Written by Anonymous Student
While hints of in-person activities, including exams, have been dropped at the beginning of August and sprinkled here and there throughout the 2020 Fall semester, it was only on October 20th during a class meeting for the class of 2023 where the official announcement of in-person examination for the final exams was made.
What a heated class meeting that was.
Due to the uncertainty posed by the COVID-19 pandemic, the Undergraduate Medical Education (UGME) office has finally made sure that out of the many in-person learning activities that would not make the cut, in-person final examinations were here to stay. The UGME’s attitude was clear that there will be no room for negotiations.
The rationale behind the decision of in-person final exam is as follows:
ensuring academic integrity
providing fair and equitable assessment to all students
committing to patient safety
providing quality assessment
In order to ensure the safety of students, the UGME COVID-19 Examination Safety & Prevention Protocol was implemented.
For those who have not read the document, students will be separated into two exam locations, asked to answer questions truthfully regarding symptoms upon entering the building, limited to 4 when using the elevator or to 1 if the student is immunocompromised, and seated row by row in an arranged manner so that physical distancing of 1.5m will be respected at all times. In addition, there will be hand sanitizer placed at the entrance and at various locations in the examination area, and a level 2 procedure mask will be given to each student to be worn at all times during the exam. The Examination Safety & Prevention Protocol also outlines how students may bring their own hand sanitizer to their station, but will need to request for accommodation to be able to eat snacks during the exam. Finally, students who have been exposed to someone who tested positive for COVID-19, have symptoms themselves, or have a child/dependent who needs care at home will be able to seek accommodation from the WELL office. That being said, it is unclear what these accommodations would look like - students may very likely be asked to sit the make-up exam in-person at a later date.
Although UGME has been making efforts since the beginning of the summer to make many necessary learning activities in-person possible - to which I express my undying appreciation and gratitude - I would like to echo many other students’ concerns over UGME’s attitude that dismisses medical students’ well-being and pose the question if in-person examinations, especially the very last battery of examinations of FMD, are even necessary in the first place.
As there has been a trend of increasing exam averages since the pandemic began, academic integrity has been put under the spotlight of suspicion albeit without tangible proof shown to students. Despite lacking concrete evidence that students are significantly more inclined to cheat during unsupervised online exams (1), nevertheless, should students feel that they have been disadvantaged due to other students’ cheating behaviours, this is undoubtedly a concern. Let’s frankly assume more students have been cheating. With this in mind, why would it be a bad idea to have in-person examinations to uphold the quality of academic assessment?
I want to clarify that I believe cheating is never justified for future physicians who are expected to be scholars and medical knowledge experts that display virtues of integrity and honesty. However, having exams in-person may not actually be the most effective and appropriate way - although it is perhaps the most easy way - to mitigate cheating behaviour.
First of all, even with the in-person exam format, cheating is not impossible, especially now as students are allowed to bring hand sanitizers or “some sort of items” to their testing station. More importantly, there are other ways to mitigate cheating behaviours. For instance, multiple choice (MCQ) exams can come in a range of quality in terms of assessing clinical science knowledge. Even if exam proctors cannot be utilized (since UGME has made it clear that they will not use proctor monitoring after much consideration), should more MCQ questions be created in a way that combines various knowledge points from different lectures and incorporating higher-order questions or scenarios to focus on assessing clinical reasoning as opposed to students’ ability to regurgitate lecture slides, cheating could be minimized - especially if the exams are given under a relatively strict time limit. On a more tangential point, cheating is more likely to occur with the motivation of extrinsic goals, such as obtaining an award recognition. (2) As such, I believe that should the faculty remove the recognition award that puts the student achieving the top grade on a pedestal, at least during this pandemic, fewer students would even be inclined to cheat to get the extra edge on exam performance in the first place.
Secondly, exams are administered for the purpose of giving students feedback so they can reflect on how well or how poorly they have learned. Since the pandemic started, unless the student has failed, there has been almost zero opportunity (the exception being the neuro block midterm) for students to review prior exams and have a breakdown of how they performed on different tested areas. These review sessions have traditionally been in-person and were the only place for students to reflect on areas they can improve upon. Considering that students have received virtually no feedback from previous assessments, cheating may be, as ridiculous as this may sound, the by-product of being tempted to verify and consolidate their knowledge during the exam period. In addition, MCQ exams under supervision is not the only assessment method used in undergraduate medical education. For example, short answers examinations (SAE) offers a valid alternative to MCQs (3) and SAEs administered online without supervision have been shown to be more resistant to cheating during the COVID-19 pandemic. (4) Open-book exams may offer a considerable option as well. (5-8)
This in turn begs the question if the best way to benefit medical students’ learning may well be having an open-book exam with more complex questions or short answer questions (9) and weighing the grading more heavily on clinical assessments, such as the OSCEs. Regarding this, the UGME has not provided a satisfactory argument on why MCQ examinations, final exams or not, are “essential activities” that must occur in-person during this time while OSCEs, which would’ve been tremendously valuable as an assessment tool for both clinical and theoretical knowledge (10), are simply cancelled this year with no specific explanations given. That being said, a conceivable reason is the difficulty of arranging OSCEs during a pandemic.
In other words, having in-person MCQ exams is feasible thus an unilateral decision was made: exams are bound to happen in-person. It is unfortunate for the students who live outside Montreal and have to travel a far distance to get to the exam site on multiple days in a week, as well as for those who live with vulnerable individuals who may become affected as students will have an increased chance of contracting and transmitting SARS-CoV-2 by participating in in-person examinations or through exposure on public transportation, etc. Also, the students who are accustomed during previous block exams to the privilege of staying at home, opening up the Safe Exam Browser at 9:14am with coffee and breakfast at a reachable distance will just have to “grow up”, adapt to the changes no matter how cumbersome, and move on.
It is true that compared to upper year medical students, the class of 2023 was not impacted by the pandemic the most. Perhaps this cohort has not earned enough “rights” to complain or maybe medical students are somehow expected to simply follow the rules demanded by the culture or the institution of medical profession; however, I want to highlight a deeper and more insinuating issue which is UGME’s underlying insidious and dismissive attitude towards students’ well-being. This was apparent through the manner in which UGME communicated with the student body and pushed for in-person examinations without any room for negotiation or discussion of alternatives.
A recent meta-analysis suggested suicidal ideation is even more prevalent in medical students than qualified doctors. (11) During the time of COVID-19, it has been known that pre-clerkship students experience even more stress than at baseline. (12) Just to name a few consequences of the pandemic, most individuals experience reduced social interaction, decreased access to services and support networks, and increased uncertainty over the impact of reduced clinical exposure. Some students may also experience increased financial instability, housing concerns, health issues and even loss of their family members.
During the class meeting, as well as afterwards, a valid concern was raised and echoed: what would be the accommodations offered should a student contract SARS-CoV-2, or present symptoms close to or on the exam day? To this, the UGME spoke of no concrete measures until the recent release of a FAQ that states they expect either a proof of COVID testing or relevant documentation prior to the start of the exam at 8:30am. Now, let’s say the student gets tested, they are then expected to follow government guidelines to self-isolate and be asked to attend the make-up exam after the isolation period or when the symptoms resolve if testing comes out negative. This implies that not only the student will likely miss some if not all of the mandatory review assessment consolidate (RAC) activities in the following two weeks following the final exams, but also may have to sit a remedial exam that may be scheduled as late as the 21st of December, rendering their already relatively short winter break even shorter.
Perhaps some, notably the UGME, may say that’s a relatively weak argument as students are equally at risk of contracting SARS-CoV-2 going to a few in-person exams as doing their daily activities, such as getting groceries, going for walks, etc. This assumption greatly undermines the efforts some students make to prioritize safety by minimizing their outdoors activities and eliminating physical contacts as much as possible. With groceries being deliverable in the modern age, it is not unthinkable to not have left one’s apartment or home continuously for weeks or months during the pandemic. Furthermore, recent data has shown that young adults are actually more vulnerable than previously suspected and are susceptible to severe illnesses secondary to SARS-CoV-2 infection. (13,14)
Maybe the safety measurement provided by the UGME will be infallible. Perhaps some people wouldn’t mind having the additional risk or the added stress of potentially delaying the start of their holidays and missing RAC because they could display some flu-like symptoms on exam day, but the UGME could have prioritized the participation of in-person clinical training activities to prevent potentially marginalizing certain individuals and to prioritize students well-being by simply keeping the final examinations online. Or at least consider more seriously to provide that option to some students.
Let’s not forget the context where continuous efforts and advocacy work have taken place to make medical students’ well-being a priority. This is one of the most important reasons why an increasing number of prestigious medical schools have adopted the pass-fail grading system for pre-clerkship assessments. Beyond fostering a nurturing and less competitive learning environment, evidence has repeatedly shown that a binary grading system significantly reduced medical student’s level of perceived stress and anxiety which led to an increase in overall well-being. (15-17) As the name implies, pass-fail de-emphasizes the importance of grade percentages, which makes one wonder if making sure the class of 2023 performs on par grade-wise with the previous years is really worth the trouble and resources of in-person exam in the first place, all while risking students’ safety and well-being.
Recently, the anatomy final exam format has been finalized to be online and taken from home. This makes it seem somewhat arbitrary which exams are permitted to be administered online and remotely and which are administered in-person.
When the UGME unilaterally pushes forward the decision of in-person exams without adequately consulting the student body in the early decision-making process, and does not empathize with students’ differential experiences or perspectives that possibly warrant a re-evaluation on the necessity of in-person examination, not only imposes additional risks and sources of perceivable stress, but also sets a discomforting precedent of inexorability and unwillingness to innovate based on student feedback that is worrisome even if UGME claims to have students’ best interest at heart.
Editor's note: The decision to implement in-person examinations was revoked and it was officially announced on November 19th that all FMD examinations for the Fall 2020 semester will be done remotely. We are grateful for the Faculty's flexibility in face of new evidence and we hope they will continue to make timely decisions by taking into consideration the current context.
References
Ladyshewsky RK. Post-graduate student performance in ‘supervised in-class’ vs.‘unsupervised online’multiple choice tests: implications for cheating and test security. Assessment & Evaluation in Higher Education. 2015 Oct 3;40(7):883-97.
Jordan AE. College student cheating: The role of motivation, perceived norms, attitudes, and knowledge of institutional policy. Ethics & Behavior. 2001 Jul 1;11(3):233-47.
Bird JB, Olvet DM, Willey JM, Brenner J. Patients don’t come with multiple choice options: essay-based assessment in UME. Medical education online. 2019 Jan 1;24(1):1649959.
Eurboonyanun C, Wittayapairoch J, Aphinives P, Petrusa E, Gee DW, Phitayakorn R. Adaptation to open-book online examination during the Covid-19 pandemic. Journal of Surgical Education. 2020 Sep 2;S1931-7204(20)30346-9.
Teodorczuk A, Fraser J, Rogers GD. Open book exams: A potential solution to the “full curriculum”?. Medical teacher. 2018 May 4;40(5):529-30.
Durning SJ, Dong T, Ratcliffe T, Schuwirth L, Artino AR, Boulet JR, Eva K. Comparing open-book and closed-book examinations: a systematic review. Academic Medicine. 2016 Apr 1;91(4):583-99.
Akresh-Gonzales J. Open-Book vs. Closed-Book Exams [Internet]. NEJM Knowledge+. 2015 Jun 25 [cited 2020 Nov 14]. Available from: https://knowledgeplus.nejm.org/blog/open-book-vs-closed-book-exams/#:~:text=Feller%20(1994)%20further%20suggested%20that,stressful%20(Philips%2C%202006).
Zagury-Orly I, Durning SJ. Assessing open-book examination in medical education: The time is now. Medical Teacher. 2020 Aug 27:1-2.
Harrison D. Online Education and Authentic Assessment [Internet]. Inside Higher Ed. 2020 Apr 29 [cited 2020 Nov 14]. Available from: https://www.insidehighered.com/advice/2020/04/29/how-discourage-student-cheating-online-exams-opinion
Coovadia A. A comparison of traditional assessment with the objective structured clinical examination (OSCE). South African Medical Journal. 1985 May 1;67(20):810-2.
Que J, Shi L, Liu J, Gong Y, Sun Y, Mi W, Lin X, Bao Y, Sun H, Shi J, Lu L. Prevalence of suicidal thoughts and behaviours among medical professionals: a meta-analysis and systematic review. The Lancet. 2019 Oct 1;394:S11.
Meo SA, Abukhalaf AA, Alomar AA, Sattar K, Klonoff DC. COVID-19 Pandemic: Impact of Quarantine on Medical Students’ Mental Wellbeing and Learning Behaviors. Pakistan Journal of Medical Sciences. 2020 May 11;36(COVID19-S4).
Maragakis LL. Coronavirus and COVID-19: Younger Adults Are at Risk, Too [Internet]. Johns Hopkins Medicine. 2020 April 9 [cited 2020 Nov 14]. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too
DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, Ansusinha E, Hahn A, Hamdy R, Harik N, Hanisch B. Severe COVID-19 in children and young adults in the Washington, DC metropolitan region. The Journal of Pediatrics. 2020 May 13;223:199-203.e.1.
Bloodgood RA, Short JG, Jackson JM, Martindale JR. A change to pass/fail grading in the first two years at one medical school results in improved psychological well-being. Academic Medicine. 2009 May 1;84(5):655-62.
Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker PA. The benefits of pass-fail grading on stress, mood, and group cohesion in medical students. Mayo Clinic Proceedings. 2006 Nov 1;81(11):1443-1448.
Spring L, Robillard D, Gehlbach L, Moore Simas TA. Impact of pass/fail grading on medical students’ well‐being and academic outcomes. Medical education. 2011 Sep;45(9):867-77.
Budhai SS. Fourteen Simple Strategies to Reduce Cheating on Online Examinations [Internet]. 2020 May 11 [cited 2020 Nov 14]. Available from: https://www.facultyfocus.com/articles/educational-assessment/fourteen-simple-strategies-to-reduce-cheating-on-online-examinations/.