Can conventional long case examination be improved?

Dear Editor,

We congratulate Bhatnagar et al., on their original article titled, “Objective structured clinical examination for undergraduates.”[1] Their study has evaluated the use of Objective structured clinical examination (OSCE) to address the problem of lack of standardized methods of assessing a medical student's clinical competence. The paper also explains in detail how an OSCE is to be conducted, to obtain meaningful results. This system of assessment of clinical competence is popular in most of the universities abroad, and some in our country. We have also been using the OSCE system for assessment of students at the end of a clinical attachment.

The OSCE was developed to overcome the drawbacks of the conventional clinical exams (CCE) using the long and short case formats. However, there are serious drawbacks in OSCE also. It tends to compartmentalize the patients’ problems into isolated systems, rather than considering a patient as a person with emotional and other needs, other than the medical problem at hand. In this regard, the CCE system still has its charm, with its holistic approach and bio-psychosocial ethos, unlike the OSCE. Moreover, CCE using the long case is still the most commonly used assessment tool for clinical competence in our country.

Many modifications are in practice to make the CCE more valid, reliable and objective. Recent studies have shown that the CCE with these modifications is comparable with the now-favored OSCE.[2-4] Some of the modification systems in use are: (1) objective structured long examination record (OSLERs),[5] (2) Leicester assessment package and (3) mini–CEX format.[6] In this communication, we would like to highlight these modifications.

The CCE was originally designed to assess the clinical skills and attitude (psychomotor and affective domains) mainly. However, we most often assess the higher order of cognitive domain, making the CCE not a valid test of clinical competence. To overcome this drawback, the recommendation is observation of the examinee during history taking and clinical examination.[45]

Variability in the patients, examiners and the student's behavior is a very important cause for poor reliability and objectivity of CCE. To overcome variability due to examiners, the OSLER recommends that the long case be divided into 10 items on which each candidate is assessed.[5] These items include (1) pace and clarity of presentation, (2) communication process, (3) systematic approach, (4) establishment of case facts, (5) systematic examination, (6) examination technique, (7) establishment of correct physical findings, (8) formulation of appropriate investigations, (9) formulation of appropriate treatment and (10) clinical acumen or the ability to identify and solve a problem. By defining the items to be examined, the examiner is reminded to be consistent with all candidates. The marks allotted to each item is criterion referenced, meaning candidates are evaluated appropriate for their level of training. All candidates should be assessed using the same time frame.

Attempts should be made to standardize the case by defining the level of case difficulty. To reduce patient-related variability, more patients with similar problems or simulated/tutored patients may be used.

The CCE, like the OSCE, is a summative examination, leading to a pass or fail of the candidate during a single encounter. However, a student who has worked hard through his/her training period may perform badly on a given day. To overcome this, LAP and mini-CEX are structured assessment tools where the candidates are observed and evaluated over several mini encounters by different faculty members during their training period.[6]

In conclusion, the CCE is a reasonably good assessment tool of clinical competence, provided attempts are made to make it objective, reliable and valid. Some of the modifications highlighted in this communication are only suggestions. Each teacher could contribute by trying to implement these modifications within their departments and institutions thus making CCE relevant.