Medical council considering alternatives to ‘outdated’ licensing exam

The COVID-19 pandemic was in full swing in December 2020 when the Medical Council of Canada (MCC) appointed a task force to review how health-care delivery is changing, what may be demanded of the next generation of doctors and how the MCC’s licensing exams and plans should adapt accordingly.

But just four months after the task force began its work, the MCC suspended one of its own major education undertakings in June of last year – the MCCQE II, the second of two qualifying exams all medical residents must take to be licensed in Canada.

The MCCQE II was intended to be an assessment of medical residents’ knowledge, skills and professional demeanour toward patients. Residents were tested at 12 “stations” where they responded to medical scenarios performed by actors.

On the face of it, the exam was halted because of unprecedented challenges in conducting it during a pandemic. But, in fact, it had been controversial since before COVID-19 as medical residents and doctors alike questioned its relevance, efficacy and the sheer financial and psychological burden it placed on medical residents. By the time it was suspended, many who had encountered it said they felt it was an outdated means to assess today’s medical residents.

Kevin Eva, chair of the task force and Associate Director at the Centre for Health Education Scholarship and professor and Director of Educational Research and Scholarship at UBC’s Department of Medicine, wouldn’t agree with the term “outdated,” but he understands the collective concerns about the exam.

“Quite literally every consultation that we engaged in, in those early stages, spontaneously led to discussions about Part II,” he says.

While the task force’s final report is under embargo as the MCC deliberates what its next steps will be, Eva says that in broad terms what is being asked is, “How can we actually make our assessment strategies more educationally oriented? How can we use them for the sake of quality improvement rather than simply being about quality assurance? The only way to get there is to have a more integrated system where the assessments aren’t just a hurdle that one needs to get across, but rather, are fundamentally intertwined with the education that one has just done.”

Beyond the obstacles brought on by the pandemic, the exam also proved to be a challenge because of when it was held – at least 12 months into residency or later, when the end of a residency program was approaching. “(That) really did create all kinds of uncertainty about what the exam was meant to be – all kinds of frustration about, if somebody has gone into a specialty area, having to re-study things that will no longer be relevant to their practice,” Eva adds.

While the stations at the exam were meant to be widely applicable, they were acted out through particular scenarios that inevitably would have been more relevant to some disciplines of medicine than others.

“The things they had to dredge up from their medical training were an unfair and unnecessary burden.”

Mike Benusic, now a physician in Victoria, saw this play out during his family medicine residency – he says that while the scope of the MCCQE II felt fair to him, he couldn’t say the same for his specialist friends taking the same test. “The things they had to dredge up from their medical training (were) unfair, and an unnecessary burden to them in already extremely intense programs where they’re getting constant assessment of their competencies specific to those programs.”

That, paired with the cost – more than $2,000 to take the exam, plus travel and accommodation fees to get to where the exam would be held – and the fact that physicians also are assessed and accredited by either the Royal College of Physicians or the College of Family Physicians of Canada, left many feeling that the broad-strokes approach of the MCC was no longer necessary.

“Both the College of Family Physicians of Canada and the Royal College have moved toward competency-based medical education,” that involves observing residents in the field rather than in an artificial setting, Benusic points out. “By eliminating the MCCQE II now, I think the MCC has admitted that, at least partially, their involvement in assessing the competency of Canadian-trained medical residents is unnecessary.”

To some, the exam still has merit – research has repeatedly found that medical professionals who have done poorly in the MCC’s exams are also more likely to receive complaints and have lower levels of patient satisfaction. But it’s clear the MCC sees this as an opportunity to take stock and decide on a path forward.

The problem is that right now, the MCC’s exams don’t necessarily fit into a broader system of education or professional development. The exam is conducted in a siloed environment, a hurdle amidst the other qualifying steps medical students must take. There’s undergraduate training, then qualifying examinations, then accreditation. “(We) want to encourage a model whereby the qualifying exams the medical council runs feed into that bigger-picture system, better enabling physicians to know what they would most benefit from putting their continuing professional development energies toward,” says Eva.

There’s also the question of what happens after accreditation, when the responsibility of self-reflection and self-improvement falls largely to the physician. “Once they’re out of there, the longest period of practice over everyone’s career is, in many ways, under-regulated,” he points out.

Students should have opportunities to do different assessments on patients that are not just white.

“If somebody is weak in any particular area, by definition, they’re not the ones who should be deciding whether or not they are weak.”

It’s also the responsibility of the MCC to move with the times – a task that involves accounting for the recent boom in virtual care, for instance, and more broadly, the ability to adapt to new crises, technologies and constantly evolving understandings of health. The key, Eva says, is assessing why residents make the decisions they do – “conceptualizing why they’re doing things in certain ways, so that we can better appreciate whether or not they’re ready to adapt their habits to new situations, or whether they’re doing it (because) that just happens to be the way they’ve been taught.”

In its deliberations, the MCC will also decide how to integrate equity into its assessments. The council only introduced gender and sexuality to its medical examination objectives in 2019, and Indigenous health in 2021. Patients’ identities can play a huge role in how they are treated by medical practitioners – will any future iteration of the MCCQE II exam, should one be established, account for that? Is it even being observed and taken into consideration enough in the field, during medical residents’ training?

The Black Health Education Collaborative was formed to improve Black health outcomes and experiences with the medical system through better medical education and practice, particularly through curriculum changes. Barbara Hamilton-Hinch, board member and Assistant Vice‑Provost Equity and Inclusion at Dalhousie University’s School of Health and Human Performance, has observed that medical students “aren’t being introduced to as many Black simulated patients that they should be introduced to. Students should have opportunities to do different assessments on patients that are not just white.”

Much has been written in the U.S. and Canada about how biases against Black patients are perpetuated in health-care education – myths about Black patients’ pain tolerance, a lack of context around the prevalence of particular chronic conditions, and lack of empathy or credibility given to the experiences of Black patients, especially Black women.

“And so, my hope is that some of these things would be different in the exam, as well as thinking about people’s religion, language, culture,” Hamilton-Hinch says.

In the coming months, the MCC will continue to deliberate the Assessment Innovation task force’s recommendations to decide whether and how the exam will return and, more fundamentally, to consider what its role is in the rapidly changing world of medical education.