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.

Computer-based simulations

The development of virtual patients is another area where rapid progress has been made. While early computer-based simulations were little more than patient management problems delivered through a computer, computer simulations now include high fidelity models of the patient care environment and the ‘patient’ responds to the management and therapeutic efforts of the examinee.

The examiner

In addition to the student and the patient, the third key element in clinical or performance assessment is the examiner. The role of the examiner is to collect evidence about the examinee’s behaviour in the context of the assessment and to pass judgement on the examinee’s competence or performance. The examiner may be a clinician, another healthcare professional or a simulated patient. After appropriate training simulated patients are, in some situations, particularly in North America, used to assess the student’s performance in an OSCE. Other members of the healthcare team frequently contribute to multi-source feedback assessment as described below.

Whatever the assessment method used, it is important to include a number of examiners. A problem with the long case in a traditional clinical examination was over-reliance on the ratings of one or two examiners. In contrast, the OSCE has input from a number of examiners which is a major advantage.

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.

Fig 30.2 An examinee’s profile demonstrating competence in some areas but not others.

Feedback

The provision of feedback to the examinee is an important part of a clinical assessment. As discussed in Chapter 2, this should be specific, non-evaluative and timely. It is an essential element of ‘assessment for learning’ and should guide the learner in their further studies. It is important that when the assessment process is planned, time is allowed for the provision of feedback. The OSCE can be considered as an example of the different approaches that can be adopted:

• Following an OSCE, students’ checklists and ratings sheets for each station can be returned to the examinee with the examiner’s comments attached.

• Following an OSCE, a meeting with the teacher can be scheduled and the examination is discussed with individuals or the class as a whole.

• During an OSCE, time can be allocated at the end of each station for the provision of feedback from the examiner to the examinee.

• After completion of a station, the examinees review at the following station their own performance at the previous station as recorded on the examiner’s checklist and compare this with a model performance as shown on a video recording.