Tricky exam questions

It’s your lucky day. A sympathetic doctor on your firm divulges the contents of a station in the objective structured clinical examination. What do you do? Do you guard the valuable information to your advantage? Do you share it with others out of fairness or loyalty? Do you tell the head of examinations about the leak? This dilemma really occurred, I heard from a friend, and the students kept the secret.

Medical students, more than any other students, are experts in examinations. They sit them every few weeks. So it is not surprising that they have developed strategies to make them less stressful. Some are straightforward, such as developing a detailed revision schedule. Others are more underhand. One strategy is to analyse past papers to spot questions or topics that may appear in future exams. Another is to listen carefully to lecturers who, deliberately or unintentionally, may leak details of a forthcoming examination. A lecturer might remark “make sure you know the clotting pathway inside out” or “the new Mental Capacity Act could well turn up in exams.” Some bold and hopeful students ask lecturers outright what will be examined. For students, failing exams can be deeply distressing. For lecturers, failed exams are a nuisance for different reasons: they make you wonder if students care about your subject and whether your teaching is any good. Worse still, it may mean hours marking the scripts of candidates resitting the exam. In short, when students pass, everybody wins.

Who is to blame?

Students, lecturers, and medical schools each have responsibilities about exams. Students should make an effort to pass—and do so without cheating. Lecturers should prepare students for exams and write new questions. Medical schools should have a fair, rigorous examination system that will produce safe and competent doctors. In the dilemma mentioned, all three parties may have been at fault

The well intentioned doctor should not have leaked the information. However kind and harmless such a disclosure may seem, it is unfair towards those students who are not tipped off. Also, it may lead students to focus on the examined topic to the detriment of other areas. This could have adverse knock-on effects on the care of their future patients. Anyone can pass an exam if aware of its content in advance. It becomes a test of memory rather than understanding. The disclosure also sets an undesirable precedent: students may expect the doctor to divulge again in the future. They may expect other lecturers to also provide hints: “But Dr Jones gives us clues!”

Medical schools, in training their teachers, should stress the importance of not releasing exam details, whether in lectures or on placements. Such disclosures defeat the purpose of examinations. They may lead to undeserved prizes and excessively high average scores for the year group. The candidates immediately below the average could rightly feel cheated.

Recently a third year medical student from a prestigious UK university dismissed medical ethics and law exams as easy because so many of the questions were recycled from past years. The particular medical school is responsible for this laughable situation. It takes time and expertise to construct exam questions, and, in a bid to save money, the school refuses to recruit enough academics to replenish the pool of questions. If students are permitted to peruse past papers, studying the pattern and content of old questions is a legitimate exam strategy. Acting ethically does not preclude finding ingenious ways to gain an advantage. It is the medical school’s responsibility to ensure that exam papers contain new and challenging questions.

A murky situation

For students in possession of leaked exam details, the situation is murkier. They may be torn between their desire to do well and their reluctance to use information that they are not expected to possess. If the exam is finals, sharing the information with others may reduce their chances of obtaining a prize and brightening their CV. In recent months, some junior doctors applying for jobs in the UK have benefited from leaked questions and marking schemes unavailable to other candidates. Faced with fierce competition and life changing outcomes, many candidates resolved the conflict between self interest and fairness in a predictable manner. They chose the former and kept quiet.

If the exam is not ranked, the students may be tempted to share the secret with friends and even the whole year. A few moral saints may decide that the leak undermines the validity of the exam and should be reported at once to the examination authorities. There is no neat solution to these types of moral dilemmas. Although it would make decision making easy, providing an absolute injunction, such as “always tell the authorities” or “always use it to your advantage,” is not sound advice. Many factors are involved, and students will need to exercise judgment in deciding which course of action is most appropriate in that particular situation. Moral problems do not occur in a vacuum, and contextual features usually play a big role in determining the right action. One way to examine the problem is to think in terms of consequences, duties, and virtues.

An ethical framework

Students will need to consider the consequences, good and bad, short and long term, of each alternative, and for each of the relevant parties, including students, teachers, the medical school, and future patients. In deciding with whom to share the information, they will need to ponder on whether they have duties to their friends, their colleagues, their teachers, and themselves. If these duties conflict, they will need wisdom—an admittedly nebulous property—to decide which duty should trump the other. If others are in the know, they can discuss the best course of action collectively. How substantial is the leak? How was the secret information obtained? How important is the exam? Is withholding the information unfair and why? They can ask themselves “What would a kind, honest, and just medical student and future doctor do in this situation?” and “Will we feel bad if we use the information and get a brilliant result, even a prize?” If the answer to that last question is yes, students should ask themselves why the success would be tinged with guilt. If students have a role model, they can reflect on what he or she would do in the circumstances.

Sometimes, there will be several morally acceptable solutions. You could tell the exam authorities about a tiny leak, revealed as a passing remark to the whole year in a lecture, affecting part of one question in a minor examination that counts for nothing. Or you might think that it is so insignificant that it does not merit such action. Either way, you might have sufficiently good reasons to defend your decision. One exercise, in testing the strength of your defence, is to image that you are in front of the university or the General Medical Council’s disciplinary committee. Would you feel comfortable defending your action? This exercise should help reduce the distorting influence of bias.

At other times the answer will be obvious. You must tell the exam authorities because the information was obtained in a totally illegitimate way—stolen from a lecturer’s office, for example—and held by a dozen close knit students. The information may concern a large part of an important exam and may have considerable repercussions on the final ranking of candidates. This injustice could have implications for the careers of several candidates, by giving them grades that overestimate or underestimate their relative ability. Also, by removing the need to revise other areas, the future patients of those dozen candidates may be at increased risk of harm. Any countervailing reasons, such as the need to perform well or to please your anxious parents, are unlikely to outweigh the reasons for disclosure.

Acting morally can be demanding and put you at a disadvantage, but morality requires us on occasion to make hard choices, and this is where courage, integrity, and other virtues are helpful. Raanan Gillon, an eminent professor of medical ethics, recounted the time when as a medical student he was asked by his consultant to conduct a scrotal examination on a patient. Five students had already examined the patient’s scrotal lump and Gillon could see that the patient was uncomfortable and embarrassed. Although he knew it would upset the consultant he refused to perform the examination. Knowing what to do is one thing; acting on it is quite another.

When exams loom large

The use of dubious exam tactics, although undoubtedly a problem, obscures a larger issue. In medical schools and elsewhere there is an unhealthy obsession with exams. Much of a student’s time is spent revising. In lectures many students care about only what will appear in the forthcoming exam. Ever looming exams stifle a genuine desire to learn in favour of a targeted, fact learning approach. For good lecturers, who want students to appreciate the richness and complexity of their subject, this single minded attitude destroys the joy of teaching. If passing exams is the sole purpose then why not give handouts and abolish lectures altogether? “Universities should teach students how to think,” one of my professors once declared. Exam obsession does not promote this aim. It encourages rote memorisation at the expense of true understanding and reflection.

I doubt fewer exams will make doctors less safe and competent. But it is likely to reduce stress in medical students, which is what fuels the need to find underhand ways to pass incessant exams. Stress will inevitably remain, and may indeed increase around examination time, but it will be for only a brief period. Harsh as it may sound, students unable to handle some stress should reconsider their career choice, lest they become patients themselves. The practice of medicine is a stressful endeavour.

For students and lecturers fewer exams will allow more freedom to explore the riches of medicine and instil a deep rooted rather than superficial interest in their subject. Exams are necessary in higher education, but to paraphrase the 16th century physician Paracelsus “too much of anything can be a poison.” Exams are poisoning contemporary medical education and the antidote is simple: fewer exams and more faith in students’ ability to learn without the threat of exams.

I thank Samantha Hettige and Ronald P Sokol for their helpful comments on an earlier draft.

Competing interests: The author is a lecturer in medical ethics and law at St George’s, University of London.

Provenance and peer review: Commissioned; not externally peer reviewed.

   

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