The National Board of Examinations conducts the Diplomate of the National Board (DNB) in broad specialities as well as in core super specialities. Established in 1975, the programme was meant to provide a common standard for postgraduate education and a commonly accepted evaluation mechanism for national and international comparison. It has attained the status of a parallel system of postgraduate education in India over the years. In his critique of this system, Sarbhadikari describes the DNB examination as a farce (1). He has attempted a study of the evaluation and examination system in light of recommended standards for postgraduate medical education and found it wanting on several counts.

The national board of examinations

The National Board, in its prospectus, states:

The setting up of a National Body to conduct postgraduate medical examination was intended to provide a common standard and mechanism of evaluation of minimum level of attainment of the objective for which postgraduate courses were started in medical institutions. Moreover, intra country and international comparison is facilitated with the availability of commonly accepted evaluation mechanism like DNB. (2)

However, the DNB has been relegated to the sidelines. What should have been a prestigious asset to the field of medical education is now a tool utilised by institutions to obtain a cheap workforce and by candidates who do not make it to the regular mainstream MD and MS courses to pursue a degree in a postgraduate discipline of their choice. It is now known that postgraduate seats in government-sponsored institutions are extremely hard to come by. With the advent of postgraduate entrance examinations and reservations in all levels of recruitment into the postgraduate courses, an average student would find two ways out: buy a seat or opt for a similar or smaller course. The DNB is a good alternative for these students. At the same time the country is seeing a great increase in institutions and hospitals in the private sector. Starting a DNB course is an easy way to label the institute as a postgraduate institution. The students who join the course would continue to work as regular residents throughout the period of study and would regularly be replaced by a new set. Stipends paid have been a bone of contention as noted by many students in an online petition. The downside remains the raw deal for students. The institution gets a renewable workforce, and a title of a teaching postgraduate institution; the students get a seat, but hardly any teaching and practically no hands-on experience, as all the patients are private patients of the concerned consultant in charge of the hospital.

In addition to the primary examinations in broad specialities and super specialities, the board provides a platform for students who have procured a postgraduate diploma to undertake further studies by obtaining a degree equivalent of the MD/MS (Doctor of Medicine, and Master of Surgery). The national board has also introduced direct five-year courses in the super specialities of neurosurgery and plastic surgery. It also provides opportunities to super specialise in sub specialities such as arthroplasty and spine surgery.

In its scope, the DNB is impressive. But in implementation it has probably been a failure. It is still premature to write it off as a “has been”. But it may be necessary to take corrective steps in order to produce a qualified and useful workforce.

Selection criteria and examination routines

The process of selection for the DNB primaries is fairly well spelled out and all the prerequisites need to be fulfilled. Candidates who already have their MS/MD just need to ensure that their degrees are recognised (3). The theory and practical exams are standardised and the candidates are allowed a choice of centre to take their exams. There are four theory papers (there are no objective papers), each consisting of 10 essays. Though these are fairly comprehensive and cover the subject well, they can hardly be considered a measure of the student`s abilities. They can, at the most, be used as a primary screening before candidates appear for their practical examinations. It may not be practical to do away with these sessions but an addition of multiple choice and analytical tests that simulate a clinical situation and also test decision making ability may help improve assessment in theory papers.

Once the theory examinations have been cleared, the candidate is given three attempts at the practicals. In the practical examinations, the DNB follows the same pattern as that of the MD/MS exams. The theory papers are just a matter of learning by rote, it`s the practical examinations which challenge the student and test his training and ability, and unless the student undergoes a well defined system of appraisal and training, s/he is unlikely to be fit to give the examination, leave alone pass the examination.

It is easy to hold the national board responsible for these problems, but the examination system alone cannot be blamed for the maladies afflicting the board.

Results of the examinations

The DNB examination is noted for its poor pass percentages. Sarbhadikari notes, correctly, that a number of the students who do pass the DNB at the first attempt are those who already have their MD and their MS degrees. It is difficult to understand what use the DNB is to them besides the addition of an equivalent qualification on their visiting cards. However, few of those who give the DNB as their primary postgraduate exam manage to clear it in the first attempt. Is the DNB going largely to candidates who have no use for it, or who are anyway not likely to benefit from it? The DNB students in their online petition state:

DNB final exams rarely depicts [sic] the published board syllabus and the exam pattern is largely descriptive, outdated and scientifically invalid. The dates of the theory and practical parts of the exam are not published in due time for the candidates to prepare effectively for the exams. This along with the long waiting period between the theory exam and the publishing of the results makes the candidates anxious and reduces the performance during the practical exam which follows very shortly after the publishing of the theory results. The practical exams are conducted erratically with no fixed dates and venues. There are numerous instances, where practical exam venues were cancelled and few [sic] unfortunate instances, where practical exam results were cancelled after the conducting of exams forcing the candidates to reappear for the exam. This is adding up to the misery of the already stressed exam going candidates leading to a suboptimal performance by the candidates. (4)

Now, many universities have prevented government institutions from running both MS/MD and DNB courses within the same institution. The DNB candidate is therefore at the mercy of private players who institute the course to acquire the status of a postgraduate institute, and at the same time, acquire staff at a low price. The DNB may be less lucrative than an MS / MD seat, but it is also cheaper for the candidate. Many institutions offering DNB courses have adequate qualifications and are reputed enough to sustain a teaching programme. Many others are not so well equipped and do not have a good patient load, and consequently the candidate is likely to suffer for want of adequate clinical material. This evil does not afflict DNB institutions alone; many institutions offering MD and MS courses suffer from a similar malady, especially outside the government sector.

The internal appraisal system of the national board

The board has set up an appraisal system both for candidates and for centres, to be conducted at six monthly intervals. These appraisals are mandatory for the centre to continue its training programme and for the student to be able to continue the course (5). It would be interesting to learn how honest these appraisals are, but such an analysis has yet to be carried out or published.

These appraisals are meant to be carried out at the local level and should include a short theory paper, feedback on the theory paper, thesis and log book review, practical examination, hospital infrastructure appraisal, a report and suggestions on the DNB training and appraisal process (5).

In practice, one finds just two essential steps in the appraisal process – a reproduction of the exam and feedback based on it, and an analysis of thesis progress and log book records. The review of progress of skills here is entirely subjective, and there is no objective analysis of the method and progress of the training programme.

The appraisal should ideally be bilateral and independent of the institution. Both the candidate`s self assessment and the assessment of the appointed assessor should be read by a third, uninvolved party. This may help identify defects in the training programme. The stress on theory examinations could explain why it is easier to pass the theory examinations than it is to pass the practical examinations. Theory examinations hardly measure the ability and sound clinical judgement of the candidate or the progress in his/her training. They can at best be a measure of the ability to reproduce what has been read.

Practical examinations depend on the acquisition of basic clinical skills and the ability to give the rationale for a plan of clinical management. This is possible if the training includes these basic skills.

Davidoff lists a number of educational initiatives designed to develop competence in individual patient care which include problem-based learning, evidence based medicine and training in the use of clinical guidelines. Problem-based learning, described as “quasi-experiential”, is a model that uses a written case rather than a living patient as a trigger to evolve a definition of the student`s learning goals as well as independent self-directed learning which can be reinforced under faculty supervision in group discussions (6).

Any form of assessment must include protocol-based enquiries based on treatment plans and current concepts. A simple reproduction of exam patterns in the assessment protocols will not suffice. A detailed assessment of patient loads and teaching protocols in the institution must also be mandatory. This would ensure that the candidate gets adequate hands-on experience. Such requirements gain more significance in light of the fact that under current rules DNB candidates have equal rights to be selected for teaching posts provided they have completed an additional year of training following their qualification (7). Further, many grievances have been expressed by DNB candidates, regarding their passing percentages and their stipend payments (3). These too need to be addressed. Dr Sarbhadhikari, has correctly noted that transparency and accessibility of all results and assessments in the public domain are a must.

Above all these, the DNB appraisal should also include a periodic appraisal of its faculty and there should be prerequisites for qualification, teaching experience, ongoing research and conference involvements and publications, in parallel with the Medical Council of India`s rules on faculty promotions. This would ensure quality amongst all faculty which would reflect on the quality of teaching and training.

The DNB`s fellowship programmes and super-speciality teaching programmes are both welcome steps, as certificate programmes of this type do not exist in the standard postgraduate teaching schedules of the universities in India. They therefore provide an opportunity for the student to acquire further qualifications without leaving the country. These programmes are relatively new and the National Board must bring in a quality control system to monitor the viability, reliability and acceptability of these qualifications, if necessary in collaboration with universities in India and abroad.

Conclusions

The National Board is a necessary institution in a country that is short of medical professionals. But it has failed to meet its objectives. The dismal pass percentage of the DNB course is not a comment on the difficulty or comprehensive nature of the course; instead it reflects on the poor training imparted to its students that prevents a good pass percentage despite the three attempts permitted for the practical exams. Urgent steps need to be taken to revamp the training, assessment and creditworthiness of the DNB courses to bring them on par with world standards and to achieve the goals set out in the constitution of the National Board.

The National Board of Examinations needs to upgrade itself urgently to avoid the tag of “National Board of Eliminations”.

The author declares no conflicts of interest in relation to the contents published in this commentary.