Mike Benusic is a public health and preventive medicine physician based in British Columbia

Picture of Mike BenusicIn March, the May sitting of the Medical Council of Canada Qualifying Examination Part II (MCCQE II) was postponed with the Medical Council of Canada (MCC) citing three reasons: “to prevent the spread of COVID-19, to be mindful of the impacts of this virus on the medical community, and to ensure the safety of all involved in our exams.” This was likely a very difficult decision to make, and in my opinion, an appropriate one. Congregating residents, examiners, staff, and standardized patients near the height of the pandemic was sensibly avoided.

Fast forward to October 2020. In many provinces the point prevalence of active COVID-19 cases is higher than in early May, with Ontario 1.2 times higher, Saskatchewan 1.3 times higher, BC 2.0 times higher, and Manitoba 17.8 times higher. Toronto Public Health has paused contact tracing in the community due to not being able to keep up with new cases and the region’s Medical Officer of Health recommends that individuals only consider leaving their homes for essential activities. Parts of Quebec are in a partial lockdown, with private and public gatherings prohibited. In Manitoba, “community transmission of COVID-19 is occurring across much of the Winnipeg Metropolitan Region” and gatherings are limited to a maximum of 10 people indoors.

Despite this, in a few weeks, the postponed congregation of residents, examiners, staff, and standardized patients is set to occur in cities across Canada. New restrictions beg the question – can these exams, in their current format, actually take place? A more fundamental question is – should they?

The MCC has established personal protective equipment and physical distancing protocols that seem sound (however they note that two meters of physical distancing may not be possible inside OSCE station rooms). In the hierarchy of controls, these are deemed the least effective means of preventing exposures. At the top: substitution and elimination.

Applying ‘substitution’ to the MCCQE II could mean substituting the format. Could the examination be undertaken virtually? The only barrier completely prohibiting this is the need for physical examination of patients. Yet it turns out that the physical exam has already been abandoned: candidates have been instructed not to bring medical instruments and directed not to have any physical contact with standardized patients. The other barriers for a virtual MCCQE II are surely great, but nearly 7 months have passed since the postponement was announced in which a sound format could have been planned.

Elimination could be applied a few ways. Certain components of the exam have already been eliminated to prevent exposures in those settings, such as rest stations. Surprisingly, the MCC notes that sequestration may still occur. Forcing residents to congregate in a room to prevent cheating is at infantilizing at the best of times; in the present circumstances it would seem low-hanging fruit for eliminating settings of potential exposure to SARS-CoV-2.

Could the entire examination be eliminated? This is not a new idea. As the pandemic has shown the world, public health is all about managing competing risks.

So what is the risk posed to the public by eliminating the MCCQE II (for at least a pandemic cohort, while maintaining the requirements for either family medicine or Royal College certification to license)?

And what is the risk that holding the MCCQE II could contribute to the spread of SARS-CoV-2, with negative consequences for all involved in the exams, the medical community and the population as a whole?