Perception of Indian Medical Students Towards University Exams and Proposed Licensure cum Post-Graduate Specialty (Residency) entrance examination (National Exit Test)

Abstract

Introduction

The National Entrance cum Eligibility Test for postgraduate medical studies (NEET-PG) in India is destined to be replaced by the National Exit Test (NExT). We assessed the perception of Indian medical students towards the change in examination patterns.

Materials and Methods

We undertook a cross-sectional study by collecting responses of students from medical colleges all over India through a pre-validated questionnaire using a Google form. The data were collected through representatives of various national-level medical student organisations and appropriate analytical tests were applied.

Results

In total, 729 responses were collected from different parts of the country, with 69% believing that NExT Step 1 shall serve as a PG entrance exam. A total of 70% wanted NExT Step 1 to be conducted every 6 months, with most agreeing on a 1-day exam (41.7%) lasting 3 h (67%). Most students (60%) preferred having no attempt limits. A majority of the students (93.6%) wanted mock tests to be conducted. In total, 81% believe that conducting university theoretical examinations as 100% MCQ-based will improve preparation for NExT Step 1. A majority of the students (69%) wanted NExT Step 2 to be considered as final year university practical examination.

Conclusion

We found that medical students prefer NExT Step 1 to be conducted every 6 months in the form of a 1-day exam of 3-h duration. Regular feedback from all stakeholders, including students, is necessary for proper implementation of the new exam, and real-time modification of the exam pattern must be undertaken in the long run once the exam is rolled out.

Introduction

Various universities across the globe have different patterns of university/professional examinations in medical schools, including long answer type, multiple choice type, viva voce type, and objectively structured clinical examinations. Medical students sit through various types of tests that determine their eligibility and ranks/scores for admission into medical specialty postgraduate courses (also known as Residency): National Eligibility cum Entrance Test-Postgraduate (NEET-PG) [1–3] in India, United States Medical Licensing Examination (USMLE) in the USA, and Professional and Linguistic Assessments Board (PLAB) in the UK, etc.

National Medical Commission (NMC) of India mandates that students appear for four professional examinations conducted during the 4.5 years of medical study, followed by a 1-year compulsory rotatory internship [1]. The degree of Bachelor of Medicine and Bachelor of Surgery (MBBS) is awarded to successful students. Those interested in further studies then appear for the competitive NEET-PG, which serves to assess the applicants’ strengths (on the basis of scores) and determine their rankings for choosing different specialties. This allows for a more informed selection process. The NMC has recently announced the implementation of National Exit Test (NExT) — a common licensing and postgraduate entrance examination — replacing the pre-existing NEET-PG exam [2]. It is proposed to be conducted in two steps (or phases) — NExT Step 1 and NExT Step 2 [2, 4].

Students must appear for and pass (obtain at least 50% marks in) NExT Step 1 — an objective, computer based, multiple choice questions (MCQ) type exam — in place of the conventionally subjective essay-writing type of final year professional exams, before commencing their rotatory internship. This format aims to discourage rote learning, mostly comprising case vignettes/clinical case scenarios that focus on problems-solving and analytical skills. The exam spans six separate papers that comprise medicine and allied disciplines, surgery and allied disciplines, obstetrics and gynaecology, pediatrics, otorhinolaryngology (ENT), and ophthalmology. NExT Step 1 scores shall determine merit for admission to medical specialty PG courses and likely guide the Indian Central/State Governments’ decisions on the matter of employments, scholarships, and fellowships, etc. [2].

While the exact pattern of NExT Step 2 remains undisclosed, it is proposed to be an objectively structured clinical examination (OSCE) — with actual or simulated cases — aimed at testing the clinical, communication, and decision-making skills of students, such as diagnosing cases, taking informed consents, and considering ethical conundrums. It shall have a pass/fail outcome and cover all clinical disciplines as NExT Step 1 with addition of orthopaedics and physical medicine and rehabilitation (PMR) [2, 5].

Indian medical students sit through two starkly different types of examinations during their student life: the mostly essay-writing pattern of university exams juxtaposed with the objective MCQs of PG entrance examination. Students have anecdotally found preparing for the different patterns of university and entrance exams challenging; however, no concrete data exist to validate the same. In a study, 54% of biology students disagreed or strongly disagreed that the exam tests the right kind of learning [6]; and in another study, it was observed that only 35.8% medical students agreed that the assessments are a reflection of the curriculum [7]. There is a direct relationship between student involvement in the decision-making processes and the perceived level of students’ satisfaction [8]. Further, despite being the major stakeholders, students have to date been largely left out of the decision-making processes and guidelines regarding the NExT examination, leading to increased distress and resentment.

The ambiguity surrounding the exact details and commencement of the NExT exam significantly affect the career trajectories of medical students as they struggle to plan out their future timelines. Students are the most affected stakeholders from the NExT exam. They are also the ones that are directly going through the current medical education system and therefore have keen insight into its strengths and weaknesses. Removing them from the decision-making process can cause important perspectives to be missed, such as the types of questions, difficulty and timing/ duration of the exam, weightage of subjects, and other such details. There is a gap in the existing literature for understanding students’ perspectives on the proposed change in the examination patterns; and thus, there is a need for empirical research on Indian medical students’ perceptions of the patterns. To the best of our knowledge, this is the first study in India to analyse the perspective of Indian medical students towards this change.

Materials and Methods

A cross-sectional study was conducted among students enrolled in NMC-recognized medical schools (known as medical college in India) of India. We submitted the proposal to the Institutional Ethical Committee (IEC) and obtained necessary approval for conducting our study during a period of 4 months. We included medical students admitted in Indian medical colleges between 2018 and 2022 and excluded those who dropped out from college.

We used a two-stage sampling technique to collect responses — in the first, we stratified medical colleges of India into six regions: North, North East, Central, South, East, and West [9]; in the second, we randomly collected samples from each stratum. The sample size was calculated using the formula: $n=\frac{z_{\alpha }^{2}pq}{l^2}$. Here, n = no. of samples; z = 1.96 (95% confidence level); p (prevalence) = 0.5; q = 1-p; l = precision limit. To the best of our knowledge, no similar study has been conducted in India till date. So, we considered prevalence of awareness about NEXT among medical students for the present study as 50%. Taking a precision of 5%, the value was calculated to be 384. Multiplying this by the design effect — set at 1.5 — we got a value of 576. Assuming a 10% non-response rate, the final sample size was calculated to 634 participants (Fig. 1).

Fig. 1.

Stratification of medical colleges and minimum sample size from each stratum

Data Collection

The responses were collected using a pre-tested and pre-validated questionnaire. The questionnaire comprised 25 questions to assess the knowledge and perception of medical students about the university exams and NExT. While maintaining anonymity, demographic details were collected: age, gender, location of medical school, year of admission, and year of study. We assessed types of questions asked in theory professional exams in the respective university and compared students' preference for the same. Further questions were specific to NExT Step 1, including knowledge of the details of the new pattern and the purpose of the exam, number of attempts allowed, duration of the exam, and opinions about and perception of the new exam as well as perceived preparedness for the exam. We assessed the need of students for mock exams and their frequency. In the last section of the questionnaire, we assessed the perception and opinions of the participants regarding pattern and timeline of NExT Step 2 with respect to the Internship (last year of the medical school before graduation). We also took students' opinions on the conduct of NExT Step 2 in addition to the final year practical exams.

The questionnaire was made using Google forms and circulated on WhatsApp groups, WhatsApp personal messages/SMS, and emails with the help of respective representatives (office-bearers) of various national-level non-profit organizations of Indian medical students. We had a diverse and representative sample from all the six regions of India, and efforts for gaining appropriate number of responses were made to ensure the same by follow-up messages on the groups as a strategy to address regional disparities, especially in the North-Eastern region of India. We assured data quality by standardizing the protocol; pilot-testing the questionnaires; checking participant eligibility; and preventing incomplete, repeat, or falsified entries with the help of aforementioned representatives. Informed consent was taken before we administered the complete questionnaire to the participants.

Data Management and Statistical Analysis

The data collected were coded and recorded in a Microsoft Excel sheet. Categorical data were expressed on a nominal or ordinal scale and were analysed using percentages and proportions, whereas quantitative data were summarized as means and standard deviations. The Trial version of the Statistical Package for the Social Sciences (SPSS 25) was used for data analysis.

Results

With total participants N = 729, majority were male (431, 59.2%). Distributions of participants on the basis of medical colleges situated in the various regions of India were as follows: North 33.7% (246), North-east 2.6% (19), Central 17.4% (127), East 22.4% (163), West 7.4% (54), and South 16.5% (120) (Fig. 1). We had most participants (274, 37.6%) from the first professional year and least (44, 6%) from the internship year (Table 1).

Table 1.

Demographic profile of the participants by gender, academic year and location of medical school (N = 729)

Variables		Frequency (Percentage)
Gender	Male	431 (59.2)
	Female	289 (39.6)
	Others	9 (1.2)
Academic Year	First Year	274 (37.6)
	Second Year	113 (15.5)
	Third Professional Year Part-1	177 (24.3)
	Third Professional Year Part-2	121 (16.6)
	Intern	44 (6)
Location of Medical College in India	Northern Zone	246 (33.7)
	North-Eastern Zone	19 (2.6)
	Central Zone	127 (17.4)
	Eastern Zone	163 (22.4)
	Western Zone	54 (7.4)
	Southern Zone	120 (16.5)

Most of the theory exams included long answer type questions (96.2%), MCQs (93.3%), and short answer type questions (91.5%). Only 5.5% exams contain clinical-based questions. Students' preference for exam pattern, however, greatly differed, with an overwhelming 623 students (85.5%) preferring MCQs, followed by 507 students (69.5%) opting for clinical-based questions, 424 students (58.2%) opting for the short answer type questions, and merely 355 students (48.7%) preferring long answer type questions (Table 2).

Table 2.

Types of questions asked in theoretical professional exams — practices, preferences, and awareness (N = 729)

Variable		Frequency (Percentage)
			Yes	No
Types of questions asked in theoretical Professional Exams (Conducted by Respective University)	Short Answer Type		667(91.5)	62(8.5)
	Long Answer Type		701(96.2)	28(3.8)
	Multiple Choice Questions		680(93.3)	49(6.7)
	Clinical Based Questions		40 (5.5)	689(94.5)
	Other types		58(8)	671(92)
Student preference on type of questions asked	Short Answer Type		424(58.2)	305(41.8)
	Long Answer Type		355(48.7)	374(51.3)
	Multiple Choice Questions		623(85.5)	106(14.5)
	Clinical Based Questions		507(69.5)	222(30.5)
	Other types		8(1.1)	721(98.9)
Awareness about Indian universities that conduct 100% MCQ-based theoretical Professional exams			196 (26.9)	533 (73.1)

We further sought if participants were aware of the entire pattern of the NExT exam and found that only 226 (31%) students were. In total, 504 (69.1%) students believed that NExT Step 1 shall serve as a PG entrance exam and 380 (52.1%) students believed that NExT Step 1 shall be a medical licensing exam, while only 314 (43.1%) students believed that NExT Step 1 shall be conducted as the Third professional Part 2 (Final Year) theory exam. Almost all students (682, 93.6%) agreed that conducting a mock test similar to NExT Step 1 would be beneficial and a slightly lesser percentage (588, 80.7%) believed a 100% MCQ-based examination for theoretical university professional exams will help their preparation for competitive exams like NExT Step 1. Students (298, 40.9%) suggested having more than three mock tests; the majority of students (512, 70.2%) preferred conducting NExT Step 1 every 6 months to improve on their previous scores. We found that most students opted for a 1-day exam (304, 41.7%) of 3-h duration (491, 67.4%). Most students (264, 36.2%) wanted the exam to only comprise clinical subjects while a sizeable number (236, 32.4%) wanted to include para-clinical and non-clinical subjects as well. A considerable number of students (439, 60.2%) favoured having no attempt limits; only six (0.8%) students preferred a single attempt limit. Most students (490, 67%) found final year theory exams to be redundant given NExT Step 1 being introduced (Table 3).

Table 3.

Perception of students towards National Exit Test (NExT) (N = 729)

Questions	Yes		No
Are you completely aware of the pattern of NExT?	226 (31)		503 (69)
According to you, what shall be the purpose of NExT Step 1?
Exam for providing Medical License	380 (52.1)		349 (47.9)
Exam for post-graduate entrance competition	504 (69.1)		225 (30.9)
Third professional part 2 (Final Year) theory exam	314 (43.1)		415 (56.9)
There is discussion that for practice, NMC will be conducting a mock exam similar to NExT step1. According to you, shall a mock test be also conducted before NExT step 1?	682 (93.6)		47 (6.4)
Do you think conducting 100% MCQ-based examination for theoretical University professional exam will help your preparation for competitive exam like NExT step1?	588 (80.7)		141 (19.3)
Do you think conducting the practical examination NExT step 2 after internship is necessary even after passing the third professional part 2/fourth year University practical exam, which are conducted before internship?	365 (50.1)		364 (49.9)
	Responses Frequency (Percentage)
According to you, how often shall NExT step 1 be conducted for the improving score of previous NExT step 1?	Every 6 month 512 (70.2)	Every 1 year 192 (26.3)	Every 2 year 5 (0.7)	Every 3 year 20 (2.7)
According to you, for how many days NExT step 1 shall be conducted?	1 day 304 (41.7)	2 days 103 (14.1)	3 days 203 (27.8)	4 days 119 (16.3)
According to you, what shall be the total duration of NExT step 1 per day?	3 h 491 (67.4)	4 h 92 (12.6)	5 h 59 (8.1)	6 h 87 (11.9)
According to you, which portion of subject shall be included in NExT step 1?	Clinical subjects along with non-clinical subjects 58 (8)	Clinical subjects along with para clinical subjects 171 (23.5)	Clinical subjects only 264 (36.2)	Clinical subjects, para- clinical subjects along with non-clinical subjects 236 (32.4)
What shall be the attempt limit(s) for NExT step 1?
One attempt 6 (0.8)	Two attempts 26 (3.6)	Three attempts 117 (16.1)	More than three attempt 141 (19.3)	No attempt limits 439 (60.2)
According to you, how many mock tests shall be conducted per year?	One 68 (9.3)	Two 199 (27.3)	Three 117 (16)	More than three 298 (40.9)
What is your opinion regarding the part 2 of the third professional theory exam (i.e., fourth year University theory exam)?	Shall be conducted in addition to the NEXT Step-1 239 (32.8)	Shall not be conducted if NExT Step-1 is being conducted 490 (67.2)
Next step 2 is supposed to be a practical exam. If NExT will be conducted, what would you prefer?	Practical exam for third professional part 2 shall be conducted separately in addition to NExT step 2 228 (31.3)	NExT step 2 shall be considered as practical exam for third professional part 2 501 (68.7)
According to the latest draft, NExT step 2 will be conducted after completion of internship. When shall step 2 be conducted according to you?	Before Starting of internship 176 (24.1)	After completing of internship 553 (75.9)
According to you, which body shall conduct NExT step 2?	Respective University/Institution 308 (42.2)	NMC 421 (57.8)

Students were equally divided on NExT Step 2 being a practical exam — 50.1% (n = 365) believed that it is necessary as a post-internship exam in addition to the university practical exam conducted in final year (before internship). They also wanted NEXT Step 2 to be considered a practical exam for final year (501, 68.7%) and a majority (553, 75.9%) of them believed that it should be conducted after completing internship. Most students (421, 57.8%) wanted the NMC to conduct the NExT Step 2 (Table 3).

The distribution of preferences regarding the purpose of the NExT was more or less uniform across students from different years of study — 63 to 74% wanted it to serve as a postgraduate entrance exam; 51 to 55% wanted it to be a medical licensing exam; and 52 to 68% wanted it to entirely replace the third professional part 2/final year exams (Table 4). The distribution of preferences regarding subject inclusion, on the other hand, varied across different years of study — most first professional students (95, 34.7%) and interns (19, 43.2%) preferred a mix of clinical, para-clinical, and non-clinical subjects whereas second, third part 1, and final year professional students (47, 41.6%; 76, 42.9%; and 48, 39.7%, respectively) preferred the exams comprise clinical subjects only (Fig. 2).

Table 4.

Purpose of NExT according to the students (academic scholar year wise distribution of responses) (N = 729)

Questions	First Professional Year	Second Professional Year	Third Professional Year- Part 1	Third Professional Year- Part 2/Final Year	Intern
According to you, what shall be the purpose of NExT?
Exam for providing Medical License
Yes	147 (53.6)	61 (54)	84 (47.5)	64 (52.9)	24 (54.5)
No	127 (46.4)	52 (46)	93 (52.5)	57 (47.1)	20 (45.5)
Exam for Post-Graduation Entrance Competition
Yes	192 (70.1)	77 (68.1)	118 (66.7)	89 (73.6)	28 (63.6)
No	82 (29.9)	36 (31.9)	59 (33.3)	32 (26.4)	16 (36.4)
Third Professional Part 2 (Final Year) Theory Exams
Yes	73 (26.6)	58 (51.3)	91 (51.4)	69 (57)	23 (52.3)
No	201 (73.4)	55 (48.7)	86 (48.6)	52 (43)	21 (47.7)

Fig. 2.

Academic year-wise preference of students towards the inclusion of subjects in NExT Step 1 (N = 729)

Discussion

The present study was conducted to assess the awareness and perception of Indian medical students towards the change in examination pattern for entrance in postgraduate courses. Our main findings concur with our hypothesis that a majority of students are unaware about the examination pattern and its purpose as an entrance or a licentiate exam. We have found that the current dominant pattern of examination, with long answer type questions, does not align with the preference of medical students, who prefer clinical and multiple-choice questions. The difference in patterns has historically been one of the causes for increased stress amongst medical students as they prepare to sit for their final year and post-graduation exams, and our study further emphasizes the need for alignment of the two patterns.

The Next Step 1 is designed to be a computer-based multiple-choice questions test, intended to bring nationwide uniformity to the undergraduate medical teaching, as well as the postgraduate entrance processes [10, 11]. The latest guidelines posit a six-part exam spread over 5 days, with 2 papers being conducted every alternate day, to replace the standard final year theory exams presently being conducted. Students, however, conclusively agreed on wanting the NExT Step 1 to be designed as a 1-day exam lasting 3 h, being conducted every 6 months. In total, 60% students preferred no attempt limit(s) for NExT Step 1. It can be inferred that the students prefer a 1-day exam rather than a 3-day tedious exam to decrease burden. Also, a 6-monthly exam might remove the undue pressure of losing an entire year. If we consider these aspects and preferences expressed by students (which are a definite possibility for implementation), the impact can be an overall well-being of the students. The pattern of examination affects students’ learning more than the educational methods. The goal of the assessment should be to promote future learning and enhance competence. The assessment affects students’ approach to learning, and might make the difference between rote learning (surface level learning) and actual internalization of key concepts (deeper learning). There are several factors contributing to students’ performance like assessment format, stakes of the examination, assessment content, examination duration, frequency, and the interval between the examinations. It is evident that success in a high-stakes exam is more important for students leading to increased stress. The overall consequence affects learnt content, retention, and depth of learning. The implementation of multiple tests throughout the year directly correlates with students’ performance in the final test [12]. They also want regular mock tests simulating the exam to be held which can be utilized by the students as practice-cum-self assessment exams to allow better preparedness before appearing for the high-stakes NExT exam. These mock exams can follow the pattern of the self-assessment exams conducted by the National Board of Medical Education (NBME) in the USA for medical students appearing for USMLE, which can be purchased by the students [13]. These mock tests/self-assessments have been conventionally helpful both US and international medical students [14]. The pattern of questions presented in said self-assessments is very similar to the actual questions that appear on the final exam; in fact, many questions are set by the same set of examiners as those who draft the final USMLE exams, thus adding to the familiarity students feel with the exam pattern and their level of preparedness. This has been associated with reduced anxiety [15] amongst students, and this can be implemented alongside NExT in India to ensure that medical students are better able to cope with the change. It was found that the students’ scores in their final exam were similar to their formative assessment scores. It was evident that the students performing poor in the formative tests had more benefits with the regular tests in a study conducted by David Geffen School of Medicine (DGSOM) at UCLA [16]. Further, as discussed previously, students conclusively prefer multiple-choice based questions to be the dominant pattern of professional examination. This will help students feel more prepared for the MCQ-based competitive exam corroborated by the findings of a study where only 2.6% of medical students preferred long essays as a mode of assessment [7]. Across disciplines, it is suggested that the open-ended questions shall only be administered where the response from an MCQ cannot suffice. The open-ended questions have low reliability but are useful in certain cases because of low cueing effect, in instances where a more comprehensive and thorough assessment of knowledge is required [17]. Thus, during formative assessment. a balanced and validated approach should be used.

Students have divided opinions on the purpose of NExT: while a majority of students agree that it should serve as a postgraduate entrance exam, only about half the surveyed population confer on it serving as a licentiate exam or as a replacement for final year exams. This shows that students are themselves not sure about the utility of NExT and their opinion about it, owing to the confusion surrounding the exam. While the idea of replacing final year examination with NExT has been debated in the past, a lack of clarity on the basic operation of the exam has left the discussion unresolved [18]. The latest draft declares that NExT Step-1 will be conducted after completion of final year and before starting internship. Our study found that in this scenario, a majority of students felt that final year university exams should not be conducted in addition to NExT Step-1. A majority of students wanted the NExT Step-1 to be composed of Clinical-subject questions only or from all the domains of clinical, para-clinical, and non-clinical subjects. The NBME states that while constructing a high-quality MCQ-based exam, two aspects should be considered: content sampling and psychometric performance. While formulating NExT Step 1, NMC can also consider specific points made by NBME in the module “Constructing Written Test Questions for the Health Sciences” [19]. Furthermore, the exam content shall be regulated on the basis of the Van der Vleuten’s five criteria for usefulness of an assessment: reliability (accuracy and reproducibility), validity (whether the assessment measures what it claims to measure), impact on future learning and practice, acceptability to learners and faculty, and costs [20].

NExT Step 2 is proposed to serve as a clinical cum practical exam to assess medical students’ acumen in patient communication, examination, and diagnosis making. It shall be held after completion of internship and comprise actual cases, objective structured clinical examination (OSCE), and/or simulations as per the latest guidelines [2]. Given that the current post-graduate examination has no provision for assessing these inarguably necessary skills, NExT Step 2 promises to be a step in the right direction to better equip students with hard as well as soft skills essential for any person entering medical practice.

Given that a dedicated practical exam is conducted as part of final year exam, the utility of NExT Step 2 alongside this practical exam is contended, with most students wanting the NExT Step 2, if implemented, to replace the final year practical exam. That being said, if both exams are still conducted (as proposed in the latest guidelines), it is logical to separately define the purposes of each exam, to avoid redundancy. In this light, the NExT Step 2, being held post-internship, should include adequate assessment of not just history-taking and examination, but also procedural skills (assessed via simulations such as those employing mannequins) which are predominantly mastered during internship. Further, a better and more objective assessment of diagnoses forming acumen can be made by incorporating OSCE-based examination.

It is common practice among interns to spend a majority of internship time focused on theoretical learning in anticipation of the postgraduate entrance exam [21]. Introduction of NExT Step 2 is expected to shift this trend back to the hospitals, and towards more clinical learning, which seems to be amiss in present MBBS education [6], by encouraging both students and faculty members to focus on clinical exposure. A majority of students also believe that they are unable to sufficiently prepare for the postgraduate exams due to their hectic internship schedule [22]. Our results also imply that students would prefer NExT Step 2 being conducted after internship.

It is pertinent to point out here that the guidelines do not specify whether the Next Step 2 will be conducted by the NMC or the individual universities/institutions [2]. In this light, it is imperative to highlight that in the latter case, there is a high likelihood of personal biases creeping into the system, with possible rise in the hierarchical dependency already rampant in medical colleges [23]. Clearing NExT Step 2 may be incentivised to coax more working hours, or other favours, out of medical students during internship. This would essentially defeat the purpose of introducing the NExT exams in the first place. Our surveyed population also agreed on preferring NExT Step 2 be conducted by the NMC itself, and the opinion is shared by faculty, as found in a study by Dulloo et al. [24].

In this regard, lessons can be learnt from the methods previously used by NBME in conducting the USMLE Step 2 Clinical Skills exam, which has been discontinued since the COVID pandemic. This practical exam was conducted devoid of any viva in order to reduce subjectivity and biases, but required interaction, in the form of history-taking and examination, with standardized patients [25]. Also, USMLE Step 2 Clinical Knowledge exam uses multimedia aids and simulations during multiple choice questions-based test to test students’ clinical and practical acumen. Lessons from these exams can be learnt and incorporated in NExT to further improve its validity. Furthermore, the potential challenges will be significantly more for implementing NExT Step 2, such as logistical issues, training requirements for evaluators, and ensuring uniform standards across institutions. Thus, these challenges will need to be addressed through cost–benefit analyses. But on the other hand, if implemented on an objective basis such as OSCE, this can also be a growth opportunity for students where the students can now be more focussed on the clinical examination skills rather than impressing a few professors and thus can lead to a better learning environment (which could have not been in the case of oral viva voce).

While the NExT is widely hailed as a welcome change in Indian medical education by students and faculty alike, the lack of clarity in guidelines has become a new detriment in students’ preparation. Thus, there needs to be more transparency and solidity in planning and implementation of the exam moving forward, with due participation of all stakeholders in the process. The broader implication of the NExT exam will be evident in long-term over millions of medical students getting graduated and the quality of doctors India will be producing. Hence, stringent quality improvement procedures shall be in place for continuous improvement. Strategies for addressing students’ concerns or questions can be through on online portal on the website of the NMC, where the questions and answers are visible to every student for transparency. This will help them have a better-preparedness for the exam.

The present study has few limitations; firstly, we aimed to achieve equal representation from different zones/regions of the country (106 participants from each zone), but we could not attain adequate participation from the West and North-East regions of the country. Alternately, we got more responses from the Northern and Eastern zones. Although the initial study design mandated equal participation from all regions, this uneven distribution can be attributed to a proportionate difference in the number of medical colleges in the North-East region. There are also some methodological constraints in our study limiting the generalizability, such as limited sample size and no follow-up questions. The NExT is not implemented yet and hence, once implemented, the participants’ perception might change with time. Hence, nationwide prospective analytical cohort studies are needed to assess exact temporal change in students’ perception. Secondly, responses were gathered through self-administered questionnaires, restricting the researcher from clarifying, probing, or verifying the responses, or observing the non-verbal cues of the respondents. We did not evaluate students’ style of learning, i.e. surface approaches vs. deep approaches which could affect the preference over the type of questions in the university exam. Furthermore, it is pertinent to check NExT Step 1 questions’ validity and reliability on a temporal basis.

Conclusions and Recommendations

We found that the majority of medical students prefer NExT to serve as an exam for post-graduate entrance competition but not the third professional part 2 (final year) theory exam. Students prefer NExT Step 1 to be conducted every 6 months as a 1-day exam of 3-h duration. Most students want no attempt limits. Majority further prefer at least three mock tests to be conducted annually. Students prefer 100% MCQ-based examination for theoretical university professional exams for better alignment with the entrance exam pattern. They also opine that NExT Step 2 should be conducted by NMC after completion of the Internship.

Regular feedback from all stakeholders should be sought before the exam is implemented. We also recommend conducting briefing sessions for not just students, but also the faculty, so that teaching in medical institutions can be aligned with the exam. It is imperative to provide adequate time between the announcement of the exam and its first implementation so that students have time to familiarise themselves with the pattern and prepare without anxiety. Finally, once the NExT exam is implemented, continuous feedback gathering and monitoring must persist without interruption. The true measure of the exam’s long-term effectiveness and appropriateness can only be assessed in real-world contexts.

Author Contribution

AJ, DD, LE, and SR formed the proposal of this study. AJ, MG, IG, SR, and SK collected the data. DD and RPJ performed the statistical analysis. AJ, MG, DD, IG, RPJ, SR, LE, SK, PS, PB, and SA. Prepared the manuscript. All the authors reviewed and approved the final manuscript.

Data Availability

The datasets analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics Approval and Consent to Participate

Ethical approval was obtained from the ethical committee of Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi-110085, India (F. No. 5(32)/2020/BSAH/DNB/PF22348-49). Informed consent was taken from each participant.

Competing Interests

The authors declare no competing interests.