Med students charge exam policy 'punitive, unfair'

Originally published in Synapse, Volume 27, Number 6, 14 October 1982

Medical students at UCSF who failed part I of the national medical board exam have filed a formal grievance with Acting Dean Robert Crede — protesting a school policy which could hold them back from entering third-year clinical clerkships.

Because the Medical School Bulletin for the class of 1984 makes no mention of the test as a requirement for advancement, the students maintain the school is guilty of breach of contract.

Just before going to press, Synapse obtained a copy of the grievance, which seeks a waiver of the "no promotion" policy and a review of the use of national board exams for purposes of promotion.

This is not the first student protest about the issue. On the day of the test in June, students presented petitions signed by approximately half the second-year class to Associate Dean Alan Goldfien.

The petitions decried the policy, saying the exam's content and format made it an improper measure of student performance for promotion. The students further maintained that the policy increased their anxiety level unnecessarily, which "adversely affected our test-taking ability."

Failed students, the petition declared, would suffer excessive punitive action. They received no response from Goldfien, who currently is out of the country and unavailable for comment.

The two-day, 16-hour test is taken after the second year in medical school as the first of a three-part exam sponsored by the National Board of Medical Examiners (NBME).

The series of tests is designed expressly for licensure and is accepted by 48 states, including California. Three attempts to pass the exam is the limit normally allowed by medical schools and the NBME.

Typically, approximately 11 percent of second-year students fail the exam on the first attempt.

Alice Wooden of the NBME said the board does not recommend the test as a promotional tool, and that "if the test is used for (a purpose) other than licensure, it has to be based on the opinion of the medical school as one measure (not the sole measure) of the students' performance."

In 1974, following the lead of other universities, UCSF made passage of the exam a requirement for graduation. Since then, stringency of the requirement has tightened.

According to Kathy Healy of Associate Dean Goldfien's office, in 1978, passage of the exam was made mandatory before students were allowed to begin their fourth-year clerkships. Then, in 1981, the Faculty Council mandated passage of the exam as a prerequisite for the third-year core clerkships — beginning with the class of 1984, which took the exam last June.

But this policy change does not appear in that class' bulletin, printed in 1980. Students contend that they received formal word of the new policy only last Spring.

At issue is who fails this exam and why. Some students feel the boards are biased in favor of individuals whose educational backgrounds emphasized similar kinds of tests.

A spokesperson for the grievers says that of 18 students who failed the June exam, only two were white men.

The remainder were minorities or women, most of whom come from economically disadvantaged backgrounds. A few of the women are older than their peers, farther away from their undergraduate training.

All of the 18 were re-tested in September, so for those who passed the second attempt (results should be known within a few weeks), the issue will become moot.

"I attribute this (failure on the exam) to my class background," commented one student. "I went to a high school where no one went to college. We were never taught test-taking skills."

(All students Synapse spoke with requested anonymity.)

Students at UCSF are not alone in their concerns.

The American Medical Student Association (AMSA) officially disapproves of using the exam for internal review or promotion, because of what it sees as inherent bias favoring experienced test-takers.

"It is definitely an issue of national concern," said AMSA president Pat Romano.

“To think that schools which use the boards for promotion do not really validate their own curriculum... such a policy shows an unwillingness to take responsibility for the grading of students.”

The student association observes that people who do well on the test tend to be white and from a middle class background — where the somewhat complex and abstract test-taking method of the boards is learned over a lifetime.

Many questions are multi-layered multiple choice — the student is asked to choose between several different combinations of responses. In many instances, failed students claim, the exam requires a learned impulse for eliminating wrong choices, rather than overall understanding of the material.

John Carbone, a coordinator of the medicine clerkship, is concerned that any exam is less desirable as an indicator than the judgment of the people who work directly with the students.

"There are students who never take exams comfortably," he said. "There should be a back-up mechanism. People from less competitive backgrounds will always be at a disadvantage. I've been a teacher for 20 years and have seen this happen repeatedly."

Henry Ralston is chairperson of the anatomy department, and himself a newly appointed member of the NBME, which is made up of prominent physicians from around the country.

Ralston believes that many faculty members are concerned about the issue.

"I think the test is a legitimate (promotional) tool if it's one of several," he told Synapse. "I don't think it should be an exclusive hurdle for all students."

Although the NBME does not keep track of failure rates by age, race or other characteristics, Alonzo Atencia of the University of New Mexico Medical School (UNM) has.

At his university, says Atencia, over a 12-year period, more than 50 percent of minority students failed part I of the boards on the first attempt.

In meetings with the associate deans of all the UC medical schools, he received estimates of similar results for this system.

"I think it correlates well with (minority students') lack of introduction to testing systems all the way back to primary school," said Atencia.

Some UCSF students maintain that failure on the exam was largely inconsistent with their performance on first and second-year classes, which was adequate or extremely good in most cases.

Synapse attempted to verify these claims, but according to Acting Dean Crede's office, problem lies in the extreme difficulty of designing exams which examine conceptual understanding rather than rote learning and test-taking ability.

If test-taking practice and familiarity play as strong a role as some students and teachers believe, failure rates could be expected to reflect students' demographic or educational backgrounds.

Uneven preparation from school to school is compounded by a wide range of the currently inaccessible. Goldfien is the only person authorized to release such information.

"I'm sure if a student appealed (the promotion policy),” said Crede, “such circumstances would be taken into consideration by the faculty council."

There also is some question as to whether UCSF adequately prepares students for the exam.

Pediatrics professor Moses Grossman thinks the use of the test for promotion is very valid, but added that "if the students had time for a practice exam or a course in test-taking, it would be extremely helpful."

The UNM is one school which offers a board review course for students who fail their first attempt. In fact, the course is used by some UC system students. Atencia studied rates of failure of his school's minority students for part 1 before and after the review course was instituted.

Before, 44 percent of second-time examinees failed. For those completing the board review, the rate was cut in half.

"If students requested that Dr. Goldfien work out a way for test-taking abilities to be improved,” said Crede, “then that would be given serious consideration."

Some schools don't use the test for promotional purposes whatsoever, while others, such as UCSF, strictly tie passage to promotion, and ultimately, could be expected to expel students who fail the exam repeatedly.

In that case, students would be unable to try an alternate licensure exam, such as the "FLEX."

Andrew Goldner, associate dean of the University of Arizona Medical School, has studied the effects of the boards on student attrition.

He said that while attrition due to board failure is insignificant, a major problem with using the exam for promotion is disrupted lives of students held back a year.

Interestingly, Goldner found that according to anecdotal accounts, the failure rate on part 1 decreases when a school rescinds required passage for promotion.

He attributes this to reduced anxiety in the test-takers. Goldner said that such a policy "shows an unwillingness to take responsibility for the grading of students."

Even if the grievance is not acted on to the students' satisfaction, the issue may remain hot for some time.

According to one student, echoing the feelings of several others, "if I don't pass (the September re-test) and they don't let me go on to my rotations, then I'll file a law suit. I've gone through too much to let this hold me back."