The long case versus objective structured clinical examinations
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7340.748 (Published 30 March 2002) Cite this as: BMJ 2002;324:748
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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,
Reader in Pediatrics, and Member, Medical Education Unit,
University College of Medical Sciences and GTB Hospital,
New Delhi 110 095, India.
E mail: drpiyush@satyam.net.in
Competing interests: No competing interests
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.
Competing interests: No competing interests
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].
Competing interests: No competing interests
Long Case Penalises the Individual
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.
Competing interests: No competing interests