Ethiopian anesthetist licensing examination: a qualitative study of concerns and unintended consequences

Background: Ethiopia increased its anesthesia workforce drastically by expanding the training of associate clinician anesthetists (ACAs). To ensure patient safety, this expansion was followed by establishing an anesthesia licensing examination, as a requirement for entry into anesthetic practice. However, there is limited empirical evidence on the effectiveness of licensing examinations in low- and middle-income countries. We have written about the perceived positive effects of the anesthesia licensing examination in another article. On the other hand, this study aimed to explore concerns and unintended consequences of the anesthetist licensing examination in Ethiopia. Summary of Work: A qualitative design was employed to collect data from 10 ACA teaching institutions. We conducted 15 in-depth interviews with instructors and six focus groups with students and graduates who took the exam recently. Interviews and focus groups were audio-recorded, transcribed verbatim, and analyzed using Atlas.ti ver9 software. Secondary data were extracted from minutes of academic committee meetings, curricula, faculty appraisal reports, and program quality self-review reports. Summary of Results: Qualitative analysis of interview and focus group transcripts revealed three categories of concerns about exam management and five categories about unintended consequences of the exam on student behavior and educational management. Exam management concerns were related to exam validity, fairness, and consistent enforcement of pass/fail decisions. Study participants also reported that the exam had negative psychosocial consequences on students and led to an increase in cheating behaviors. In addition, the licensing examination was perceived to have promoted teaching and learning for the exam, increased the workload on faculty, and resulted in superficial and patchy educational reforms.  Discussion and Conclusion: Our study identified some concerns and unintended consequences of the Ethiopian anesthetist licensing examination. These lessons learned may contribute to improving the quality of licensing examinations in Ethiopia and beyond. Take-home messages: Licensing exams are not without concerns. The strength of the evidence supporting the appropriateness of exam decisions determines exam validity.