Is licensing examination for doctors beyond repair?
This article appeared originally in the China Daily on 23 June, 2021.
Author: Pamela Tin, Head of Healthcare and Social Development at Our Hong Kong Foundation
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‘I think now if I were asked to do the internship, I would quit and leave Hong Kong." This is the testimony of a non-locally trained doctor going through Hong Kong's medical licensing examination. The nearly 25-year-old system has taken a bit of a backseat in the recent debate on whether to employ an examination or non-examination route to admit non-locally trained doctors into Hong Kong. This should not, however, be the crux of the issue for a city that has not seen an end to its doctor shortage crisis. Instead, like other places in the world, both routes could and should exist simultaneously.
Hong Kong offers non-locally trained doctors two conventional entry routes — full and limited registration. The former features a licensing examination and post-examination internship. And while the latter does not, it restricts doctors by duration, venue, and scope, and ultimately does not allow progression to full registration. To this day, limited-registration doctors make up less than 1 percent of our doctor workforce.
The Hong Kong Special Administrative Region government's latest proposal is set to provide an additional pathway for non-locally trained doctors to attain full registration, without taking the local licensing examination. In the meantime, we must also ask ourselves why so few doctors attempt, let alone pass, the examination in the first place. Since 1996, only 7.5 percent of our doctors have entered through this pathway, compared to the United States' 25 percent.
A doctor choosing to pursue the licensing examination would expect instructional support and a clear syllabus to prepare for the examination. However, from a lack of transparency on the content examined to inadequate revision materials, the examination support measures are barely cutting it. In Our Hong Kong Foundation's recently published study that interviewed non-locally trained doctors practicing in the city's public healthcare sector, a doctor said they are not provided with "any ideas on what materials … to study from". Not to mention that, during the COVID-19 pandemic, the city's lack of international examination centers brought the administration of the examination to a complete standstill. This meant that Hong Kong effectively handicapped its full registration pathway, with no doctors taking the examination last year.
The licensing examination also does not offer a regular and transparent standard setting of questions, a process that is crucial to ensuring that the passing standard remains at the level required of a graduating medical student in Hong Kong. If the premise of the local licensing examination is to ensure the quality of doctors is on par with local medical graduates, why are we not holding ourselves to the same standard.
The most concerning challenge is how experienced doctors are assessed like fresh medical graduates. Specialists are critically underrepresented in our public system, yet the examination assesses knowledge outside specialists' scope of clinical practice. This means that doctors need time to study materials taught during pre-clinical years, time that could be better spent on delivering services using their advanced skill set. Furthermore, non-specialist doctors with both international and local experience are still required to undergo basic training as an intern after taking the examination. These requirements reflect a lack of consideration for the candidates, requiring them to take two steps back before taking one step forward.
Compared with other places that also administer a local licensing examination such as the United Kingdom and Australia, Hong Kong has a lot to learn. Both systems provide ample support, including comprehensive examination guidance, international examination venues, and standard setting exercises with local medical students. In fact, the UK made a landmark initiative to require all medical graduates, including local graduates, to pass the same examination from 2024 onward. Other places have been providing a level playing field to uphold fair examination standards. This has evidently not been the case in Hong Kong.
So does this mean that our licensing examination is beyond repair? As highlighted by Chan Lai-wan, professor emeritus at the University of Hong Kong, during the foundation's report launch, there are many obstacles in our licensing mechanism, but also, "there are a lot of things Hong Kong could do to open itself up". Referring to the foundation's recommendations on the local licensing examination, Chan said Hong Kong can start by providing comprehensive revision materials. It should regularly calibrate the examination with local students to uphold fairness and consider workplace-based assessment as an alternative to assess the clinical aptitude of more-experienced doctors.
Placing a yardstick too high and hoping the best doctors will not come up short is a strategy that has failed us for many years. Hong Kong has little to lose and a lot to gain in ensuring a level playing field, which is vital for a merit-based assessment of global medical talent. The question is no longer about what assessment measures are better, but how we can better our assessment measures.