The HKCFP Exit Examination revisited: reflections from an external examiner

Doris Young

HK Pract 2022;44:1-2

After 15 years as the external examiner for the Hong Kong College of Family Physicians (HKCFP) Exit Examination, I have reflected on the changes I encouraged over that period, to ensure the examination was of a high standard and succeeded in producing ‘academicians’ for Family Medicine in Hong Kong. To place the changes in context, I need to go back to the beginning and explore the original objectives of higher training for Family Physicians and whether the examination is still valid and is capable of delivering the future leaders of the Family Medicine specialist workforce. Finally, I will comment on what changes the Speciality Board might consider, to improve the quality and outcomes of the various components of the Exit Examination.

Looking back in order to move forward

The HKCFP conducts a six-year vocational training programme (including basic training and higher training). Competency is assessed by an intermediate examination (Conjoint HKCFP/RACGP Fellowship Examination) and a final examination (Exit Examination of Vocational Training). The Specialty Board of HKCFP is responsible for conducting the Exit Examination of Vocational Training. The aim of this examination is to test if candidates have achieved the required standards at the end of their Family Medicine training and are qualified to provide high-quality specialist care to the community as a family physician. The components of the current Exit Examination are as follows:

Practice Assessment: assesses the candidate’s knowledge, application of skills and ability to organise and manage an independent family medicine practice AND

The Consultation Skills Assessment (CSA): assesses the candidate’s knowledge, skills and attitudes in communication, problem solving, working with families and management in different types of family medicine consultations including complex psychological conditions AND

Clinical Audit: assesses the candidate’s knowledge, skills and attitudes in critical appraisal of information, self-audit, quality assurance and continuous professional improvement OR

Research: assesses the candidate's ability to conduct a research project which includes: performing a literature search and defining a research question, selecting the most appropriate methodology to answer the research question, performing appropriate analysis and interpreting the results with a discussion and conclusion.

Review and Appraisal of the current CSA, Audit, Research components of the Exit Examination

Over the last few years, CSA assessment was changed from on site direct observation (which was very labour intensive) to reviewing six videotaped consultations. Has this assessment achieved its objectives? Should we change the Learning-Action- Performance (LAP) framework after using it for 25 years? Candidates have followed the LAP framework (first introduced by the inaugural external examiner Professor Robin Fraser) like a recipe but there are other options for assessing consultation skills. I hope the Specialty Board will consider using other assessment formats to test whether candidates display advanced clinical skills matched to those of a ‘specialist Family Physician’ par excellence.

The audit segment is a quality improvement activity (Plan-Do-Study-Act) in the trainee’s practice and should be performed by trainees to demonstrate improvement in their chosen areas in their clinics. Over the years, I have observed some candidates picking popular topics, where they can share background literature and similar or even identical criteria settings. Many of the audit topics are not innovative or original enough and one has a sense the aim is to merely pass the exit examination, rather than to achieve true improvement in clinical practice.

For the research segment, on the other hand, the topics have varied, reflecting local clinical and health services research needs in the General Out-patient Clinics (GOPCs). The research option has been gaining popularity, with more candidates now choosing research rather than audits. The standards of the research projects are high, which has helped to grow capabilities in building primary care research in Hong Kong. In view of this excellent scholarly output, should we make conducting a research project compulsory in the Exit Examination?

Further thoughts on the way forward

So, what should be done about the audit component? I believe that performing small audits in one’s practice is essential to improve practice quality. It emphasises the value of quality improvement and focuses on patient safety and outcomes. Practice audit can be made compulsory during the last year of basic training with a presentation (formative assessment), as well as a compulsory two-year research project during higher training. Completing this work will fulfil the objectives of producing academicians or scholars in Family Medicine after six years of vocational training.

In addition, would it be timely to add an oral defence component to both the research and audit assessments, for candidates to field questions from the examiners? This approach will ensure that they do understand and learn from their research and audit projects.

These are some of my observations and suggestions for the Specialty Board to consider in planning the future of the HKCFP Exit Examination. We want to ensure higher trainees not only possess advanced clinical skills, but as Family Medicine academicians, understand and are competent in family practice and primary care research, ready to teach and mentor their colleagues.

It has been a great privilege to act as external examiner over the past 15 years. I am grateful for the support I received over that time and the close friendships that have ensued. I wish all my colleagues in the HKCFP continued success in their careers and will always be ready to lend a hand, especially to my successor as external examiner.