General principles
Clinical assessments are integral to undergraduate and postgraduate medical education and training, and are designed to verify that those involved in the care of patients meet safe clinical standards. Assessments can be formative and/or summative. Formative assessments (such as workplace-based assessments) allow you to receive feedback on and monitor your own performance. Assessments such as these can be highly effective adjuncts to learning if they promote reflection on your own performance and recognition of areas for improvement and further development. Summative assessments, on the other hand, are used to evaluate whether you have achieved a required competence or standard in terms of knowledge, skills or performance, which may be set by licensing bodies such as the General Medical Council in the UK or postgraduate colleges. Assessment can also be used to provide evidence of safe practice: for example, simulation assessments for doctors in difficulty, or for recruitment and selection into specialty training.
This chapter provides an overview of the spectrum of clinical assessment methods, with a particular emphasis on objective structured clinical examinations (OSCEs) and clinical simulation scenarios. Guidance is offered on how to prepare for formal assessment, including the role of deliberate rehearsal, along with hints for optimising your performance in clinical and communication skills assessment.
Methods of assessment
The most widely used clinical assessment methods include OSCEs, short cases, long cases and clinical simulation scenarios ( Box 20.1 ), during which you may be observed performing an integrated sequence of clinical, practical and/or communication skills.
| Assessment format | Patient/mannequin | Marking structure | Example |
|---|---|---|---|
| Objective structured clinical examination | Either, in multiple stations testing different domains | Checklist or global judgement | 8-minute OSCE station where the candidate is required to obtain consent from a simulated patient for venepuncture and then perform this procedure on a part-task trainer (often 6–12 stations per OSCE) |
| Short case | Patient | Global judgement (usually two examiners independently mark the student on several cases) | 20-minute station where the candidate is required to examine three patients with evident physical signs (systolic murmur, abdominal mass and abnormal gait) and present the findings |
| Long case | Patient | Global judgement | 60-minute station where the candidate is required to take a full history and examine a patient with chronic liver disease. The candidate is expected to formulate a differential diagnosis and plans for investigation and management (not normally during the case but the candidate presents to the examiner afterwards) |
| Clinical simulation scenario | Mannequin | Often global judgements of domains, e.g. behavioural marker system with areas such as communication, leadership, situation awareness, task management | 20-minute station in which the candidate is required to assess and treat a simulated mannequin patient who is having an anaphylactic reaction |
Different assessment formats test different aspects of your professional competence or expertise. Short cases, for example, will usually focus on testing either your clinical examination skills or your ability to take a history from a patient. Modern assessment methods such as OSCEs and clinical simulation allow assessment of knowledge, skills and attitudes in an integrated manner and can permit candidates to demonstrate a higher level of performance through ‘showing how’ and ‘doing’ ( Fig. 20.1 ).
Assessments are linked to the learning outcomes of a course or curriculum, and ‘blueprinting’ is used to ensure there is appropriate coverage of the required knowledge, skills and behaviours across the examination. In order to perform well in clinical assessments, it is therefore crucial that you familiarise yourself with both the curriculum and the domains or skills on which you are being assessed. Not all skills will be assessed at each examination ( Box 20.2 ).
| OSCE station | Gastroenterology curriculum | Respiratory curriculum | Cardiology curriculum | Procedural skills | Resuscitation skills | Communication skills |
|---|---|---|---|---|---|---|
| 1. Venepuncture | ✓ | ✓ | ||||
| 2. Cardiovascular examination | ✓ | |||||
| 3. History taking | ✓ | ✓ | ||||
| 4. Abdominal examination | ✓ | |||||
| 5. Advanced life support | ✓ | ✓ | ||||
| 6. Explanation and advice | ✓ | ✓ |
Once you have achieved a level of competence in a clinical skill or domain, you may be considered to be ‘entrustable’ in this professional activity. For example, a final-year medical student may be ‘entrusted’ to perform peripheral cannulation on a patient if they have demonstrated competence in the specified domains (such as obtaining consent from a patient for the procedure and technical competence in the procedure itself).
Clinical simulation
Clinical simulation, using either high-fidelity patient mannequins or simulated patients, is increasingly employed for teaching and learning in healthcare, as it supports deliberate rehearsal of clinical skills in a realistic setting without compromising patient safety. Experiential learning such as this (‘learning by doing’) also supports the transition from theory to practice. Clinical simulation is commonly included in both undergraduate and postgraduate assessments to evaluate a candidate’s ability to integrate a number of complex skills or domains, which may include clinical examination, practical skills and drug or fluid prescribing. Often the scenario will involve an acutely unwell patient who is experiencing a medical emergency such as life-threatening asthma, where the use of a real patient is not feasible ( Box 20.3 ). The patient mannequin is set up in a realistic clinical environment (such as a simulated ward), with real props and equipment (such as a nebuliser mask), and there is often an additional member of staff in the room (playing the role of the nurse, for example) who can perform tasks and provide results of investigations if requested by the candidate. Sometimes a facilitator may also be the ‘voice’ of the patient, giving important prompts (‘I can’t breathe’ or simulating audible wheeze). The examination brief will clarify what is expected of you during the station but it is likely that you will be assessed on your competence in physical assessment, communication skills and the initial management of the patient.
