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MBBS examinations--are we asking the right questions? N Ananthakrishnan, S Ananthakrishnan, A OumachiguiDept of Pediaatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0008295143 Keywords: Education, Medical, Educational Measurement, Gynecology, education,India, Obstetrics, education,Pediatrics, education,Surgery, education,
The National Health Policy (1983) clearly requires that the entire basis and approach towards medical and health education at all levels are reviewed in terms of national needs and priorities and curricular and training programmes he restructured to produce personnel of various grades of skill and competence, who are professionally equipped and socially motivated to effectively deal with day to day problems, within the existing constraints[1]. The purpose of this paper is to examine whether the current undergraduate medical examination system conforms to this direction. It has been mentioned that in the U.K. the pattern of medical examinations took shape towards the end of the nineteenth century and although modified in some detail in the last few decades has been retained in its essentials by most examining bodies to the present day[2]. The system in India has been even more resistant to change except in the last decade or so when the need to increase objectivity of, examinations and thus their reliability and validity became increasingly realised. The greater effort required on the part of teachers and examiners to fulfil this task has led to a large body of them remaining content as Webber says with the feeling that "The examination is a necessary but onerous task that is best overcome by the easiest possible method"[3]. This study presents a five year analysis of the question papers of a major university holding undergraduate examinations to emphasise how far the current written examination fails short of the ideal.
The question papers in the summative evaluation of Madras University for the final MBBS examination in the subjects of Paediatrics, Obstetrics and Gynecology and Surgery were analysed for the five years prior to the university ceasing to hold medical examinations with the advent of the Tamil Nadu Dr. MGR Medical University. Madras University was chosen as the example as it typifies the pattern of examination in most of the states of India where separate medical universities do not exist. It was felt that analysis of the question papers of the two medical universities in India would not be representative of what is happening in the other hundred odd medical colleges in India. Obstetrics and Gynaecology: The weightage for various topics in 5 years seen that question papers were analysed. It was seen that - (i) 98% of marks over this period were for recall type of questions and only 2% involved problem solving. (ii) In five years there were no questions on the following subjects - antenatal care, normal labour, normal puerperium, nutrition in pregnancy, pre-eclampsia, social obstetrics, demography, infections of the genital tract, cancer cervix, normal menstruation, dysfunctional uterine bleeding, leukorrhoea, mass in the lower abdomen, prevention of WF and Caesarean section. Most of these conditions are those that a primary care physician is likely to encounter. (iii) Family planning (a National Programme) received only 5% weightage over 5 years. The weightage for other frequently encountered problems was as follows: Abortions ...4% Neonatology ... 3% Postpartum haemorrhage .... 4% (iv) Irrespective of their relative importance to the primary care physician, 70-75% whose work is estimated to involve maternal and child health, equal and minimum weightage was given for multiple pregnancies, forceps extraction, vacuum extraction, rupture uterus and breech presentation. (v) No fixed weightage was apportioned for various subtopics and what appeared in the examination largely depended on the whims of the examiner. Paediatrics: The papers for the subject of Pediatrics were also analysed for 5 years. (i) During this period there were no questions demanding problem solving and 100% of the question paper tested only recall. (ii) There were only 1 or 2 short notes in 5 years on subjects such as ORS, pertussis, helminthiasis, universal immunisation programme and national programme for prevention of blindness. (iii) Topics which received less than 5% weightage included cerebral palsy, hepatitis, vitamin A deficiency, marasmus, PEM, iron prophylaxis, umbilical sepsis, IMR, ICDS, mental retardation, Down syndrome, anemia, Apgar score etc. (iv) Most of the weightage in the papers was for the following subjects: Tuberculous meningitis, pyogenic meningitis, infections in early childhood, hepatomegaly, Fallot's tertralogy, neonatal and febrile convulsions, jaundice, diphteria etc. Again the weightage did not appear to depend either on commonality of the problem from the view of a primary care physician or national importance of the subject. Surgery: The papers for the subject of surgery were analysed for 6 years. In surgery, a greater proportion (13.1%) of the paper was devoted to problem solving. However, a skewed distribution of weightage was noticed in this subject also. There were no questions at all in 5 years on hospital infections or use of antibiotics. Nutrition, fluid electrolyte balance, shock and wound healing, formed only 0.3% of total marks. Vasectomy, common tropical conditions like filariasis, surgical complications of helminthiasis and leprosy formed 0.6% of the total marks in 5 years. Anorectal problems which is of the one commonest conditions encountered in practice constituted only 1.4% Oral cancer, which is one of the commonest cancers in India, had only 28 marks out of a total of 1400 marks during this period.
The purpose of this analysis is to draw attention to certain lacunae in the current written examination. Although only three subjects have been used as examples, the problems are essentially similar with all disciplines. There is undue and overwhelming emphasis on recall questions to the near total exclusion of questions which test problem solving ability. Weightage in any subject should depend on two aspects: (i) the commonality of the problem and thus the frequency with which a primary care physician would encounter it, (5) its national importance as part of the national health programmes. It was seen in all three instances here that no specific weightage was assigned to any topic based on any criteria. The occurrence of a topic in the examination paper depended on the examiners preference and had no bearing on its importance in the national context. The second aspect which became obvious was that over 70% of the paper was of the long question type with its obvious disadvantage of subjectivity in scoring. Short notes comprised the rest. There were no short structured answer questions or MEQs. Attempts have been made by some universities to overcome subjectivity of undergraduate medical papers by introduction of MCQs. However, in the absence of training in formulating MCQs, lack of prevalidation due to obsession with secrecy, non-maintenance of banks and neglect of item analysis this has only led to replacement of bad essay questions by bad MCQs.
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