Assessment of Students Competence in Health Professionals Education

1. Assessment of Students Competence in Health Professionals Education Professor Hossam Hamdy University of Sharjah

2. Five Basic Questions • WHY? • WHAT? • HOW? • WHEN? • WHOM?

3. Purpose of Assessment • Providing feedback • Guiding student learning • Insuring medical competence

4. WHY? • Consider assessment as a diagnostic test for the disease “medical incompetence” • False negative = failing a competent student • False positive = passing a student who is incompetent

5. TRUTH TEST

6. 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

7. WHAT Should Be Assessed? ACGME Competencies • Patient care • Knowledge • Practice-based learning and improvement • Interpersonal and communication skills • Ethics & Professionalism • System-based practice

8. Blueprinting Test content matches objectives • Assessment matches competencies learnt • Assessment matches format of learning, “PBL”

9. Aim of Blueprinting Reduce: A. Construct under-representation: Biased sampling Few items covering a topic e.g. OSCE B. Construct irrelevant variance: Flawed items format Inadequate sampling of student Behaviour.

10. Blueprinting • Identify clinical problems that examinees should be able to handle. • For each problem, define the clinical tasks in which the examinee is expected to be competent. • Define level of performance / resolution

11. Blueprinting • Prepare a blueprint to guide the selection of problems to be included in the assessment. • Let the characteristics of the clinical problems define the tasks to be included in the assessment.

12. A Simple Blueprint

13. Pre-Clerkship Phase Theme B.Sc. Exam Blueprint 2003-2004

15. HOW?Choice of Method U = W R x W V x W E x W A x W C 1 2 3 4 5 U = Utility R = Reliability V = Validity E = Educational Impact A = Acceptability C = Cost/Available Resources W = Weight

16. Reliability • Reliability = reproducibility • Inter-rater: Multiple examiners across different cases • Inter-case:“multi use format (OSCE)”

17. Reliability Reliability is matter of sampling • Across content • Across Tasks • Across Problems

18. Test Sample Test Sample Domain of Interest  

19. “Reliability”Practical Implications • Sample adequately across content • Clinical competencies are inconsistent across different tasks • Test length is crucial if high-stakes decisions are required • Use as many examiners as possible

20. Validity • Validity = measures what it intends to measure • Select appropriate test formats for the competencies to be tested. This action invariably results in a composite examination.

21. Professional authenticity A Simple Model of Competence Performance or hands on assessment Does Shows how Written, Oral or Computer based assessment Knows how Knows Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7.

22. Performance assessment in vivo: Masked SPs, Video, Audits….. Does Performance assessment in vitro: OSCE, SP-based test….. Knows how (Clinical) Context based tests: MCQ, essay type, oral….. Knows Factual tests: MCQ, essay type, oral….. Shows how Validity Climbing the Pyramid . . . Does Shows how Knows how Knows

23. Educationalimpact

24. WHOM • Self • Peers • Supervisors • 360º“Different Stakeholders”

25. Written Assessment Methods Context-free questions Stimulus Format Context-rich questions EMQ, KF, A & R “MCQ” Open ended questions types SAQ, MEQ Response Format MCQ types

26. The MCQ’s Family

27. Written Assessment of Clinical Competence • MCQs 1) Best Single Response • 2) Extended Matching • Key Features Questions • Constructed Response Questions

28. Components of an A-type Question A 35-year old man has had a stomach ache all afternoon. He ate the following lunch: two big McDonalds hamburgers, an ice cream shake, large fries. Vignette, Scenario, Or Stem Which is the most likely diagnosis? Lead-in

29. Components of an A-type Question • Abdominal aneurysm • Appendicitis • Bowel obstruction • Cholecystitis • Colon cancer • Pancreatitis • Too much lunch Options A, B, C, D, E & F are distracters Option G is the key

30. Sample Good Question & ‘Cover The Options’ Rule A 32-yo man has a 4-day history of progressive weakness in his extremities. He has been healthy except for an upper respiratory tract infection 10 days ago. His temperature is 100 F, BP 130/80, pulse 94, respirations 42 and shallow. He has symmetric weakness of both sides of the face and the proximal and distal muscles of the extremities. Sensation is intact. No deep tendon reflexes can be elicited; the plantar responses are flexor. Which of the following is the most likely diagnosis? A. Acute disseminated encephalomyelitis B. Guillain-Barré syndrome C. Myasthenia gravis D. Poliomyelitis E. Polymyositis

31. Sample Good Question & ‘Cover The Options’ Rule A 32-yo man has a 4-day history of progressive weakness in his extremities. He has been healthy except for an upper respiratory tract infection 10 days ago. His temperature is 100 F, BP 130/80, pulse 94, respirations 42 and shallow. He has symmetric weakness of both sides of the face and the proximal and distal muscles of the extremities. Sensation is intact. No deep tendon reflexes can be elicited; the plantar responses are flexor. Which of the following is the most likely diagnosis? A. Acute disseminated encephalomyelitis B. Guillain-Barré syndrome C. Myasthenia gravis D. Poliomyelitis E. Polymyositis

32. Diagram of Rank-Ordered Options for a Good One-Best-Answer Item D C A E B Least Most Correct Correct Answer Answer Note: Options must be homogeneous (eg, all diagnoses, all muscles). You must be able to rank-order the options on the same dimension.

33. Sample Flawed Question & ‘Cover The Options’ Rule A. It occurs frequently in women. B. It is seldom associated with acute pain in a joint. C. It may be associated with a finding of chondrocalcinosis. D. It is clearly hereditary in most cases. E. It responds well to treatment with allopurinol. Which of the following is true about pseudogout?

34. Gender A D Inheritance Rx E C B Associations False True Sample Flawed One-Best-Answer Item Which of the following is true about pseudogout? A. It occurs frequently in women. B. It is seldom associated with acute pain in a joint. C. It may be associated with chondrocalcinosis. D. It is clearly hereditary in most cases. E. It responds well to treatment with allopurinol.

35. Test application of Knowledge not just recall of isolated facts Basic Science Recall of Isolated Facts Item: What area is supplied with blood by the posterior inferior cerebellar artery? Basic Science Application of Knowledge Item: A 62-year-old man develops left-sided limb ataxia, Horner's syndrome, nystagmus, and loss of appreciation of facial pain and temperature sensations. What artery is most likely to be occluded?

36. E “Old” Style Biochemistry QuestionTesting Recall of an Isolated Fact Acute intermittent porphyria is the result of a defect in the biosynthetic pathway for A. collagen B. corticosteroid C. fatty acid D. glucose E. heme F. thyroxin

37. E Application of Knowledge Item: Biochemistry/Genetics An otherwise healthy 33-yo man has mild weakness & occasional episodes of steady, severe abdominal pain with some cramping but no diarrhea. His aunt and a cousin have had similar episodes. During an episode, his abdomen is distended, and bowel sounds are decreased. Neurological exam shows mild weakness in the upper arms. A defect in which of the following biosynthetic pathway is the most likely cause of the patient’s problem? A. collagen B. corticosteroid C. fatty acid D. glucose E. heme F. thyroxine

38. Item Assessing Recall of an Isolated Fact What is arterial blood gas analysis most likely to show in patients with cardiogenic shock? A. Hypoxemia with normal pH B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis E. Respiratory alkalosis

39. Alternate Item Assessing Application of Knowledge: Diagnosis A 74-year-old woman is brought to the emergency department because of crushing chest pain. She is restless, confused, and diaphoretic….. Which of the following arterial blood gas analysis results is most likely? A. Hypoxemia with normal pH B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis E. Respiratory alkalosis

40. Summary • Stimulus – Context rich “Patient Vignette” • One best answer, not one single correct option • Cover the options rule

41. Summary Avoid: • All / non of the above • Except • Negatively worded items. “Which one of the following statements is incorrect.”

42. Extended Matching R-Set

43. Theme: Neuroanatomy: Blood Supply of the Brain Options: A. Left anterior cerebral artery E. Right anterior cerebral artery B. Left posterior cerebral artery F. Right posterior cerebral artery C. Left middle cerebral artery G. Right middle cerebral artery Left lenticulostriate arteries H. Right lenticulostriate arteries Lead-in: For each patient with neurologic abnormalities, select the artery that is most likely to be involved. Vignette: “Items” 1. A 72-year-old right-handed man has weakness and hyperreflexia of the right lower limb, an extensor plantar response on the right, normal strength of the right arm, and normal facial movements. Ans: A 2. A 68-year-old right-handed man has right spastic hemiparesis, an extensor plantar response on the right, and paralysis of the lower two-thirds of his face on the right. His speech is fluent, and he has normal comprehension of verbal and written commands. Ans: G

44. Options and Lead-in: Diagnosis Theme: Abdominal Pain A. Abdominal aneurysm K. Kidney stone B. Appendicitis L. Mesenteric adenitis C. Bowel obstruction M. Mesenteric artery thrombosis D. Cholecystitis N. Ovarian cyst - ruptured E. Colon cancer O. Pancreatitis F. Constipation P. Pelvic inflammatory disease G. Diverticulitis Q. Peptic ulcer disease H. Ectopic pregnancy – ruptured R. Perforated peptic ulcer I. Endometriosis S. Pyelonephritis J. Hernia T. Torsion For each patient with abdominal pain, select the most likely diagnosis.

45. Sample Diagnosis Items: Abdominal Pain • A 25-year-old woman has sudden onset of persistent right lower abdominal pain that is increasing in severity. She has nausea without vomiting. She had a normal bowel movement just before onset of pain. Examination shows exquisite deep tenderness to palpation in right lower abdomen with guarding but no rebound; bowel sounds are present. Pelvic examination shows a 7-cm, exquisitely tender right sided mass. Hematocrit is 32%. WBC is 18,000/mm3. Serum amylase activity is within normal limits. Test of the stool for occult blood is negative. Ans: B • An 84-year-old man in a nursing home has increasing poorly localized lower abdominal pain recurring every 3-4 hours over the past 3 days. He has no nausea or vomiting; the last bowel movement was not recorded. Examination shows a soft abdomen with a palpable, slightly tender, lower left abdominal mass. Hematocrit is 28%. WBC is 10,000/mm3. Serum amylase activity is within normal limits. Test of the stool for occult blood is positive. Ans: E

46. Key – Feature Questions • Any single problem is not equivalent to any other problem in assessing C.P.S. and C.D.M. Problem solving skills are specific to the case or problem encountered. • C.P.S. and C.D.M. need to be measured over many problems before general inferences could be made. • Clinical problem solving and decision making skills are dependent on the effective manipulation of those few elements of the problem that are critical to its resolution – “key features” • Assessment should focus on the problems key features “Bordage and Page, 1991”

47. Question Formats • Write-in “WI” - Diagnosis and Treatment • Short-Menu “SM” - History, Physical “2-45 Options” Examination and Laboratory

48. Case 2 Paul, a 56 year old man, consults you in the outpatient clinic because of pain in his left leg which began two days ago and has been progressively worse. He states his leg is tender below the knee and swollen around the ankle. He has never had similar problems. His other leg is fine. Question 1 What diagnosis would you consider at this time? List up to three? Question 2 With respect to your diagnosis, what elements of his history would you particularly want to elicit? • Activity at onset of symptoms 11. Hormonetherapy 21. Previous back problems • Alcohol intake 12. Impotence 22. Previous neoplasia • Allergies 13. Intermittent claudication 23. Previous urinary tract infection • Angina pectoris 14. Low back pain 24. Recent dental procedure • Anti-inflammatory therapy 15. Nocturia 25. Recent immobilization • Cigarette smoking 16. Palpitations 26. Recent sore throat • Colour of stools 17. Parenthesis 27. Recent surgery • Cough 18. Paro .. Noctural dyspnea 28. Recent work environment • Headache 19. Polydipia 29. Wounds on foot • Hemetemesis 20. Previous knee problems 30. Wounds on hand

49. Constructed Response Questions • A written question • A statement, journal article or report • A problem scenario: clinical, basic science or community • Photographic or other investigative data The response generated by the student may be:

50. Constructed Response Questions • A very short answer – one or several words • A short answer – notes or lists • A long answer – essay, dissertation, referral letter or report • A physical task – a project or another complex performance such as cardiopulmonary resuscitation or conducting an investigation