but is often neglected in medicine. Exam bursaries or lower fees would also reduce the financial barriers that can impede trainees’ career progression. At an examining body level, more transparency in the processes used to set standards and reliability testing would help to reassure candidates. 

Lastly, exams must be deemed fit for purpose in order to justify their significant impact on the lives and wellbeing of trainees. Some exams, such as the Membership of the Royal College of Physicians (MRCP), the Membership of the Royal College of General Practitioners (MRCGP), Membership of the Royal College of Surgeons (MRCS), and the United States Medical Licensing Examination (USMLE), have been studied. The predictive validity of these exams has been demonstrated, confirming that success in them is linked to clinical performance and later career success. However, many other exams currently have limited evidence to justify their validity and predictive power. 

Postgraduate medical exams are undeniably important gatekeepers of trainee progression, which help to safeguard patient care. However, at a time when the retention of doctors is falling and the prevalence of burnout is increasing, perhaps we must reassess what we are asking of trainees and reflect on whether the personal sacrifice required is appropriate. 

Ricky Ellis is a urology specialist registrar at Nottingham City Hospital and intercollegiate research fellow. Twitter @RickJEllis1

Duncan Scrimgeour is a general surgical registrar at Aberdeen Royal Infirmary and past intercollegiate research fellow. Twitter @dsgscrimgeour

Peter Brennan is a consultant oral and maxillofacial surgeon at Queen Alexandra Hospital, Portsmouth and research lead for the Intercollegiate Committee for Basic Surgical Examinations. Twitter @BrennanSurgeon

Conflicts of interest: None.