Podcast: Is it time to replace high-stakes exams with graduated licensure?
Transcript
Dr. Mojola Omole: Hi, I'm Mojola Omole.
Dr. Blair Bigham: I'm Blair Bigham. You're listening to the CMAJ podcast. Jola, this week is a personal week for me. We are talking about high stakes exams.
Dr. Mojola Omole: Tell me a bit more why it's very personal for you.
Dr. Blair Bigham: Well, my Royal College exam was scheduled for 2020. I don't know if that rings a bell, but something very big happened that year. Just weeks before I was going to write the exam after 12 months of solid preparation to memorize all of Rosen's Emergency Medicine, our exam was canceled, and that was ridiculously stressful.
Dr. Mojola Omole: I cannot imagine. You guys were rescheduled, right?
Dr. Blair Bigham: Eventually, we were scheduled a couple of times. Eventually, we were able to write the written, and they scrapped the oral board. They just couldn't figure out a way to deliver it during the pandemic.
Dr. Blair Bigham: We did end up writing it, but the whole question around how were we going to get licensed, how would the college allow us to practice, it was stressful. It was nuts for a while.
Dr. Mojola Omole: I cannot imagine studying for an exam and then it getting canceled. I remember joking that before I had a baby, that the greatest moment of my life was when I opened that email and it said that I passed my Royal College exam. When I had my son, my first thought was, "Damn, I wish it was a girl."
Dr. Mojola Omole: Second thought was, "This is not as exciting as when I passed my Royal College exam," because I knew I was going to have that baby one way or another, but I did not know if I was going to pass my Royal College exam.
Dr. Blair Bigham: The waiting to find out if you passed is just brutal.
Dr. Mojola Omole: Just that 12 months before it, your life is consumed by this one event. Two days of an exam written and one afternoon or morning of an oral exam consumed the better part of your life. Most of us didn't sleep.
Dr. Mojola Omole: We couldn't eat properly because we were so nervous about this exam that you start to wonder, "This doesn't test what I can do as a doctor. This tests how much I can memorize and then put on a piece of paper."
Dr. Blair Bigham: Totally. Then we can't forget about the cost of this as well. About $5,000 by the time you pay all the fees. Everyone had to travel to Ottawa in the past for the oral board, which is bizarre when people all over the country have to take it, and we're all jumping on Air Canada or WestJet to get to Ottawa.
Dr. Blair Bigham: It does seem like an odd system, that once in your life, one day, everyone shows up and writes this big exam, and if you fail, it's very consequential.
Dr. Mojola Omole: Today, this is the perfect article that looks at this. Both Dr. Chan and Dr. Thoma wrote a commentary in the CMAJ talking about how can we replace these high-stake exams with a graduated medical licensure in Canada?
Dr. Blair Bigham: Let's get chatting. Doctors Brent Thoma and Teresa Chan are two of the authors of the commentary in CMAJ entitled, Replacing High Stakes Summative Exams with Graduated Medical Licensure in Canada. Dr. Thoma is an emergency and trauma physician in Saskatoon. He's also associate professor of emergency medicine at the University of Saskatchewan.
Dr. Blair Bigham: Dr. Chan is an associate professor of medicine at McMaster University, where she is the Associate Dean of Continuing Professional Development. She was also one of my preceptors when I was a resident. Hi, Teresa. Hi, Brent.
Dr. Brent Thoma: Hello.
Dr. Teresa Chan: Hi.
Dr. Blair Bigham: What prompted you to write this commentary about a fundamental shift in the way we kickstart our careers?
Dr. Brent Thoma: I think that COVID provided some definite disruption to our exam system as any Canadian medical student or resident who would realize. One of our historical exams on the pathway to licensure ultimately was canceled. There was disruption in terms of how the exams were going to happen, where they were going to happen.
Dr. Brent Thoma: Which I think got a lot of people talking about what the exams are doing, why, and how. I certainly look back at my exam year and think back of all of the stress that was devoted to that. I can't say it's the same for every specialty. I can say that in emergency medicine, the focus of almost that entire last year until those last few weeks after the exam is over, is not necessarily in my mind on, "What's my first day going to be like?"
Dr. Brent Thoma: It's really on you want to pass that exam. You do not want to go through that year again. I had weeks leading up to that exam and I don't think this is an isolated experience, I had weeks leading up to that exam where I was logging 40 hours on my flashcard app to memorize those things. Maybe not even working as much clinically as I could, because I wanted to be prepared and pass that exam.
Dr. Brent Thoma: Maybe that's being too honest, but I think that is what is happening in a lot of our specialties. I don't think that's the optimal way to transition to practice. That's where some of the conversations that we started having about what would a different approach look like, which ultimately led to our editorial.
Dr. Blair Bigham: I was one of the people who was affected by the pandemic when my exam was deferred. Even without the pandemic we had spent, we either used vacation time or the program drops your shift commitment down from 16 to eight. We had about eight or nine months where we were only working half time.
Dr. Blair Bigham: The program helped us do that because we needed time to sit in a coffee shop and memorize our textbook. What does the evidence say around how beneficial that is? I learned a lot in those eight months. I learned minutiae and I became a bit of an encyclopedia but, at the same time, I wasn't at the bedside seeing cases. What does the evidence say about the best way to get ready for independent practice?
Dr. Teresa Chan: There's not a lot of strong evidence either way. I think that, if everything pans out, probably, as with most things, it's a combination of all the above that are going to help. It's about putting it together in a very evidence-informed, theory-informed way that's based on what the best practices and the best evidence that we have available can be.
Dr. Teresa Chan: However, I do think that probably it's a false dichotomy to say that it has to be either-or. In fact, in our proposition, we don't say that it's in either-or, we're saying that graduated licensing probably does need to have some checks and balances and some knowledge testing.
Dr. Teresa Chan: There's no more efficient way to test someone's knowledge base than probably some book learning test, but it is something that we have to be judicious about.
Dr. Blair Bigham: What are some of the problems with the current system?
Dr. Brent Thoma: If we're going to have a system that prepares someone to practice medicine, I think the absolute best way to know if someone can practice medicine is to have them practice medicine and keep a close eye on them. We do that in our transition-to-practice stage in our mentor training.
Dr. Brent Thoma: But there's that shift from when you go from being a resident, a senior resident, and having direct supervision a lot of the time and oversight over what you're doing, to not having that at all. That's a big leap no matter what you're doing. I would say that having a single high-stakes exam is really one of the big problems.
Dr. Brent Thoma: It's high-stakes. It's everything in one basket. Everything builds around it. It's only testing your book knowledge. It's not testing your practical ability to apply that knowledge. I think that we can do better in helping our trainees transition in a supported way, while also reducing the buildup and stress, and negative consequences that are created by having a single high-stakes examination.
Dr. Teresa Chan: There's a really famous education scientist that works in the Netherlands. His name is Cees van der Vleuten. Dr. Van der Vleuten's been talking about something called programmatic assessment for decades now. Programmatic assessment just means that you need a program of assessment. You can't just have one thing.
Dr. Teresa Chan: It's not one or even two exams, but a much more robust program of assessment is going to be maybe portfolio assessment. Maybe you would actually present some submission that says, "I've done this or that." An example of that would be some of the workplace-based assessments we do now, where people have to have entrustable professional activities that they have rated.
Dr. Teresa Chan: Those are all going into a big portfolio. Add to that, a scholarly project, a health advocacy project, and then maybe some checkpoint exams along the way. Now, you start having a really great multimodal experience that helps really understand whether or not someone is focally deficient, globally deficient, or actually just rocking it all the way across the board and ready for practice.
Dr. Brent Thoma: Teresa, if I can jump in there though, I think if I heard that I would be like, "We don't want to add a bunch more stress, a bunch more assessments to what we already have." I think what we're talking about is maybe not just putting it all in that one exam, but spreading that exam out, so it's not one high-stakes exam.
Dr. Brent Thoma: Maybe it's 10 really low-stakes exams where you see how you're doing and you're able to calibrate over training, and making sure you're getting all the information. You're not just working your way up to this one exam in fifth year or the final year.
Dr. Brent Thoma: You've intermittently been doing that studying to prepare for that throughout. If you have a bad day here and there, it's not going to be the end of the world, you've just got to get back up on the horse, figure out what you can change your strategy on.
Dr. Brent Thoma: Overall, make sure that we're making things actually less high-stakes and less stressful, and less, honestly, detrimental to the wellness of our senior trainees who are putting their all into this.
Dr. Blair Bigham: Let's just cut to the chase here. When we look at what happened during the pandemic, there were a lot of defenders of the status quo and they were saying that it protects public safety. They were saying it's psychometrically validated. I don't really know what that means, but they kept saying it over and over again.
Dr. Blair Bigham: What do the defenders of the status quo have to say about why we're putting Jola and I through these exams that we don't think there's a ton of value in?
Dr. Teresa Chan: I think that there's a perception that the public want to make sure that we know what we're doing. I think that high-stakes exam is one way that everyone understands in the world, that if you can write a certain exam that's often seen like a bar exam or other equivalents.
Dr. Teresa Chan: We're not the only profession in the world that has some exam, the accountants do it, the lawyers do it. There's lots of different professions that do it. The nurses have theirs as well. Now, the accountants actually have moved to that multiple low stakes exams and it's staged.
Dr. Teresa Chan: There are lots of precedents that if we look across different domains and different professions, that there are other ways of doing things. Legacy is really hard to give up and the rights of passage in any culture are hard to move away from.
Dr. Mojola Omole: In general surgery, we already have yearly exams and we have our CAGS exams, which mean nothing because I failed mine my final year of residency and I still passed my Royal College. My question is, do we need to be having written exams? How does me knowing how to tell you how to do a hernia repair actually mean I know how to a hernia repair?
Dr. Brent Thoma: I have a few other thoughts on that. One of the things that I think, Blair, you mentioned, you talked about how you became a bit of an encyclopedia in that. Now, I don't know that you would study in the same way that you had.
Dr. Blair Bigham: I agree.
Dr. Brent Thoma: Had you not had this big exam that you were preparing for. In some ways, is there value in you being an encyclopedia and memorizing everything as opposed to being able to practice it and look it up and probably not that speaks to the structure of our exam? Is there value that there was this thing that was really pushing you to know everything that you could and be prepared for?
Dr. Brent Thoma: Perhaps, I think some could make that argument. I think it's also comforting for a program director or for someone else who's like, "We're not totally sure, but they passed their exam." Well, there's comfort in that psychometric validity and thinking that, this person passed this exam, so they must be okay.
Dr. Brent Thoma: Now, I would argue you that probably isn't a good barometer of that you're a better doctor if you pass this exam. We looked around when we were writing this editorial to find another major national credentialing organization in medicine that does not have some major high-stakes exam component in it.
Dr. Brent Thoma: We may hear or find that we missed one, but we didn't find any of those when we looked. It seems to be a bit of an expectation. Also, I think that's become cultural. I did it, you did it, to not have those other people after us do it? I think that would be disconcerting potentially to some people who have trained in our system, and feel that we've been really well-served by our system.
Dr. Brent Thoma: I think it's really important to be honest, the Canadian system of training physicians and licensing physicians is looked at as first class, really well done by the rest of the world. It's not like we're talking about taking something that's abysmal and has not done well and has not been replicated around the world.
Dr. Brent Thoma: We're talking about changing something that for all its warts probably is still doing a pretty good job of keeping patients safe and going in a direction that is a little bit different.
Dr. Blair Bigham: There are often days when I'm working in the high-speed, high volume, high complexity, emergency department thinking, "Having studied for that exam has really helped me feel that I'm not missing anything," that I'm confident. With that said that, we do have this high class system that is known around the world.
Dr. Blair Bigham: Knowing that deep down inside, even as someone who has advocated against the exam, I'm glad I was forced to prepare for it. Tell me what this new system that you've proposed in your commentary might look like.
Dr. Teresa Chan: I would say that it's a combination of if anyone has heard of the graduated licensing system that we have for driving cars in Ontario, it's loosely based on something analogous. The idea would be that we probably need to have a mix of both book learning, which is knowing all the stuff so that you can show up and know that you have that knowledge base.
Dr. Teresa Chan: We need to have some of that. Then, we need to have some way of being able to show that you can go beyond book learning. As Jola pointed out, it's about making sure that you can walk the walk and not just write about or talk about the walk. In that case, it's about having a transitional period where you have some intermediate license that's not fully unsupervised, but that is unsupervised in parts.
Dr. Teresa Chan: Supervised with an asterisk and allows you to be in that liminal space between being the attending, and then being the trainee. Some kind of a transitional license that allows you to do that. We did propose that maybe that's where you still would have a filter of a sequential testing that could actually very efficiently check if someone knows what they're doing.
Dr. Teresa Chan: Then, you'd actually have a period where they would actually work on doing the practice, reflecting on it, and assembling some performance based portfolio. Jola in your specialty as a surgeon, it might be that you do a certain surgery with a preceptor around as a surgical assist that would actually attest to your ability to perform a great lap chole, for instance.
Dr. Teresa Chan: For Blair, it might be observe you on rounds one day and observe you running a resuscitation another day, and assemble that kind of testimonial. That's the idea, some graduated system where you actually do some of the work. Align it actually with the other parts of the triple C curriculum and the competence by design curriculum that we have already rolling out to be able to harmonize those things, and actually bring credence to them.
Dr. Mojola Omole: Would that not just be a fellowship? Isn't that the function of fellowships?
Dr. Blair Bigham: Hang on, Jola, are you proposing that I have to be in this position even longer?
Dr. Mojola Omole: No, I'm just saying that if you're doing a fellowship, you are supervised like, that is, when you're doing a fellowship you get more hands-on supervision. There are some people who do fellowships. I can speak for my specialty in just doing more general surgery, doing community general surgery as their fellowship. That almost becomes like a graduated license.
Dr. Brent Thoma: I think one of the concerning trends I've seen in our medical of education system, particularly given how long training is, but maybe this is inevitable and I'm interested in hearing from both of you who have done fellowships, but I've heard it said that our residency programs aren't training for practice, they're training for fellowship.
Dr. Brent Thoma: Now, that is interesting to me because my understanding is you get to the end of that training, you should be able to practice as a general surgeon. You should be able to practice as a vascular surgeon, an emergency physician, whatever other training that you've been through. You shouldn't need a fellowship to be competent in the core aspects of your specialty.
Dr. Brent Thoma: To me, this idea of a graduated license, what this might look like, you're at the end of your training, you're in your fifth or the last six months of practice, you're going to get more independence. You're going to get a different license. It's going to be safe for your attending to allow you and considered normal for your attending to allow you to operate in the OR by yourself.
Dr. Brent Thoma: It will be six months later without them in the building, but now you'll have them in the building. In that time, they might be able to look at your quality improvement data. They might be able to track metrics on your performance and go over those, have you reflect on those, and figure out how to improve your practice.
Dr. Brent Thoma: While also making sure that you're, you're meeting similar quality standards of your peers. The challenge currently and the reason we can't do that really easily is because it's hard to tease apart right now with our current system, what is the performance of the trainee and what is the influence of their faculty member?
Dr. Brent Thoma: Maybe they only prompted you a few times in that surgery, but if they wouldn't have been there and you wouldn't have gotten those prompts, would you have still been okay? Would you still have the same good outcome that you did. There's still some interdependence there.
Dr. Brent Thoma: The idea of a graduated license would allow us to get at more directly the consequences and the outcomes that the soon-to-be, fully independent attending is looking at.
Dr. Mojola Omole: I do think the idea of a graduate licensing your final six months makes sense. We should build residency programs for those things. When you say, is residency preparing you for fellowship or for a job, I am a bit old school in saying that because of the restrictions in terms of work hours, I do not think you've seen everything you need to see after five years to necessarily go into practice.
Dr. Teresa Chan: I think that will vary from specialty to specialty. I think that as we start to desynchronize time from training and acknowledge that maybe there needs to be some time variability and need to think about the contexts of where we're training. It's probably controversial to say this, but some people may need less exposure because of innate properties of observation and attention.
Dr. Teresa Chan: Their brain is just wired differently. They just happen to see different cases than someone else with a different context, a different set of skills, a different set of exposures, and maybe their brain is just wired differently. I think that this is where we need to start teasing apart exposure, time, baking. It's not like we're all a standard recipe.
Dr. Teresa Chan: Each one of us is subtly different. Each one of us may be brilliant in different ways. We have different abilities. Some of us have different disabilities. Acknowledging that all of those things will come into play in this arena as we think about what the length of training should be, maybe we should stop thinking about the length of training, but training to competence rather than training to duration.
Dr. Brent Thoma: I want to jump in and just say I love that comment, Jola, because I think it really reinforces what we are talking about. Under our current system, we are saying at the end of your training program, you are good to go for independent practice.
Dr. Brent Thoma: That is what we are saying. The idea of a graduated licensure where you would actually have what you actually need to demonstrate that your outcomes are meeting what they need to and that you're not needing assistance and help. You're able to call for assistance and help when you can and you're safe and all of those different things.
Dr. Brent Thoma: That would potentially demonstrate and feed that opportunity to have a little bit more experience in training before you are signed off. Right now, you passed that exam, you've done time, you've got all the EPA check marks you want, without any independent practice, you are licensed for independent practice.
Dr. Blair Bigham: I want to ask a question that I find really hard as an educator. Sometimes now, I'm asked to fill out evaluations for students or residents. Sometimes there's very strong residents. In the last couple months, I've had a couple residents who are quite weak, mostly because they're on a rotation. It's just not their domain.
Dr. Blair Bigham: They're in the ICU doing a rotation, but they're never going to be an intensivist, but I'm asked to fill out these EPAs and it's hard to be really objective in that when the resident's sitting in front of you, they've done their best, they've been engaged, but they're not competent.
Dr. Blair Bigham: I feel bad clicking a low number. I wonder, are there problems with the way people might have to fill out this new type of evaluation that's less objective than that written exam?
Dr. Teresa Chan: Objectivity is probably just a myth. I think you're just saying this for drama, because I know that in your understanding of what evidence-based medicine actually truly is made of, you probably also know that everything's about subjective reality in these interrelational observations. It's going to be subjective because it's shaded by my view and what I attended to.
Dr. Teresa Chan: It's subjective by what the trainee chooses to ask you to fill out a form on what skill. There's so many layers of choice that go into each one of these encounters, the exam also is full of choice. Someone decides what question goes in, that's not objective, it's a collective of examiners who decide that these are good questions.
Dr. Teresa Chan: Maybe there's some reliability as in consistently high performers will score better on this question than low performers. You can do some of that stuff on the backend, but I don't know that objectivity is actually even a real construct in all of these encounters.
Dr. Mojola Omole: Theresa, can I push back on that? When we're talking about subjectivity, I would say though, the one thing that is good about the exam versus competency-based and evaluations that Blair's talking about is when you're talking about people of color, talking about women and other genders in certain specialties, those people face daily microaggressions and discrimination that do come up in evaluations.
Dr. Mojola Omole: There are residents that are labeled as, "This person is this and this." Then I work with them. I'm like, "There's nothing wrong with this person." I know surgery. We could be malignant about that. Once one person makes up their mind in your program that they do not like you, no one else in the program will like you.
Dr. Teresa Chan: I get where you're coming from, obviously, as a woman and someone who doesn't identify as someone who is of a dominant racial profile within our Canadian context. I would say though that the "objectivity" of a standard exam assumes that you all have the same background. You all have the same abilities, that everyone can read at the same rate.
Dr. Teresa Chan: That everyone can answer the questions and comprehend them in the same way. There's lots and lots and lots of bias baked into those structural exams too. It's why in the U.S., they're making the USMLE pass-fail because we know that we disadvantage underrepresented minorities, women.
Dr. Teresa Chan: If you have to do all the childcare and then study for your Royal College exam, it is harder to pass the exam. Let's just put it that way. If you have to do all the laundry at home, and then you have to write the Royal College exam and there's no one fussing over you, and putting food on your table.
Dr. Teresa Chan: My mom recounts when I was in my exam year, my dad was like, "You just study." She elbowed him and said, "Yeah, you just studied for your Royal College exam because I did all the cooking and the cleaning, but your daughter doesn't have someone to do that for her."
Dr. Teresa Chan: That's the reality of it, it's that even in an "objective test situation" there are structural biases and implicit assumptions that we make about that testing scenario that may actually affect the performance of an individual.
Dr. Blair Bigham: I want to turn towards making your commentary a reality. What would the next steps or the baby steps forward be to better achieve less reliance on these high-stakes exams that have their own flaws and transition to more of this graduated licensure that you've proposed, which also has a couple of flaws and may need some ongoing tweaking?
Dr. Brent Thoma: I think, number one, it would probably be acknowledging that no independent one thing is going to make our system dramatically better. That it's going to be a phased transition and one that's going to have to get a lot of people at the table. I think regulatory bodies would have to be on board with this kind of thing.
Dr. Brent Thoma: We're talking about giving more autonomy to our senior trainees. We're going to need to have them knowing what that is and what that looks like. I think we'd have to define what that looks like. I think similar almost to the process in which individual specialties looked at and got together and figured out what are the fundamental things that our trainees need to be able to do.
Dr. Brent Thoma: What are trustable professional activities? We might need to get a better understanding about what some key metrics there are in each specialty that are really owned by an individual practitioner in that space and see what those outcomes in. Maybe in the intensive care space, Blair, it'd be interesting to know, "What's your line infection rate when you're on the ICU and lines are put in?"
Dr. Brent Thoma: I don't know if that's a good metric for you or if that's too systemic, but how does it compare with every one of your other colleagues? If you're at 42% and everyone else is at five, I've got some concerns about what's going on there. What are the other metrics in terms of length of stay in the ICU for various types of patients?
Dr. Brent Thoma: What does your charting look like? What are your long-term outcomes, possibly some other elements that would be specialty specific and coming up with those things, I think is going to be hard. The benefit of that though, I think is also going to exist because we're going to be developing standards for quality improvement to be based upon for institutions and systems.
Dr. Brent Thoma: Hopefully then, if you're a trainee and you're starting to get some of your metrics back and they're not really hitting the mark, you'll be looking at how do I improve those metrics? That's going to start building a culture of actual continuing professional development that is data-driven, but that's going to take some time.
Dr. Brent Thoma: I think really what we're almost looking at is a bit of a merger of quality improvement and the metrics that we use for that with education towards the end of training for our most senior trainees.
Dr. Teresa Chan: And I imagine actually there's also probably some role for us to do this as an option elective process for new faculty, or new attendings in the community, or people who have just graduated to give them some scaffolded program that maybe you put it as a fellowship, as Jola pointed out at the beginning.
Dr. Teresa Chan: To test pilot it so that you can iron out the kinks and have a system where we collect data, you've got your full license technically, but we're going to be here to help you improve, you set your goals, and we fold that in.
Dr. Teresa Chan: I think that there's a really cool chance for us to be experimental in the continuing education space, because guess what? Everyone's got their license already. Can we work out the kinks of what a great educational program looks like to kickstart your career in that first six to nine or 12 months until you just bake in those analytics, you bake in the continuous improvement? Then, you learn how to do that in maybe a certificate or a fellowship or just an optional way.
Dr. Teresa Chan: Then once we've ironed that out, I think that's when you start thinking about a pilot with actual stakes involved in it and pushing it to pre-graduation, pre-licensure after you've ironed it out in a group that would be doing it optionally. I think that those are the things that great innovations usually start with some prototype. I think we can prototype in the continuing education space.
Dr. Blair Bigham: You've laid out Teresa a perfect roadmap there. Brent, your idea of the aspirational place to be, where we can use big data and metrics to really inform our own self-improvement sounds really exciting. I want to thank you both as somebody who suffered a lot with a delay of the Royal College exam from the pandemic and being surrounded by my peers and for a lot of us, this was a catastrophic life event having spent nine or 12 months preparing for an exam that then ultimately only half happened.
Dr. Blair Bigham: To see a proposal for an alternative, I think is really exciting, even though deep down inside, the study process for that exam probably made me the emergency doctor I am today. Thank you both for joining us.
Dr. Mojola Omole: Thank you.
Dr. Brent Thoma: Thank you both.
Dr. Teresa Chan: Thanks for the pushing back
Dr. Blair Bigham: Dr. Brent Thoma and Teresa Chan are two of the co-authors of the commentary CMAJ entitled, Replacing High Stakes Summative Exams with Graduated Medical Licensure in Canada. Dr. Thoma is an ER and trauma physician in Saskatoon and an associate professor in emergency medicine at the University of Saskatchewan.
Dr. Blair Bigham: Dr. Chan is an associate professor of medicine at McMaster University, where she is also Associate Dean in professional development. (silence) Well Jola, what do you think?
Dr. Mojola Omole: They definitely had some compelling arguments for why we need to rethink the way we test and give the community and patients the comfort that we are graduating the best of the best that are going to keep them safe.
Dr. Blair Bigham: I found Teresa's comment very interesting, that it makes sense, it sounds right to the public, "Oh ya, you passed an exam." That's very easy to communicate. We may have, within the medical community, a lot of work to do to move away from high stakes exams, but maybe with the public as well.
Dr. Mojola Omole: I completely agree with them. I do think graduated licensing, I've never thought about it as a formal process, but that graded responsibility, which residency is supposed to be, but then let's end it with your final six months instead of locking yourself into a room or into Starbucks studying, practice.
Dr. Mojola Omole: Do what you're supposed to do, with knowing that someone is just a few minutes away there to help you. I think formalizing that last six months would be massively beneficial for our trainees.
Dr. Blair Bigham: In terms of the content in the textbook, there may be better ways to teach it than being locked up. Maybe if it's a low frequency event, you could do simulations, you could do bedside teaching. There's other ways of getting that information than just living in a coffee shop, reading a book.
Dr. Mojola Omole: For sure. This has been a fascinating talk and a lot of food for thought in terms of things that we can reimagine because of the pandemic. Now that we have virtual visits, this is something else that we can reimagine. Reimagining how we make sure that our trainees are ready for practice.
Dr. Blair Bigham: Also, well taken care of in that process. It is so stressful. I don't think we can underscore that. We have to balance, whatever that added safety margin some people believe may occur from these exams, the juice isn't worth the squeeze for what it puts people through.
Dr. Mojola Omole: In all honesty, I couldn't pass that exam today if I had to.
Dr. Blair Bigham: Neither could I. Well, I can still tell you 14 dialyzable drugs if you ever need to know.
Dr. Mojola Omole: Wonderful.
Dr. Blair Bigham: Just in case my phone dies and I need to start a toxic patient on dialysis in the emergency room. That's it for this week's episode of the CMAJ podcast. Please remember to share and like, or comment online. It's the best way for us to get the word out.
Dr. Mojola Omole: I'm Mojola Omole.
Dr. Blair Bigham: I'm Blair Bigham.
Dr. Mojola Omole: Until next time. Be well.