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Heads: A medical student completes their Bachelor of Medicine and Bachelor of Surgery (MBBS) degree after five years of mentally exhausting and back-breaking toil. They then go on to complete one demanding year of internship in a hospital. Now they want to start their clinical practice. The regulatory body of physicians has some other ideas though. It wants them to give yet another exam, covering the same subjects they have cleared during MBBS. When they think they have the right to be practicing independently, they have to study hard and undertake an exam again.
Tails: A regulatory body of physicians in the country knows the quality of medical teaching in the country is not uniform. The standard of training during internship also varies greatly. Yet, after attaining MBBS degree and completing internship, every medical doctor is deemed qualified enough to manage the patients without any supervision. The regulatory body, therefore, introduces a uniform licensing exam that every doctor needs to pass before starting independent clinical practice. It believes that only those who had attained a minimum acceptable level of competence will eventually be capable enough to pass the exam and thus be qualified to treat people.
Medical licensing examinations are considered a tool to gauge a doctor’s competence for unsupervised clinical practice. The National Licensing Examination (NLE) was announced on 24th September 2020 in Section 20 of the Pakistan Medical Commission (PMC) Act 2020.1 The idea was inspired by similar exams in many other countries.2 Fast forward more than one year, this exam still faces stiff resistance from many medical students and Pakistan Medical Association (PMA).3,4 Broadly, there are two main objections: The nature of the exam itself, and its applicability. The medical students deem it unfair to be asked to appear in another exam after obtaining their MBBS degree. Another point of contention is in including all current medical students. It is argued that only those students should be asked to undertake the exam that began their MBBS education after the PMC Act 2020. A petition filed in Lahore High Court to this effect was dismissed by the adjudicating judge, making it mandatory for all current and future medical students to pass the NLE.5
Is this exam really so flawed that it should be abandoned altogether? Is PMC justified in taking this exam? Are the concerns of the protesting students valid? Is there a middle ground in this conflict? Let us analyze the current format of the NLE and compare it with the two most coveted medical licensing exams in the world.
The NLE is designed as a two-step examination. The first step is the multiple-choice questions (MCQ) based theory component containing 70% MCQs from clinical sciences and 30% MCQs from basic sciences. A student has to pass this first step in order to qualify for the second Clinical Skills Examination (CSE). The CSE aims to evaluate essential clinical skills required by a general medical practitioner through a structured clinical examination. The students can appear in the first theory component only after acquiring their MBBS qualification. Both steps need to be passed in order to attain permanent medical license from PMC.6
The United States Medical Licensing Exam (USMLE) is the most well-known medical licensing exam in the world. It is a three-step exam comprising of Step 1, Step 2 Clinical Knowledge (CK), and Step 3. Step 1, an MCQ exam, is attempted by the local students at the end of 2nd year of medical education. It is designed to test the examinee’s aptitude to apply basic and integral science concepts to clinical scenarios. Step 2 CK is an MCQ exam that assesses the examinee’s grasp on the medical knowledge and understanding of clinical sciences that are considered essential for patient care under supervision. Local students appear in this exam in the 4th year of their medical education; passing this exam is essential to receive medical graduation. Step 3 is again an MCQ exam that assesses the candidate’s caliber to apply medical knowledge for unsupervised practice of medicine. This exam is attempted after obtaining medical graduation and passing the exam is necessary to practice independently in the US. After the decision to abandon the Step 2 Clinical Skills (CS) examination in February 2021, there is currently no clinical examination in the USMLE. International Medical Graduates (IMGs) need to clear Step 1 and Step 2 CK (not necessarily in order and at no fixed time) to become eligible for Step 3.7
The Professional and Linguistic Assessments Board test (PLAB) is a two-part exam taken by General Medical Council (GMC) of the United Kingdom (UK).PLAB 1 is an MCQ based exam that tests the examinee’s ability to apply the acquired medical knowledge to answer clinical-scenario based questions. PLAB 2 is a clinical exam that tests the candidate’s clinical and communication skills on standardized patients.8 Currently, only IMGs need to appear in the exam in order to practice medicine independently in UK. This is set to change from 2024; GMC has announced Medical Licensing Assessment (MLA) that both UK locals and IMGs will need to pass from 2024 onwards in order to attain the medical registration.9
It is clear from the above discussion that regulatory bodies in many countries including the US test their local students with standardized exam in addition to their medical college graduation. The UK has also announced a similar system for their local students from 2024. Therefore, concept of the NLE is a sound one, based on the international practices. The problem may lie in the format and timing of the exam.
MBBS curriculum is broadly divided into two categories: Basic sciences and clinical sciences. Basic sciences, as the name suggests, contain core subjects that are essential to understand the basics of human body. These include subjects like anatomy, physiology, biochemistry, pharmacology etc. These are typically focused more during the first three years of MBBS. Clinical sciences deal with more practical subjects like medicine, surgery, paediatrics, gynaecology etc. These subjects are given more emphasis during the final two years of MBBS.
The key to the deadlock may lie in the timing and curriculum of NLE. Currently, a student is asked to study all the subjects again after obtaining MBBS degree for the MCQ based theoretical exam.6 This means studying the basic sciences again, the portions of which they may have studied years ago. The exam may be divided into three separate portions comprising of a) MCQ exam of basic sciences, b) MCQ exam of clinical sciences, and c) a clinical skills exam. The idea is to take the exam when the students are actually studying the examined subjects, rather than taking it all together in the end. Table 1 demonstrates the proposed format and timing of the NLE.
TABLE I: PROPOSED FORMAT AND TIMING OF THE NATIONAL LICENSING EXAMINATION
NLE Step 1
2nd Year MBBS
NLE Step 2
4th Year MBBS
NLE Step 3
Clinical and Communication Skills
Structured Clinical Examination
5th Year MBBS
NLE=National Licensing Examination; MCQ=Multiple-choice questions; MBBS=Bachelor of Medicine and Bachelor of Surgery
Splitting the exam into the three proposed steps will be advantageous for all concerned, i.e. PMC, medical students, and the public. PMC will achieve the desired objective of assessing a physician’s competence before offering registration. Students will be appearing in NLE steps that will be covering subjects in accordance with their current/recent MBBS curriculum. This will reduce the burden for the students and make the exam more agreeable for them. The public will receive healthcare only from those doctors who would have proved their competence.
Heads or tails?
We win both ways!
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2. Archer J, Lynn N, Coombes L, Roberts M, Gale T, Regan de Bere S. The medical licensing examination debate. Regul Gov 2017;11(3):315-22. https://doi.org/10.1111/rego.12118.
3. Gabol I. Protest against NLE: 12 medics injured as police resort to baton charge, pepper spray in Lahore. Dawn [Internet]. 2021 August 30. [Accessed on: October 12, 2021]. Available from URL: https://www.dawn.com/news/1643376.
4. PMA to stage protests in districts against National Licensing Examination. Dawn [Internet]. 2021 June 14. [Accessed on: October 12, 2021]. Available from URL: https://www.dawn.com/news/1629189.
5. Court holds NLE applicable to students graduating after 24 September 2020: PMC. The Nation [Internet]. 2021 July 30 [Accessed on: October 12, 2021]. Available from URL: https://nation.com.pk/30-Jul-2021/court-holds-nle-applicable-to-students-graduating-after-24-september-2020-pmc#:~:text=Islamabad%20%2D%20The%20Pakistan%20Medical%20Commission,promulgation%20of%20PMC%20Act%202020.
6. Pakistan Medical Commission. National Licensing Examination for medical graduates [Internet]. 2021 June 04. [Accessed on: October 12, 2021]. Available from URL: https://pmc.gov.pk/Documents/Others/NLE%202021%20syllabus%20(June%204,%202021).pdf.
7. United States Medical Licensing Examination. Step Exams. [Accessed on: October 12, 2021]. Available from URL: https://www.usmle.org/step-exams
8. General Medical Council. A guide to the PLAB test. [Accessed on: October 12, 2021]. Available from URL: https://www.gmc-uk.org/registration-and-licensing/join-the-register/plab/a-guide-to-the-plab-test.
9. General Medical Council. Medical Licensing Assessment. [Accessed on: October 12, 2021]. Available from URL: https://www.gmc-uk.org/education/medical-licensing-assessment