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Rapid Responses: Rapid Responses published:
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Biophysical Semeiotics and Medical Education.
- Sergio Stagnaro (29 March 2002)
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The long case versus objective structured clinical examinations
- Daniel M Sado (31 March 2002)
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Long case vs. OSCE: Is there a need for comparison?
- Piyush Gupta (1 April 2002)
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Long Case Penalises the Individual
- David J Lucey (5 April 2002)
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Sergio Stagnaro, Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genoa) Italy
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Sirs, interestingly, Geoff Norman’s intriguing paper (BMJ 2002;324:748-749, 30 March ) faces, in noteworthy way, the unavoidable argument of best evidence medical education, underlining that, in discussions about it as well as in clinical medicine, intuitions will frequently be at variance with evidence. As far as clinical medicine is concerned, I must to point out that such a statement is truth, but exclusively as regards of the old, traditional, acàdemic physical examination. On the contrary, by the aid of “biophysical-semeiotic” examination, every intuition passes successively through the precise, objective, critical filter of a “new” physical examination, based on accurate and reliable data, biological systems provide learned doctor, using a simple stethoscope (1-3). Fortunately nowadays Biophysical Semeiotics is a reality (See HONCode ID N. 233736, http://digilander.iol.it/semeioticabiofisica) and I consider preisworthy those mass-media, and particularly medicine peer reviews, as BMJ, BCMJ (4), and NEJM (5), which spread the news that physical semeiotics is no longer the Cinderella among other numerous medical disciplines. Sergio Stagnaro MD, Active Member NYAS. 1) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica del torace, della circolazione ematica e dell’anticorpopoiesi acuta e cronica. Acta Med. Medit. 13, 25,1997. 2) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica: la manovra di Ferrero-Marigo nella diagnosi clinica della iperinsulinemia-insulino resistenza. Acta Med. Medit. 13, 125,1997. 3) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica: valutazione clinica del picco precoce della secrezione insulinica di base e dopo stimolazione tiroidea, surrenalica, con glucagone endogeno e dopo attivazione del sistema renina-angiotesina circolante e tessutale – Acta Med. Medit. 13, 99,1997. 4) Stagnaro S. Depression, Anxiety and Psychosis. B C Medical Journal, Volume 43, Number 6, page 321, July-August,2001. 5) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [PubMed –indexed for MEDLINE]. |
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Daniel M Sado, 5th year Medical Student Southampton University
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As a final year medical student who has been through numerous long case examinations and is about to do an objective structured clinical examination (OSCE), I read with interest the article by Professor Norman about the relative merits of these 2 types of examinations.1 As suggested by Norman, these exams are designed to assess “clinical competency.” In my view neither type of exam achieves this aim particularly well. Let me take as an example the general medical long case I have just done. This was a patient who had come into hospital with an asthma attack. I presented the case and then was asked a series of questions about the relevant investigations and management of the patient. The panel gave me a B grade for my performance, thus suggesting that I am “clinically competent” in general medicine. But what if my case had been the horrendously complicated neurological case that one of my colleagues had to see? Then it might have been a different story. And then, what if the panel who examined me had been made up of two consultants known to fail students having asked them a string of obscure questions? Or even, what if my patient had been a “rambling” historian who had a variety of different diseases and kept digressing away from the questions posed? These are all problems that students come up against in long case examinations. One of the other problems with both long case examinations and OSCEs is that they are high-pressure examination situations in which nearly everything you do is being watched. This is obviously not like everyday clinical medicine. Because of this, students will behave differently in these exams than they do in “real life” on the wards. Since these types of examination do not reflect a students day-to-day ability and behavior on the wards, should they be used as an assessment of future clinical competency as a doctor? I believe that the clinical competency of students could be better carried out by not using one off long cases or OSCEs at all. The opinions of the consultants and team that the student has worked for on general medical and surgical attachments should be considered. The long case has been shown to be a good way of examining students only if it is performed on 10 different patients and assessed over 200 minutes.2 This never happens in formal exams where most medical schools give the student only one case and around 30 minutes of questioning about it. The consultants that students work for should have heard them present a vast number of cases of patients with various conditions. Hence these consultants should have a much more rounded view of a students ability than a one off long case panel. The teams the student has worked for will have a good idea whether the student has been a valuable member of the team who has communicated well with patients and staff and is proficient in basic skills like venepuncture, IV cannulation and carrying out arterial blood gases. Furthermore, to go along with the opinions of the consultant / team the student has worked for, students could be given a short answer paper in which core pre registration house officer level knowledge of common disease diagnosis, investigation and management is assessed. What is your differential diagnosis and how would you investigate / manage a patient with chest pain, high temperature post operatively, right iliac fossa pain etc. This way of examining students would be far more rounded than the hotchpotch of questions that are asked in the long case. References: 1)Norman G: The long case versus objective structured clinical examinations. BMJ 2002; 324:748-9. 2)Wass V, Jones R, Van der Vleuten CPM. Standardized or real patients to test clinical competence? The long case revisited. Medical Education 2001;35:321-5. |
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Piyush Gupta, Reader in Pediatrics University College of Medical Sciences, New Delhi 110 095, India
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Dear Sirs, The editorial by Norman (1) based on the article by Wass et al (2) is yet another, adding to the string of comparisons between the traditional long case and the neoteric objective structured clinical examinations (OSCE). The editorial is likely to add fuel to the fire raging between the hard- liners and the radicalists. The tug-of-war has been going on for more than two decades and can go on forever. I am sure that it is not possible to come up with a solution or evidence of supremacy of one method over the other. The reason is simple. There is no need to compare the two! The two are entirely different methods and achieve distinct purposes. OSCE is a competency-based evaluation aimed at testing the psychomotor and affective domains with an inbuilt system for systematic feedback. While the OSCE may test specific skills, it does not evaluate the comprehensive understanding of the candidate. It tends to segregate the patient’s problem into components rather than testing him as a whole. This drawback can be overcome by combining OSCE with a traditional case presentation. The Middle Path Why should we discard one method of evaluation for the other? Is it that whenever something new is discovered the old becomes redundant? Birth and death are universal and this applies to humans as well as ideas. In between being born and dying, young and old live together and that is what completes a society. So what’s wrong, if concepts live together in an amicable manner. Whenever a new thought is introduced, comparison with the existing one is inevitable. The long case has been here for ages and the OSCE is here to stay. It is time to realize that OSCE can't replace long case altogether or vice versa. So, stop comparing the two and go for a middle path approach. Learn and propagate the language of reconciliation. The world will look better if both the long case and OSCE are incorporated in the scheme for assessment of medical undergraduates. And for god’s sake, stop issuing key messages as highlighted in this editorial, i.e. “the long case is a bit better, if time is equal”. Comparisons are good to keep the statisticians in profession but hardly help those who understand the language of adjustment. 1. Norman G. The long case versus objective structured clinical examinations. BMJ 2002; 324: 748-749. 2. Wass V, Jones R, van der vleuten CPM. Standardized or real patients to test clinical competence? The long case revisited. Medical education 2001; 35: 321-325. Piyush Gupta,
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David J Lucey, Medical Student University College Dublin
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Sirs, I have recently had the pleasure of being at the guinea pig end of this experiment. Professor Norman (1) asserts that the long case has a reliability of 0.82 compared to 0.72 for the OSCE (although how one can be so exacting without a gold standard is beyond me). As someone who has experienced a long case comprising a mystery ear lobe cyst with incidental psoriasis I feel that the author has missed an important point in his analysis. Even if we are to assume that the reliability scale in question is perfectly accurate, this is in respect to a given group of medical students as a unit. However, if one was to calculate the probability of an individual student receiving an unfair mark, it would undoubtedly be increased in regard to the long case. This is because it relies on an all- or-nothing, Russian roulette method of case allocation. In the case of OSCEs, one can be unfortunate or ignorant at a proportion of stations but a well designed setup ensures that a candidate will average out at their standard (at a reliability of 0.72). The reliability is valid, therefore, at the level of the individual as well as the group in the case of OSCEs. Professor Norman makes an argument based on the nostalgia of “long tradition”. Perhaps it is time to reflect as to whether there is convincing long term follow up data on the validity of the long case. It may be that we are merely making the same mistake with ever increasing confidence. All too often, success in such clinical examinations is a reflection of good exam technique, of set-piece posturing and theatrical percussion. Similar observations may be made of many other forms of examination, including the essay. Such methods are often compared to each other in a circular argument. They are all too often as much a reflection of ones knowledge of what pleases the examiner as they are a gauge of ones competence. A retrospective study by Erlandson and his colleagues at the University of Michigan (2) as quoted in the Oxford Textbook of Surgery (3) on surgeons in training found the worrying result that honours in surgery had no bearing on a surgeons later performance. Overall medical school honours did confer a statistical advantage. Could it be then, that a persons overall drive and ambition to achieve such honours are the true mark of future success and that the examination method itself is, in relative terms, a confounding factor. Sincerely, David Lucey (1) Norman G. The long case versus objective structured clinical examinations. BMJ 2002; 324:748-9. (2) Erlandson EE et al. Resident selection: Applicant selection criteria compared with performance. Surgery 1982; 92: 270–5. (3) Dodson TF. How should surgical candidates be selected? Chapter 51, Oxford Textbook of Surgery; 2nd Edition on CD ROM. Oxford University Press 2002. |
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