“One hundred and eighty-five”. That was the answer to my question.

The question, that I’d posed somewhat naively to our intrepid assessment coordinator, Amanda Consack, was “how many assessments have the 2015 class undertaken during medical school?”

“Do you mean everything?” she asked.

“Yes. Everything, I answered, not wanting to sound wimpy.

In her typical fashion, Amanda provided me not only with the precise answer, but also the following breakdown by type and curricular phase.

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Seems like a big number. Given that our curriculum spans a total of about 140 weeks, this means our graduates have been examined, in one form or another, an average of more than once per week during their four-year program. Closer examination reveals a somewhat less ominous picture. The 32 RATS (Readiness Assessment Tests) and 41 Quizzes are very low stakes methods used by our Course Directors to review course material. They’re therefore used as Formative assessments (to guide student learning), as are the 19 mid-terms utilized by most of our first and second year courses. The 37 “Assignments” and 7 mini-Scholar exercises, also have a largely formative role, and used primarily for teaching the Integrated Roles (non-Medical Expert Competencies). The major sources of Summative Assessment (for the purpose of ensuring students have achieved curricular objectives) are the end of course finals, OSCEs, NBME examinations and ITERs (In-Training evaluation reports) used in the Clerkship. Most of this apparently burdensome assessment load, therefore, is for the purpose of informing our students and curricular leaders as to the effectiveness of the learning process.

Nonetheless, 185 is a big number, and one might reasonably ask, “Why?” Is all this worth the considerable effort, expense (on our part), and stress (on the part of our students)? Do all these assessments make for a better-educated, more practice-ready graduate?

On one side of this issue is the “assessment drives learning” camp, which feels quite strongly that students must be led to the appropriate learning by their intrinsic desire/need/compulsion to succeed in examinations. This approach actually takes advantage of the drive for objective and external validation that allowed our students to succeed in the highly competitive medical school application process.

However, many feel that this approach promotes purpose-driven learning only and fails to establish the “deep learning” necessary for career success. It also falls short of embedding lifelong learning skills that are so important to ensuring ongoing physician competence. This camp, which has both strong faculty and student support, would much prefer a somewhat more Utopian educational environment where faculty directs learning and trust that students will enthusiastically undertake their studies because it’s fundamentally important to their own educational goals, personal interests, and future needs as physicians. They are, after all, adult learners selected from the most motivated and academically accomplished young people our society produces. These folks will go on to argue that postgraduate programs, the Medical Council of Canada and provincial regulatory bodies will, down the road, provide more than sufficient opportunities to ensure they are qualified to do fill the roles they choose to engage.

Unfortunately, this controversy can’t be resolved on the basis of the sort of objective, controlled evidence we all crave. There are no randomly controlled trials, and we would prefer not to assess only half our class and wait a generation to evaluate the fallout.

But that’s not to say we lack evidence of student success.

The Medical Council of Canada, National Board of Medical Examiners, and USMLE all provide external examinations that our students undertake and which allow comparison to other Canadian or North American schools, and show that our students do quite well in comparison to their peers. The Canadian Graduation Survey provides our school feedback from our graduates as to their satisfaction and sense of preparedness for residency, and shows that our students rank their educational experience at or above Canadian means. Perhaps most importantly, our students do very well in the increasingly competitive postgraduate matching process, with the 2015’s matching their 2014 predecessors in achieving a 100% match, with most achieving their first choices. The more informal feedback we receive regularly from preceptors who encounter our students and graduates in electives and postgraduate programs is very favourable and leaves our curricular leadership with the sense that “we must be doing something right”.

travelWith regard to my view on the assessment controversy described above, I’ve come to feel that the purpose rather than the number of assessments is the key issue. In doing so, I’ve been drawn to the image of the Inukshuk. These are the elaborate arrangements of stones that have come to symbolize Inuit culture and are featured on the flag of Nunavut. I’d always assumed these were simply a native art form. I came to learn a few years ago from a prominent educator who I admire greatly that these are, in fact, cairns, left along migration routes in order to guide travellers to their destinations. In bleak and featureless landscapes, they point to the next step along the way. They also mark places

where provisions might be stored for the journey. They are, therefore, sources of both direction and nourishment. Our examinations, small and large, should do the same. They should provide encouragement to sustain the journey, and direct further learning.

And so, our 2015 graduates have truly encountered a series of milestones set along the way by a faculty that’s gone ahead, knows the trail, and is now intent on ensuring that those who follow will safely reach their destination. To our graduating students I would say that you have earned the right to be confident – confident in your knowledge, confident in your abilities, confident that your judgment and personal qualities will equip you for the challenges ahead. You are capable of being excellent physicians and, more importantly, excellent contributors to our profession and to our society. On behalf of all your proud faculty at Queen’s, I bid you safe travels.

 

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education