E104 John Neary on Royal College Exams in 2020, Cancellation of MCQE Part II, and Exams in Med Ed
Listen to this podcast on SoundCloud
Chad Ball 00:12
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only master classes on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human.
Ameer Farooq 00:43
This week on the podcast we spoke with Dr. John Neary, an internist at McMaster University. Dr. Neary was instrumental in submitting a motion that asked that the Royal College exam be waived for all trainees graduating in 2020. Given the challenges that COVID-19 were presenting for the administration of the exam, we also talked about the recent decision of the Medical Council of Canada to eliminate the MCQE Part II. Beyond these two very specific and controversial topics, we had a much deeper conversation with Dr. Neary about the nature of examinations in medical education. We'd love to hear your thoughts. Did studying for your royal college exam make you a better physician? Email us at [email protected], or tweet at us @CanJSurg.
John Neary 01:30
Yeah, so I was born in London, Ontario. I remember, I went to medical school, just realizing how many people in medical school came from families that were medical families. I was not from a medical family. Although some professional family, my father was a history professor at Western. He still is. I grew up in London, I did my undergraduate at Queen's University in pure mathematics, which was not intended as a course of pre-med study but turned out to be that way. I would say it was overvalued by medical schools when I applied after starting a master's degree and realizing I was not cut out to be a mathematician. And then I studied medicine at the University of Toronto, chose to come to McMaster for residency after having a really good experience interviewing here for CaRMS. And really never looked back after landing at McMaster. I did the three years of core Internal Medicine, chose to do a fourth-year in... they called it general internal medicine, but that was before general internal medicine was recognized as a specialty. And I finished up at a time when there was a great need to expand general internal medicine services across Canada because of the rapidly rising number of hospital inpatients. So I was able to get a faculty position without needing to do a great deal of extra training. I joined the faculty in 2011. And I've had a few different leadership roles since then.
Ameer Farooq 03:10
I love it. That's fantastic. Well Dr. Neary, we really wanted to chat with you today. Because, you know, you really kind of put your head out, so to speak, or stuck your head out and put yourself out on a limb last year, when you circulated this petition and created this petition when the royal college essentially decided to postpone the royal college exams. And it was very uncertain at that time. And I know this intimately because I was one of the people who was affected directly by the Royal college exam being delayed. I was all set to write my exams, then obviously, the issue of the pandemic arose, and those exams got postponed. So, can you talk a little bit about, you know, sort of what the situation was and how you got involved and what your petition was asking for?
John Neary 04:05
You know, it's hard 15 months later to remember exactly what things were like in March 2020. But there was just this unprecedented sense that everything in the world that we take for granted is changing so rapidly. And that all across society, conventional ways that things were done had to be changed radically overnight, in the face of this pandemic, that threat to public health and to the function of society. And I think, you know, people like us in the medical profession saw this thing even more acutely than most people because it affected our work life, as well as the basic function of society. We were hearing stories from overseas from countries that had been hit more quickly than we had about retired nurses being called back to work, about pathologists being pressed into service and ICUs, to working under intensivists doing some simpler frontline tasks. About massage therapy students being rushed into practice and that sort of thing. There was a sense out there that a lot of rules for how things are done in peacetime, if you will, were being temporarily suspended or reconsidered in the face of this crisis. I don't have a leadership role in residence education right now. I used to have roles in that system, I stepped away from them a couple of years ago, when I became division director here at McMaster. But I do a lot of clinical teaching. And I try to keep my ear to the ground as to what's going on. And there was certainly a sense from people I talked to and people who I followed on social media, that the initial response from the Royal College to the pandemic last March didn't reflect either the gravity of the situation, or the really pressing need to give these trainees a pathway to full certification on the timeline that the rest of the system required. So a lot of people finishing their final year of residency training, who were due to finish their residencies in June, required certification by the Royal College, in order to get independent practice licenses. In order to get hospital based physicians, in order to start the fellowships that they'd matched to in July. And the notion that the examinations would be postponed indefinitely, and that people wouldn't have a pathway to certification struck me as, you know, unfair to these exam candidates, but also inadequate in terms of the social need to get these young and highly skilled and energetic and motivated physicians into practice during a healthcare crisis. Now, the first day of the pandemic turned out to not be quite as much of a crisis in Canada, as it looked like it might be, but that certainly was not apparent in March.
Ameer Farooq 08:02
Right. So again, to put it in context, the written exam, I think was about to be, or we were about to write it at the end of April. And that's when the Royal College said that they were going to postpone the exam and there was no real kind of idea at that point when it would be rescheduled.
John Neary 08:26
For context there, I mean, if you look at some of the other health professions, I mean, the Canadian physiotherapy exam that was due to happen last fall. The last time it happened, was I think, November 2019. There has been no opportunity for graduating Canadian physiotherapists to do their practical exam to get an independent practice license since November 2019. So that's the kind of situation that was potentially on the table for physicians and surgeons finishing residency in Canada.
Ameer Farooq 09:03
And for our non-Canadian listeners, the Royal College certification is sort of everything, right? Like there's no oversight necessarily from the provincial governing bodies in terms of who can practice. It's all about, like, if you have your royal college exam certification, that is what sort of certifies that you're allowed to practice.
John Neary 09:26
So, that's a really interesting question Ameer. And healthcare in Canada is regulated at the provincial or territorial level, with 10 provinces and three territories. And I'm certainly not familiar with all the details of legislation, regulation, nor do I have any legal background whatsoever. But broadly speaking, the provincial licensing authorities which are often known as colleges, which have the legal authority to issue medical practice licenses in each of those jurisdictions, most or all of them, are required by legislation or regulations issued by those provinces or territories to require certification by the Royal College of Physicians, Surgeons of Canada, or the college of Family Physicians of Canada, which are the two examination authorities, as well as licensed here by the Medical College of Canada, which we'll get to later. In order for someone to be granted a practice license. So, the requirement for certification by the Royal College is enshrined in law by many of the provinces. And in principle, the provinces and territories could have changed that legislation, those regulations. But that would have required, you know, up to 13 legislatures to take on that work. And, you know, they had other things on their mind.
Ameer Farooq 11:01
Right. I mean, again, it's hard, as you pointed out, it's very, very hard to remember what a crazy time that was back in April and March. And it's fun to listen to, you know, other podcasts and things like that, that were dated from that time, because you realize how little we actually knew about COVID-19, even 15 months ago. I mean, the vaccine, right? Like we didn't know when that was going to be. It's just a crazy period of time. So, your petition, can you sort of spell out like what exactly you were asking the Royal College to do? And what sort of motivated...or like, what were you hearing from residents that made you want to put together such a petition?
John Neary 11:42
I'm actually gonna correct you on one point there, which I think is important, in terms of anyone who is interested in doing this sort of advocacy work within the profession. I think it's a critical point to understand. It wasn't a petition. It was a motion from members of the Royal College for a formal special meeting of the members to vote on resolutions that would require the Royal College as a corporate body to take certain actions. And I think that's really key here. Because there have been a lot of petitions during this pandemic. And it's not that petitions have no power. I think if you step back from it, these organizations, the Royal College, the Medical Council of Canada, they exist, and they have the power they have in part, for historical reasons, but you know, in part because they seem to have a certain social legitimacy. And I think, you know, if there was enough of a crisis of faith in those institutions, if they were seen to be illegitimate, then that could prompt changes in that legislation, or regulation. I think we've seen that more recently at the Medical College of Canada, where they were getting such harsh criticism over the problems at the MCC QE-II last month, that they had to back down. I think they were afraid of having their enshrined legislative role removed. But that sort of social political power is hard to exercise. But the Royal College in law is a member driven organization. Everyone who isn't FRCPC or FRCFC, is a member of that institution. And the members ultimately have the authority over the function of that institution and the bylaws of the organization that provide a pathway whereby a sufficient proportion of the members, I think it was 5%, could request a special meeting to vote on resolutions and that meeting would have to be granted. So, the resolutions that we asked to subscribe to called for the creation of a special onetime pathway to certification. And we laid that out in a sort of cascade of options. That would either include an attestation from the training program, that the candidate was ready to practice, possibly based on the review of iters plus a written examination or if the Royal College couldn't administer an online examination quickly enough, just the adaptation from the program. And by the way, I will freely admit here that when I wrote these resolutions with input from a couple people, we had completely forgotten about IMGs, which I'm quite ashamed of, and just have to acknowledge. And finally, if they couldn't, you know, if their own house couldn't pull off either of those two things, and they would simply have to certify everyone who was exam eligible, based on exam eligibility alone. And we put that one in, simply so that, you know, if we got enough signers on these resolutions and had the meeting and passed the resolutions, then they would have no way out. They wouldn't be able to say, well, it's too late, we can't do this. You know, if they couldn't do either of those two things, they'd have to certify everything.
Ameer Farooq 16:09
This motion, it quickly gained a lot of traction. Like I think, you know, it was very quick for you to get the number of members to actually sign up, like enough members to actually sign on to make this motion proceed. Is that right? Like, I think it was a couple of days?
John Neary 16:28
We got up to something like 2500, within about a week or so. You know, and that was all based on some sharing on social media. And, you know, people imagined sharing through email and such. There was no organized campaign. It was just a few of us tweeting in our spare time, and then people amplifying that.
Ameer Farooq 16:53
Right. And it created a big conversation, I think. One, obviously, about the pandemic and how we were going to respond to that. And the spoiler alert here is that this did not pass, right? And ultimately, everyone did have to write their exams, although in a slightly different fashion. Like, none of us I think had to do an oral exam. We did do a written exam eventually in September, but not the oral exam. But I think the interesting part about this was one is sort of, it raised all these questions about how we would respond to the pandemic, and what the best way would be moving forward. I think the other equally interesting thing about it was sort of like the whole question around certification and the role of the exam in certification. You know, like a lot of people said, well, if residents had their fighters - fighters are the end of residency sort of evaluations - that once your program director signs off on, theoretically, that means that you can go out and practice independently from their perspective. But a lot of program directors said those fighters don't really mean a whole lot, and that they don't really, you know, they're not enough of a check to say that someone is fit and qualified to go out into practice. So, I'm curious about your thoughts on both fronts? Like, what do you think that this whole kind of issue raised about, perhaps how we should respond to the pandemic in this type of situation, and secondly, the nature of the exam itself and what it's trying to achieve?
John Neary 18:30
Thanks, Ameer. I think the timing of the pandemic was really important in terms of what we proposed in these resolutions. I think if the pandemic had reached Canada, in, say, December 2019, I think we would have looked at this a lot differently, because first of all, there would have been more time to find a solution to the examination problem. But secondly, I think the impact on trainees and on the examination process and the precedent setting value of it would have been very different. We framed this very consciously as a call for a one-time pathway. And ironically, a year later, large parts of Canada were facing larger waves of the pandemic causing at least as much dislocation now in their system, I'd say because of poor governance and other domains have nothing to do with medical licensure. But, you know, at the time, we saw this as a problem that was going to affect precisely one cohort. And this cohort of, you know, I think one of the values of the certification exams is simply that they compel people to do the hard work of learning all the content that's going to be examined. And I remember feeling knowledge wise that I was a far better internist, right at the time that I wrote my exams that I had a year prior. And that wasn't just because of spending an extra year of residency, it was because of all the deliberate studying. I think that's broadly the case that people study leading up to those exams in a way that they don't necessarily have time in their career. But they've largely done that. Like they've done a lot of that work by the time this was happening. So, I didn't think that changing the exam format was going to change how that cohort would prepare. They've done a lot of that preparation. And I didn't think it was going to set an important precedent for future cohorts, because this is such a singular, one off situation. I don't think exit exams for medical and surgical specialties are an unreasonable step in education and certification, I think they're very sensible steps in peacetime. I think when you have this sort of unprecedented social crisis, and you need this health care workforce, to be doing their work, and entering practice and not spending all their time, you know, dressing up the final minutiae for their exams. It's appropriate to have different standards in that seemingly one-time situation than you would every other year. I think if you look at the history of assessment in the medical profession in Canada, it's changed over time as circumstances have changed. In medical education, it was accelerated during the Second World War because there was a need to get people into practice in the forces. I think there's a bit of an analogy there. So no, I don't think these exams are illegitimate fundamentally. You know, if the college was unable to deliver an online written exam in May of 2020, I think that would have been, you know, a very central process, they couldn't do it. When you get to the MCC QE two, that's a very different question. But I think that you want to talk about that later. With regards to the fighters. Again, I'm not an expert on every specialty and every training program in the country. But I think there is a general sense that fighters aren't a great assessment of readiness for practice. On the other hand, a lot of these exams have passed rates, of well over 90%. My understanding is that many of the exceptions that are surgical specialties. So, I think this is probably a more complicated question in surgery than in many other specialties.
Chad Ball 22:58
I really like so much of what you say, and I reflect and think back to my own exam, like yourself, and like Ameer. And, you know, you're exactly dead on. I mean, I remember leading up to that exam and having, you know, a couple of weeks off just to sleep a bit and study and come off the call schedule. Certainly, there were, you know, faculty who are now my partners, who were sort of critical of that, you know, each year. And I remember thinking that and having a little bit of that insight at the time, like the reason to do that has nothing to do with the content, because to your point, we'd all studied for, you know, a year and we'd done that work. It's just the drive, the motivator to consolidate that knowledge at a time, you know, and a place that you would never do it without that, whatever you want to call it fear, preparation deadline date. You know, and that's really how I personally look at the exam in its entirety.
John Neary 23:56
There's actually no exam. And you can swear everyone to secrecy when they show up at the Royal College, you know, there's no exam here, we just wanted you to study. That would get a lot of the point accomplished. Not all of it. I mean, I think again, in peacetime, I think the exams do have an important role for identifying the odd person who's not safe to practice. But yeah, I think there's a balance of benefits and harms here that swings in a different direction during a pandemic.
Chad Ball 24:28
Yeah, it's well said and it's also interesting to contemplate, you know, your mention about surgery and interventional fields in general, I think. Probably there is something that's maybe a little different or is worthy of deeper thought there. And, you know, historically, you would always sort of hear people say, well, so and so would pass the exam, but boy, I wouldn't let them operate on me or I wouldn't want them operating on my family. So, there was always a disconnect between the didactic component, the knowledge component, and then the actual interoperative technique as well as perioperative decision making. And that is interesting. And I would think that, you know, a five-year evaluation by a reasonably common residency program would certainly handle or have a good sense of your technical and perioperative decision making as opposed to the content of the exam. So, you're right. I mean, it is a multifaceted question. I'm curious, for you personally, you know, in your leadership position in the GIM world, what were some of the individual sort of stresses that you saw amongst a lot of your trainees? Because I'm sure they interacted with you in a very special and probably different way than a lot of us who were quieter and maybe inappropriately so. Certainly, weren't leading the charge like you. I mean, I think a lot of us listening that have passed our exams have been working for a while. You try and think back, but it's a little bit lost. And, you're trying to have sympathy and empathy for that scenario, which sounds horrific. But I'm curious, what sort of stresses that you helped deal with and that you saw yourself?
John Neary 26:20
That's an interesting question, Chad. I mean, pretty quickly, once the steps started, I was actually in touch with a diverse group of residents from across Canada. From many different specialties, you know, not predominantly internal medicine. In fact, there was, if anything, the surgical specialties may have been overrepresented among the people who I heard from and spoke to a lot in the weeks after we published these resolutions. The internal medicine PGY-3s were actually in a less precarious position than most other string examination candidates, because this wasn't the final exam for them. This was an exam for their IM certification prior to their subspecialty residencies, most of which are two years long. And in fact, that sort of core IM exam used to happen in PGY-4, in their first year of doing cardiology, or endocrinology, or whatever. And it was moved into the PGY-3 year in part because the attention that they needed to pay to their studying during the PGY-4 year was thought by the specialty programs to really distract them from learning a subspecialty. You know, and as well, often too late for them to apply that knowledge they're studying. So, they moved into PGY-3.
Ameer Farooq 28:04
Yeah, it was a stressful time. As someone who went through it, it definitely was a challenging thing to work through. And I think it was important for me to remember my struggles in some way, were dwarfed by, you know, the society at large and what everyone was going through, and I tried to keep that in mind. But it's certainly not easy when you're about to start your fellowship, or as many of my cohorts were doing, when you're about to start your practice and you have this exam looming over your head. So, it's not something that really should be underestimated. So again, I think that's part of the reason why we were so grateful that you were, you know, more than anything, just the fact that you were willing to kind of just say and acknowledge that this was a tough thing that people were going through, I think that made a huge difference. And, you know, rather than sort of everyone saying just deal with it, you know, we had to deal with SARS, so you should be able to deal with this too. I think the fact that someone was willing to kind of just go out there and say, hey, this is a very challenging situation. What about considering doing something like this?
John Neary 29:12
You know, it's funny you say that. I was a first-year med student during SARS. We lost our entire neurological clinical skills curriculum to SARS. And we never made it up. Like we never made it up. So, maybe I remembered that on some subconscious level. I want to follow up on something I think you said earlier Ameer, which was that, eventually we got enough signatures for these resolutions. And that led to a special meeting and the resolutions were voted down. So, the movement failed. I sort of bring that back to something you said earlier about the tension between the sort of, not quite legal, but you know, very formal rules-based nature of these resolutions, and the sort of more amorphous social pressure. You know, that is really all that's going on when people write petitions and that sort of thing but was also part of this. We didn't win the victory we wanted to win here, which was to certify people in the spring. You know, I think some things were accomplished here. I think when we had enough signatures to call the special meeting, although in the end, the Royal College that there weren't quite enough signatures, and some were invalid, but they said they'd call the meeting anyway. I think the threat of the special meeting, and of the members learning that they actually had this power, that they could take control of the institution if they wanted to, helps push the Royal College to make some concessions. The big one of which was to cancel the oral exams, and at least verbally commit to finishing the written exams in the autumn. And, you know, I don't know, but I think it's possible, the written exams wouldn't have been finished in the autumn if they hadn't been so frightened of this movement in the spring. I don't know that. At the MCC, and say, the physiotherapist. You know, it's not clear that certification exams were necessarily going to happen in the autumn of 2020. You know, I think the other thing that I'm gratified by, out of what happened last spring is that I think a lot of the graduating residents and other exam candidates learned a lot of lessons about how our regulatory system works. And I hope, in the decade to come, are going to be pushing for change in these institutions. So, they'll be more responsive to social needs and the needs of trainees, both in peacetime, and the next time there's this sort of singular event.
Ameer Farooq 32:35
Yeah. And, you know, to be clear, I don't envy the position that the Royal College was in. This is certainly not something that anybody I think, was prepared to handle or to know what to do. But I echo what you're saying that I think it's on all of us also to now realize that if we want things to change, then you know, you do probably have the power to do so. But you have to be able to become involved, just like you did, and actually put yourself out there and try to do something if you want things to change in a substantial way. You know, you mentioned we've kind of been dancing around the idea or the topic of the MCQE part two. So just for our listeners, before we kind of dive into that, can you explain what the MCQE-II is, and kind of how that fits into our medical training?
John Neary 33:31
For sure, Ameer. I'm going to need to give a bit of a history lesson here. Although I'm no historian, but my dad's a historian, so I kind of grew up with this stuff. So, my understanding of the history here is up until about 1911 or 1912, every province had its own medical licensing exam. And these were just general medical licensing exams. We didn't have the same concept of specialization. You were licensed as a physician. That was it. And if you wanted to, you know, if you practice in one province and wanted to practice in another, you had to go and do their exam, which made things very difficult for practitioners. It's still that way. The law, like every province has their own bar exams. You can't just move from one province to another and apply for a license. The Medical Council of Canada was established at that time to create a national licensing exam that all of the provinces would subscribe to. And that was a very worthy endeavor at that time. And that's the exam that's now known as the MCCQE-1. It's a written exam. It's online, but it's not an oski that people do right after finishing medical school. Now that exam used to get you a general license. Then in 1929, the Royal College was brought into existence to certify people for specialty practice. The number of specialties grew over time. And then the College of Family Physicians came into existence in the 1980s or 1990s. And at that time, the general practice license was abolished except for existing practitioners. So now in order to practice medicine in Canada as a New Entrant, you need to be certified in either one of the Royal College specialties, or in family medicine, which is also a specialty, which is regulated by the College of Family Physicians in Canada. There is no general practice license. Before that has happened at some point, the Medical Council of Canada had brought in an oral exam, or Oski, called the MCC QE-II, which people had to do after finishing their one-year rotating internship in order to get that general practice license. So that was the sort of exiting internship exam that would let you practice medicine, if you weren't then going to specialize. When the general practice license was abolished, they kept the MCCQE-II. And when the rotating internship was gradually abolished and converted into, you know, the first year of whatever your residency program is. The structure of medical education moved farther and farther away from this generalism at the beginning of residency, which again, was then called internship to a sort of direct entry into your specialty practice, that this exam persisted in the second year of residency. And it has less and less connection to what people are doing at that time. You know, people who, again, are going to be pathologists, and they're, you know, in their second-year residency, all they're doing is pathology. And they have to spend a weekend doing this exam that's about obstetrics and pediatrics and internal medicine and population health. And it doesn't get you anything, except that you need to pass it in order to get your practice license when you finish your residency. So it used to be your general practice license and now gets you nothing. You know, I think to have that sort of Oski at the end of medical school, would have a certain legitimacy, but to have it in second year residency just makes no sense. And everyone knows it makes no sense. And so, when the Medical Council of Canada was having trouble administering this exam, the discourse that was going on within the profession, which I wasn't leading, I mean, I had, you know, I weighed in from time to time, but I wasn't a leader in that discourse. It was different to what was going on with the Royal College. I think the even the most harsh critics of the Royal College, and I wasn't one of their most harsh critics, you know, would generally say things like, you know, this exam format needs to change. And if you can't administer it quickly, during this unprecedented pandemic, then you need to waive it for this cohort and let them through. Very few are saying things like this exam is illegitimate, it has no necessary role in education and certification. But people were saying that about the MCCQE-II. They were saying, this is an exam that exists for historical reasons. It has no legitimacy in our education process. And a lot of you are going further and saying this is purely a money grab.
Ameer Farooq 39:00
Right, you know, like, I think we all remember doing the LMCC part two and, you know, having to prepare for things we would never have to do ever again. Like I remember my scenario being something like, you know, advising that you're the mom of a child who you think the child is not exercising enough or something like that. And really the exam was, it seemed a lot more to be almost about like knowing how to do these specific kind of communication techniques, you know, that you could be empathetic of and talk to a patient well, than really about any kind of medical knowledge per se. I mean, I think there were a few stations that did involve some basic kind of medical knowledge that you need to know how to treat a sick patient. But you know, certainly a number of stations seem to be more about communication than anything else.
John Neary 39:55
I think that's an accident. I think they very consciously in recent years tried to reframe this as being an exam on the non-medical expert CanMEDS roles, you know, to sort of frame it as being these general competences that are unrelated to what your specialty is. But, you know, first of all, they haven't exactly done that, because it does still test you on, you know, all these different areas of specialty practice. But, you know, no one except family medicine will be doing all of them. And secondly, you can't actually test people on those things usefully in a sort of generalist way, when they're all in their specialties. Like you can't test pathologists on their communication skills in scenarios that have nothing to do with pathology. It makes no sense.
Ameer Farooq 40:45
I guess the question or the thing that people would always bring up, which is sort of a moot point now that the MCC has canceled the exam or gotten rid of it. But, you know, I think the perennial thing was that it was seen as a way to sort of ensure that there was a minimum bar for Canadian physicians in terms of how they would interact and how they take care of patients. And I think many people saw this as a way to make sure that particularly IMGs were meeting a certain minimum standard. How do you sort of think about that?
John Neary 41:21
So those are two interesting, I think, broader different questions Ameer. I thought about this a bit last week, in preparation for this conversation. And they are thinking about the way that medical (I say medical, and of course I also mean surgical) medical, broadly, education in Canada is structured. If you think about other professions, they're organized very differently from ours. Take dentistry, for example. I mean, you don't do dental school, and then dental residency. Well, a few people do. If you want to be a periodontist, or prosthodontist, you do X training. But you go to dental school, and you get qualified as a dentist. There's no sort of necessary reapplication in the middle of that training. Medicine is very unusual in that you do this three- or four-year program that gets you a degree, but no practice license. And then as a mandatory step, you have to then match to a second phase of training in one or another specialty, which only then gets you a practice license for anything at all. And that's not the way medicine was historically. It's the way it is now. I mean, I guess, to take that analogy if you will to its breaking point. I think if you were going to completely tear down the structures of our profession and the structure of how we educate people in rebuilding from the ground up with no reference of what we had historically, I'm not sure you'd start with everyone in the scope of what we now consider medicine and surgery - doing four years together, and then branching off. I could see a system where, you know, after an undergraduate degree, or some sort of one year, like preparatory Health Sciences professional starter year, people might be studying immediately to be psychiatrists or orthopedic surgeons or family physicians. And there would be no question about the sort of generalist exam at this somewhat artificial cut point in training. You know, with the structure we have, I'm not saying that would be better, I'm saying it's plausible that it could work that way. And when you look at you know, newer health professions that have more recently become recognized by the state, like Midwifery, you know, they have a singular organization of their education. They don't have this cut point in the middle. With the organization we have right now, if the MCC QE or an exam of that nature is important for assessing some general safety to practice or generalist competencies or non-medical expert competencies, it should happen after med school, not in PGY-2. That's the simple answer. Like right after med school is a sensible time to assess those things.
Chad Ball 44:44
Yeah, that's a very good point. You know, it's interesting to reflect a little bit based on what you've said about the American Board of surgery and look at the training paradigm and how it's shifting. You know, the traditional five-year surgical residency, which you know, then you do your American board or your Royal college exam and go onto fellowships as you know, from one to three years beyond that, is in the process of really changing. So, in the US the American boards plan, it's for you to do a general surgical experience. That's three years, at which point you then enter one of five pathways. Could be HPB and oncology, it could be trauma and acute care surgery and so on. And there certainly is a lot of... that does make a lot of sense to me on a lot of different levels.
John Neary 45:30
We see it in medicine too you know? Where I mean, neurology used to be an internal medicine subspecialty. It spun off at some point. They no longer do their IM boards. And, you know, I don't think anyone's questioning why neurologists no longer do their IM boards. Those in vascular surgery no longer does the general surgery boards, because it's now a direct entry residency. So, changes of this nature have been made in different places, from time to time.
Ameer Farooq 45:57
What I'd be really interested in asking about is, if you had to be the one kind of redesigning things, and coming up with a system for how to deliver exams that really actually tested people's competencies, let's say, starting at the medical school level, you know, how would you sort of design that? You know, and in particular, what I'm thinking about is, do we even need a national examination across Canada that tests all medical schools, given that most medical schools are pretty equal? And then, you know, the second thing is about the specialty exams, and particularly I'm thinking for the, perhaps more procedural ones, how do we make sure that we continue to make really strong candidates kind of after thinking about all the questions around fighters and the legitimacy of evaluations to begin with?
John Neary 46:52
If you were going to set any sort of generalist examination to test the medical school examination curriculum broadly, I think the logical time to do that is around the end of medical school and not during residency education. I think that's the deepest problem with the MCC QE-II. I think I'm not convinced we actually need that within the Canadian system right now. The pass rates of the MCC QE 1 and 2 for CMGs are both very high. I don't think it's clear that failure on those examinations leads to intervention. Nor do I think that the studying people do before those examinations is really important for their long-term skills development. It's not at all comparable to how people study for the royal college exams. And I think in assessing the need for any of these sorts of examinations, you need to look at the benefits and the harms and the harms of imposing another examination on trainees both in terms of financial cost, the effort it entails, the psychological stress during very demanding training programs. These things aren't trivial. I think about this, earlier, with the royal college exams, I forget how this came to my mind. But I thought for a while. And when I helped with oski development for our program at McMaster. Why are all these conventions, like exams, closed book? Why can't you look something up during your exam if you want to? I mean, it will take time. That might not look good. But if you want to look something else, why can't you? And that's the world we live in. But even beyond that, I mean, the nature of these oral examinations, where you're doing one thing at a time, really doesn't replicate the nature of medical and surgical practice. So, I mean, I think there's a lot of things that can maybe optimize about exam technique, but I think this structure of didactic written exam plus some sort of practical exam for exit from a specialty residency is fundamentally legitimate. You asked earlier about competence based education, and no excellent surgical education. I think it is a more useful construct in surgery than in other branches of medicine. I had to do an EPA the other day for a fellow who worked with me for six months in clinic, and the competency was managing a GI on clinic. And I'm like, come on guys. This isn't an EPA, you know, evaluating how you ran this clinic for six months. That's an either. I didn't have an existential problem with the royal college exams. I thought there was an intervention that was needed last spring. I'm glad the MCC QE-II has been eliminated because I think it was a very silly thing to put people through in PGY-2. And if this leads them to try to improve the MCC QE-I, well, we'll see what that looks like.
Ameer Farooq 50:47
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your comments and feedback. So, feel free to email us at [email protected] or connect with us on Twitter @CanJSurg. Thanks again.