The Specialty Certificate Examination in neurology
An exam for neurology
Neurology successfully launched its first annual Specialty Certificate Examination (SCE) in May 2009, having previously piloted a knowledge-based assessment in 2006. The SCE was developed by the Federation of Royal Colleges of Physicians of the UK in partnership with the Association of British Neurologists.
Candidates passing the SCE are assured that they have:
sufficient knowledge to practise neurology to consultant level
a qualification that is understood and respected by the public and the medical community
achieved a standard that compares favourably with equivalent assessments anywhere in the world.
Not an ‘exit exam’
Anyone holding MRCP(UK) or who is occupying a UK training post may sit the neurology SCE. For specialist registrars (SpRs) (appointed before 2007) and for consultants, it is voluntary, but for post-2007 neurology specialty trainees it is an essential precondition to their obtaining a certificate of completion of training (CCT). Those obliged to sit the examination will typically have made at least one attempt before their penultimate year assessment. The SCE covers only the knowledge component of the specialist curriculum, other elements (clinical skills and attitude/conduct) being assessed in the workplace. It is not, therefore, an ‘exit exam’ but one of several tests of competence. Passing candidates obtain a certificate, but only those obtaining a full neurology CCT may use the post-nominal MRCP(UK)(Neurology).
Best of five
The examination itself (termed a ‘diet’ because all candidates must sit on an appointed day) involves two three-hour papers, each comprising 100 ‘best of five’ (BOF) questions. Candidates attend a computer-based testing centre not far from their home, where (equally anxious) teenagers are sitting the Driving Standards Agency's theory test. Questions appear on individual computer screens in a random order, giving each candidate a unique experience. BOF questions test not only knowledge but also intuitive clinical thinking. A brief clinical scenario precedes the lead-in question (eg ‘What is the most likely diagnosis?’) and five possible answers, each potentially correct but one ‘most correct’. By contrast, multiple-choice true/false questions offer only the definitively right or wrong – rare in clinical practice.
Eighty per cent pass rate
In common with all trainees who sat SCEs during 2008–09, candidates who attempted the first diet of the neurology SCE found it harder than they had expected. However, the examination is not designed to generate large numbers of failing (and stuck) trainees. A painstaking standard-setting process, aimed at the level of knowledge sufficient to practise as a newly appointed specialist, produces a pass mark that should allow around 80% of UK trainees to succeed at the first attempt. The results of SCEs to date in most specialties have met this expectation. Indeed, neurology's pass rate among UK trainees in 2009 was 87.5%. Those who have held a UK clinical neurology training post for four years should have acquired the necessary knowledge, though some preparation is recommended if one is to be confidently among that 80%. Certain topics appearing in the examination (eg nerve conduction study data, glioma histopathology, ABCD2 scoring) are quickly promoted to a registrar's ‘must-read’ list. The existence of the SCE therefore encourages trainees to equip themselves better for their work.
Question topics
Certain topics with specific presentations (eg mononeuropathies) readily lend themselves to the BOF format. Enough questions exist on Lambert–Eaton myasthenic syndrome and on dementia with Lewy bodies, as well as exotica like neuromyelitis optica and NMDA encephalopathy. Fewer questions exist, however, on important issues better suited to essays, such as ethics, non-organic disorders and non-specific symptoms, simply because they are more challenging to write. The adult neurology curriculum includes paediatric neurology and so registrars can expect occasional questions on children and babies.
Style matters
All questions hinge upon a clearly written clinical stem that reflects good clinical practice with (where relevant) adherence to National Institute for Health and Clinical Excellence guidelines. Clarity and word economy are important, as is use of the past tense and consistency of spelling and punctuation, to facilitate ease of reading. Eponyms are discouraged and modern terminology promoted (eg vestibular schwannoma not acoustic neuroma). The answer options must fall in the same domain (eg five possible treatments or five possible investigations, thereby avoiding two equally correct answers). Images are encouraged (mainly scans) but the examination cannot yet accommodate video. Being international, questions on UK law, including Driver and Vehicle Licensing Agency rules, are currently avoided; their importance probably justifies their inclusion only for UK trainees, with alternative questions for overseas candidates.
Question writing
The question-writing group comprises 25 consultant neurologists, some with previous MRCP(UK) question-writing experience. All must contribute 15 questions in good time for checking by non-medical editors before the annual meeting. Each question undergoes several levels of scrutiny. At the writing meeting, small groups of four to six discuss each question in detail, averaging five to eight minutes per question. An effective group needs a skilled clinician typist familiar with keyboard shortcuts. Another with internet access can usefully check the evidence underlying a question (eg ‘aren't the ankle jerks typically preserved in Fabry's disease?'). This is a good time to ask, ‘What is the learning point of this question?’ and ‘Is this what we want our registrars to know?’. Questions surviving this rigorous process are selected against curriculum; the blueprint ensures appropriate proportions of different neurological presentations plus statistics, ethics, etc. Selected questions are then discussed, amended and improved at the two-day meeting of the examining board. Surviving questions are individually assigned an agreed pass mark at the two-day meeting of the standard setting group.
Benefits to question writers
Question writing expands writers' knowledge of neurology but also of writing style and spelling. It is a friendly but hard-working group and meetings are an opportunity to catch up with old friends. The process also better equips the team to cope with criticism, since question writers cannot be precious about their own questions; fair and meaningful candidate assessment always trumps a writer's sentimentality. Real cases can prompt good question ideas but the plea ‘It was an actual case!’ is no bar to a question's improvement. If the group prefers the patient to be 20 years younger with diabetes and taking warfarin, the question changes.
Cost
Unfortunately, the SCE presents trainees with a considerable financial hurdle (£800 for those who sit in the UK, £1,000 for those who sit overseas). Yet still it loses the Federation money, through the necessary but costly processes of peer review, editorial scrutiny and detailed quality assurance. The loss would be far higher if question writers did not give their intellectual effort and time voluntarily, and if trusts did not allow professional leave for consultant attendance at question-writing meetings. It is hoped that, as the SCE gains international credibility and a wider uptake, the extensive investment will be recouped.
The future
The neurology SCE has met its primary objectives. Having passed, trainees can feel confident that their knowledge has progressed since MRCP(UK) and that they know enough to give sound specialist advice from the first day of their consultant post. The examination is evolving and building momentum and it is hoped that it will be adopted more widely abroad. Its electronic format should soon allow inclusion of video material. More contentious, however, is that the public's demand for assurance of specialists' knowledge may lead inevitably to consultants eventually also having to sit the examination for revalidation.
Declarations of interest
PEMS is Chair of the Neurology Specialty Certificate Examining Board.
Acknowledgements
The authors are indebted to all those who have contributed to the development of the neurology SCE, as question writers or as members of the examining board or the standard setting group, for the generous devotion of their time and unstinting effort.
- Royal College of Physicians
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