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 Table of Contents  
EDITORIAL
Year : 2021  |  Volume : 2  |  Issue : 3  |  Page : 201-203

The NExT challenge – The national exit test


1 Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi; President, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission10-Dec-2021
Date of Decision11-Dec-2021
Date of Acceptance11-Dec-2021
Date of Web Publication28-Dec-2021

Correspondence Address:
Dr. Puneet Dhar
Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_106_21

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How to cite this article:
Dhar P, Nundy S. The NExT challenge – The national exit test. J Med Evid 2021;2:201-3

How to cite this URL:
Dhar P, Nundy S. The NExT challenge – The national exit test. J Med Evid [serial online] 2021 [cited 2022 Jan 24];2:201-3. Available from: http://www.journaljme.org/text.asp?2021/2/3/201/333950



The National Medical Commission (NMC), established as an Act of Parliament, was conceived in 2019 and came into force in 2020. Its aims are to establish equitable healthcare for all and to improve access to quality and affordable medical training, thus ensuring an adequate competence of doctors throughout India. This would be done by laying down policies to achieve and maintain high standards by regulating medical education, research and practice. The NMC will also assess the changes in the infrastructure needed, help coordination between the numerous autonomous medical boards and assist in future planning to achieve these goals.

The entrance to medical undergraduate courses previously necessitated the candidates taking numerous examinations in different Indian cities at different times. Now, under the NMC, this has been unified for all medical institutions – central, state, deemed universities, private colleges and the autonomous Institutes of National Importance (e.g. All India Institute of Medical Sciences [AIIMS] and JIPMER) by a combined National Eligibility cum Entrance Test Undergraduate (NEET-UG). The rank obtained from this examination determines the candidate's priority for central counselling for the 15% under the All India quota. There is also a separate merit list and counselling for the remaining 85% under the state quota as well as the private medical colleges. This has saved the 17 lakh or so youngsters who are keen to become doctors a considerable amount of hardship and expense.

The next reforms proposed by the NMC are similar postgraduate (PG) entrance tests (NEET PG) by unifying the numerous final qualifying MBBS examinations into a single National Exit Test (NExT). Part 1 of this will be an objective scored test and Part 2, the clinical portion, will have a pass/fail outcome. It is proposed to use the merit-based NExT for admission to PG speciality courses as well as to provide a license, a seal of competence, for fitness to practice in India for Indian as well as for foreign medical graduates (FMGs). A press note dated July 30, 2021[1] stated that this would be implemented from the first half of 2023, and a mock run is planned in 2022.

The NExT promises to be a game changer, especially for achieving a uniform and standard level of medical education for the whole country.

It will also make the internship year more meaningful! A little over two decades ago, the basic speciality PG degree course was changed from 2 to 3 years by incorporating the post-internship 1 year of house surgeon period into the MD/MS itself with the PG entrance examination right at the end of the internship. This meant that the new graduate used this time instead of being exposed to different medical and surgical specialities during the internship rotation to mainly prepare for the entrance tests. They would spend their time joining different coaching platforms such as DAMS, MARROW and others which imparted rote learning skills relevant to the entrance examinations but were a poor substitute for the practical skills a young doctor might pick up during an effective internship! The lack of interest of the interns in being trained also resulted in their clinical teachers presuming that even those interns who attended the wards were disinterested and used them for pure clerking duties and for collecting clinical reports. A corollary has been the 'dummy' internship which exists particularly in private hospitals where certificates for this compulsory rotation are provided without any attendance requirement.[2]

The NExT exam being held before the internship begins will ensure that the practical aspect of the internship experience will be restored to its intended role of training a young medical graduate basic medical and communication skills, providing an exposure to a wide range of departments and helping him or her to choose a speciality which interests him or her. The joys of crossing the threshold from being a medical student to a doctor can be immeasurable if unimpeded by having to prepare for a 'career deciding' examination! The 'dummy' internships would also be ended by the mandatory requirement of the NExT-2 component which will test practical skills.

The third benefit of NExT will be to broaden the opportunities for FMGs and help streamline both Indian and foreign graduates into a single flow. Indeed, it has the potential to even reverse the brain drain. Many doctors trained abroad either want to come and work here for charity or service or to gain better exposure in areas such as minimally invasive surgery, living donor-organ transplantation or tropical medicine. Until the FMG exam was started, it was virtually impossible for anyone with a foreign degree to work in India. Even in its current version, the relevance of the exam is questioned with an abysmally low pass percentage, further dissuading foreign graduates to return to this country.

A fourth benefit is that NExT could be used for other purposes such as the revalidation of registration or standardise criteria for allocation to state-specific issues such as a merit list for mandatory rural service.

The draft regulations on PG education[3] also seem to seal the fate of the PG diploma courses. These are a relic of the 2-year PG course era when a lesser 'diploma' of 1 year was possible (without the mandatory thesis/dissertation) for those unable to secure a 'full' PG degree. In this way, these candidates were able to complete a 'certified PG course' which would serve as a 'specialist qualification' on its own or be a precursor to a fuller degree later by the time of the next entrance examination. Examples are the Diplomas in Child Health, Gynaecology, Ophthalmology, Anaesthesia and TB and Chest Diseases. These are in the process of being phased out, and no new diploma courses will be offered from 2021 onwards.

A final advantage of the NExT is the proviso for the validity of the marks for 3 years from the eligibility date to be granted the license, unlike the current practice of trying their luck in every single examination that arises! Although this may cause some confusion in equating scores between different exams held in different years with possibly different perceived standards or degrees of difficulty – these would require to be ironed out by some mechanism of standardising the results, for instance using percentiles. The collateral gain of the extended 3-year validity of the scores could assist students to explore interim research projects, other passions or job opportunities, experience a different branch of medicine and make a more informed decision on what career path they want or finish a rural (or religious institutional) bond without concerns that it would affect their future prospects in their medical career. A delay beyond 3 years, however, would require a fresh examination to be taken and scored! A mechanism to address regional disparities of rural bond durations, armed forces and other in-service quotas will need to be worked out if these exceed the 3-year validity period!

This reformation process will face some inevitable obstacles. There is already discontent that the draft regulations undermine the role of the states (health being a state subject!) or even reduce their available workforce pool if the exam is held as a part of the MBBS itself. Also is there adequate infrastructure to manage the massive number of candidates who will appear? Will there be multiple-choice questions? How will it affect the private medical colleges? Will the autonomy of Institutes of National Importance be affected?[4]

The biggest challenge could well be that we are defining the end point rather prematurely without a mechanism first to tackle the differences across states or centres or correcting the regional and interregional imbalances. This would require a concerted effort by training faculty and educating all the stakeholders well in advance.

There is a fear that unlike MBBS exams which are held twice a year, the NExT exam appears to be conceived as an annual event. It may be better to conduct it more frequently as happens for its US and British 'equivalents' such as the USMLE, IELTS English test, GRE or GMAT

Another disadvantage could be that NEXT-1 will test students on all years' subjects but be held right after their final year. So students will spend their final-year learning facts from all the previous years combined and may not be able to preserve and to strengthen their clinical knowledge and understanding which form the core at the terminal end of the MBBS course! This could need more extensive reworking of curriculum-like modules are taught in an integrated system-wise fashion rather than watertight subjects taught in isolation or reworking clinical exposure significantly from the first year onwards.

This could of course be circumvented by making the exam more clinically relevant and case vignette based but this will need effort from the faculty members as hard work to generate, validate and standardise these questions, and there is an innate tendency to shift back to less objective ways of testing but which are easier to formulate.

A wonderful opportunity exists of using the practical side of the NExT-2 to standardise the teaching of soft skills bedside manners, ethical considerations, taking informed consent, asking questions about sensitive issues/breaking bad news, etc. These could be tested perhaps in an objectively structured clinical examination (OSCE) format. Some centres including ours have begun using OSCEs extensively including formative assessments as well.

There are other contentious and more chronic issues to be dealt but may not be possible only with NExT, for instance the language of the examination, namely the relevance of fluency only in English. Many states have questioned why the exam could not be in regional languages, which is what is required for them to communicate with the patients! It does not help to explain that most medical teaching is in English including the fact that most references to published papers and books are to those from outside this country! This does put an additional burden on the rural poor of affording expensive reference texts in English and then not having a fluency in the language! A more concerted effort may be needed to make the curriculum and texts itself indigenised as per our national needs possibly in vernacular as well, as has been done by NCERT at the school level. Only then can the exam match up to measure what was taught appropriately!

Also, the PG entrance process needs to balance the number of preclinical/paraclinical and clinical PG seats to the tailored requirements in the country. Rather than an arbitrary and constant increase in all PG seats over time, there needs to be a dynamic rationalisation according to our needs! Until then, there will continue to be an inequity of PG seats against UG pass outs and non-PG rural and other requirements.

Finally, the whole process should minimise bureaucratic or political interference as has marred the national PG admission and counselling process in the entire year of 2021. The draft declaration has still left grey areas in vague officialese – so multiple departments are involved with scope for confusion amongst them. Exam and counselling processes can possibly be under the purview of the Medical Council of India, the National Board of Examinations, Directorate General of Health Services and National Testing Agency and even AIIMS Delhi. This causes confusion and blame-shifting and delays. The draft document should clearly spell out a single agency rather than the vague 'The designated authority to conduct the NExT shall be as specified by the NMC'!

Nevertheless, we believe the NExT examination to be a bold and decisive step which will not only result in a uniform standard of medical education and training in this county but raise it to so-called 'international' levels. We hope that it succeeds.

Acknowledgements

Appreciate critical inputs from Dr. Dharini Prasad and Dr. Anirudh Dhar, especially with respect to the students' viewpoints.



 
  References Top

1.
Available from: https://pib.gov.in/PressReleasePage.aspx?PRID=1740 678. [Last accessed on 2021 Dec 10].  Back to cited text no. 1
    
2.
3.
4.
Ranjan P, Ranjan R, Kumar M. National exit test: How will one size fit all? Ann Indian Acad Neurol 2020;23:145-9.  Back to cited text no. 4
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