A new national exam for medical students
Is it a move towards national standardisation?
All doctors wanting to practise in the United Kingdom will have to pass a new national licensing exam, starting from 2022. In June 2015 the General Medical Council (GMC) approved plans for the United Kingdom Medical Licensing Assessment (UKMLA). The exam will be taken by medical students on graduation and any doctor from overseas who wants to practise in the UK. The details of the exam are still to be finalised, but the GMC has promised it will offer a “straightforward and transparent route to medical practice in the UK.”
What exists now?
At the moment, only non-European medical graduates have to sit a licensing exam, called the Professional and Linguistic Assessments Board (PLAB) test, before practising medicine in the UK. The PLAB test consists of 200 single best answer questions and an objective structured clinical examination with 14 clinical stations. However, this is changing. The PLAB test is to be replaced by the UKMLA, but the major difference is that medical students educated in the UK must also take it. Previously, there has been no national licensing exam for UK medical students before becoming fully licensed to practise.
Why is it being introduced?
The GMC claims that the new licensing exam will lead to a system that is “fairer and more reassuring to the public.” It will provide a clear standard of competence that is required to practise medicine in the UK. The statement also suggests that the exam could be used to “help drive up standards” over time to create “an international benchmark test for entry to medicine.”
Another motivation behind these plans is to measure the variation between graduates, both from the UK and abroad. The PLAB test results reflect a wide range of competency between countries, with a low average pass rate for the first and second parts of the test at 63% and 65%, respectively. Although the ability of UK graduates has not been questioned, the GMC has also reported some variation in standard between UK medical school graduates, alongside varied assessment quality between medical schools. This has led to plans for more consistent assessment.
The format of the UKMLA is being worked on by the GMC, and plans are in place for the exam to be taken by international graduates in 2019-20 and UK doctors graduating in 2021-22. Before the tests are fully rolled out, the GMC has promised a public consultation and to “engage with partners and groups affected” to determine the timing and content of the tests. As with the PLAB test, the UKMLA will likely include a single best answer section and a clinical objective structured clinical examination section. Alongside these, there may be sections on UK healthcare (such as legal and organisational knowledge), and patient safety and human factors.
Implications for students
It is likely that the reaction from medical students will be collective sighs at a further exam. Medical students in the UK have seen the introduction of the situational judgment test and the prescribing safety assessment as additional exams they must pass before they can start the foundation programme. Added to this, the Shape of Training review proposed that the point of full GMC registration should be moved to the end of medical school, rather than the end of the first year of the foundation programme. The introduction of a further exam—the UKMLA—presents another hurdle for medical students to overcome within a short time.
And how will the exam data be used? For example, will the exam be a minimum standard of competency or will it also be used to differentiate students who pass? The cost of the exam must be dealt with too. The GMC suggests that it is likely to be shouldered by the final year students sitting the exam.
Do we need it?
Some are welcoming the change to a benchmark test from the GMC. Medical house officer Nicholas Wong, of Whipps Cross Hospital, London, wrote in a rapid response on thebmj.com that “the greatest benefit of a national licensing exam is an overall increase in standards of medical education, with graduates having to conclusively prove ability in a wide range of medical subjects.”
The GMC currently regulates medical schools in standard setting documents such as Tomorrow’s Doctors, and questions have been raised as to whether the UKMLA is required. In a rapid response posted on thebmj.com, Rod Jennings, a general practitioner principal, labelled the exam as “unnecessary,” stating that “the GMC already assesses UK medical school competence and produces a detailed report with recommendations. Furthermore medical school examinations include external assessors to ensure appropriate standards are kept.”
Currently, medical schools can dictate the elements of teaching they want to emphasise on their course. However, there are concerns that this diversity will be lost with the UKMLA, which will seek to impose a higher level of standardisation between all graduates. In 2010 the Medical Schools Council formed an Assessment Alliance for sharing assessment materials, which, according to a spokesperson, will make it “technically feasible to create a national assessment that maintains the autonomy and individuality of medical schools.” The GMC has also stated that they “do not want to create a ‘one size fits all’ system of undergraduate education,” with the aim to maintain the variety present between medical schools.
Concerns still need to be dealt with. Could a national exam encourage direct comparison or competition between schools? Would curriculums and assessment focus too sharply on passing the UKMLA? Though supportive of the UKMLA in principle, Harrison Carter, co-chair of the BMA Medical Students Committee, warned that “a didactic approach to teaching for this assessment would be unacceptable, as teaching to the test could sacrifice the amount of time available for experiential ward based training.”
The premise behind the introduction of the exam is bound to undergo further scrutiny. One of the main reasons for introducing the exam is to protect patient safety, but none of the major reports looking into patient safety in recent years, such as those led by Francis, Keogh, or Berwick, have recommended a standardised licensing exam as a solution or that newly qualified doctors specifically posed a risk to patient safety.
Research published in The BMJ suggests that students taking the PLAB test perform considerably worse overall than UK graduates taking the exam for membership for the Royal College of General Practitioners (MRCGP). This suggests that the UKMLA could be strengthened in its assessment of doctors from overseas, but questions remain around whether this evidence base can be applied to UK trained medical students. The introduction of the UKMLA should, in theory, help to ensure a high standard of care from junior doctors in the NHS, but the practicalities of implementing the changes and the evidence base remain unclear.
What we know
- A new UK licensing exam called the United Kingdom Medical Licensing Assessment (UKMLA) is to be introduced for all medical students. The first exam for UK students is likely to take place in 2022
- The exam is an attempt to standardise competence of all new doctors who want to practise in the UK
- The format is likely to include multiple choice questions, objective structured clinical examination-style stations, and questions about healthcare and law in the UK
- The GMC has promised a public consultation on the introduction of the exam
What we don’t know yet
- The evidence base behind the introduction of the exam
- The confirmed format or date for the inaugural exam—how evidence based will these assessments be?
- How this new assessment will fit with other exams students must take around the same time
- What will happen if a medical student fails the UKMLA but passes all other exams
- Will the introduction of this exam see less variety between medical school curriculums?
- Will it encourage further comparison between students from different medical schools?
- How much will the exam cost students?
1University of Nottingham
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- General Medical Council. GMC council approves development of UK medical licensing assessment. GMC, 4 June 2015. www.gmc-uk.org/news/26549.asp.
- General Medical Council. PLAB pass rates: pass rate PLAB part one and part 2 by year for the five years to date. GMC, 2015. www.gmc-uk.org/doctors/plab/23456.asp.
- General Medical Council. Publication of evidence on undergraduate medical education, 10 December 2014. www.gmc-uk.org/18___Publication_of_evidence_on_undergraduate_medical_education___with_correction.pdf_58720973.pdf.
- General Medical Council. Taking forward work on a UK licensing assessment. 2 June 2015. www.gmc-uk.org/10___Taking_forward_work_on_a_UK_licensing_assessment.pdf_61114454.pdf.
- Wong N. Rapid response to Gulland A. GMC proposes single test for all doctors wishing to work in UK. BMJ 2015;350:h3094.
- Jennings R. Rapid response to Gulland A. GMC proposes single test for all doctors wishing to work in UK. BMJ 2015;350:h3094.
- Francis R. Independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009. 24 February 2010. http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113447.pdf.
- Keogh B. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report, 16 July 2013. www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf.
- National Advisory Group on the Safety of Patients in England. A promise to learn—a commitment to act: improving the safety of patients in England. August 2013. www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf.
- McManus I, Wakeford R. PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: data linkage study. BMJ 2014;348:g2621.
Cite this as: Student BMJ 2015;23:h4208