What’s the difference between a medical student and a convict? The answer: A convict doesn’t pay $50,000 a year for the privilege of being fingerprinted and patted down.
I am referring, of course, to the increasingly stringent security measures that have come to characterize modern educational testing. As student-evaluation techniques have migrated from face-to-face assessment to computer-based exams administered in dedicated testing centers, evaluators have become less and less likely to know examinees, leading to heightened precautions around exam security.
I recently interviewed a group of fourth-year medical students who had just taken Step 2 of the United States Medical Licensing Clinical Knowledge Examination at test-administration centers. Each of the students had paid $560 for the privilege, and had devoted nine hours to the single-day exam, which consists of eight sections of 40 to 45 questions each. Over the day, they received a total break time of 45 minutes. Students must pass the exam to obtain a medical license, and scoring well is an important factor in gaining admission to competitive medical specialties. So anxiety tends to run high.
This inevitable anxiety is compounded by Checkpoint Charlie-esque security measures. IDs are checked. Each students wears a unique number on his or her shoulder throughout the day. Students are fingerprinted each time they enter and exit the testing room (up to 16 times). They are patted down and asked to roll up their pants legs and pull their pockets inside-out. If they wear a jacket or sweater into the exam room, they cannot take it off. They are warned that they will be under constant camera surveillance.
Not merely watching remotely, Big Brother is on the scene. Proctors roam the examination room, swiping their IDs on badge readers around the room to prove that they are patrolling appropriately. Should “even a suspicion of irregular behavior arise,” they warn, students will be ejected from the testing center and their scores invalidated. One student told how a friend approached her during a break, smiled, and commented good-naturedly, “This is the worst.” “I didn’t know how to respond,” she said. “Knowing that they were watching, I returned only a blank stare.”
Another student, a former U.S. marine, said he had found the entire atmosphere of the exam eerily familiar. He had served in Iraq, helping to preside over the return of inhabitants to Fallujah after the city’s recapture by U.S. forces. “It was weird,” he said. “They were using many of the exact same procedures and equipment we used in Fallujah. It took so long for them to verify identities that you almost didn’t dare leave the room, for fear you couldn’t get back in time. I finally had to show one of the proctors how to do it properly.”
Of course, these techniques are not merely for medical students. Aspiring accountants and architects, students sitting for the GRE, and prospective employees of Silicon Valley companies are all subjected to these medieval measures. Testing firms’ reputations for trustworthiness seem to rest on the degree to which they treat their examinees distrustfully, an attitude that tends to institutionalize a culture of suspicion.
Some might say that a high-security approach to testing students is not only necessary but laudable. In the case of medical testing, the health of the nation is a vital resource, and we cannot afford to place it in the hands of physicians who might have succeeded through academic dishonesty. Who would want a loved one to be cared for by a physician who had cheated on the medical-licensing exam? As public policy, exam hawks argue, we should demand the very highest security in all such testing.
But perhaps we have gone overboard. After all, the core of the patient-physician relationship is trust. The Hippocratic Oath, which has shaped the ethics of medicine for many centuries, enjoins the physician to respect patients’ privacy and dignity and to always put each patient’s interests first. We entrust to our physicians all sorts of matters we would not share with anyone else—private details of our health and personal relationships, access to intimate parts of our bodies, sometimes even our lives. We want to trust our physicians. No one is arguing that security is unnecessary, but perhaps we haven’t quite yet found the sweet spot.
What message are we sending to medical students when we subject them to the sorts of security procedures we would normally reserve for inmates in the criminal-justice system? The implicit message is: “We can’t trust you. And because we can’t trust you, we will monitor your every move. You will feel our warm breath on the back of your neck every minute of the day, and we will treat even a hint of irregularity as proof of guilt.”
And what happens when students in medicine, law, accounting, and other professions get out into practice? If they required the strictest exam-security measures to gain entry into their fields, can we reasonably suppose that the apparently irresistible temptation to cheat will suddenly evaporate the moment they become licensed? Do we need to institute similar oversight measures in the professions to ensure that practitioners are not betraying our trust and bilking patients, clients, and the government? At some point, we need to trust these professionals to conduct themselves professionally, not because they fear detection and punishment.
Draconian exam-security procedures have a corrosive effect on professionalism. As one medical student put it, “What does it say when people just a few months from earning their M.D.'s—who are supposed to be among the most trusted people in our communities—are treated like convicts? It is really disheartening.”
Perhaps the most telling comment came from the former marine: “The really sad thing is that I wasn’t particularly bothered by it. As a student, I have been taught to expect such distrust. We learn to take it for granted.”
Richard Gunderman is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and a vice chair of the radiology department at Indiana University’s School of Medicine.