The Nightmare Begins

A lost decade in Melbourne

How the University of Melbourne Medical School ruined me — and what its own marking sheets, obtained under freedom of information, reveal about the few hours of examinations that undid years of work.

Preface

A Brief Background

I came to Australia in 2002 to undertake a PhD at Monash University. I had recently completed a Masters degree in physiology and neuroscience concentrating on the mechanisms of epilepsy and while visiting relatives in Melbourne I contacted people at Monash to ask whether they had projects in that field, they did. The scholarship on offer was modest but the prospect of living and studying somewhere new appealed to me so I accepted.

I completed the PhD and published the results that shed light on a novel mutation then thought to cause a form of human epilepsy.

My time in Australia as a PhD student was a good one. I made close friends, worked well with my supervisor, and grew to like Melbourne. On that basis I decided to apply to the Melbourne University Medical School as an international student. The cost was substantial, around US$320,000 including living expenses but between US student loans and my own savings I judged it manageable. The first part of my time in Australia had gone well and I had no particular reason to expect that the second part would not.

Preface

Stutter

Some background that becomes relevant later. I have had a speech stutter all my life. It usually resolves by adulthood; in a small number of cases it persists and mine did. I have never felt shame about it and have no fear of public speaking but I found early on that it made other people uncomfortable and that I was often kept at a distance as a result. It was simply a feature of my life and not something I dwelt on.

Part One

Preclinical Years

The course was structured differently from what I had expected but it was a means to an end and I did not question it at the time. There were no discrete subjects of the kind a conventional medical school would offer. Instead the course ran in semesters with titles such as "the digestive system," covering the abdomen and its paired and unpaired viscera and drawing together anatomy, histology, pharmacology and pathology in a single continuous sequence of lectures rather than as separate disciplines. After two years I advanced to the clinical school at St. Vincents Hospital.

Part Two

The St. Vincent's Clinical School

I should say at the outset that the clinical school itself was ok. The clinicians, surgeons and nurses I worked with were civil and I have nothing negative to say about any of them. They were willing teachers, the patients I saw were generous with their time and in all my time on the wards I never once encountered any difficulty over my stutter from a patient or a clinician.

My experience with the Dean of the clinical school, Associate Professor Wilma Beswick was remarkably different. From our first encounter her manner towards me was consistently hostile and belligerent. She sat me down with her staff present and told me that my speech was offensive and that I did not belong in Australian medicine. She repeated that view on many subsequent occasions.

As clinical students we were required to perform long cases: clerking a patient on the ward, taking a history, conducting a short physical examination and presenting the findings to a faculty member for assessment. When I presented cases to anyone else at St. Vincents, I received the ordinary mix of constructive criticism and generally positive feedback. With Beswick the assessment was consistently negative and I was told repeatedly that I would not pass the end-of-year examinations. At one point I gave a written synopsis of one of my own cases(that Beswick completely ripped to shreds when I presented it) to another student to present to Beswick. She reviewed that student's presentation of my case very favorably. So at this point it was clear to me that Beswick had a clear agenda to make my life as miserable as possible.

By the end of that first semester at the clinical school I had decided to take a year off as hostility against me began to reach fever pitch. I returned to the United States and took a post-doctoral position at Harvard University where I did some productive work.

I thought carefully about whether to return to Melbourne and eventually decided to complete the course. In hindsight that was a mistake. Somebody once said that if a person threatens you, believe them. I learned that the hard way.

When I returned, Beswick told me that I was required to petition the faculty for additional time on the oral OSCE examinations on the basis that my stutter would prevent me from completing them within the standard time. This concerned me because I had never needed additional time in any previous semester and had never asked for it. Sitting with extra time also meant sitting separately from the rest of the testing cohort which raised the possibility that the material I was given would not be identical to theirs. I'll return to that point later.

Part Three

The End-of-Year Examinations

Two conditions were attached to my sitting the end-of-year examinations. The first was the petition for extra time described above. The second was that I enrol in the stuttering clinic with the stated aim of resolving my stutter before the examination.

I sat the oral OSCE stations after the rest of the cohort had finished. Several things about them were irregular. At the venepuncture station I was asked to perform a mock procedure on a plastic arm. Throughout the clinical year we had practised venepuncture exclusively with vacutainer tubes on many occasions. No vacutainer tubes were provided at the station. What I was given instead was a set of 50cc syringes and ordinary laboratory test tubes. At other stations the simulated patients did not respond to the questions I put to them.

I failed the examination and was directed to repeat the year which required me to produce a further US$100,000 within fifteen days. The alternative offered was another year off to become, in the University's words, "financially sorted." In practice that second option amounted to the end of my candidature: no lender would advance me another $100,000 after a failure of a full year and I would immediately have become liable for repayments of more than $4,500 a month on the loans I already held. My financial position had been set out to the University in detail.

I contacted the University to explain my predicament. The response was that I should pay the fees and repeat the year, or withdraw from the course. I asked for a meeting with a senior member of the faculty and was told I would have to wait five months because the deans were unavailable. After repeated requests I was granted a meeting with the Dean of Medical Education, Geoff McColl.

By that stage I did not expect the meeting to be conducted in good faith and it was not. I raised the absence of the vacutainer tubes and was told that the equipment had been a recurring problem at that station, that the examiner had made allowance for it and that I had passed that particular station. I will return to that later because the marking sheet said otherwise. He worked through the rest of my results with me (which I was not allowed to see) and advised me to write to the Medical School dean requesting fee relief while indicating in the same conversation that the University's financial position made an award unlikely. He did not accept that my own position was as constrained as I had set out to him and insisted on the view that I could fund at least three further semesters and that when I run out of money the world would become a different place and that I'd get all the further loans that I want.

The meeting produced no practical outcome. Faced with finding $100,000 in fifteen days or leaving the country, I immediately hired a local solicitor(lawyer). The first step we took was a freedom of information request for copies of the OSCE marking sheets.

Part Four

The Marking Sheets

Venepuncture

McColl had told me that the examiner compensated for the missing vacutainer tubes and that I had passed the station. The marking sheet does not support that account. I failed the station. The Exhibit A — venepuncture marking sheet records no adjustment for the missing equipment. It records instead that I was "not familiar with vacutainer and needle adaptor devices." Vacutainer tubes were the only equipment we had ever used in practice.

Two things about the sheet are worth noting. Despite not being given the equipment we had trained on, I improvised and was awarded most of the available marks for technique. But the sheet also contains a discretionary five-mark section, "Technical Skills," left entirely to the examiner's judgement. I was awarded one mark out of five, and the examiner's written comment attributes the difficulty to unfamiliarity with equipment that was not made available to me.

Diabetes Complications

The Exhibit B — diabetes station marking sheet opens with a blood pressure examination, for which I was awarded 1 mark out of 6. Two correct actions are visibly circled on the sheet; credit was given for one. I'll return to this station later.

The more difficult section to account for is "Assesses feet," worth 10 marks, on which I scored 4. The only itemised award is for "spends adequate time at both feet," worth 2; the remaining 2 marks are not attributed to any listed criterion. Against that, the "Examiner Question" section at the end of the sheet, which asks the candidate to describe the findings of the examination just performed, is marked at close to full credit. Those were my own clinical findings.

I do not understand how a candidate can report the correct examination findings while being scored as having failed to perform the examination that produced them.

Dysphagia Interview

This station is the clearest example of the problems I encountered and the two documents can be read side by side. We were taught that examination content would follow the practice PBLs in our clinical instruction manuals. Exhibit D — the dysphagia PBL is the relevant teaching material; Exhibit C — the marking sheet is what I was assessed against.

In the first two sections I was expected to ask about nasal regurgitation and about the timing of the obstruction relative to swallowing. Neither appears in the PBL and neither bears materially on the diagnosis yet together they accounted for roughly 7 per cent of the station. I was given no credit for asking about associated coughing but was credited for asking whether the patient had coughed up blood (haemoptysis), which is difficult to reconcile: the second question presupposes the first. I was also expected to ask whether the patient had undergone a previous endoscopy, in a case where the patient was presenting with the symptom for the first time.

The PBL states that a barium swallow is arranged to determine the level of obstruction, which is the standard first investigation in swallowing abnormalities. The marking sheet does not list it as the correct answer. It is recorded on the sheet that I said "Ba Swallow," and the response is scored 0. I do not accept that this was an oversight and is clear evidence that I was targeted for failure.

The station also required me to be shown an endoscopy image and to offer a diagnosis from it. No image was provided. The examiner recorded this on the sheet in their own hand: "no picture provided." The sheet's printed instructions allow 2 marks for that question and direct the examiner to supply the correct answer where the candidate cannot give it. The fact that a second major mistake went unnoticed now leaves no doubt as to their intentions.

I failed the station, with a total of 13 out of 40 and a recommendation of "unsatisfactory."

Part Five

Repercussions

I put the marking sheets and the rest of my evidence to the medical faculty expecting my concerns to be considered. What I received in response was Exhibit E — a letter from the University's solicitors, invoking the Surveillance Devices Act 1999 (Vic), citing penalties of up to two years' imprisonment and fines of up to $28,036.80, and putting me on notice that the University would "take all action necessary to ensure that its rights are protected."

After almost a decade in Melbourne I left Australia with no degree, substantial debt, and no realistic route back into either clinical medicine or productive research.

Part Six

The University's Response

After ten years without a substantive reply, I was able through an intermediary to put the case to the University again. The response came from the newly appointed Head of the Melbourne Medical School, Steve Trumble. I set out the same material as appears on this page and received Exhibit F — his letter of 4 November 2018 in reply. In it he found no fault with the inconsistencies in the marking, with the absence of credit for correct answers, or with the failure to supply the required image. On the blood pressure station he wrote:

As explained above, there were no marks available for estimating it (blood pressure) by auscultation, as this is a poor discriminator of performance.

Steve Trumble

On the marking sheet itself, he is correct: Exhibit B awards no marks for auscultation. What it does require is palpation of the radial pulse to estimate blood pressure. I am not aware of any method by which a diastolic reading can be obtained that way.

When I pointed out that a candidate could therefore score full marks without auscultating at all, the reply was:

A candidate who didn't auscultate for the Korotkoff sounds would be marked right down for global technique. It would be a very rare candidate who didn't auscultate, as they would be clearly incompetent.

Steve Trumble

Nothing on the marking sheet supports that. There is no criterion on Exhibit B requiring auscultation, and none permitting a deduction for its absence.

On the diabetes station he wrote:

I note that the examiner gave you marks for the responses you gave to the questions at the end of the examination, despite your pulse palpation and sensory testing techniques having scored poorly. This is sometimes a problem with the 'check box' nature of older OSCE exams, with points being given for the provision of the correct information even when erroneously derived.

Steve Trumble

This response made absolutely zero sense. If my pulse palpation and sensory testing were genuinely inadequate, the findings they produced should have been inadequate too. Correct findings derived from a technique scored as poor is not a marking artifact; it is an indication that one of the two scores is wrong.

He also wrote:

I remain concerned that you appear not to understand the OSCE technique and are also accusing us of errors that were not committed. The course is not riddled with massive deficiencies, as you attest.

Steve Trumble

When the specific omissions were put to him in detail, his position changed:

If a resource was not provided in an OSCE due to an administrative error — and it seems that was the case — than that is indeed a mistake and I'm sorry it occurred. These procedural errors occasionally occur in the 5,250 OSCE stations we deliver to our medical students each year. Our approach is to exclude those missed marks from the overall tally. So if the response was worth up to 2 marks, that station should be scored out of 38 rather than 40. It rarely makes a pass/fail difference but it's fair.

Steve Trumble

That is the remedy the University says it applies. It was not applied in my case. None of the errors were corrected at the time, and the marks at stake were considerably more than two. The correspondence ended shortly afterwards with:

I'll need to move on

Steve Trumble

Part Seven

Conclusion

The documents on this page are the University's own records. They show a station assessed without the equipment the course had trained us on, a station scored against an answer the teaching material identifies as correct, a station requiring an image that was never supplied and whose absence the examiner recorded at the time, and a marking scheme that awards no credit for the technique the University's own guidance describes as essential. They also show that the University has a stated policy for handling exactly these errors, and that the policy was not applied to me.

If the faculty had concluded that I was not suited to the course, it could have said so and returned my course fees. That would have been a defensible outcome and I would have accepted it. What happened instead cost me a decade, a career in two fields, and a sum of money I am still repaying. I have set out the record here so that it exists somewhere, and so that anyone can examine it and reach their own conclusion.

Readers

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