h3 class="Body">The COVID-19 pandemic has become a challenge for the education in almost all countries of the world. The on-line mode of training has become detrimental for the medical universities, with their teaching at the patient’s bedside. Although the «pandemic regime» has become less burdensome for preclinical disciplines, the inability to conduct practical classes in the anatomical museum or biochemical laboratory undoubtedly compromises the quality of training, while online exams do not allow lecturers to evaluate the students’ performance in depth.

In the Russian medical universities, where the preclinical exams are still taken as a viva voce, its online version puts students in unequal conditions, depending on the quality of internet connection and proficiency in gadgets’ applications. In this regard, it appears to be quite reasonable to inquire: why in the Russian medical universities the preclinical exams are still taken in the obsolete manner: didactically limited, strictly within the framework of discipline, orally, using examination cards; despite the application of the Moodle platform, which is very suitable for the written exams; and despite the fact that in recent years Anatomy and other fundamental disciplines in the Russian medical universities constantly upgrade their teaching-learning modalities and students’ assessment, using the latest achievements of medicine and pedagogy, such as 3D technologies, big data, interactive techniques using brainstorming, case studies and much more, but all these innovations are not applied to the existing format of the disciplinary exams. Certain new elements are being introduced, such as «situational assignments», practical skills assessment, but the mode of the exam does not change. Viva voce, which can hardly be considered completely free of subjectivity, retains its subject limitedness, demonstrates students’ capacity to recall the material of the textbook or the lectures, rather than ability to think and apply knowledge.

In the overwhelming majority of the universities all over the world, for several decades, written examinations are practiced by all preclinical departments, such as anatomy, histology, biochemistry, physiology, pathological anatomy, pathophysiology, microbiology, pharmacology, and public health. All these disciplines collect together to conduct one common exam per semester. What are the advantages of the written exams and why they are not applied in the Russian medical universities?

One of the main reasons, in our opinion, is a lack of the integrated preclinical medical curriculum and its cornerstone — problem-based learning. In order to integrate the exams, preclinical departments need to integrate the entire teaching process, in other words to provide «horizontal integration». Only in this case we will be able to stop teaching our subjects isolatedly, as if we are trying to graduate anatomists, physiologists and biochemists, and start teaching medicine. As a pilot project, in our opinion, it makes sense to take a step towards an integrated written exam in preclinical medicine, which may be conducted on the Moodle platform and is quite suitable to be taken on-line, if pandemic does not allow to conduct face-to-face exams.

Different universities in America, Europe, Asia and Australia use various modes of written preclinical exams. My experience is based on teaching of Anatomy in the three Malaysian universities with an integrated curriculum and problem-based learning, which are applied not only in the Commonwealth countries, but far beyond their borders. Each semester exam includes several components, most commonly three of them, such as tests, practice skills exam, and an essay exam.

The test exam includes multi-choice questions (MCQ), which should meet certain criteria. Firstly, be at least of Level 2 of Bloom’s taxonomy. Since it is rather difficult to set up questions of the highest Bloom’s taxonomy levels in the format of MCQ, the best single answer questions (BAQ), which require a scenario, are taking over MCQs. Since all preclinical departments participate in the exam, each of them receives quotas for the number of questions in accordance with the number of lectures delivered. Secondly, all tests should be original and unique, they are set up for every exam, and their content is strictly confidential to the students. In some medical universities of the RF students have access to the question banks of a thousand of tests, including on the mobile applications, which they are simply trying to remember, as the exam tests will be selected from these banks. In our opinion it should be avoided. Thirdly, the tests should not contain conflicting or overlapping questions from different departments. Before the questions are selected for the exam, they should be vetted by all departments. Usually the tests are presented by each lecturer to the meeting of representatives of all preclinical disciplines. Vetting is an extremely important methodological event, as a result of which, the quality of questions may be significantly improved. The number of tests per exam is on average 40—60.

Example of the BAQ with a scenario. A 5-year-old boy presented in the clinic with a swelling in the neck. It was located anteriorly in the midline of the neck immediately below the hyoid bone. It was painless, movable, quite small (10×15 mm). The doctor suspected a thyroglossal duct cyst and sent a patient to take MRI.

Which of the following clinical features is MOST likely indicative of the thyroglossal duct cyst? Answer: A. Location below the hyoid bone; B. Small size; C. Location in the midline of the neck; D. Painless mass on the front of the neck.

Objective structured practical examination (OSPE). In the Russian literature, there is a definition «objective, structured, practical exam», which is not an entirely accurate interpretation of the idea of this exam. «Objective structured» in this context means «structured by the objective or purpose». The purpose of the exam is to test the student’s practical skills in accordance with the objectives of the practical class. Preclinical departments receive quotas for the OSPE exam according the of number of practicals they conduct, for example: Anatomy and Histology — 8, Physiology and Pathophysiology — 4, Pathological anatomy — 4, Biochemistry — 2, Microbiology — 3, Public Health — 2, Pharmacology — 2. For each task students are given 3—4 minutes, during which they need to identify the histological preparation, diagnose the X-ray, take a biochemical or microbiological test, etc.

Problem-based questions (PBQ) exams is a quintessence of the entire exam session. The students receive assignments which looks like real «clinical cases», but to fulfill them, no clinical knowledge or practice are required. It only tests knowledge and analytical skills in preclinical medicine. Usually the exam includes 6—8 cases, each of which is set up by different preclinical departments, while other departments are requested to contribute. For example, pathologists set up a case of acute myocardial infarction. The departments of anatomy, biochemistry, pharmacology get their quotas: the anatomists will ask about coronary arteries or their branches, involved in the disorder of this particular patient, biochemists — about lab tests, pharmacology — coronarolytics, etc. While in the examination cards only general questions are commonly formulated, for example, about the blood supply of the heart, in PBQs students need not only to recall certain information about coronary arteries, but apply their knowledge to the particular clinical scenario.

Example of the MEQ (prepared by pathologists)

A 56-year-old patient complained of the periodic appearance of bright red blood in her feces for 3 months. Her maternal grandmother and aunt suffered from familial adenomatous polyposis. The patient immediately underwent a rectal examination, and a blood test was taken. Her serum carcinoembryonic antigen was 60 ng/ml (normal up to 3 ng/ml). Colonoscopy revealed an abnormal mass of 3×4 cm in the rectum at a distance of 10 cm from the comb line. A biopsy was performed, and colorectal carcinoma was histologically diagnosed.

Total of 30 marks are allotted to this scenario with the following distribution among the disciplines: Anatomy (6 marks), Histology (4 marks), Physiology (8 marks) and Pathology (12 marks).

1. Describe the blood vessels that became the source of intestinal bleeding in this patient — 6 marks (Anatomy).

2. Describe the features of the normal intestinal mucosa in the area of the tumor in this patient — 2.5 marks (Histology).

3. List 3 types of cells in the epithelium of the normal intestinal mucosa at the level of the tumor in this patient. 1.5 marks (Histology).

4. Describe the physiology of defecation in this patient. 8 points (Physiology).

5. State the 2 signs/symptoms in support of the diagnosis in this patient. 1 marks (Pathology).

6. Describe the pathogenesis underlying the disease of this patient. 4 points (Pathology).

7. List the other 6 causes of rectal bleeding. 3 marks. (Pathology)

8. Describe the common histopathological type of colorectal cancer. 2 marks. (Pathology).

9. Describe the expected changes in the blood test of this patient. 2 points. (Pathology).

The final mark will include the exam score (80%) and current performance (20%), which will accumulate the results of quizzes, problem-based learning, etc. The exam score will include PBQ (30%); OSPE (20%), MCQ (20%) and BAQ (10%). The overall score is converted to the grades, from A+ to C— (pass), D and E (fail). Students which score over 90% are awarded A+. These grades are easily converted into our common grades: from excellent to unsatisfactory.

We believe this information will be beneficial to the preclinical lecturers and medical education units which are interested in the new effective and objective methods of students’ assessment not only in separate disciplines, but in preclinical medicine as a whole.

Поступила 24.08.2021

Received 24.08.2021

Принята в печать 31.08.2021

Accepted 31.08.2021