Replacing high-stakes summative examinations with graduated medical licensure in Canada.

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Publisher: CMA Impact Inc.
Document Type: Article
Length: 1,913 words
Lexile Measure: 1800L

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The COVID-19 pandemic has disrupted the medical assessment system in Canada. Examinations delivered by The College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (RCPSC) were delayed, cancelled or adapted. As these examinations are required for independent practice, this had a negative impact on trainees, supervisors and patients during a time of great stress within our health care system. (1) Although disruptive, these challenges provided an opportunity for change by unfreezing the historical approach to medical licensure in Canada --an approach that can be characterized as arduous, expensive, logistically challenging, poorly aligned with clinical practice and potentially biased.

The current medical licensure practices in Canada depend on high-stakes, standardized, summative examinations that were developed to uphold the medical social contract to guard patient safety and benefit society. (2) However, no evidence has shown that these exams contribute to this outcome. Although psychometrically sound exams provide superficial reassurance as a safety net that "catches" trainees who are not prepared for independent practice, the incredibly high pass rates of graduates from Canadian training programs suggest that this function is largely redundant. (3) In contrast with this approach, best practices in medical and continuing education support the use of competency-based assessments, guided by robust programmatic assessment models. Programs guided by these models employ frequent, low-stakes assessments within the clinical environment, along with specialty-wide or internally created local exams; such programs are being implemented throughout the medical education system, (4) and have resulted in increased assessment volume (5) and quality. (6) Although further evidence of competence in clinical practice may be required to maintain the social contract, licensing exams, as currently structured, do not provide this evidence.

The ongoing use of high-stakes examinations for licensure has numerous unintended consequences. Standardized exams test nonsalient variables and are at risk of biases (e.g., financial hardship from paying to write and attend examinations, structural racism affecting examination literacy and preparation) that may inhibit the movement of our health care institutions toward equity, diversity and inclusion. (7) The medical licensing process directs valuable and limited resources (e.g., time, energy, focus) toward passing an exam, potentially detracting from the more meaningful goal of preparing for independent practice. Moreover, the focus on a single high-stakes examination does not support the development of lifelong, self-directed learning. These exams can also increase stress among trainees to a degree that threatens mental health and wellness. (8) Lastly, the exams remain painfully expensive for both the trainee and the regulatory body, at a time when student debt continues to soar.

Although landmark changes have been made in response to vigorous advocacy and debate, (9) including the removal of the Medical Council of Canada's second qualifying examination from licensure requirements, passionate voices urge further modernization to increase flexibility and alignment with intended outcomes. A modern model of assessment for licensure that integrates both training programs'...

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Gale Document Number: GALE|A691484576