Transcript Improving Long cases and short cases in clinical examination

Improving Long cases and
short cases in clinical
examination
Prof. Pushpa Raj Sharma
Department of Child Health
This presentation
• Teaching clinical
skills
• Evaluation of
clinical skills
How do we teach clinical
skills?
• Ask students to
read the skill.
• Demonstrate it to
the students.
• Ask students to
re-demonstrate it.
• Correct the
demonstrated skill.
• Ask student to rere-demonstrate it.
Common problems with
clinical teaching
•Lack of clear objectives and
expectations
•Teaching pitched at the
wrong
•level (usually too high)
•Passive observation rather
than
•active participation of
learners
•Inadequate supervision and
•provision of feedback
Students
activity
Teachers
activity
Slice 3
Slice 4
Common problems with
clinical teaching
• Little opportunity
for reflection and
discussion
• "Teaching by
humiliation"
• Informed consent
not sought from
patients
• Lack of respect for
privacy and dignity
of patients
• Lack of congruence
or continuity with
the rest of the
curriculum
Challenges of clinical teaching
•Time pressures
•Competing demands clinical (especially when
needs of patients and students conflict);
administrative; research
•Often opportunistic makes planning more difficult
•Increasing numbers of students
•Fewer patients (shorter hospital stays; patients
too ill or frail; more patients refusing consent)
•Often under-resourced
•Clinical environment not "teaching friendly" (for
example, hospital ward)
•Rewards and recognition for teachers poor
A child with cough or
difficulty breathing
• Essential skills (High morbidity, High
mortality)
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Effective history taking
Physical examination
Identification of the patients problem
Formulation of the differential diagnosis
Planning of investigations
Management
Communication
Example of clinical
teaching
• Decide whom you are teaching?
– MBBS third year students (20 students)
• Decide what you want to teach?
– Examination of the respiratory system.
• Decide how you want to teach?
– Make four group.
– Ask each group to list the organs that can be
examined applying inspection, palpation
percussion and auscultation.
– Ask each group to write the normal findings.
– Ask each group to list the diseases of each
organ and common clinical signs of these
disease.
Example of clinical teaching
(contd.)
• How I will know if students have
understand?
– Demonstrate examining a child for
respiratory system examination.
– Divide student in group of 2.
– Ask them to examine a patient.
– Ask them to re-demonstrate specific
clinical procedure to elicit specific signs.
– Discussion
What I am teaching?
How will I teach it?
Who I am teaching?
How will I know if the
Student understand
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Why we want to
evaluate?
Assessment drives learning.
Observe competency for the job description.
Correct the mistakes.
Find out the prerequisite.
Find out the adequacy of the curriculum.
What do you want to evaluate?
• the existing knowledge of the
disease.
• the communicating skill with
patient/guardian.
• the writing skill.
• the presentation skill.
• the skill of eliciting signs.
• the skill of diagnosing, investigating
and treating of specific problem.
Evaluating clinical skills
• Clinical history writing.
– Poor reliability
• Log book
– Good validity but often unreliable
• OSCE
– Good reliability but may not be reliable
for overall skills.
Long case examination, as it
exist
“Luck of the draw”*
• Selection of the cases by examiners.
• Distribution of cases randomly.
• Approximately one hour for history,
examination and student to synthesize.
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Communication skill not observed at all.
Process is not observed.
Product is assessed.
Discussion frequently on the theory.
Approach and expectations vary with individual
examiner.
*Stokes J. The clinical examination-assessment of clinical skills, medical
education booklet no 2(Dundee Association for the Sudy of Medical
Education)
Five required attributes of an assessment process:
Reliability - a measure of the variation in scores
Validity - the degree to which an assessment is a
measure of what should be measured.
Acceptability - the degree to which the assessment
process is acceptable
Feasibility - the degree to which the assessment can
be delivered to all those who require
Educational impact - the degree to which the
assessment can assist the student to improve his or her
performance,
Evaluating clinical skills
• Observed clinical examination:
– Good validity but poor reliability unless
multiple observation made.
– Time consuming, logistic problems in
recruiting patients.
• Non observed clinical examination
– Poor reliability unless multiple cases
seen. Good validity.
– No assessment of student interaction
with patient.
Reported Reliability when
4h testing times are used
for different test formats
Wass V, Vleuten CV, Schatzer J, Jones R. Assessment of clinical competence.
Lancet 2001;357:945-49
Improving the long case
examination
• 1979: Harden and Gleeson developed
the OSCE*
• 1997: Gleeson developed the
OSLER**
*Harden RM, Gleeson FA. Assessment of clinical competence using an objective
structured clinical examination (OSCE). Medical education, 1979;13:39-54.
** Gleeson F. Assessment of clinical competence using the objective structured long case
examination record (OSLER). Medical Teacher. 1997; 19: 7-14
Objective Structured Long
Examination Record
(OSLER)
• Ten item analytical record form.
– 4 items for history taking, 3 items on
physical examination, 1 each for
formulation of investigations,
management and clinical acumen in a
logical sequence.
• All candidates are assessed on the
same ten items.
• Time is 20-30 minutes for the
examination.
• Items are representatives: whole
OSLER’s components
• History taking
– Clarity of presentation, communication
process, systematic approach,
establishment of case facts.
• Physical examination
– Systematic approach, examination
technique, establishment of correct
physical findings.
• Assessment of clinical acumen
– Ability to identify and solve problems
Standardizing the long case
based on the difficulty of
the case
• Standard case
– Single problem
• Difficult case
– Up to three problem
• Very difficult case.
– More than three
problem
Awarding marks in the
OSLER
• P+: Very good/excellent. (60-80%0
• P:
Pass/ bare pass.
• P-:
Below pass
(50-55%)
– Each items has to be graded followed by
overall grade of the complete performance
Department of Child Health
Example of Paediatric Final Examinatio
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Observed by two examiner.
Filling the forms with specific tasks.
Grading the candidate.
Both examiners grade on the specific
tasks.
• Average is taken.
Marks
20
Clinical Examination Skills
Time allocated 5 minutes
Observes professional manners,
Performs proper & relevant
clinical examination according to
instructions given and applies
correct clinical methods
systematically
and appropriately
Proceeds appropriately
according to age.
Discussion Time allocated 10 minutes
Gives correct findings with logical
interpretation and conclusion.
Justifies diagnosis/es.
Suggests appropriate & relevant
investigations and management
(including recent advances)
Exce
llent
Good
Adequate
Inadequat
e
Poor
Comments
(Comments MUST
be made
for all ratings of
'Inadequate' and
'Poor')
Marks 60
Time allocated 30 minutes
Interviewing & Clinical Examination Skills
Introduces self to patient, obtains informed
consent, elicits corrected relevant history.
Uses correct clinical methods systematically to elicit
important clinical findings with special emphasis on
detailed examination of the relevant system.
Proceeds appropriately according to age.
(The allocated 30 minutes – 15 minutes for each examiner)
Case Presentation
Examiner – 1 Name :
Presentation skills
Correctness of findings
Logical interpretation of findings
Suggests & justifies relevant investigations.
E
x
c
el
le
nt
G
oo
d
Adequ
ate
Inad
equa
te
Poor
Comments
(Comments
MUST be made
for all ratings of
'Inadequate' and
'Poor')
Miller’s Pyramid of
Competence
Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990;
65:563-67
What the parents feel?
Lack of informed consent
59 (51%)
Inconvenient by participation
38 (55.9%)
Too many candidate per patient
25 (21.5%)
Hassle of relating the history
repeatedly
Inadequacy of payment
13 (1.8%)
Examining the child for too long
7 (6%)
Not handling the child gently
7 (6%)
10 (8.6%)
*Arachi JK, Sumanasena SP, de Silva KSH. Clinical examination in paediatrics at final
MBBS: view of children and parents. Ceylon Medical Journal;2003, Vol 48, No 1, 12-14.
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