I was facilitating a medical humanities (MH) module at a medical school in Aruba, Dutch Caribbean. We were using role-plays to explore the patient’s perspective of illness. The undergraduate medical curriculum at the school had been modified to strengthen standards and meet accreditation requirements. Most offshore Caribbean medical schools initially established to prepare students for North American licensing exams have modified their curriculum in line with accreditation standards.
The school admits students from countries in North America (the United States and Canada), South Asia (India, Pakistan, Bangladesh, and Sri Lanka), and Africa (mainly Nigeria and Ghana) to the undergraduate medical program. The focus was on preparing students for the United States Medical Licensing Examination (USMLE). The marks obtained in USMLE Step 1 determined residency choices. There was tremendous pressure on students to do well. Many Canadian students at the university also took Step 1 as the clinical rotation sites were in the United States and many also wanted to pursue a residency and a possible future career in the country. The percentage of students passing the USMLE Step 1 on the first attempt was also a parameter examined by the accrediting agencies and was important for the school.
Change is always difficult, and many faculty and students were comfortable with the school predominantly coaching students for the USMLE. The school leadership and the curriculum committee invested a lot of time and resources in convincing faculty, students, and parents regarding why the change was necessary and how teaching-learning will improve. The MH module was one of the new initiatives.
My co-facilitators and I tried our best to make the sessions interesting and interactive. Some students believed these and other newly added activities took away their time and focus from USMLE preparation. Many were of Asian origin but were raised in the United States (US). They believed in expressing their views. After we finished the session a student came up to me and mentioned that he did not understand why the school and I were teaching them all this material as it is never asked in the USMLE and hence is not important.
Many initially did not accept the curricular changes, switching to an integrated curriculum, and adding an extra 16 weeks to the course. A few students transferred to other schools with shorter courses. I interacted with visiting faculty from the US and Canada. They mentioned that they faced similar problems. I also read about students usually not attending lectures in US medical schools. Lectures are recorded and students speed up and listen to the recordings. Step 1 scores hugely influenced students’ future careers and hence their study habits.
Scoring well in competitive exams is important for students. In many parts of the world practical training is often neglected to prepare for postgraduate entrance examinations. Strategic learning is common among students. The USMLE has now shifted to a pass/fail decision for step 1, and this may relieve the pressure on the students during the basic sciences. Step 2 clinical knowledge (CK) is still scored, and these scores may now become important, and an area of focus during their clinical years.
Caribbean offshore schools mostly operate geographically separate campuses. The basic science years on the ‘islands’ may be less stressful due to this change. Competitive exams with limited seats have a huge influence, and coaching classes and books/guides to help students perform better, receive much attention.
Competitive exams (for licensing, and further study) greatly influence medical students and residents. These high-stakes examinations demand concentration and sustained effort from the examinees. In India, there was concern about students using the period of internship at the end of the undergraduate medical course to prepare for residency entrance examinations. A challenge for medical educators is rewarding characteristics, behaviours, and concepts that may not be tested during high-stakes examinations but are vital for a good doctor. How do we reward helpfulness, empathy, patient support, peer support, participation in community activities, personal health and wellness, and advocacy among other characteristics so that students wholeheartedly participate and consider these as important as scores in high-stakes examinations? Role-modelling of these behaviours and values by educators is important. The solutions may require thought, time, and effort. USMLE and other high-stakes examinations cast a long shadow on medical education but maybe not completely in the way the exam developers envisaged!
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