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06 Sep 2016

We all know the story. First day of medical school. Turn to your left. Turn to your right. Only one of the three of you will be here in a year’s time. It made the lead character from Saw look like Dr Phil.

Luckily for us, and for our patients, medicine has come a long way from those days.

Examinations and assessments aren’t what they used to be, and medical school certainly isn’t as barbaric as it used to be. As for what follows, residency is a relatively comfortable time of your career when it comes to assessment, where you can journey the garden of medicine as you get pulled one way or another towards your specialty.

Registrars? Well… it’s complicated.

Colleges occupy a unique position in the Australian social fabric. They have a monopoly on how specialist doctors are created from our pluripotent medical graduates, because society expects the highest of standards when it comes to the training of doctors in Australia.

This social contract is not taken lightly by the colleges, and curriculum renewal is a constant standing item on most education committee agendas.

Changes are underway in assessment. Colleges are moving decidedly away from single pole vault-style barriers to a race of multiple hurdles. They should be applauded for doing so.

However, examination and assessment is still a tricky area. On the scale of difficult professions, medicine is right up there.

The starting point for the colleges is a set of over-achievers who often haven’t failed a single assessment in their lives. How do you create an assessment that can discriminate between these trainees appropriately? How do we best identify the underperforming trainee?

Because that’s what this is ultimately about, isn’t it? The trainee that lacks insight, or lacks skill, or maybe is just having a rotten time with life and all that comes with it. How do you manage that trainee without the stigma of failure? How do you protect those that need help while sifting out those who just aren’t making the cut?

With record numbers of graduates making their way through the training system, the problem of the underperforming trainee will only become bigger.

It’s a numbers game alright. The number of dollars spent on lawsuits by trainees and colleges on failing to progress. The number of doctors who expect to move into consultant positions at the end of their training without having to deal with free market forces in the process. The number of people who leave medicine entirely through dissatisfaction with an assessment, when maybe things would have gone differently in another specialty and another area.

Examination and assessment was a key area of discussion at our last Council of Doctors in Training meeting.

We currently have a working group discussing the principles that should guide open and transparent assessment in medical training.

Now, I don’t want to foreshadow what this group of trainees might come up with, but I will share an analogy with you.

It feels like the models that fail are like traffic lights without a yellow light. You’re either a trainee in the green, or you hit a red light. There’s no in-between and usually it’s at the end of the training when the red lights come along, which can be a massive shock for the trainee involved. Tens of thousands of their dollars, tens of thousands of hours of their lives… all gone. Just to sit at a red light.

Good assessment utilises the yellow light. Think of your first failure as a yellow light. Your supervisors send a message to you saying, “Look, things aren’t fantastic at the moment. The light ahead of you is red, unless you can lift your game”.

Most importantly, and here’s the significant part, you get feedback on how to get those green lights coming back your way. Good feedback is a core element of good assessment.

In all my discussions with trainees, I’ve never met a doctor who wanted to take the easiest path to their end point. They understand that training is not a green light corridor. Early openness, transparency in assessment and honest feedback are essential to becoming the doctor most trainees want to be. Trainees shouldn’t be afraid of failure, and neither should the colleges. If we are, there’s something wrong with our system.

Published: 06 Sep 2016