Fazal Elahi ( College of Physicians and Surgeons, Karachi. )
Elsewhere in this issue appears a study on “Long case” as a method of examination in clinical subjects.1 Whatever may be the merits or demerits of this method as a tool of assessment it is quite clear that it is not being used properly. The reasons may be many. They may be grouped as sins of commission, omission or “beyond control”. It is also well known that students are very dissatisfied with this method. The crucial point to consider would be whether “Long case” is “irreplaceable” in which case feasibility, large number of candidates and administrative problems will have to be considered for remedy or can it be replaced by another method, in which case the concurrent validity will have to be proved. It has been suggested by the author that OSCE (Objective Structured Clinical Examination) may be a suitable alternative.
During many medical education workshops, on OSCE in which the highest echelons of examiners and professors, including foreign professors participated, the concept emerged that OSCE may replace short cases and oral examination effectively. It is very effective for observing practical procedures and attitudes, testing.snap diagnoses”, clinical methods, “spotting “, interpretation of laboratory investigations, detection and interpretation of clinical data and, to some extent, problem solving. Because OSCE is objective, it takes away examiner bias (i.e. subjective judgement of examiner, fear of examiner, etc) and can be tailored to the situation. There are many other inherent advantages of OSCE, but everyone agreed that it needs training of examiners and pre-examination hard work by them. It also needs training of the candidates in the method of examination. Preferably the teaching, continous (or formative) assessment or class tests have to be conducted as OSCE prior to its adaptation for the final examination (i.e. certifying examination). Another idea that emerged was that OSCE must first be “universalised” in concept and practice amongst the faculty and students in Pakistan before its adoption. It was pointed out that even after more than a decade of its publication this method is not being used in many universities of the world because of inherent difficulties. How would it be feasible in Pakistani MBBS examinations which are notorious for indiscipline and non-conformity to rules and regulations as well as their poor/non implementation? It was suggested that in the first phase higher examinations., e.g. FCPS, may be more amenable to this change.
Coming back to the question whether OSCE can replace “Long case” in any clinical examination. The “Long case” tests evaluation by the candidate of the whole clinical situation as in real life. There is a continuity and organisation of ideas, their coherent presentation, originality of thought and action in eliciting data (both clinical and investigational ), identifying and solving of problems (i.e. suggestions for solving the problems). OSCE lacks these aspects by virtue of structuring of various components which are tested separately. In OSCE there is no coherence, no continuity, no real life situation, no cue from mistakes, no “Second chance”. No doubt, OSCE tests thoroughness, preciseness, adherence to method, etc., but leaves little for the candidates originality, organisational ability and resource fullness which are also the desirable attributes of a clinician.
Hence, presuming that both the OSCE and traditional examination were to be administered it is doubtful if OSCE can effectively replace the Long case. A via media suggested is to retain the long case and replace the rest by OSCE provided the long case were to be assessed objectively (which is quite possible) and administered by an adequate number of examiners.
It would be interesting to observe that neither OSCE nor the traditional long case tests a very important component of clinical competence which is called patient management. In real life the clinician assesses a total situation, then takes measures to solve the problem after diagnosis. He evaluates his efforts himself by seeing the success or failure of his treatment and proceeds by collection of further data, re-assessment of the whole situation, re-planning and re-evaluation. This cycle, comprising of data collection, assessment of clinical situation, planning and evaluation of effect of treatment, goes on till the patient is cured (or otherwise). In a fixed examination model (OXCE OR Long case) this testing is not possible. It is possible with simulated exercises either written or computerised. It is tested par-excellence during on job training and clinical posting when the candidate can be observed closely by one or more chiefs (i.e, examiners) in a continuous assessment over a period of months or years. Problem oriented records are kept in one patient management system. Briefly called SOAP (where S stands for subjective data, O for objective data, A for assessment, and P for plan) the trainee (i.e., candidate) maintains continuous problem oriented records which may be easily assessed by the chief (i.e, examiner ). Continuous assessment is also the only method which tests the attitudes adequately.
Thus, it should be clear that clinical examination cannot be regarded as one entity in time and space. It is a continuous process and must cover all aspects of the attainment of objectives initially laid down, including cognitive objectives of highest order, i.e, problem solving, analysis, synthesis and evaluation, psycho-motor skills, and desirable attitudes. It must be emphasized that the efficiency of any examination depends on the objectives. Unless the objectives are realistic and relevant and the training geared to those objectives the examinations howsoever meticulously planned and administered will lose their validity.
In conclusion it is suggested that OSCE, if adapted may be useful for examining a large number of candidates in a short period, suppilemented with a long case, tested objectively.
1. Hussain, K.S. A critical evaluation of “The long case” in final MBBS examination. JPMA., 1985: 35.