With the Union cabinet intending to replace the Medical Council of India with the National Medical Commission (NMC), many changes in how India trains a doctor are in the offing. Of these, an important one is the proposed National Licentiate Examination (NLE), now approved to be amended to a National Exit Test (NEXT), aimed at ensuring a minimum quality standard for the nearly 61,000 MBBS (bachelor of medicine, bachelor of surgery) graduates India produces annually. NEXT, which intends to ensure uniformity in quality of the MBBS graduates, however, is susceptible to basic design flaws which risks reducing it to just another exam that does not deliver on what it aims to do. We highlight the key arguments from our recent detailed published analysis (goo.gl/er6MoR) on an “exit" exam model.
The parliamentary standing committee on health and family welfare in its 109th report released on 20 March has brought to fore various reservations and suggestions on the proposed NMC Bill, which contained several references to NLE. In response, the Union cabinet on 28 March set aside the NLE and decided to make the MBBS final year examination, slated to be called NEXT, a common exam across India, which will also serve as the licentiate examination. How will such an exam, currently only testing students for theory and practical (including bedside) knowledge in final year MBBS subjects, be standardized across the country remains unknown.
Lack of doctors, gross absenteeism in the public sector, crumbling infrastructure, and rising costs are a few ailments that our health system suffers from. Stories of negligence by providers and profiteering by private hospitals have recently captured headlines, along with chronic challenges of accessing affordable, and quality health services. It has led to healthcare coming to the fore as an important political issue, as evidenced by the major policy announcements in the recent Union budget.
We, as a society, have certain expectations of MBBS graduates. They should possess a minimum set of knowledge, skills and attitude to examine patients appropriately, be empathetic, assume healthcare team leadership, be able to treat non-complicated disease conditions, conduct a vaginal delivery, read an ECG, treat diarrhoea, etc. Will NEXT test for these abilities? Earlier reports have suggested that the NEXT is to become another MCQ (multiple choice questions)-based test, an often used model for standardized tests across country. It would not test any higher order of learning or clinical skills, and is thus unwarranted. That said, a status quo final year MBBS exam will not lead to desired change.
There are a few robust global models to draw from. The United States Medical Licensure Examination (USMLE), which came into effect from 1992, has become more clinically applied over the years. Since 2015, the USMLE in all its three steps has added components of patient safety and quality improvement, concepts that are only recently making small inroads in pockets of Indian medical education. The proposed United Kingdom Medical Licensing Assessment (UKMLA) aims to ensure that the graduate “has the skills and competence to practise", and has been structured to be implemented over many years in order to come out with a well-designed test. The design of these exams thus has been well thought through, is evolutionary and not static.
Regulators should take a cue from these examples and take sufficient time to design the NEXT. The three-year period after which the NLE (and now NEXT) is scheduled to be operational once the NMC Bill gets passed is not adequate if a robust test, with a supporting environment and infrastructure, is to be designed. This period might be just enough to come up with a refined prototype of the test. A hurriedly implemented NEXT will make things worse and further alienate medical students, who have been protesting for the past many months about sections of the proposed NMC. The NEXT should integrate and build on the internal mechanisms and framework of the MBBS course.
A MBBS licensing exam should not just test the medical theoretical knowledge component. That is, an MCQ-only based NEXT will not serve the purpose. It has to test skills and should have both written and clinical components. Moreover, it should evaluate soft skills required to practise as an empathetic medical professional. Since NEXT will also act as an entrance to post-graduate programmes, it is important to make sure that it should not be easily gamed and provide fodder for the post-graduate medical exams coaching centre business. Since the positive externalities of producing a competent doctor are high, government should actively upgrade infrastructure in nodal institutions which could facilitate conduct of the NEXT.
A test is as good as its intended purpose. While an entrance test is aimed at selecting from a pool of applicants, a licentiate and exit exam serves to assess the knowledge, skill and attitude of each qualifying MBBS doctor. The proposal of a common licentiate exam should find support among the public given the precarious state of healthcare in India, plagued as it is with frequent complaints of medical negligence, a rising trust deficit manifesting in increasing cases of violence on healthcare providers, and an ineffective, corrupt regulatory system. A well-conducted NEXT would help a patient repose confidence in the competence of his/her treating doctor.
With the idea of NEXT, a window of opportunity has opened to rectify ills in medical education. Silos can be broken, concepts of competence-based learning, inter-professional education, etc., can be incorporated to achieve the aim of producing a MBBS graduate with intended skills and training. It should not be frittered away by reducing it to just another imperfectly designed and hurriedly implemented exam garbed in the cloak of medical education reform.
Sambit Dash and Anant Bhan are, respectively, a biochemistry teacher at the Melaka Manipal Medical College, Manipal Academy of Higher Education, and a researcher in global health and bioethics and an adjunct professor at Yenepoya (deemed to be university), Mangaluru.