Exploring 'failure to fail' behaviour among examiners of undergraduate medical programs

Even though a lot has been written on 'failure to fail' behaviors of educators in developed and resource-rich countries, there have been no studies from developing and resource-constrained countries, which are among the major contributors of international medical graduates to the healthcare systems worldwide. Understanding such behaviors of examiners has significant implications for professionalism, patient safety, and healthcare worldwide. Using game theory, the current study explores the determinants of 'failure to fail' underperforming medical students from examiners of six medical schools in Pakistan.

A qualitative multi-institutional case study was carried out in Pakistan. Using a purposive maximum variation sampling technique, 15 examiners of basic and clinical sciences from six medical schools providing undergraduate medical education were selected and interviewed. The data were transcribed verbatim and analyzed using a Framework analysis approach.

The examiners were against passing any student who did not deserve to pass, but they reported failure to do so. Using Game Theory, we identified four key elements that may influence examiners' decision-making in assessment: players and their strategies, perceived personal payoffs, perceived social payoffs, and game rules (policies, norms, and practices). The examiners comply under pressure from various players, including the students, friends, family, higher administration, and political figures. Their behaviors were also influenced by rules set by examiners, the assessment system, the competitive market, and socio-culture environment.

The personal, social, and systemic constraints and consequences lead to poor assessment of medical students' knowledge and competence, which has significant implications for patient safety and healthcare worldwide. Some of these constraints may be unique to the developing countries' context; however, many others are prevalent even in the developed countries. Whether through examiner peer mentorship, restructured institutional incentives, or clear assessment policies, breaking the equilibrium of 'failure to fail' lies in a society of integrity and accountability.