Comparing the Development in Medical Physiology Exam Design in the US and the UK
Authors: Witchel Harry 
Published: May 2024

AIM: To discuss and contrast the recent development of medical physiology assessment between the UK and USA. HYPOTHESIS: The assessment trends set by the USA are regularly imported to the UK, but often the transplants do not take. DISCUSSION: Over the past twenty years educators in the UK have witnessed nominal improvements in medical exam writing policy. Much of this has been driven by American educational advances and theories. The main driver of this one-way trans-Atlantic progression is the larger student numbers in the USA. Until now, the UK has not had a national exam for qualifying newly graduating doctors. The new Medical Licensing Assessment (MLA), which will form the basis of national qualification, will begin to provide such a national test this year (2024) in the UK. Thus far, many USA trends in automated testing have been imported to the UK, but not always successfully. For example, in the early 2000s, nearly all medical schools in the UK instituted extended matching questions (EMQs) [1], but by the late 2000s, nearly all UK medical schools abandoned EMQs [2]. Starting in the late 2000s, single best answer (SBA) formats of 5-option MCQs became a requirement for exam writers. The idea was that high level thinking and judgment would be required to pick the best of the five plausible answers. Again, for post-graduate medical students in the USA, this fit well with diagnostic vignette questions, but for 18-year-old year 1 physiology students in the UK, who were still wrestling with factual knowledge, these judgment exams seemed over-ambitious. Yet, they were enforced upon exam writers. Another policy enforced was that questions could not be negatively phrased, as this has the potential to confuse students under pressure. Although this policy is well-intentioned, negative questions are essential for MCQs directly eliciting student's knowledge on symptoms and other ideas that cannot be reversed. For example, in the item, "What is a symptom of heart failure?" it is nearly impossible to write four plausible distractors, whereas, "All of the following are common symptoms of heart failure EXCEPT" could have "dehydration" as a correct negative answer. Finally, there is a current policy that SBA stems should be phrased so that a student should be able to propose the answer without seeing any of the options. This has been called "the cover test" because if the exam quality team cannot answer the question without seeing the options, the test item is rejected. This means that questions starting, "which of the following" are now rejected immediately. From the student perspective, this policy means that the process of selecting an answer from the list of options is transparent; the answer is recognised rather than weighing proposed options. But this makes it nearly impossible to ask questions about cause-and-effect relations where there are multiple related events such as, "Which of the following is a potential cause of high cardiac preload?" The supposed cover-test version would be, "What causes preload to increase?", which plainly is not a transparent question, as there are so many answers. CONCLUSION: The assessment processes that evolve in the USA are more suitable for the USA context than for the context in the UK. However, the UK educates very well using its home-grown processes. [1] George, S. (2003). Psychiatric Bulletin, 27(6), 230-232. [2] Eijsvogels, T. M., van den Brand, T. L., & Hopman, M. T. (2013). Perspectives on Medical Education, 2, 252-263. None. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.