Long format exams
Guidance on Long-Format Examinations, Disability, and Reasonable Adjustment
Senior Postgraduate and Comparable Professional Exams
Section 1 – Purpose and scope of this guidance
This guidance is intended for candidates undertaking long-format, high-stakes examinations at senior level, including senior postgraduate medical examinations such as Specialty Certificate Examinations (SCEs), and comparable assessments in other professions.
It is written for candidates who experience disproportionate difficulty related to disability, neurodivergence, fatigue, or cognitive load, and who may be questioning whether exam outcomes accurately reflect their professional competence.
The aim of this document is to:
- help candidates distinguish between difficulties arising from assessment design and those arising from lack of capability;
- explain how long-format exams can create structural disadvantage;
- clarify how reasonable adjustment duties apply in this context;
- reduce inappropriate self-blame;
- support informed, professional discussions about adjustments and assessment fairness.
This is a candidate-facing document. It is not legal advice, but it is grounded in Equality Act principles, GMC expectations, and established assessment science.
Section 2 – Cognitive fatigue, recall, and clinical relevance
Long-format written examinations place sustained demands on attention, working memory, information retrieval, and error monitoring. As cognitive fatigue accumulates, these functions deteriorate predictably in all humans, regardless of motivation or preparation.
Under fatigue:
- recall becomes slower and less reliable;
- error-checking deteriorates;
- slips and misinterpretations increase;
- insight into declining performance reduces.
Crucially, this pattern differs from clinical practice. In real clinical work:
- tasks are variable rather than continuous;
- clinicians consult guidelines, notes, and colleagues;
- decisions are paced and revisited;
- recognising cognitive limits is itself a professional skill.
Errors made under prolonged exam fatigue do not map neatly onto clinical competence. Long-format exams therefore risk testing endurance and fatigue tolerance rather than applied clinical knowledge and judgement.
Section 3 – Exam length, cumulative cognitive load, and delivery model
Exam length should not be understood only as scheduled paper time. From a cognitive perspective, it is the total period of sustained demand placed on the candidate.
In practice, long-format exams often include:
- travel to unfamiliar locations;
- navigation, parking, or public transport demands;
- mandatory early arrival (often 30 minutes or more);
- security checks and waiting periods;
- prolonged testing in controlled environments.
Candidates may therefore begin the exam already cognitively loaded.
For neurodivergent candidates, transitions, uncertainty, sensory load, and unfamiliar environments can consume additional executive resources. This extends the effective exam day well beyond the formal timetable.
Cognitive fatigue accumulates across long exam days. Performance in later papers is increasingly influenced by fatigue rather than knowledge. Importantly, individuals cannot reliably self-assess when cognitive performance has declined significantly.
Why extra time alone may worsen disadvantage
Extra time can be helpful where speed is the primary barrier. However, where the difficulty relates to sustained cognitive effort, extra time:
- lengthens exposure to fatigue;
- extends an already demanding day;
- may worsen performance later in the exam.
An adjustment that increases duration without reducing cumulative load may fail to remove disadvantage.
Highly controlled exam environments also limit meaningful recovery. Genuine cognitive recovery often requires disengagement, movement, and environmental change, which may not be achievable in test-centre settings.
Proportionality and professional status
By the time doctors reach senior postgraduate exams, they have demonstrated integrity and competence over many years of regulated practice. While exam security matters, highly restrictive delivery models carry cognitive costs.
The issue is not trust versus mistrust, but proportionality. Where security measures materially increase fatigue without clear benefit to validity, they risk compounding disadvantage rather than safeguarding standards.
Section 4 – What candidates can reasonably ask for
Candidates are entitled to adjustments that remove disadvantage, not merely those that are routinely offered.
When considering adjustments, it is often more effective to describe:
- cumulative fatigue;
- time-on-task effects;
- impaired recall and error monitoring later in the day;
- limited recovery opportunities;
rather than relying solely on diagnostic labels.
When extra time is not enough
If fatigue is the main barrier, extra time may worsen disadvantage. Candidates can reasonably explain that extending duration does not address the underlying problem.
Structural adjustments may be more appropriate, including:
- dividing exams into shorter sections;
- spacing assessment across sessions or days;
- ensuring meaningful rest and recovery;
- avoiding delivery models that extend the effective exam day where alternatives are feasible.
These adjustments do not lower standards; they change conditions so competence can be demonstrated.
Evidence may include:
- previous successful adjustments;
- occupational health or educational reports;
- consistent patterns of fatigue-related difficulty;
- information about how fatigue affects cognitive performance.
Section 5 – Common misconceptions (and why they miss the point)
“Everyone finds exams tiring”
The issue is not fatigue itself, but how it accumulates and affects performance. For some candidates, fatigue develops earlier and has greater impact.
“Extra time should fix it”
Extra time addresses speed, not fatigue. In long exams it may increase disadvantage.
“You’ve passed exams before”
Earlier exams may have been shorter, spaced differently, or taken in more familiar environments. Passing previous exams does not mean all formats are accessible.
“This is just stress or anxiety”
Cognitive fatigue affects recall and error monitoring even in calm, motivated candidates. Focusing only on anxiety overlooks structural causes.
“If these adjustments were reasonable, they’d already exist”
Many relevant adjustments already exist but are not applied to cumulative fatigue or exam length as a whole. GMC guidance makes clear that adjustments are not exhaustive and must be considered case-by-case in consultation with the individual.
Where responses rely solely on “we don’t do this” or “this isn’t normally offered”, this may indicate that the request has not yet been considered in line with professional expectations. Such responses do not, in themselves, determine reasonableness.
“This is about resilience”
Endurance is not the same as competence. Clinical practice depends on judgement, prioritisation, and recognising limits, not tolerating prolonged artificial strain.
Section 6 – Why this is not about lowering standards
Reasonable adjustments do not change:
- the curriculum;
- the knowledge required;
- the marking standard.
They change the conditions under which competence is demonstrated.
Endurance is not a professional standard
GMC guidance, including Welcomed and Valued and Health and disability in medicine, emphasises safe and effective practice with reasonable adjustments. It does not identify endurance of prolonged artificial testing as a marker of professional competence.
Requiring candidates to tolerate cumulative fatigue risks elevating endurance into a de facto standard that is not intrinsic to clinical practice.
Adjustments protect validity
When fatigue dominates performance, exams may measure endurance rather than understanding. Structural adjustments can improve validity by allowing knowledge and judgement to be demonstrated consistently.
Fairness is not sameness
Treating everyone identically does not ensure fairness. Adjustments aim to ensure the same underlying standard is assessed, even if conditions differ.
Section 7 – When the format itself may be the barrier
At senior specialist level, it is more plausible that difficulty in long-format written exams reflects features of assessment design than a sudden lack of clinical capability.
Indicators of structural mismatch include:
- repeated difficulty despite preparation;
- marked deterioration later in the exam;
- knowledge evident in clinical work but not under prolonged exam conditions;
- limited benefit from extra time;
- fatigue as the primary limiting factor.
Capability is the least likely explanation
Doctors reaching this stage have demonstrated competence repeatedly. Where outcomes diverge sharply from clinical performance, assessment format should be interrogated first.
Narrow failure matters
Where failure is by a small margin, even modest disability-related disadvantage can be decisive. The presence of other contributing factors does not remove the need to consider whether disability made a material difference.
Iterative adjustment
If disability is known and an assessment is failed, it is appropriate to review whether the adjustments used were effective in practice and whether future assessments should be approached differently.
Assessment design and anticipatory responsibility
Certain MCQ features – negative phrasing, double negatives, ambiguous qualifiers, complex linguistic structures – are known to increase cognitive load and error rates, particularly under fatigue.
Research shows these effects disproportionately affect neurodivergent candidates. Because such features are foreseeable and systemic, they fall within exam bodies’ anticipatory responsibilities.
Pre-emptive review is important, but non-neurodivergent reviewers may not always identify practical accessibility problems. Where disability is known and failure is narrow, it is reasonable to review whether question design plausibly contributed to the outcome.
This does not imply examiner fault or automatic re-marking. It supports fairness and validity by ensuring assessments measure knowledge and judgement rather than vulnerability to linguistic traps.
Section 8 – Summary and reassurance
Difficulty with long-format exams does not equate to lack of clinical competence.
At senior level, exam outcomes must be interpreted in light of:
- cumulative fatigue;
- assessment design;
- delivery constraints;
- disability-related disadvantage.
Questioning exam format, seeking better-aligned adjustments, or asking for reassessment of what is reasonable are legitimate professional responses.
Your competence is demonstrated daily in patient care, reasoning, teamwork, and judgement. No single endurance-heavy exam can fully capture that.
