Is there ever a single best answer (SBA): assessment driving certainty in the uncertain world of GP?

ABSTRACT

Uncertainty is inherent in all areas of medical practice, not least in primary care, which is defined by its acceptance of uncertainty and complexity. Single best answer (SBA) questions are a ubiquitous assessment tool in undergraduate medical assessments; however clinical practice, particularly in primary care, challenges the supposition that a single best answer exists for all clinical encounters and dilemmas. In this article, we seek to highlight several aspects of the relationship between this assessment format and clinical uncertainty by considering its influence on medical students’ views of uncertainty in the contexts of their medical education, personal epistemology, and clinical expectations.

KEYWORDS:

• Uncertainty
• medical education
• general practice
• medical student
• assessment

Uncertainty is inherent in all areas of medical practice, not least in primary care, which has been described as a clinical environment defined by its acceptance of uncertainty and complexity [1]. The degree to which a physician can tolerate uncertainty in clinical practice has potential consequences for the doctor, the patient and the wider society. For medical students in the UK, the General Medical Council (GMC) emphasises the importance of being equipped to manage clinical uncertainty at the point of graduation, as well as the ‘emotional challenges’ this brings [2]. The GMC highlights the necessity for all doctors to recognise uncertainty and learn to navigate it with confidence.

Single best answer (SBA) questions are a ubiquitous assessment tool in undergraduate medical examinations. However, it is important to recognise that the repeated process of choosing a single ‘correct’ answer from a list may produce an unrealistic image, and, at worst, an expectation of certainty in clinical practice [3]. Cooper et al. [4] have recently voiced concerns that the SBA format and secondary care-based content of the Medical Licensing Assessment (MLA) ‘omits the daily challenges of the GP where there usually exists no single best answer’. This article seeks to highlight several aspects of the relationship between clinical uncertainty and this assessment format. Within the current contexts of government targets of 50% of medical students becoming General Practitioners (GPs) [5], and difficulties in recruiting and retaining GPs [6], we intend to consider what impact this assessment format may be having on the future primary care workforce’s ability to navigate clinical uncertainty through its influence on education, epistemology and expectation.

How may medical students’ views of uncertainty in medical education be influenced by SBA questions?

The Association of American Colleges explain that ‘the real challenge of college, for students and faculty members alike, is empowering individuals to know that the world is far more complex than it first appears’ [7]. Developing an appreciation for the complexity of clinical practice, and the uncomfortable uncertainties embedded within this, requires time and experience: prioritising the learning process above the learning outcome [8]. It is important to consider to what extent SBA assessments compliment this pedagogical opinion. Witt et al., in part, attribute medical students’ drive for a single correct answer to the grey areas in clinical practice to their discomfort with uncertainty and to growing up in an ‘era in which powerful search engines are almost always within reach and quick answers to everything are at our fingertips’ [8]. Simpkin and Schwartzstein [9] worry about the impact this can have on patient care, fearing that ‘an obsession with finding the right answer, at the risk of oversimplifying the rich iterative and evolutionary nature of clinical reasoning- is the very antithesis of humanistic, individualised patient-centred care’.

Learning approaches adopted by medical students tend to fall into three categories: deep, strategic and surface-level learning [10]. Each approach has different underlying motivations, namely understanding concepts, maximising examination scores, and rote memorisation, respectively. Learning approaches are not fixed traits [10,11] and are under the influence of several factors including the format of examinations [12]. SBA questions, by encouraging students to prioritise assessment technique above grappling with complex concepts or developing decision-judgements [3], risk impairing the development of appropriate learning behaviours.

Medical students are developing lifelong learning competencies [13], and the format of assessment they undertake will influence the learning approaches they choose. Cooke and Lemay [14] argue that recognising the existence of more than one correct answer may actually strengthen the validity and reliability of the assessment tool. It may also encourage continuous professional development that recognises the complexities of medical practice and correlates with the iterative process of clinical decision-making.

How may medical students’ personal epistemologies be influenced by SBA questions?

Epistemology, the study of knowledge and its certainty, simplicity, sources, and justification, is often considered to be developmental in nature [15,16]. Maturation in personal epistemology can be associated with seeing knowledge as ‘uncertain, context-dependent, constructed, and critically evaluated’ [16]. Most students enter medical school with simplistic levels of epistemological thinking [17]. Knight and Mattick [17] refer to the ‘seductive fallacy’ of students considering uncertainty in medicine to be temporal: that ‘an answer will be found that will clarify things, bringing back black and white issues of certainty’. Undergraduate medical education requires sophisticated thought processes, and should therefore, at least in part, encourage medical students to become more mature in their personal epistemology.

Several studies have highlighted how undergraduate education may influence GP trainees’ epistemology. Guenter at al. [18] explain that ‘education is focused primarily on increasing our knowledge base, developing our skills in accessing the evidence, and refining our clinical reasoning, all in service of the false assumption that every clinical problem can be solved’. The authors highlight that this is not unique to general practice; however, the prevalence of uncertainty generated by ‘low disease probability and the undifferentiated presentation’ means that medical students may identify a difference between how they are assessed and what Cooke and Lemay call ‘clinical reality’ [14]. Howman et al. [19] reached similar conclusions: that current medical education may be perpetuating the idea of being able to “’fix’ the patient”, which has a detrimental effect on becoming comfortable with navigating uncertainty.

Learning to accept the uncertainty of medical evidence is a sign of a maturation in personal epistemology [15], and the format of assessments, particularly at the point of graduation, should reflect this. Otherwise, examination questions risk reinforcing, rather than challenging, the ‘black and white’ epistemologies of the students answering them. There is a paucity of evidence about the influence that SBA questions have on medical students’ epistemology; however, Eastwood et al. [16] in their study of epistemic cognition in medical education recommend that medical educators consider how ‘prominent epistemological perspectives in medical education, such as … reductionist approaches to assessment, may influence or impede implementation of new approaches to medical education’, including those which shape students’ understanding of uncertainty and complexity.

How may medical students’ expectations of uncertainty be influenced by SBA questions?

SBA questions imply a context of certainty for decision-making [14]. For students in pre-clinical years in particular, this risks creating a false perception of the degree of certainty in which judgements are made in clinical practice [20]. As medical educators and GPs, we find that the clinical environment in which medical students learn to navigate uncertainty is influential: they are socialised into the culture of their clinical environments, and this includes the extent to which uncertainty is accepted. As such, primary and secondary care settings provide very different learning experiences. Johnston and Bennett [21] describe primary and secondary care as ‘linked but nevertheless distinct paradigms of medicine’, with differences in identity, philosophy and epistemology. Julian Tudor Hart [22], writing almost fifty years ago, described how a medical student on placement in secondary care ‘seldom sees a patient who has not already given a history at least twice, and often 10 or 12 times before’, and is shielded from the ‘symptom-chaos of primary care’. Transformations in epistemology occur in these contexts: even experienced medical students consider it a revelation that accepting clinical uncertainty in primary care is a legitimate strategy [23].

Primary care placements may well portray the greatest clinical chasm between the mirage of certainty portrayed in SBA questions and the ‘symptom chaos’ of the undifferentiated presentation. For medical students who subsequently train in primary care, this may precipitate the need for a significant adjustment in expectations about what is considered ‘good practice’ [24]. Understanding the iterative process of diagnosis may also be influenced by this assessment format, by replacing the need to learn differential diagnoses [20] with a list of five options, and by encouraging earlier commitment to a diagnosis, a recognised maladaptive response to uncertainty in primary care [19,25].

Conclusion

We assert that an SBA assessment format will influence medical students’ understanding of, and preparation for, clinical uncertainty, as well as their resultant ability to navigate it. Commitment to SBA formats risks perpetuating a ‘seductive fallacy’ about uncertainty in medicine. Alternatives to SBA assessments have been proposed which seek to reflect the absence of a single best answer and the presence of uncertainty in clinical practice. These include very short answer questions [3], clinical prioritisation questions [20] and script-concordance testing [26]. Whilst each assessment method will influence medical students’ learning approaches uniquely, the format ought to align with their clinical experiences, maturing epistemologies, and developing expectations. It is vital that medical educators consider what the assessment method implies to the student about the uncertainties they will inevitably encounter.

Author contributions

All authors were involved from the conception and design of the project through multiple team meetings. NG wrote the main body of the paper with substantial amendments made by GG and GK. All authors reviewed and approved the final paper before submission. We have all agreed to be accountable for all aspects of the paper.

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

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

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Funding

The author(s) reported that there is no funding associated with the work featured in this article.