The need for national exams

Last month I participated in a webinar with Indonesia. Someone dropped me the question what I think of national licensing exams in medicine. The tone in which the question was phrased indicated that that person was not happy with them and probably sought confirmation from me. Even after so many years with experience in assessment, I have no yes or no answer.

I think it really depends on the circumstances in a country. An important contextual variable is the homogeneity or heterogeneity of the schooling system in a country. If you have a large country with many medical schools, both state-funded and private, national exams are functional. In my own country we have a very homogeneous schooling system. Secondary schools are very selective. We only have 8 medical schools. We have a national blueprint to which all curricula have to adhere. We have a strong accreditation system. In such a situation there is less of a need for national exams.

I am a strong advocate of collaboration in assessment. From my Swiss colleagues I understand their introduction of national exams led to a lot of collaboration between schools, which in turn improved the quality in their assessment strategies. So here is an example of a small country where the national exams seem functional. In my own country, we collaborate across schools on developing and administering progress testing. Four times per year, some 10.000 students complete such a progress test. To me this has many advantages. High quality tests are being made in collaboration under strict quality control procedures. Individual students get a lot of feedback. Growth in any subject area can be monitored. Schools get a lot of feedback on their performance. The cost of development is shared and therefore very reasonable. If a (smaller) country would think of national exams, I certainly would recommend to introduce progress testing.

Any country having national exams, even if they include OSCEs, should reflect on what they are missing. National exams are standardized exams. Not everything can be well assessed with standardized testing technology. Clinical skills in-action, complex skills such as collaboration, communication, professionalism, interprofessional skills require more than standardized testing technology. In my view schools are in no way discharged of making a robust in-school assessment approach that assesses the full range of skills that are needed for training competent health care professionals, regardless of the presence of national exams.

In all, my opinion on national exams is nuanced: it all depends. In some situations, there is a clear need, in others not. Collaboration in assessment is very advisable for many reasons. Finally, realize that not everything can be assessed in national exams.