Osce Skills for Trainees in Medicine: A Clinical Exam Guide for Students in the Health Professions

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© 2015 Augustine Efedaye Ohwovoriole. All rights reserved.

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Published by AuthorHouse 10/12/2015

ISBN: 978-1-5049-3506-7 (sc)

ISBN: 978-1-5049-3507-4 (hc)

ISBN: 978-1-5049-3508-1 (e)

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To The Ohwovoriole Royal Dynasty, a Coterie of Teachers

Assessment Drives Learning

Contents

Preface

Acknowledgement

1 Assessment of Trainee Competence in Medicine

2 Overview of Objective Structured Clinical Examination

3 History - Taking Skills Station

4 Communication and Ethics Station

5 Physical Examination Skills Station

6 Practical Procedure Skills Station

7 Objective Structured Practical Examination

8 Written or Static Station

9 Structured Viva Voce

10 Practical Assessment of Clinical Examination Skills

Glossary of Medical Education Terms

Bibliography and Resources

Tables and Illustrations

Figure 1.1. Assessment Tools by Clinical Competencies Based on Miller’s Pyramid.

Figure 2.1. Basic Scheme of an OSCE Circuit.

Figure 2.2. Factors that May Affect Performance of a Candidate in Their Clinical Assessment.

Figure 3.1. Seating Position During History-taking.

Figure 4.1. Verbal and Non-verbal Forms of Communication.

Figure 4.2. The Face as the Mirror of the Mind.

Figure 5.1. Physical Examination Diagnostics.

Figure 6.1. Varieties of Instruments and Devices that can Be at a Practical Procedure Station.

Figure 7. 1. Schematic Representation of an OSPE Circuit.

Figure 7.2. Potential Test Materials at OSPE Stations.

Figure 8.1 Instruments and Devices that May Find Their Way to the OSCE Written Station.

Figure 8.2. Imagings and Other Materials that Might be at Written Stations.

Figure 8.3. Chest X-ray of the Patient at Presentation

Figure 8.4. The ECG Tracing of Thomas Cole

Figure 9.1. The Viva Voce Setting.

Figure 9.2. Materials and Themes for a Structured Oral Examination.

Figure 10.1. Structure of PACES.

Table 1.1. Cognitive Levels in Bloom’s Taxonomy

Table 1.2. Assessment Tools by Competencies and Domains

Table 2.1. Types of Task Encounters or Stations in OSCE

Table 2.2. A Rating Scale for Assessing a History on Vomiting

Table 2.3. Common Provisions by OSCE Station Type

Table 3.1. An Assessment Guide for a History of Abdominal Pain

Table 4.1 Basic Steps in the Process of Clinical Communication

Table 4.2. Some Popular Communication Skills Models

Table 4.3. Assessing Communication Skills at Breaking Bad News (for Postgraduates) *

Table 5.1. Doctor-Patient Positioning for a Physical Exam

Table 5.2. Assessment of Physical Examination of Abdomen

Table 6.1. Rating Scale Assessment of Blood Pressure Measurement

Table 7.1. Features of OSPE Stations

Table 7. 2. Scoring an Experiment Station: Analytic Determination

Table 7.3. Checklist for Station on Measuring Blood Pressure

Table 9.1. Merits and Demerits of Traditional Orals

Table 9.2. Marksheet for Structured Viva Voce Station XX

Table 10.1. PACES Structure and Activities

Table 10.2. Comparing PACES and OSCE

Table 10.3. Assessment Criteria for History Taking Skills in PACES

Table 10.4. Assessing Communication/Ethics Skills in PACES

Table 10.5. Assessment Criteria for Physical Exam Skills in PACES

Table 10.6. Scoring Criteria for a Brief Consultation Station

Preface

The assessment of trainees is a key aspect of medical education as it is widely recognised that assessment drives learning. The tools of medical education and its assessment are continually changing. Trainers and trainees have to keep abreast of the trends. The objective structured clinical examination (OSCE) system has become more or less the modern gold standard in assessment of clinical students worldwide.

I have been very intensely involved with medical education including OSCE at both the undergraduate and postgraduate levels in the last several years. My purpose of writing this book and the sister version directed mainly toward the teachers is partly to use this experience to guide the trainee to clearly pass their OSCE and partly to assist teachers who are new to or unfamiliar with the OSCE system.

Most trainees in Medicine and the allied professions of nursing, physiotherapy, pharmacy, dentistry etc. are likely to have a date with OSCE at the undergraduate, postgraduate, licensing and/or selection examinations. Yet too many students are scared of the OSCE system of assessment, a very fair and friendly exercise. Clinical trainees cannot therefore afford to be ignorant of OSCE.

The overarching ambition of every candidate is to pass their examinations. Your being successful at a clinical examination involves several factors, a very important one of which is your examination approach and technique. A good knowledge of the subject matter is necessary but not sufficient for you to present a impressive performance in the clinical examination especially when using tools of assessment like the OSCE, the objective structured practical examination (OSPE), and such other related examination formats like the Practical Assessment of Clinical Skills (PACES).

For you to do well in these performance-based exercises, you ought to have thoroughly prepared yourself and mastered the techniques. This book will guide you toward the goal of easily passing your clinical examinations. The book aims to equip you the trainee with the knowledge, skills, and attitudes/behaviours required of you to pass OSCEs and related examinations that demand exhibition of clinical competencies.

OSCE Skills has ten chapters. The first three chapters introduce the reader to the fundamentals of student assessment (especially OSCE) in medical education. The other chapters address systematically the various types of encounters (history taking, physical examination, communication etc) popularly referred to as stations in the parlance of OSCE and related exercises. Each encounter chapter stands on its own, starts with an explanation of the purpose of the type of station and then details what in the assessment

checklist the examiners are likely to be looking for at such a station. The prerequisites of handling the station are presented. There is a generous provision of materials to aid reading and internalisation of the message being conveyed. Every chapter also contains illustrative examples and appendices including assessment objectives for a variety of presentations or clinical scenarios. Trainees will find these examples very valuable in self assessment and in preparation for their final examinations.

Trainees and others using this book should note that the OSCE Skills is on how the candidate should prepare for and behave during clinical and practical examinations in the settings of OSCE and/or its variants. The book is not a substitute for standard books on diagnosis or management of medical disorders. You, the candidate, must study your chosen standard texts and acquire the necessary clinical competencies through training; and then apply the techniques and advice espoused in this book to guide you to respectable performance in the clinical and/or practical examination.

Good luck in your next OSCE encounter!

Candidates and Examiners, please give me a feedback at [email protected] on how we can improve OSCE Skills.

A.E.O

Acknowledgement

To Professor E.E. Ekenedigwe for his provision of radiological imagings, Professor M.A. Araoye for permission to use ECG tracings, and to my dear children, Toketemu and Dohwodese, for assistance in word processing.

1

Assessment of Trainee Competence in Medicine

1.1. Assessment of Trainee Performance

1.2. Purpose of Trainee Assessment

1.3. What To Assess in the Medical Trainee

1.4. Types of Trainee Assessment

1.5. Tools for Assessment of Competencies.

1.6. Chapter Summary

1.7. Chapter Recap Exercises

1.8. Bibliography and Resources

Assessment of Clinical Trainees

1.1. INTRODUCTION

Expected Outcomes of Trainee Learning

The paramount goal of a curriculum for training in the health professions is to graduate competent and knowledgeable persons with the right attitude to practise the profession. To be satisfied that the trainee has achieved the intended and expected outcomes of student learning, the student has to be put to the test. This process is often referred to as assessment, more popularly known as examination.

Assessment may be defined in several ways but a simple one is that it is:

the systematic gathering and analysis of evidence to determine how competent a student is in the context of curricular goals.

The term assessment is derived from the Latin word "assidere which means to sit beside. Sit beside" suggests that student learning or its outcome is observed critically at close quarters or bedside. Trainee assessment is typically performed by teachers in the discipline or related areas.

1.2. PURPOSE OF TRAINEE ASSESSMENT

The purpose of assessment in a medical training programme is multi-fold and will depend on the reason for which the assessment has been embarked upon. Trainee assessment is of benefit to all stakeholders in the training process and healthcare delivery: student (yes, trainees too!), the teachers, the university, the profession, and the public. Some of the principal reasons for embarking upon the student assessment process include the following:

• For the Trainee

○ To determine if a student has achieved the learning outcomes envisaged for the programme

○ To provide feedback information to the learner

○ To promote behaviour of self-reflection and self- correction

○ To promote access to advanced training

• For the Public and the Profession

○ To protect the public through identification of and denial to practice by inept individuals

○ To identify, classify, and certify/license competent trainee graduates to practise

○ To provide information for evaluation of a curriculum. or programme

○ To maintain professional and academic standards

1.3. WHAT TO ASSESS IN THE MEDICAL TRAINEE

A training programme should have well articulated goals and objectives expressed in its curriculum detailing the intended learning outcomes for the trainees. It is the attainment of these goals, objectives, and learning outcomes that are the subject of student assessment. The standard content of trainee assessment consists of knowledge, skills, and attitude and behaviours.

Competencies Suitable for Student Assessment

In the health professions, domains or competencies suitable for student assessment include the following:

• Knowledge of the specialty

• Relevant data gathering skills

• Communication and interpersonal skills.

• Ability to interpret data and synthesise

• Performance of clinical procedures

• Attitude and behaviours

• Ethics and legal aspects of the profession

• Professionalism.

Bloom and Miller

Benjamin Bloom’s Domains of Educational Activities

Two names are closely associated with development of assessment in the medical education specialties: Bloom and Miller. In 1956 Benjamin Bloom identified three domains of educational activities:

(a) cognitive, mental skills (Knowledge);

(b) affective, growth in feelings or emotional areas (Attitude);

(c) psychomotor, manual or physical skills (Skills).

The cognitive or knowledge domain is the most well described and applied of the three domains. In the majority of cases, assessment will focus at one or more of these levels. Table 1.1 summarises the main categories of the Cognitive Domain of Bloom’s Taxonomy. The categories range from simple recall of facts to problem solving and judgement.

George Miller’s Pyramid of Competencies

George Miller introduced a concept similar to that of Bloom in the clinical setting, often referred to as Miller’s pyramid or triangle of competencies Miller’s triangle lists competencies ranging from factual knowledge (knows) at the base of the pyramid to professional practice (does) at the work place occupying the apex of the pyramid. The skills at the apex are more difficult to assesses but new tools such as the mini-CEX have been developed to assess these at the workplace.

1.4. CATEGORIES OF TRAINEE ASSESSMENT

Assessment may be categorised in a number of ways. Assessment may be written or performance- based. Another fundamental classification of tests is the division into formative and summative assessments. The difference between formative and summative assessments lies in the purpose of the assessment and at what stage in the training programme the assessment is undertaken.

Formative Assessment

The purpose of formative or diagnostic assessment is to determine how much the student can do and what their areas of strengths and weaknesses are. Feedback to trainees doing well can also help motivate them further. A formative assessment is usually undertaken within the course of the programme and not at the end; it is not usually used to make decisions as to determine the candidate’s passing or failing the course.

Summative Assessment

Summative assessment is used to take decisions about the progress or fate of the trainee. Summative assessment is sometimes referred to as assessment of learning as against formative assessment which is also referred to as assessment for learning. Summative assessment is used by trainers to discover what a learner has achieved during the programme of study by gathering information from different sources, and should usually take place at the end of the programme or course. It often consists of multiple tests from the final examination and in-course or continuous assessment. The outcome of the summative assessment is used to determine exiting from a programme, placement, promotion, fitness to practise a profession or ranking of candidates.

1.5. TOOLS FOR ASSESSMENT OF COMPETENCIES

For an assessment to be reliable and effective, some techniques are better suited for certain skills than others. Figure 1.1 and Table 1.2 show the types of tools usually recommended for assessment of a variety of competencies. No one technique is good enough to assess all competencies. Therefore, in any given course, several tools are often used in the assessment of students especially those in the health professions, a principle referred to as triangulation.

Figure 1.1. Assessment Tools by Clinical Competencies Based on Miller’s Pyramid.

At the base of the pyramid are the simplest skills of remembering facts and at the apex the complex competencies of how a clinician performs in real life situation at work. The Assessment tools range from factual tests for assessment of ‘knows’ to in vivo techniques for assessment of what the clinician ‘does’ at the work place.

The triangulation principle posits that whenever possible, full assessment should be obtained from more than one source, on more than one occasion, and using more than one assessment method. Thus a comprehensive assessment may consist of marks derived from in-course tests, MCQs, essays, and clinical assessment.

1.6. CHAPTER ONE SUMMARY

Trainee assessment is the process of ascertaining whether students have achieved or are achieving intended learning outcomes. The process may involve answering questions using pen and paper (written examinations) or candidates being observed performing technical and clinical tasks (performance-based assessments). These assessments may be done in the context of formative testing to find what candidates may need to improve upon or for decisions (summative assessment) to be taken on the candidate’s progress.

Effective assessment should encompass testing at different levels in the cognitive domains and in the pyramid of competencies proposed by Miller. Trainee assessment should embrace the principle of triangulation.

1.7. CHAPTER ONE RECAP EXERCISES

1. In what five ways is assessment of benefit?

2. What is the difference between formative and summative assessment?

3. Name two persons closely associated with assessment of trainees.

4. List five competencies that can be assessed in your discipline.

5. i. Enumerate the six levels in the cognitive domain of Bloom’s taxonomy.

ii. To which levels of Bloom’s taxonomy do writing an open essay and answering MCQs respectively belong?

6. i. What is the full name of Miller (of the Pyramid of Competencies’ fame)?

ii. What are the levels of competencies in the pyramid or triangle of Miller?

7. Justify the use and give examples of triangulation in the assessment of trainees in the health professions.

1.8. BIBLIOGRAPHY AND RESOURCES, See page 228

2

Overview of Objective Structured Clinical Examination

2.1. Introduction

2.2. Purpose of OSCE

2.3. Organisations Using OSCE or its Variants

2.4. Scope of Assessable Competencies in OSCE

2.5. Categories of OSCE Station

2.6. What Examiners Are Looking for in OSCE

2.7. Assessing Candidate Performance in OSCE

2.8. Operational Elements of an OSCE Station

2.9. Tips for the OSCE Candidate

2.10. Chapter Two Summary

2.11. Chapter Recap Exercises

2.12. Bibliography and Resources

Overview of OSCE

2.1. INTRODUCTION

Some of the motives for the assessment of medical trainees were outlined in Chapter 1. These purposes may be summarised as: judging mastery of essential skills and