30 Clinical and performance-based assessment
The importance of clinical assessment
The assessment of competence can be distinguished from performance assessment. Tests of competence, such as the objective structured clinical examination (OSCE), demonstrate in a controlled situation what an examinee is capable of doing. Performance assessment tools such as record analysis or multi-source feedback assess what the individual does in practice. The Miller pyramid provides a framework for assessment with the bottom of the pyramid being the assessment of knowledge and the higher levels of the pyramid being the assessment of performance (Fig. 30.1).
Considerations in clinical assessment
The patient
There are benefits to be gained from the use of a range of patient representations in the clinical examination. The choice of patient representation will be influenced by what is being assessed, the level of standardisation required, the required realism or fidelity and the local logistics including the availability and relative costs associated with the use of real patients and trained simulated patients (Collins and Harden 1998).
Simulated patients
Difficulties in standardising real patients and a lack of availability in some situations led to the development of simulated or standardised patients. These have been used for assessment as well as teaching. The simulated patient, as described in Chapter 25, is usually a lay person who has undergone various levels of training in order to provide a consistent clinical scenario. The examinee interacts with the simulated patient in the same way as if they were taking a history, examining or counselling a real patient. Simulated patients are used most commonly to assess history taking and communication skills or physical examination where no abnormality is found. Simulated patients have also been used to simulate a range of physical findings including, for example, different neurological presentations. The term ‘standardised patient’ has been used to indicate that the person has been trained to play the role of the patient consistently and according to specific criteria.
Simulators and models
Simulators, from the very basic models used to assess skills such as skin suturing to the more complex interactive whole-body manikins such as SimMan, have been used increasingly in medical training as outlined in Chapter 25. They have an important role to play in assessment. The Harvey cardiac manikin, for example, has been used at an OSCE station to assess skills in cardiac auscultation. Simulators are valuable to assess procedural and practical skills including the insertion of intravenous lines, catheterisation and endoscopy technique. While simulators have played a key role in competence assessment in other fields, notably with airline pilots, simulators have been slow to make an impact in assessment in medicine. The situation has changed rapidly and such devices now play a prominent role in clinical assessment. Indeed in some instances surgeons are allowed to perform a procedure in clinical practice only after they have demonstrated competence on a simulator.
The examiner
A student’s profile
A wide range of different learning outcomes or competencies including clinical skills, practical procedures, decision making and problem solving, collaboration and team working and professionalism and attitudes is assessed in a clinical examination. It makes little sense simply to allocate a percentage score for each component and then to sum these to produce a total mark of, for example, 62%. Excellence in carrying out an examination or practical procedure should not compensate for unprofessional behaviour or an inappropriate attitude. The answer is not to agonise over the relative importance of each element of competence and the allocation of a percentage for that element but to produce a competence profile for the examinee. This indicates for each candidate, as shown in Figure 30.2, the domains where their performance is satisfactory or perhaps excellent and those domains or competencies where their performance falls short of what is expected.
