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Increasing safety concerns over medical licensing exam

Lauren Vogel | CMAJ | October 9, 2020

The Medical Council of Canada is going ahead with MCCQE II exams despite some exam site cancellations.

Oct. 20 Update: With less than a week to go before the MCCQE Part II, 10 of 19 examination centres have cancelled local sittings in Toronto, Ottawa, Kingston, Hamilton, Vancouver, Winnipeg, Montreal and Quebec City. The exam may still proceed as planned in Calgary, Edmonton, Victoria, St. John’s, Halifax, London, Sudbury, Sherbrooke and Saskatoon. 

Oct. 16 Update: According to the Royal College of Physicians and Surgeons of Canada, a candidate who wrote a recent internal medicine specialty certification exam in Toronto subsequently tested positive for SARS-CoV-2. Toronto Public Health has contacted seven other people who were in the same exam room. The Royal College noted in a media statement that candidates were allowed to remove their masks once the exam commenced. As of October 15, the Medical Council of Canada still anticipates that 1000 of the candidates originally registered for the MCCQE Part II will still sit upcoming examinations. Candidates can choose whether to participate or defer based on their own circumstances. 

Resident doctors are worried about the safety of sitting the upcoming Medical Council of Canada Qualifying Examination Part II (MCCQE II). Earlier this year, the Council postponed the licensing exam to avoid the potential spread of SARS-CoV-2. Now fall and winter exams are going ahead despite a resurgence of infections and COVID-19 cases countrywide.

“Resident physicians will criss-cross provinces to write this exam, potentially exposing themselves to COVID-19 [and] bringing this back to their communities and hospitals,” Dr. Giuliana Guarna, an obstetrics and gynecology resident, warned in the Hamilton Spectator. “It is not an overstatement to say that attendance at this exam could prove deadly.”

Sites that normally host the MCCQE II in Hamilton, Kingston and Montreal have cancelled due to public health concerns. Yet, the exam will proceed as planned in other cities, including COVID-19 hotspots like Toronto and Ottawa.

According to Dr. Esther Kim, president of Resident Doctors of Canada, safety concerns about sitting the exam have increased over the past week. “We have become aware that some candidates are being required to travel outside of their home jurisdiction to sit the exam and that in some situations, they are required to travel to an area that is now identified as a COVID hotspot.”

In Kingston’s case, nearly a third of 90 candidates scheduled to sit the test at the site would have travelled there from elsewhere in the province, Canada and the United States.

The MCC has committed to providing a safe exam environment, Kim noted. However, more exam sites may refuse to host the test as the second wave worsens.

In response to safety concerns, the MCC established protocols for physical distancing and abandoned hands-on components of the exam. “We are ready and planning to safely administer our exams at as many of the planned sites as we are able to,” says Maureen Topps, CEO of the MCC. She says the organization saw the pandemic as an opportunity to “innovate and reflect on how we deliver exams and we are doing so.”

But according to Dr. Mike Benusic, a public health physician based in B.C., pandemic measures also eliminated the main justification for conducting tests in person. “The other barriers for a virtual MCCQE II are surely great, but nearly seven months have passed since the postponement was announced in which a sound format could have been planned,” he argued in a recent CMAJ Blog.

Dr. Michelle Cohen, a rural family doctor in Ontario, wonders if the technical difficulties surrounding the remote-proctor option for the MCCQE Part I earlier this year scuttled other innovations.

According to Kim, many residents feel the MCCQE II is redundant in modern medical training. Doctors who passed the test used to be able to practice as general practitioners – but now even generalists require additional postgraduate training and certification.

Topps defended the exam last year by citing evidence linking performance on the test with professional outcomes. “While medical education and the assessment of medical students and physicians have evolved… the need for an objective and standardized assessment of core physician skills has not,” she argued.

Now, as the pandemic is disrupting examinations across the continuum of medical training, Topps says the MCCQE II will be essential to assess generalist expertise in skills like diagnosis, management, communication and professional behaviour.

The merit of that argument will be put to the test in the coming weeks and months.

Dr. Mohamed Sarraj, an orthopedic surgery resident from Hamilton, says it’s not surprising that people who perform well on tests also perform well in practice. “But that same checkpoint is examined in so many places: in medical school, in Royal College examinations, and now with competency by design, there are evaluations on a weekly basis.”

Sarraj says the MCCQE II poses a “delay and hindrance” when residents could be focusing on their chosen specialties. “I’m putting all of that aside to go back and study obstetrics for this exam and patient populations I’m never going to see in my practice as an orthopedic surgeon.”

Dr. Chad Singh, an emergency medicine resident in Hamilton, tweeted that residents need a “clear answer” about whether the MCCQE II will run. “I’ve been studying for this exam tentatively… and have no idea if it will be delayed again.”

Piecemeal cancellations in some areas may drive up risk in others. For example, hundreds of residents who were scheduled to take the exam in Hamilton may have to travel to Toronto instead. And Cohen notes that many residents won’t have time off work to self-isolate before and after travelling.

Other residents may not be able to sit the exam, even if they want to. Many family medicine residents didn’t receive a fall or winter exam spot because priority went to doctors who have finished their residencies and are practicing under temporary licenses.

“What makes the situation upsetting is the exam itself is so unnecessary,” Sarraj says. “You have people who are getting provisional licenses extended over and over because they don’t have a spot for this exam, who are already caring for patients. That tells you our licensing is already robust enough.”

Medical licensing authorities will extend provisional licenses for anyone who is unable to sit the exam this fall. But they haven’t confirmed if they will grant or extend provisional licenses to people who are unwilling to take the exam because of the pandemic.

 

Photo credit: iStock.com/megaflopp


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