Re-examining single-moment-in-time high-stakes examinations in specialist training: A critical narrative review

Abstract

In this critical narrative review, we challenge the belief that single-moment-in-time high-stakes examinations (SMITHSEx) are an essential component of contemporary specialist training. We explore the arguments both for and against SMITHSEx, examine potential alternatives, and discuss the barriers to change.

SMITHSEx are viewed as the “gold standard” assessment of competence but focus excessively on knowledge assessment rather than capturing essential competencies required for safe and competent workplace performance. Contrary to popular belief, regulatory bodies do not mandate SMITHSEx in specialist training. Though acting as significant drivers of learning and professional identity formation, these attributes are not exclusive to SMITHSEx.

Skills such as crisis management, procedural skills, professionalism, communication, collaboration, lifelong learning, reflection on practice, and judgement are often overlooked by SMITHSEx. Their inherent design raises questions about the validity and objectivity of SMITHSEx as a measure of workplace competence. They have a detrimental impact on trainee well-being, contributing to burnout and differential attainment.

Alternatives to SMITHSEx include continuous low-stakes assessments throughout training, ongoing evaluation of competence in the workplace, and competency-based medical education (CBME) concepts. These aim to provide a more comprehensive and context-specific assessment of trainees’ competence while also improving trainee welfare.

Specialist training colleges should evolve from exam providers to holistic education sources. Assessments should emphasise essential practical knowledge over trivia, align with clinical practice, aid learning, and be part of a diverse toolkit. Eliminating SMITHSEx from specialist training will foster a competency-based approach, benefiting future medical professionals’ well-being and success.

Keywords:

• Assessment
• High-stakes examinations
• Competency-based medical education
• Specialist training

Acknowledgements

None.

Ethical approval

Not required.

Author contributions

NS and SF individually conceived the ideas contained in this manuscript. NS drafted the initial manuscript, and SF contributed to its critical revision. NS and SF approved the final manuscript for submission and have agreed to be accountable for all aspects of the work.

Disclaimers

None.

Previous presentations

None.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

No direct funding was provided.

Notes on contributors

Navdeep S. Sidhu

Navdeep S. Sidhu, MBChB, PGCertHealSc(Resus), FANZCA, MClinEd, FAcadMEd, is an anaesthesiologist at North Shore Hospital, Auckland and Director of Medical Admissions in the School of Medicine, University of Auckland, New Zealand. He is Chair of the Educators Subcommittee, Australian and New Zealand College of Anaesthetists. He has a master’s degree in clinical education and was awarded the 2019 Distinguished Clinical Teacher Award by the University of Auckland. Twitter/X: @DrNavSidhu

Simon Fleming

Simon Fleming, MBBS, FRCS (Tr&Orth), MSc, PhD, MAcadMEd, MFSTEd, MASE, AFHEA, FRSA, is an orthopaedic surgeon, past president of the British Orthopaedic Trainees” Association, past vice-chair of the Academy of Medical Royal Colleges Trainee Doctors Group, and is a co-chair for the International Conference in Residency Education. He has a PhD in medical education and was recognised as the International Leader of the Year by the Royal College of Physicians and Surgeons of Canada. Twitter/X: @OrthopodReg