With the declaration of ‘NMC, National Exit Test Regulations, 2023’, arguably the most important component of the National Medical Commission Act 2019 is now active. The NExT aims to hit three birds with one stone; to act as a Licentiate examination for MBBS students to practise medicine, to replace the existing licentiate examination for foreign MBBS graduates and to be a post-graduate entrance examination. With two parts – one to test knowledge, the other skills – the structure of NExT is akin to prevalent licentiate exams around the world. While the NExT is desirable as a standardised test to ensure “minimum standard” of a MBBS graduate, a plethora of issues including utility of assessment methods, quality of questions, types of skill testing, role of university & internal exams, unintended consequences are issues that need addressing.
A licensure examination, as the name suggests, gives licence to an individual. The word derived from Latin word licentiatus, which means having freedom, signifies competence of an individual to practise a profession. With widely varying quality of medical education in India and a mindless growth of medical schools; with an ever pressing problem of shortage and absence of faculty, inadequate infrastructure, lack of hands-on training, it is essential that the “minimum standard” for an Indian Medical Graduate as envisaged by the National Medical Commission, the regulator, be ascertained.
And one of the ways to ascertain it throughout the country is to have a standardised test. The minimum standard set by NMC covers three components, the three basic tenets of medical education – knowledge, skills and attitude. The Step 1 of the NExT exam will be a Multiple Choice Questions based Theory exam, testing knowledge mainly. The Step 2, a Practical or Clinical and viva-voce exam, will mainly test skills and attitude.
The NExT thus aims to standardise the knowledge and skills of all the MBBS graduates who aim to practise in India. There was another important need for the overhaul of the Indian medical education system including introduction of Competency Based Medical Education (CBME) and NExT, of that of NMCs recognition by World Federation of Medical Education (WFME), but more about it later.
Contrary to popular belief, no examination or assessment is perfect or ideal, and is as good as the purpose it serves. Assessments have components like reliability, validity, feasibility, educational impact and feasibility that determine its utility.
That brings us to the assessment tools that the NExT plans to employ - different types of Multiple Choice Questions in Step 1 of NExT. Unlike what is commonly seen like in the quiz show Kaun Banega Crorepati (KBC), there are several types of MCQs. A MCQ could have a single best response (Type A), multiple best response (Type K), extended-matching (Type R) and so on. All of them serve specific purposes in testing knowledge.
It must be noted that making good quality MCQs is a rigorous process requiring enormous expertise and Indian medical education exams seldom produce decent questions. There are several studies that have analysed questions, in internal examinations and university examinations and found that they largely fall short for being of good quality. Added to this, faculty in medical schools are not adequately trained to create good quality MCQs. The NExT proposes a hefty 540 MCQs in six sections over a 13.5 hour exam (USMLE has 322 MCQs in seven sections). Such a system can cause stress and anxiety and stand to affect the well-being of students as reported for the US licentiate examination.
It cannot be the prerogative of one AIIMS, or a PGI, to develop, analyse, retain, throw out and have the repository of rightly benchmarked quality MCQs for NExT. The Undergraduate Medical Education Board (UGMEB) of NMC perhaps has to develop a National Board of Medical Educators (NBME) style agency, with medical educators across the country with diverse representation, that would take care of this massive need.
Not just that but with the turn of the system there needs to be rigorous analysis of MCQs for theory assessment. For example, there are several ways to analyse MCQs. DI or Difficulty Index tells whether a question is too difficult that none of the students could answer, or too easy that everyone answered correctly. DI can range between 1 and 0 and the optimal DI is 0.15. Detailed analysis of questions and student performance must be carried out, data shared with researchers at-large to analyse, and not concealed in the labyrinths of NMC. Transparency is the only way in which the NExT can be made robust over the years.
This policy change of introducing NExT can spur several unintended consequences. In a recent study, in which more than seven and half thousand MBBS students across all years participated, about 65% students expressed the opinion that essays and short notes in college & university examinations should be replaced by MCQs, so that they can be prepared for NExT and USMLE examination. This is in complete contrast to what the purpose of assessment in a medical school is. Assessments must be aligned to learning objectives and instructional strategies which in medicine include knowledge, skills and attitude and which cannot be assessed through MCQs alone.
One must ask why then the students overwhelmingly prefer MCQs over short and long answer questions, which have an important role in evaluating reasoning, high order cognitive process and problem solving. The reason is simple – whatever is crucial for the career will be deemed important and other things deemed as frills. Needless to say, such standardised testing, unless mindfully curated to avoid being gamed, will only foster the dependence on coaching; now at a risk of transcending into earlier years of MBBS. This is completely opposite of what the NExT originally intended to achieve – to reduce the preponderance of the coaching system. It will take sustained, mindful and concerted effort to do best in the strategy currently chosen for NExT.
Dr Sambit Dash, PhD, is an Assistant Professor of Biochemistry in Manipal Academy of Higher Education, Manipal, and comments on higher education, public policy & health. He tweets @sambit_dash. Views are personal.