Assessment as dispute: the bar exam and the future of medical educationABSTRACT
Introduction: The proposal of a “Bar Exam” for newly graduated physicians has sparked intense debate within Brazilian medical education. Amid the rapid and unregulated expansion of medical schools, concerns have arisen regarding the quality of training and patient safety. However, the exam raises questions about its pedagogical validity, regulatory effectiveness, and social impact.
Development: This essay critically discusses the proposal by analysing its theoretical basis, practical consequences, and ethical implications. Drawing on literature review, international experiences, and data on inequality in access to the medical profession, it argues that a terminal, feedback-free assessment focused solely on cognitive measurement tends to reproduce inequalities and become a mechanism of exclusion. The text also explores the political and market-driven interests involved and proposes more formative and fair alternatives for assessment.
Conclusion: The “Bar Exam”, as currently proposed, does not address the structural problems of medical education in Brazil. The path toward quality requires continuous assessment, regulatory public policies, and a commitment to equity in professional training.
Keywords:
Bar Exam; Licencing in Medicine; Assessment; Medical Education
RESUMO
Introdução: A proposta de um exame de ordem para médicos recém-formados tem gerado intenso debate na educação médica brasileira. Em meio à expansão acelerada e desregulada de escolas médicas, surgem preocupações com a qualidade da formação e a segurança do paciente. Contudo, o exame suscita questionamentos quanto à sua validade pedagógica, à eficácia regulatória e aos impactos sociais.
Desenvolvimento: Este ensaio discute criticamente a proposta, analisando sua base teórica, suas consequências práticas e suas implicações éticas. Com base em revisão da literatura, experiências internacionais e dados sobre desigualdades no acesso à profissão, argumenta-se que uma avaliação terminal, sem feedback e voltada apenas à aferição cognitiva tende a reproduzir desigualdades e transformar-se em mecanismo de exclusão. O texto também explora os interesses políticos e mercadológicos envolvidos e propõe alternativas avaliativas mais formativas e justas.
Conclusão: O exame de ordem, tal como proposto, não resolve os problemas estruturais da educação médica no Brasil. O caminho para a qualidade exige avaliação contínua, políticas públicas regulatórias e compromisso com a equidade na formação profissional.
Palavras-chave:
Exame de Ordem; Licenciamento em Medicina; Avaliação; Educação Médica
INTRODUCTION
The evaluation of health professionals, especially physicians, occupies a central place in debates about the quality, regulation and ethics of professional practice. The proposal for a compulsory licensing exam for newly graduated physicians, popularly known as the “Bar Exam” in Brazil, with reference to the test applied by the Brazilian Bar Association (OAB), has been gaining momentum in recent years, especially in the face of an increase in the number of medical schools and accusations of poor training. The term “Bar Exam” is used intentionally in this essay to emphasise the analogy with the exam applied by the OAB in Brazil. Although we recognise that expressions such as “Licensing Exam” or “Proficiency Exam” are more commonly used internationally, we have opted to keep “Bar Exam” to make explicit the parallels and tensions specific to the Brazilian context. At first glance, the Bar Exam seems to respond to a legitimate demand for quality control. However, a deeper analysis reveals that the measure may not only fail in its regulatory objective, but also deepen social inequalities, distort the training process and favour private interests. The aim of this essay is to critically analyse the proposed Bar Exam in medicine, its justifications, limitations and implications. Based on a theoretical-critical approach, the aim is to reflect on the role of assessment in medical training and to explore alternative ways of promoting justice and quality in Brazilian medical education.
DEVELOPMENT
The discussion about a Bar Exam for doctors articulates multiple fields: educational policy, corporate interests, civil society’s demands for safety and quality of care, and the ethics of professional regulation1. Although the proposal is often presented as a technical and neutral solution, it is essentially a political measure, with profound implications for training and access to medical practice.
Recurrent grounds: quality and safety
Proponents of the measure argue that the exam would act as a necessary screen to ensure that only qualified physicians work in health care. In a context of unbridled opening of medical courses - many of which have poor infrastructure, insufficient teaching staff and limited liaison with health services - concern about the quality of training is legitimate. Data shows that the number of medical schools in Brazil has risen from 83 to over 300 in two decades2, many of which are in small private institutions. There is also a call for society to be protected from possible medical errors committed by poorly trained professionals. However, these justifications need to be examined in the light of the available evidence and the pedagogical coherence of the proposal.
The lack of scientific evidence
A systematic review that analysed licensing exams in countries comparable to the UK concluded that there is no robust evidence that these tests are associated with better clinical outcomes, reduced errors or improved quality of care3. In other words, the idea that a single test can guarantee the competence of a health professional is not empirically supported. Furthermore, high-consequence assessments that take place only at the end of the training process, without feedback and without any impact on the educational path, contradict fundamental principles of contemporary medical pedagogy, such as formative, continuous and contextualised assessment4.
Social and educational impacts
Another critical aspect concerns the measure’s exclusionary potential. Experience with the OAB exam shows that students with higher incomes, who can afford preparatory courses, report higher pass rates5. In medicine, the impact could be even more perverse: considering that many low-income students enter public universities or private colleges with grants, an eliminatory exam at the end of the course would prevent them from practising the profession for which they were trained. This punitive logic shifts the responsibility for education onto the individual and obscures systemic flaws in educational regulation. In addition, it strengthens the preparatory course market, the revenues of which often finance the very private institutions that contribute most to the unbridled expansion of the supply of medicine course places6.
Assessment and power: who does the exam serve?
As Luis Beneviste7 points out, assessment is a political act. It expresses power relations and defines who can and cannot belong to a particular professional field. Foucault8 also describes assessment as a technology of control that disciplines and normalises behaviour. The Bar Exam, therefore, should be understood not just as a technical tool, but as an instrument of symbolic regulation, which can both protect and exclude, depending on how and by whom it is conceived. In this regard, it is essential to analyse the actors involved in defending the proposal. These are often the same organisations that profit from exam preparation or have an interest in maintaining the market reserve. Instead of tackling the root of the problem - the poor quality of some medical training - the responsibility is shifted to the student, turning the exam into a new social class filter. Furthermore, the pressure to pass high-stakes exams can compromise students’ mental health, aggravating anxiety and exhaustion in a scenario already marked by psychological suffering in medical training9.
International models: inspiration or distortion?
Proponents of the exam often cite countries like the United States as examples of systems that apply licensing exams. However, in these contexts, the exams are part of a wider set of assessments, which include direct observation of clinical skills, simulations with standardised patients or OSCEs (Objective, Structured, Clinical Examination), continuous feedback and extensive supervised internships10. Importing only the theoretical test stage, without considering the complexity of the training models in these countries, represents a dangerous distortion. International literature has emphasised that knowledge and clinical performance are not equivalent, and that assessing only one dimension of knowledge disregards the complexity of medical practice.11
Viable alternatives: formative assessment and institutional regulation
It is possible to guarantee quality in medical training through fairer assessment processes that are continuous and integrated into the training programme. To this end, it is essential to strengthen public policies such as the National Higher Education Evaluation System (SINAES)12) and to take up experiences such as National Interinstitutional Commission for the Evaluation of Medical Education (CINAEM), which proposed external institutional evaluations aimed at pedagogical improvement rather than punitive approach. Among the viable alternatives is the adoption of formative and longitudinal assessment strategies, such as the Progress Test13 - an instrument applied periodically throughout the course, which makes it possible to monitor the evolution of students’ knowledge, stimulate self-knowledge and feed back into the teaching-learning process. This tool has already been used with good results at several Brazilian medical schools, through inter-institutional consortia, and reinforces the concept that learning is a continuous process, not a final cut-off point. Other instruments - such as the reflective portfolio, the mini-CEX (Mini Clinical Evaluation Exercise) and structured feedback - could also be used more widely, favouring the development of clinical, ethical and communication skills in a contextualised and student-centred manner. These practices are in line with programmatic evaluation models, which have been gaining prominence in international literature.14) In addition, there is an urgent need to invest in the pedagogical training of teaching staff, guarantee adequate structural conditions for the operation of courses and expand student permanence policies. Assessment must fulfil its role of monitoring, caring for and promoting development, and not as an exclusionary filter at the end of the training process.
FINAL CONSIDERATIONS
The proposal for a Bar Exam for newly qualified doctors engages legitimate concerns about the quality of medical training and patient safety. However, when analysed in depth, it is revealed to be a measure of low pedagogical effectiveness, weak in terms of scientific evidence and with a high potential for deepening social and educational inequalities. The focus on terminal, punitive and decontextualised assessment ignores contemporary advances in medical education, which value continuous training processes, structured feedback, assessment of clinical competences and reflective engagement by students. Furthermore, responsibility for failures that are largely systemic and regulatory is transferred to the individual. Regulating the quality of medical training is necessary, but it needs to be done through public policies committed to educational justice and the institutional strengthening of medical schools. Should we be assessing? Yes, but we should be training, transforming and guaranteeing quality care, not excluding or selecting on the basis of socio-economic criteria. More than a test, what is at stake is the medical training project we want to build: centred on technique or ethics? On exclusion or equity? On individual performance or collective responsibility? The answer to these questions will define not only the future of medical education, but also the type of care that Brazilian society will be entitled to receive.
References
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Research data is available in the body of the document.
