Saturday, 18 May 2013

Why DNB exam tougher than MS/MD exam? ......................55513

Dr Kalyan R Kone

There were 6 people (accompanied by their relatives) sitting in the small waiting room outside the ward waiting for their call inside. They looked battered, tense and had such a depressed look in their eyes that even Shylock would have sympathized with them. They had cleared their DNB (Diplomate of National Board) theory exam and were making last minute preparations for their practical exam. If I were not told that they were all Doctors, I would have thought that they were all waiting for their turn to see a psychiatrist.
Dr Kalyan R Kone
Five out of six of those waiting doctors were appearing for the second or third time. In spite of that, they didn’t know what would be in store for them except one thing — only one or two would pass out of the six candidates.
I thought for a moment that it was a good ploy by the NBE (National Board of Examination) to generate funds – after all, where would these poor guys go except appearing again and again, the only other option being a generous bank/land balance in excess of 70 lakh rupees (the average present rate).
In MD/MS exam, when a candidate is appearing for the second or third time, the local examiners would try to push him/her out by offering generous help. But DNB exam has no local examiners for offering help. In the end, after three weeks of agonizing wait, those six waiting doctors found out that only one out of them cracked the practical exam.
This is not a fabricated story – this is happening every year all over India in every DNB exam centre. I don’t know whether this is a cruel joke or harassment in the name of exam. I personally know some of those who had failed the exam in spite of good practical knowledge and successful practice. For primary DNB candidates, it is a “life or death” exam. For the diploma holders, the degree is like small regalia to show to their MS/MD cousins that they are equivalent to them and most importantly for a personal reason, to stem the inferiority complex simmering in them.
It is well known that a person joins DNB course only after he/she exhausts all the avenues of getting a masters or diploma from a government medical college. These people also can’t afford the crores of rupees of capitation fee demanded by private medical colleges. But one thing is true — most of the Doctors joining this programme enlist in it out of pure interest for the subject.
When one assumes that only weaker candidates join the DNB, it is logical to surmise that the final exam would not be made relatively tougher. But the NBE wants to punish the people who join its courses by doing a completely illogical thing — the exam is made a lot tougher than the MD/MS exam. This can be deduced from the fact that three out of five students taking DNB exam after MS/MD fail in it.
The joke is — even the DNB examiners, if they would take the test, would fail in the exam. The students joining MS/MD know exactly when they would come out with the degree (most of them pass in the first attempt or else they will be kicked out with some help in second or third attempt). But the DNB students don’t have slightest clue regarding this.
Nobody is asking the NBE to make the DNB exam very easy, but to make it on par with the MS/MD exam. The NBE should not punish, instead, it should reward the students joining its courses. It should not tamper with the performance of the students and fix the pass percentage of the exam to a meagre 20-30 per cent because even a bright student can fail in the practical exam if the examiner wants to do so.
How can two external examiners decide about the capability of a student in a single day – some students can express themselves better, some can’t do it so well. The first case also decides whether the student can focus his mental energy on the next case — it is the domain into which the internal examiner steps in and rescues the student because of the association he shares with the student for the past three years, which is sorely lacking for the student taking the DNB practical exam.
It is an open secret that half of the doctors appearing for the final MS/MD exam pass only with the help of the internal examiner in a government medical college (this goes up to 70-80% in a private medical college). All those students appearing in MS/MD exam take the exam in a familiar terrain just like home ground advantage in a football match – two out of four examiners are known, the wards are familiar, the cases would be informed beforehand and no shortage of help during actual exam time.
In this context, one has to understand the level of stress imposed on DNB students — none of the examiners are known, the wards are unfamiliar, the cases are unfamiliar, no help during the exam time, sometimes there is difficulty in communicating with the patient because of the language problem — all these after a long journey to the DNB practical exam centre and overnight stay at a hotel.
The NBE should introduce a way of continuous assessment of the student along with the DNB final exam. The weightage of the final exam can be determined depending on the branch of medicine. This, in a way, would promote the continuous learning of the student during his course and decrease the stress on the student during the final exam. I hope the NBE would listen to this suggestion and make necessary amends.
In the open, MCI (Medical Council of India) and NBE fight with each other but covertly they work towards the same end — to maintain the superiority of medical colleges. The NBE makes sure that nobody escapes easily out of its system and then the MCI harasses those who come out with DNB degree by denying the same level of recognition as a MS/MD. The DNB degree applicants and holders are becoming scapegoats in this tussle. This has created a lucrative private medical college trade, which doles out degrees for money.
It is high time that the NBE increases its pass percentage so that more number of doctors would be willing to join its courses and which, along with supplying Doctors to the starved Indian health sector, will also reduce the spiralling costs of the postgraduate education offered by the private medical colleges.
The NBE should realize that the society does not require extraordinary doctors but average, reasonable doctors on par with the MS/MD postgraduates.
Author’s Clarifications:
1. DNB exam is much tougher than MS/MD. I had cleared DNB in my first attempt following MS (AIIMS) and MCh (Urology). But my colleagues who appeared along with me (premier institutes like AIIMS, SGPGI) failed the practical exam. I had also cleared my FRCS (Ed) in my first attempt. But I felt FRCS was much easier than DNB. (FRCS exam gives more tension only because of the amount of money involved.)
2. Many private hospitals are given permission to take DNB students irrespective of the amount of training they can offer. For medical branches it is partially OK, because most of the students at least will be educated by the patients. But for surgical branches, the DNB programme offered by some of the corporate and private hospitals is plain nonsense, where the DNB trainee is treated like glorified duty doctor (this makes good business sense to those hospitals because proper duty doctors demand much more salary than DNB trainees).
3. I do not agree with the statement that they are all inferior students. Even if you equate them with the private medical college students (both didn’t get the PG degree through entrance) how can you explain the near 100% pass percentage of private colleges with 30% pass percentage of DNB? If one opines that training in a medical college makes the difference, then it is a big lie because at many private colleges (not all) the training is as bad as DNB training.
4. Following some other countries’ guidelines, when your own country is deficient in doctors, is idiotic. Are we training doctors to make Americans and Europeans happy? We should have our own benchmarks and guidelines.
I may be wrong in the DNB pass percentage statistics. The percentages are based on personal experiences and the stories told by the applicants. Only when the NBE comes forward and publishes its statistics yearly, we will know the true picture. And one more thing – I am yet to see a DNB convocation where 3000 students are given degrees.
I have not personally experienced DNB training. I just wrote after hearing the travails of students during their training and finally, when they appear for the exam. I have personally witnessed the discriminatory attitude of medical college authorities, MCI and even patients towards DNB postgraduates. I don’t have any personal scores to settle by writing this article.
Examiners’ leniency matters a lot in the practical exam. I want you to go back to 60′s and 70′s when MBBS pass percentages used to be very low. What happened to the present crop — have they become suddenly intelligent in spite of extraordinary increase of medical knowledge? It is the attitude of examiners that has changed.
Recently, I witnessed a postgraduate exam where a particular student argued (he was right) with the examiner regarding the treatment in a major case. He was given very low marks by that egoistic examiner. Only when the internal examiners insisted because he was their best student and drastically increased their marks the student could pass.
The DNB student sorely misses his mentor and teacher on the other side of the examination table. If a student performs well at three stations and doesn’t do well with the fourth examiner — it doesn’t matter. But, most of the students are average — a poor score at one station is enough to fail them.
In financial market there are certain terms — “spread your risk” and “don’t put all the eggs in one basket”, which is also true in the medical field. I am asking for continuous assessment of the student by holding 6 monthly semester exams (objective and short answer format) for the DNB students, which should be given at least 50 per cent share in the final exam. They should be also trained by the NBE by holding 3 or 4 monthly practical training sessions besides the education offered by the parent institution.
When I am asking for “on par” treatment, it means that the DNB students and MS/MD students should have the same level of measurement of skills — they should have the same examination pattern. My personal opinion is — there should not be different certifying bodies and MCI and NBE should merge in to one single institution. Independent governing bodies should be constituted to take care of MBBS and PG education.
Leave my personal opinions. Everybody has his own prejudices. I will come to the comments — 2 comments by Dr Abie Lawrence were excellent — Putting the examiners themselves through the process and general certification process. 1 comment by Dr Raj regarding the basic clinical training is also relevant — Centres where the results are consistently poor should be de-recognised. The comments made by Dr Dhruv and Dr Manoj Sharma are also excellent — what we are missing is the teacher-pupil relationship and patronship.
We should not forget the adage that “Fifty per cent of all doctors graduate in the bottom half of their class” — irrespective of where we keep the bar. It is the society’s choice where to keep that bar. If the bar is kept very high, there will be fewer Doctors and if the bar is very low, we would be creating more Yamas. We have to find the right bar so that sufficient number of doctors are released into the community with adequate training.
I had seen some excellent Doctors who in spite of failing the DNB exam had sufficient knowledge to take care of the patient, which means that the DNB bar is slightly higher than required. Even students passing out from the premier institutions fail in the DNB exam, which I have personally witnessed and it makes even stronger case about the futility of keeping standards so high.
Even the Doctors released from premier institutions are not Gods, they also learn by experience once they independently start their medical practice. Medicine does not stop at the exam table — it is a continuous learning process. We see again and again in the medical practice — it is not the medical knowledge but the ethics that is more problematic nowadays.
Only when Doctors come forward and discuss regarding the changes that are required and exert pressure, the health ministry would bend a little and make the necessary changes. The present institutions are happy with the status quo. We have to make them change their attitude.

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1 comment:

  1. Dr Sanjay Udhani18 May 2013 at 16:56

    totally agree..., Too much of hardship to prove nothing .., some sensible people need to restructure DNB board and formulate exam conduction in much logical way.