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Specialist exams - time for change?

This week, a thousand-odd medical and paediatric registrars sat the “exam of their lives.” Lives which were put on hold for over a year, with patient families waiting in the wings, hospitals on skeleton staff, thousands of dollars spent, all culminating in what will invariably go down as one of Australia and New Zealand’s worst vocational educational debacles.

As someone on the other side of the FRACP nightmare, I watched with sympathy and horror as two separate events unfolded: the absolute outpouring of grief and dismay from my BPT colleagues on social media, and the emotionless initial response from their respective college. The disconnect between those who set the exam and those who sat it was clear. On one side, tales of candidates crying on kerbsides (1), going home to children only to tell them that unfortunately study wasn’t finished yet, local directors of physician training and other senior clinicians and trainees fielding phone call after phone call from inconsolable registrars, and on the other, a haphazard and badly co-ordinated series of missteps, with no reference to the mental health impact, and concerningly, no reference to local and national support centres. Let’s not forget that this time last year, Chloe Abbott committed suicide prior to sitting this very exam.

The true impact and fallout of this event will surely come to light in the coming months, but in the meantime, my thoughts have been continually wandering over to the question that, 2 fellowship exams later (one which is still not over yet) I cannot help but keep asking– is this really the best way to train our specialists? Is it time to question the status quo?

Let’s look at the current format of how most of our specialists are trained. We have a two to six plus year training program, in which time we are supervised and immersed in our speciality of choice. There are often two major hurdles in the format of examinations – one at the start and one at the end of our training. The examinations cost tens of thousands of dollars, by the time you add course fees, examination and travel costs. A year or more of (often) full time work and intense study culminates into a five hour test that does not respect whether you have not slept, are tired, are pregnant, coming off night shift or have spent all night consoling an upset child. I am particularly distressed to learn that a breastfeeding woman was not allowed to express during her examination (1). It’s no wonder then, that in this high-stakes, high-stress situation, one life event, one work or personal crisis, one bad day may derail the entire effort. It is literally a “sudden-death” exam.

The impact on women and primary carers of children and elders cannot be discounted. I have lost count of the (predominantly) women I have encountered who have not been able to set aside the massive amount of time required to commit to such an undertaking. Their career stagnates, opportunities rush past them, and before they know it, they are left behind. If they have sat the examination this week, many of them will not get a second chance, or, it may not be feasible to do so for a number of years. Those with mental illness and chronic illness, like myself, struggle to keep their head above water, those with no history of mental illness suddenly find themselves struggling, and before we know it, we’ve added to the list of doctors who have succumbed to mental illness. This does not seem to be a very fair way of benchmarking the quality of independent clinical practice. The colleges have the enormous responsiblilty of doing just that, but at what cost?

So, do these examinations actually add to your knowledge base in the long term? Well certainly I must say that 4 years on, most of my written FRACP knowledge has disappeared. This is not an uncommon thing to hear and I wonder what benefit there is from such a large burst of information processing. A literature search on the topic yielded more articles on “how to” actually pass these sorts of exams, rather than whether they result in any long term retention of information. Of course we cannot compare between specialties or even between countries because the format has been almost universally adopted among medical colleges. Exams are just a stepping stone to a lifetime of learning, but with such emphasis on examinations, I ask the question – should shorter duration, mini exams be considered? Certainly those with other competing interests and commitments will find it more feasible to jump through those hoops. The curriculum has also come into question – in modern day clinical practice, how relevant is it to learn the intricacies of pharmacology when that kind of information is readily available at our fingertips and is ever-evolving? If you are an anaesthetist, then I would think that you should probably be intimately aware of the properties of propofol and remifentanyl, however as an intensivist, I have certainly forgotten the side effects of all the monoclonal antibodies that I feverishly memorised prior to my FRACP exam. Of course, "immunosuppression" and "overwhelming sepsis" are of particular importance as I find myself battling these complications on a daily basis, but a neuropathy of the fifth digit is probably of fleeting significance to the modern day intensivist. The fact that I was able to recall that Bacteroides fragilis is associated with colon cancer at a MET call the other day certainly made me look clever, but was probably not worth the emotional angst required to gain such knowledge.

There is of course the argument that “the exams make you a better doctor” and “although I struggled at the time, it was worth it at the end” which is worn like a badge of honour and admittedly I used to be one of those people. However, the human cost, not just for the candidates but for their patients and their families has become obvious in light of these recent events. It is simply too much to ask. I have no easy solution as to how to revolutionise medical education but I’m sure there are much smarter and more creative people out there who can. If the result of training is a continuous stream of burned out and distressed clinicians, if the outcome of one day has left a thousand doctors crying on kerbsides, then it is, by default, not a good enough system. We can do better.

To those of you affected by this week, we are here for you. Please look after yourselves, seek help from anyone and everyone, spend time with those that you love. The medical community is here for you. And when you’re on the other side of it all, maybe you will become one of those people who may revolutionise medical education for all.

Sandra Lussier is an advanced trainee in Intensive care medicine and general medicine. She is the CICM Victorian trainee rep and the trainee representative for the CICM welfare special interest group. Opinions are her own.


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Some further reading on the RACP exams:

Some other news sources regarding the RACP incident:

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