The long case has been the mainstay of teaching
and assessing medical students (and postgraduates) over many decades. It
has the advantage of familiarity, tests the students in a real life
setting on a real patient, and presents realistic challenges to the
students. However, it has several limitations that compromise its
utility. It is well recognized that there is a lot of task and context
specificity in clinical competence, meaning thereby that a good
performance in a certain context or case does not necessarily imply an
equally good performance in another context; e.g. it is often
erroneously presumed that if a student can perform well in a complicated
central nervous system (CNS) case, he/she can also perform equally well
in an anemia case. Hence, generalizability of long case assessment
becomes a problem [1]. The only way to overcome this is by increasing
the number and variety of cases being assessed per student, which
becomes non-feasible given the time-consuming nature of the unstructured
discussion that takes place. Further, the student is not actually
observed while interacting with the patient or performing the
physical examination – though sometimes, the assessors may ask the
students to demonstrate one or more physical signs. The student-assessor
interaction is thus restricted to presentation skills rather than to
various aspects of clinical competence. This induces at best, construct
underrepresentation, and at worst, construct irrelevance, raising
questions on the validity of such assessment [2]. The authenticity of
assessment is therefore compromised, and it is not surprising that we
hear about the ‘death of the long case’ [3].
The Mini-Clinical Evaluation Exercise (m-CEX) was
developed to address some of these issues. It is a simple modification
of the traditional long case, using direct observation and focused
feedback as important means to teach and assess clinical competence. An
assessor observes the student taking history and performing physical
examination, using a structured format. The student then provides a
diagnosis and a treatment plan. The assessor then provides educational
feedback to the student, based on his observation. Each encounter takes
about 15-20 minutes, and 6-8 encounters a year provide sufficient degree
of reliability [4]. Assessment on multiple cases, ‘subjective’
assessment, and multiplicity of assessors of all levels is considered
strength of this method. Unlike Objective Structured Clinical
Examination (OSCE), it assesses the student on a complete task and in
authentic settings. A structured framework of observation and feedback
in a short time makes it feasible in inpatient as well as outpatient
settings, and also a powerful formative assessment tool.
There are very few reports of use of this modality
from India, the first one of its use in Pediatrics from India being in
2010 [5]. This issue of the journal carries a paper on m-CEX [6]. The
authors have reported a good acceptability. This is likely to improve
further as teachers gain experience in providing useful feedback, and as
students find this feedback improving their learning. It will be
interesting to see the use of this tool in other medical schools too.
Teaching in the outpatient setting is a critical
input in physician training. However, a shortage of time due to clinical
workload limits the teaching in this setting. Also, a relative lack of
challenging opportunities to the students for using their prior
knowledge for constructing new knowledge, limits its utility. Based on
cognitive psychology, many models of one-on-one clinical teaching within
a short time available to clinicians have been developed and tested.
These models are learner-centric, and primarily depend on learner
motivation for their success. One minute preceptor (OMP) [7] and SNAPPS
[8] are some examples. SNAPPS is an acronym for Summarize the
history and findings, Narrow the differential, Analyze the
differential, Probe the teacher, Plan management and Select
issue related to the case for self-study. Unlike m-CEX, which is
applicable mainly for the senior students and postgraduates, SNAPPS can
be used for even junior medical students. There have been many reports
indicating its acceptability and utility. Students generated more
differentials and were able to justify them better; they expressed
uncertainties better and sought clarifications in addition to
identifying areas requiring further study. Another paper in this issue
of Indian Pediatrics explores this model in terms of its
educational utility [9].
Physicians need training in gathering evidence and
then evaluating their own patient care practices. This concept of
practice-based learning and improvement (PBLI) is now recognized as an
important competency [10]. The learners need to be provided
opportunities to reflect identify their learning needs, and then engage
in developing those needs. There is evidence to suggest that PBLI
results in better healthcare outcomes and patient safety. A concept
paper on PBLI in this issue of the journal elaborates further on the
teaching and assessment methods for developing PBLI [11].
Tweaking the existing teaching-learning and
assessment methods in the light of cognitive psychology is an important
exercise. The closer we bring learning and assessment to reality, and
more we actively engage the learner, more authentic and long-lasting the
learning is going to be.
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