|Year : 2022 | Volume
| Issue : 1 | Page : 1-2
Assessment of clinical skills – Is it time to revisit the role of the long case?
Robert William Pickles
Department of Immunology and Microbiology, School of Medicine and Public Health, University of Newcastle, Callaghan; Department of General Medicine and Infectious Diseases, John Hunter Hospital, New Lambton Heights, NSW, Australia
|Date of Submission||09-May-2022|
|Date of Decision||30-May-2022|
|Date of Acceptance||30-May-2022|
|Date of Web Publication||23-Jun-2022|
Dr. Robert William Pickles
Department of General Medicine and Infectious Diseases, John Hunter Hospital, New Lambton Heights, NSW 2305
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pickles RW. Assessment of clinical skills – Is it time to revisit the role of the long case?. Arch Med Health Sci 2022;10:1-2
There have been significant changes in the medical education landscape over the past two decades, not only in respect of curriculum design but also in the assessment of clinical skills. In many countries, curricula are moving toward a competency-based curriculum, driven partly by licensing authorities. Likewise, in Australia, since the opening of the medical school at the University of Newcastle in 1978, problem-based learning has gradually replaced the traditional courses that existed before this. All courses in Australia now follow a similar problem-based curriculum design.
Assessment of clinical skills has also undergone a significant shift over this time period incorporating the need for doctors to be able to work as part of a complex multidisciplinary team in an increasingly complex health-care environment. There remains, however, concern that aspects of clinical skills learning and competence are declining. It is felt by many that assessment drives learning and practice of clinical skills. With the moves toward competency-based curricula, entrustable professional activities have been developed across both undergraduate, as well as graduate medical training programs. This has involved some shift away from traditional barrier methods of the assessment of competence toward competency-based training and assessment.
Traditional methods of summative assessment of clinical skills include long and short cases, as well as vivas. The short case entails students/trainees being asked to examine one part of the patient and describe what they find and suggest appropriate investigations with one or two examiners. In the long case, the trainee spends up to an hour with a patient before presenting their findings to one or two examiners. That discussion may involve aspects of the differential diagnosis, along with clinical reasoning relating to further assessment and management of the patient. Criticisms of the use of the medical long case as a summative assessment tool include the fact that most such assessments are not directly observed and as such are not able to evaluate communication style and behaviors with the patient. In addition, the method of physical examination cannot be assessed (although this is less of an issue when short cases are also employed). Standardization of the long case is also problematic, both in respect of the clinical content (intercase reliability) and calibration of the examiners (interrater reliability).
Long cases are time-consuming and highly labor intensive to organize. Research has shown that ten observed long cases are required in order to achieve the test reliability needed. North American training programs have long since abandoned long and short cases to assess clinical competence. However, they remain a feature of some programs in Australia, the UK, and Ireland, for example. In the Australian and New Zealand physician training programs, the traditional summative barrier examination of two long cases and four short cases still exists, despite the challenges posed by modern educational theory, as well as, over the past 2 years, the COVID-19 pandemic which has wrought havoc across a wide spectrum of educational programs.
In Australian University medical programs, which are a mix of undergraduate and graduate courses, long cases have gradually been phased out as summative assessment tools. They have been replaced by a suite of tools that have been developed to try to find an appropriate balance between validity, reliability, and practicality. These include the objective structured clinical examination (OSCE), although research using the OSCE as a tool for the assessment of clinical competence also suggests that a minimum of 3–4 hours of testing time using OSCE stations is required due to the large intercase variability of trainee performance. The objective structured long examination record (OSLER) was also developed, including some direct observation of the trainee interacting with the patient.
Over the past few years, since both formative and summative long cases were dropped in an Australian Medical School, the examination has focused on multiple-choice questions, and the use of OSCEs, along with ward supervisor reports in later clinical years. Just before this change, students from other Australian medical schools have attended our hospital as part of their final year elective program. When asked at the end of their elective attachment for feedback on their experience, they commented that the most useful aspect was the observation of formative long case presentations by local final year students as well as physician trainees. On further probing as to why they found this to be useful, the comment was that “this is what we will be doing as interns.”It would seem on the surface, therefore, that in order that universities produce “work-ready” practitioners, some training, at least at a formative level, in the practice of long cases should occur, even if the long case does not feature as a summative assessment tool. Indeed, at my own university program, formative long cases have been reintroduced in the later years of the program in recognition of their role in promoting clinical reasoning in medical students.
Long cases do have validity, it is what one does every day with patients. We take the history and then do a targeted physical examination based on the hypothesis. Clinical medicine remains a hypothetico-deductive process. Most experienced clinicians will say that long cases should be retained and it is interesting to see that the students feel the same too.
Clearly, long cases need to be done in sufficient numbers to maintain their reliability as assessment tools. We may use checklists like the OSLER to give consistency and reduce bias. If we do the long cases properly and in sufficient numbers, it will drive practice. Let us not throw the baby out with the bathwater!
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