Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Hurrah!
- Martin Talbot (31 May 2008)
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OSCEs may assist GP Training
- Andrew N Papanikitas (1 June 2008)
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Long cases and the getting of wisdom.
- Roger K.A. Allen (1 June 2008)
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The Long Case is Mortal
- Brian C Jolly (2 June 2008)
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A well argued case
- Makarnd K Oak (3 June 2008)
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Resurrection in a different form
- Stephen P Tyrer (11 June 2008)
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A solution
- John B Cookson, Paul Lazarus; Leicester Medical School (12 June 2008)
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Martin Talbot, Medical Educator Sheffield Teaching Hospitals, S10 2JF
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Another article clearly arguing for the retention or reinstatement of the long case. I wonder when medical schools in the UK are going to respond to the evidence? Competing interests: Dr Talbot is an education visitor for the GMC |
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Andrew N Papanikitas, GP ST3 Aylesbury GPVTS
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Dear Sir/Madam, I wish to introduce a note of caution, lest we overly malign the Objective Structured Clinical Examination (OSCE) in clamouring for the 'Long case' in asessing undergraduates. OSCEs have been used to test both clinical and communication skills - I experienced this first-hand in 2003 when qualifying from Guy's King's and St Thomas' Medical School. British medical Students also spend a great deal of time in, and often end up training for, General Practice. The 7.5 minute or 10 minute OSCE- consultation is excellent preparation for this. I certainly felt that my final-year OSCE (perhaps unfairly) gave me an advantage over older (non- OSCE veteran) colleagues when attempting the new MRCGP Clinical Skills Assessment. It may also have helped in managing the 10-minute consultation (my own perspective) in 'real-life'. More importantly perhaps, just as GPs can have a bad consultation (out of a session of 12-24 patients) and still be considered excellent, so can students. For a long case to be a 'fair' exam for undergraduates this would have to be reflected in the marking, possibly raising quality assurance problems, or in an increased number of cases assessed per student. Best Wishes Competing interests: co-author: Get through clinical finals, a toolkit for OSCEs, RSM Press 2006, and Get through the DCH Clinical, RSM Press 2008 |
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Roger K.A. Allen, Senior Consultant Thoracic and Sleep Physician Wesley Medical Centre, Auchenflower, Brisbane, Australia
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I agree that the long case is essential in the examination of both medical students and specialist physicians as it is the closest thing to real life. As a former examiner of both (University of Queensland and RACP), I have observed that something beautiful happens when a candidate finally reaches that level of competence where nothing "throws" him or her. You think to yourself,” I wouldn't mind if she happened to treat my mother" or "I'd like to him in my team in an emergency room" or "even in a foxhole under fire." There are some long cases which are more demanding than others but what shines through regardless is plain for the examiners to see. It is like a sailor who remains composed regardless of a sudden change in the weather, an unfavourable tide or a man overboard. That is what medicine is all about. All the new patients I see daily in my consulting rooms are "long cases". The only difference now is that my experience is so much greater, my neural associations with a whole range of things medical and non- medical are more complex, and my ability to "read" people is far better. What would have taken me an hour takes me half this time. However this all started with countless practice of long cases leading up to my FRACP exams twenty eight years ago. The long case was by far the most daunting compared to the two multi- choice written papers and the short cases. We trainees could tell who would pass as we practiced with each other and with senior registrars who acted as "examiners". It was like driving with someone going for their driver's licence or sailing with someone who knew the ropes. My long case was a very suntanned railway fettler from North Queensland who had both haemochromatosis (so much for the "bronze" in "bonze diabetes") and paraplegia of recent onset due to a spinal abscess which was due to melioidosis. I shall never forget that man as I have never since seen this cause of paraplegia, although I have seen several cases of melioidosis. What gets you through a "difficult" long case is what I call "control" and "method" as well as lashings of common sense, lots of previous long cases and also real life cases in your ward work, mastery of “nerves” and as well as wisdom. This is never learned in a library. You must be "on the tools". Some candidates never made the grade regardless of how many times they did long cases. They never mastered its complexity as it is a very intellectually taxing endeavour in my opinion. In my day you had only two attempts at the FRACP exam and then you were out which meant we were playing the game for real. It was pass or you die. The "adrenaline factor" is essential in the training as it occurs with real live patients. I also think a good physician has a sixth sense but this only comes with experience and some never have it. I am indebted to those colleagues with whom I practiced after work and on weekends and to the wisdom and skill of those who used to listen to our cases and to our examiners. I also think that this system is what makes Australian physicians well regarded throughout the world. Long may the high bar of the ‘long case” continue as without it graduates risk being suboptimal. When a fighter pilot flies he wants a wingman he can rely on and that is how I regard the other consultants with whom I work. Competing interests: I am a current member of the Joint Adult Medicine and Paediatrics Subcommitte for Continuing Professional Development, Royal Australasian College of Physicians |
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Brian C Jolly, Professor Centre for Medical and Health Sciences Education, Monash University, Victoria Australia, 3800
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There has been more resistance in Australia to laying the long case to rest than elsewhere. For example it is still used in the University of Sydney graduate entry programme, so obituaries may, as Teoh and Bowden suggest, be premature. As a licensing examination the long case is 150 years old this year. Irrespective of Talbot's pleas, the evidence suggests it is showing its age (even though some healing oils might be applied) and would contribute much to the case for euthanasia. There are two major problems. Teoh and Bowden may have overcome the first, which is that to be reliable and to move beyond case specificity, you need to use many long cases in the assessment of an individual. Of course, you need to do the same for any measurement instrument that assesses clinical competence. But for many medical schools one (or two) long case(s) became almost the sole arbiter of clinical competence and in that role it is woefully inadequate solely because of its unreliability and capriciousness. As they point out, to get more reliable and valid data from a long case it has to be observed (probably in its entirety) by the assessors and 8-10 cases need to be used. Most research-frenzied clinically dedicated academics do not have the time to devote to this, which is why substitutes such as the Mini-CEX (1) have been developed that focus on day to day work activities and can, indeed should, be assessed by senior clinicians. The point is that there are no quick and easy assessment tools - they all require time and effort. The other claims for resurrection focus on the need to capture the essence of clinical practice in assessments – arguments that address both face- and construct- validity. But there are, and have been for some time, significant doubts about what constitutes the clinical reality on which the long case was based. For example Martin (2) reports “No one pays for the time it takes to get a detailed, complete medical history. As a direct result, there are few mentors in training programs with the time and skill to teach history-taking by example. …. That is why practicing physicians seldom take the time to plough through thick and jumbled medical records, or spend the time it might take to learn everything necessary about a patient's problem. This is not criticism, this is simply honest observation. It is reality, and the observation applies to all of us." (2 Section C). In the last 5 years my longest single interaction with a doctor, of about 15 in total, was circa 20 minutes – and the shortest 3.5 minutes. The former was a senior house officer investigating my community acquired pneumonia and the latter a consultant surgeon, who asked precisely 5 questions. If Teoh and Bowden have discovered a potion that rejuvenates academic clinicians’ passion for giving feedback to students on 14 long cases, could they please send some to Melbourne. Otherwise, may the long case rest in peace. 1 Wilkinson JR; Crossley JGM, Wragg, A; Mills P, Cowan G; Wade W. Implementing workplace-based assessment across the medical specialties in the United Kingdom. Medical Education, 2008;42:364-373. 2. Martin L. The House Officer’s Survival Guide Lakeside Press 1996. http://www.lakesidepress.com/pulmonary/books/house/cont1.html Competing interests: None declared |
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Makarnd K Oak, Consultant Gynaecologist Wishaw General Hospital 50 Netherton Street Wishaw ML2 0DP
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Editor, The case for resurrecting the long case is a daring challenge posed by the authors and I firmly believe that the profession must take this on and implement its suggestion. I can only speak for the system in the UK and that too based on personal experience of only a handful of medical schools but opinions of many of the clients of this system that is the students themselves. In the UK at least it appears that over the last decade all aspects of medical profession and education are owned by everyone else but the medical profession. Fear of litigation from unsuccessful students, explosive growth of evidence based medicine, risk management and protocol driven medicine have attempted to and to a considerable extent have succeeded in reducing medicine to binary notation. Communication skills and political correctness lobby dominate undergraduate and to an extent postgraduate teaching. The outcome becomes all too obvious when doctors coming through current education and assessment system come out in the real world. Of course medical educators must share the blame but this is unjust because a large section of medical education is delivered by non doctors and a proportion of the remainder is no better than DIY medicine. Here is another argument that will lend credence to professional music student analogy that is real patients do not always follow a binary path and do not come with neat colour coded body parts; all aspects of real medicine and the real world are uncertain and every budding doctor must be able to make the best of this uncertain world and it is our duty to ensure that we as a profession take back responsibility for education, assessment and standards from the jaws of protocol driven medicine, fear of legal challenges, political correctness and of course the Health and Safety. If the present trend continues then the real loser will be the very person for whose all claiming to be working-the patient and the accountability will lie squarely on our shoulders-rightly we will be asked what did we do when all this was happening. Mr MK Oak
Competing interests: None declared |
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Stephen P Tyrer, Consultant Psychiatrist Southland Hospital, Invercargill, 9501, New Zealand
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The practice of psychiatry relies, above all, on the ability of the practitioner to obtain a relevant history and mental state examination from a patient. For this reason the Royal College of Psychiatrists has regarded this skill as vital in the assessment of candidates for the MRCPsych Examination and, until very recently, the assessment of a long case interview has been considered to be a cornerstone of clinical assessment (1). However, for the reasons cogently expressed by Brian Jolly, the College relinquished the long case in the format of the MRCPsych in Spring of this year and has replaced this with an OSCE. We still believe strongly that the ability to interview a real patient and synthesise the information relevantly is important and we will continue to assess this ability but in a different setting. The new regulations for the MRCPsych Examinations require candidates to complete a number of Assessed Clinical Encounters (ACEs) as well as other Workplace Based Assessments during training. A proportion of these ACEs will be assessed by a validated College approved assessor, with these marks counting towards the final summative assessment. This arrangement overcomes the problems of reliability of a single examination assessment. We might be hesitant to recommend a restaurant on the basis of one good meal but once we have had a number of of equally tasty offerings the confidence of our gustatory beliefs are vastly increased. 1. Tyrer S. Non mors praematura: Commentary on the long case is dead. Psychiatric Bulletin, 2007;31:447-449 e-mail: stephen.tyrer@sdhb.govt.nz Competing interests: I am a past Chief Examiner of the Royal College of Psychiatrists |
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John B Cookson, Undergraduate Dean Hull York Medical School, Paul Lazarus; Leicester Medical School
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Teoh and Bowden make many good points in their case for resurrecting the long case as a “final barrier” assessment of clinical competence. They also identify its weakness; poor reliability unless a large number of cases are used. However it all depends on what you mean by the long case. The popular impression is of a full inductive history, a general physical examination of all the main body systems, followed by an in depth discussion. Creating an examination like this with enough challenges to achieve reliability becomes logistically impossible. Both of us have therefore in our different institutions been involved in developing an examination which consists of up to eight cases, each involving a focused history and examination followed by a discussion with the examiner. The process is fully observed. The process uses a clear range of competencies to be expected and explicit grading criteria. It is also sequential. All students see four patients and those who are not entirely satisfactory (between one quarter and one third of the year) see four more, with decisions being made on all eight. This therefore conserves resources directing them where they are most needed at the cut off point between the competent and the incompetent, surely the main purpose of a “barrier” assessment. The system has now been in operation for 8 years and for many hundreds of students. Among other advantages it encourages students to develop the essential links between history, physical examination, diagnosis and management in each clinical challenge as the consultation progresses, not at some remote point afterwards. Feedback from students who have sat this examination strongly indicates that it is perceived as a fair and acceptable test of their abilities. Moreover, our more recent experiences have demonstrated that it is practical to combine such assessment of consultation and problem-solving abilities with other elements of professional competence, such as testing procedural skills and high level communication skills, in an OSCE-style format, thereby broadening the assessment blueprint without compromising examination reliability. Competing interests: None declared |
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