The Long Case is Mortal
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
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.
Competing interests: No competing interests