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.
-------------------------------------------------------
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 EXIT EXAMINATIONS: IS IT TIME TO HAVE A DIFFERENT
THINKING?
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.
HISTORY OF WHO PASSED AND WHO FAILED
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 (http://www.intercollegiate.org.uk/html/results.html)
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 INTERNATIONAL AND ABOUT 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.
INTENTION VS REALITY
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.
MONOPOLY
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.
CONCLUSION
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.
------------------------------------------------------------
------------------------------------------------------------
©M HEMADRI
Follow me on twitter @HemadriTweets
No comments:
Post a Comment