Mr Lasitha Samarakoon, RCSEd Council Member, asks RCSEd Trainees Committee Chair, Mr Michael Okocha to share his thoughts on what makes examinations stressful for trainees, what an ideal examination looks like from a trainee’s perspective and what examiners can do on the day to make the process less stressful.
What Makes an Examination Stressful for Trainees?
The stress of a high-stakes examination is rarely confined to the examination itself. For senior surgical trainees, particularly those sitting the FRCS at ST7 or ST8, failure may carry significant professional, financial and personal consequences. There is the immediate cost of resitting, further months of preparation, disruption to family life and, potentially, delayed progression at a point when trainees are approaching the end of training. There may also be a perceived reputational cost, however misplaced that perception may be.
Uncertainty amplifies this pressure. Candidates inevitably question whether examiners are consistent, whether they have interpreted a question correctly and whether a neutral expression, silence or change in tone signifies poor performance. This is particularly relevant during vivas, where interaction with the examiner becomes part of the examination environment.
Human factors in high-stakes assessment are not routinely taught throughout surgical training. Candidates may therefore encounter cognitive overload, freezing or an understandable tendency to overinterpret examiner behaviour without having developed strategies to manage these responses. These pressures may be experienced differently by international medical graduates, neurodivergent trainees and others for whom communication style or familiarity with the examination culture can become an additional variable.
What Does an Ideal Examination Look Like From a Trainee’s Point of View?
An ideal examination should feel like a structured professional conversation in which the candidate is given the best possible opportunity to demonstrate whether they meet the required standard. It should be rigorous, but the difficulty should arise from the clinical judgement and knowledge being assessed rather than avoidable uncertainty about the process.
Transparency and standardisation are therefore essential. Candidates should understand what is expected of them and how they will be assessed, without making the examination so predictable that it ceases to test genuine clinical reasoning.
More importantly, examination-style practice should become a routine part of higher surgical training rather than something concentrated immediately before the FRCS. This need not mean repeatedly recreating the final examination. Regular low-stakes viva-style questioning, structured clinical reasoning and opportunities to articulate decision-making under pressure would allow trainees to become familiar with the assessment environment long before the stakes are at their highest.
Some specialties and regions already incorporate repeated FRCS-style assessment throughout training. This approach has the potential to reduce the artificiality of the final examination and ensure that performance on the day reflects clinical competence rather than unfamiliarity with the examination format.
What Can Examiners Do on the Day to Make the Process Less Stressful?
Perhaps the most important contribution an examiner can make is to be consistently professional, courteous and neutral. Candidates are highly sensitised to examiner behaviour and may interpret a smile, nod, reassurance, silence or change in expression as evidence that an answer is either correct or incorrect. Attempts to be reassuring can therefore inadvertently create additional uncertainty.
Professional neutrality does not mean being cold or hostile. It means providing each candidate with a consistent environment, asking questions clearly, maintaining an appropriate professional distance and allowing the examination process rather than interpersonal cues to guide the candidate.
Examiners should also recognise that high-stakes assessment is itself a human-factors environment. A brief hesitation or momentary loss of fluency does not necessarily reflect a deficit in knowledge or judgement. The objective should always be to create the conditions in which a candidate can demonstrate their true level of competence.
Ultimately, the greatest opportunity lies before examination day. If structured, low-stakes examination practice were embedded throughout higher surgical training, the final FRCS would become less of an unfamiliar high-stakes event and more the culmination of a method of assessment with which trainees were already comfortable.