External examining – a challenge for new curricula?

End of year examinations will soon take place in most medical schools in the United Kingdom (UK). Success means progression to the next year of study and for students sitting final examinations, provisional registration with the General Medical Council (GMC) and the right to be called `Doctor'.1 In the United States, Canada and elsewhere, all medical students sit the same qualifying examination2 but in the UK each medical school is autonomous and has its own system of examinations, including finals. Given that all medical schools in the UK pursue the same educational aims and learning objectives, as specified by the GMC,3 all medical students should attain the same minimum standards by the time of graduation. How is this ensured? The GMC recommends that `use is made of external examiners to ensure that the requisite standards are maintained'.3 In its code of practice for the assurance of academic quality and standards in higher education, the Quality Assurance Agency (QAA) for Higher Education offers a framework for external examining in UK higher education institutions (HEIs).4 The QAA emphasises that `external examining provides one of the principal means for the maintenance of nationally comparable standards'. There is considerable variation between institutions, however, in relation to their use of external examiners.4 While an element of diversity and innovation is welcome, some principles should be followed. The general principles outlined by the QAA are as follows: The external examining function should assist institutions to ensure that: • The academic standard for each award and award element is set and maintained by the awarding institution at the appropriate level and that student performance is properly judged against this; • The assessment process measures student achievement against the intended outcomes of the programme appropriately, and is fair and fairly operated; • Institutions are able to compare the standards of their awards with those of other higher education institutions. The GMC recommends that `examiners are trained to carry out the tasks assigned to them and apply the school's assessment criteria consistently'.3 It follows that external examiners should take part in the same training programme as internal examiners. The provision of briefing documents is not a reliable substitute for training. The use of untrained external examiners in routine assessments, or as adjudicators in borderline, pass-fail decisions is a potential source of variability and unreliability in the assessment process. Medical schools which only use external examiners as additional internal examiners miss a valuable opportunity. As observers of the examination process external examiners can provide course organisers with otherwise unavailable information on interexaminer variability as well as the standard of student performance. Despite the importance of the role of external examiners there is very little associated medical education literature. Within nursing education, however, where there have been two quality control directives, issued by the Higher Education Quality Control Council and the UKCC, it has been suggested that HEIs need to develop more sophisticated systems of external examining to ensure the quality and standard of awards.5 Tomorrow's Doctors recommended that medical schools develop more integrated curricula6 and all UK medical schools have adopted this recommendation to a greater or lesser extent. How does the QAA code apply to medical schools with innovative, integrated curricula? One of the stated precepts of the code is that `institutions should ensure that their external examiners are competent' and should have `appropriate levels of academic and/or professional expertise and experience in relation to the relevant subject area and assessment'. Integrated curricula generally have integrated examinations, however, so that there is no longer a specific role for narrow subject specialists. We argue that external examiners should be selected because they are familiar with best practice in assessment and can comment on the fairness of the assessment process. They must also be familiar with local curriculum goals and may be important facilitators of change within evolving curricula. Universities take reports by external examiners very seriously. By identifying the strengths and weaknesses of assessment systems, external examiners can have a beneficial effect on curriculum development. It has been suggested that medical education in the UK should move to a common system of qualifying examinations similar to those used in the USA and Canada.7 A first step in this process may be the joining together of confederations of medical schools to share expertise in examinations. For example the Scottish Deans Medical Curriculum Group have produced a document on the Learning Outcomes for the medical undergraduate in Scotland and have agreed to consider the definition of common levels of achievement across the five medical schools in Scotland.8 The evolving role of external examiners needs critical review. Research is needed on the most effective and efficient methods of selecting and using external examiners in integrated curricula. Is it not time to share experience, expertise and evidence, so that there is greater congruence between medical school expectations and the ability of external examiners to rise to their new responsibilities?

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