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Assessment of Clinical Competence in Health Professionals Education

Professor Hossam HamdyUniversity of Sharjah

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Professional Competence

The Habitual and Judicious use of:

• Communication

• Knowledge

• Technical Skills

• Evidence-based decision-making

• Emotions

• Values and reflection to improve the health of the individual patient and the community

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WHAT Should Be Assessed?

ACGME Competencies- Patient care- Knowledge- Practice-based learning and

improvement - Interpersonal and communication skills- Ethics & Professionalism- System-based practice

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Blueprinting

Test content matches objectives

• Assessment matches competencies learnt

• Assessment matches format of learning, “PBL”

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A Simple Model of Competence

Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7.

Knows

Shows how

Knows how

Does

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Pro

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Written, Oral orComputer based assessment

Performance or hands on assessment

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Validity Climbing the Pyramid . . .

Knows

Shows how

Knows how

Does

Knows Factual tests: MCQ, essay type, oral…..

Shows howPerformance assessment in vitro:OSCE, SP-based test…..

DoesPerformance assessment in vivo: Masked SPs, Video, Audits…..

Knows how(Clinical) Context based tests:MCQ, essay type, oral…..

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Assessment of Clinical Performance

Fundamental to “Good Medical Practice”

“What doctors do in controlled representations” of practice e.g. “OSCE”

“What doctors do in real life”

Rethans et al, Med Ed 2002.

Workplace-Based Training and Assessment

Effective Workplace Training

“The ability of faculty to accurately observe trainees performing

these (history-taking and physical examination) tasks and provide

effective feedback is thus one of the most important aspects of medical training.”

Learning

Problems of Workplace –based Training

Not observed No assessment of Competencies No feed-back

Effective Workplace-Based Assessment

“sampling collection of data concerning specific patient encounters for a number of different domains”

Reflects routine performance

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•Unobserved 30 – 45 minute interview and examination on a selected patient

•Candidates present only their findings to the examiner

The Traditional Long Case Examinations (LCE)

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• It assesses the integrated interaction between the student/doctor and the real patient

• Authenticity high

• More valid than the task given in an OSCE

• Little is known about the construct validity and consequential validity “Educational Impact”

)LCE (Validity

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• Poor intercase reliability

• Content specificity is the most crucial issue in the assessment of clinical competence

• Broad sampling across cases is essential “Multiple Biopsies”

• Logistics will be difficult

)LCE (Reliability

Mini-CEX

Real patients 12 - 14 ~ 6 / years Only components of the encounter

observed 15-20 minites (Norcini 2003) Formative

Four real patients The whole encounter is observed Focused history & examination Clinical reasoning & decision-making Communication skills 20-30 minutes Summative / formatives

Direct Observation Clinical Encounter Examination “DOCE”

(Hamdy et al, Med Educ, 2003)

Case Based Discussion

Trainees select two case records for discussion with assessment

Focus on evaluating clinical reasoning and decision making

Clinical Work Sampling (CWS)

Sample performance in the workplace

Collection of information concerning specific patient encounters, admission, discharge, ward follow up

Portfolios

Direct Observation Practical Procedure Skills “DOPS”

Whole procedure observed from start to finish Simulators Or Real Patient

Multi-source Feedback (MSF) 360 Degree Assessment

Peers Supervisors Nurses Secretary Lab Technicians Patients

Feedback

"The most basic focus of feedback addresses the quality of the task performed. Using well defined criteria, trainees are given specific information about whether they achieved the required level of performance " .

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Problems of Workplace Based Assessment of Performance

Sampling: variability in the complexity of patients problem

Judges errors:

Time: Requires adequate allocation of time and resources.

Management of Data: not easy

Validity and Reliability: variable