Evidence based checklists for objective structured clinical examinations

doi:10.1136/bmj.38943.463565.68

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Christopher Frank, clinical programme leader (frankc@pccchealth.org)1

¹ Providence Continuing Care Centre, 340 Union Street, PO Box 3600, Kingston, ON, Canada K7L 5A2

Accepted 17 July 2006

How doctors examine a patient is often influenced more by tradition than by evidence. But trainees should be assessed on what works and not personal preferences

The objective structured clinical examination has been used to evaluate the clinical skills of medical trainees for more than 25 years. Many examinations use checklists as the main indicator of performance, although some people advocate global ratings.^{1^–3} The development of these checklists is challenging. Doctors devising checklists often disagree about what should be included and the weighting given to items. This is particularly true with checklists for physical examinations, where tradition, different training sites, and specialty backgrounds influence opinion.

Reasons for concern

The physical examination represents a link with the history of medicine, and many clinicians have strong opinions on the merits of specific clinical signs. Clinicians have begun to critically review many aspects of physical examination, but this critical approach does not seem to have been applied to the development of checklists for objective structured examinations. Gorter and colleagues reviewed the literature on developing these examinations and found that only 41% of the 29 papers described the process of checklist development. None of the papers reported that checklists were based on the available literature, and only three reported use of published evidence.4

Examples

I reviewed the checklists for physical examination stations from undergraduate and postgraduate examinations at a Canadian health sciences centre and from a multicentre examination to provide examples. I also reviewed the checklists in an examination preparation book.5 The items discussed below were chosen because there was controversy about the clinical value of a particular aspect of a physical examination or the possible weighting of marks.

I used JAMA's rational clinical examination series as a distillation of evidence for specific procedures.⁶⁷ For each of the procedures potentially included …