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Work based assessment h.davies@shef.ac.uk

Work based assessment h.davies@shef.ac.uk. Challenges and opportunities. Choosing assessments?. What do you want to assess - e.g. Professionalism Clinical reasoning Technical skills Clinical evaluation Who do you want to assess Med student Resident Practising physician.

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Work based assessment h.davies@shef.ac.uk

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  1. Work based assessmenth.davies@shef.ac.uk Challenges and opportunities

  2. Choosing assessments? • What do you want to assess - e.g. • Professionalism • Clinical reasoning • Technical skills • Clinical evaluation • Who do you want to assess • Med student • Resident • Practising physician

  3. Choosing assessments • Patient outcome gold standard but attribution a problem • Judgements largely based on process measures • Case mix and reliability an issue

  4. Assessors • If sufficient subjective judgements are combined the collated judgement about performance can be reliable • i.e objectivity and reliability are not the same thing • Assumes that assessor has both observed competence in question and can make a judgement about its quality • How many assessors is enough?

  5. MSF in healthcare settings • Feedback about observable behaviors is provided by some or all of • Physician colleagues (peers, referring MDs, referral MDs) • Co-workers (e.g., nurses, pharmacists, dieticians) • Patients • Self • If trainee borderline or in difficulty sample more

  6. Insight

  7. MSF • One to one feedback • Problems may need further diagnostic work • Need support mechanisms in place

  8. Bias • Consider sources of bias such as • Gender • Working relationship • Working environment • Ethnic group • University of graduation

  9. F1/F2 SHO SpR AHP GP Nurse Cons SASG F=524.1 p= <0.001

  10. Mini-CEX case complexity

  11. Validity • Extent to which a test assesses what it purports to • Content validity • Criterion validity • Construct validity • Face validity • Consequential validity • Recognised need for further validity data in relation to MSF and other work based assessments1 Evans, R., G. Elwyn, and A. Edwards, Review of instruments for peer assessment of physicians. BMJ, 2004. 328(7450): p. 1240.

  12. Validity • Content validity • Blueprint assessments to the curriculum • Evidence from a range of sources supporting the hypothesis that the score really measures what it is meant to

  13. Relationship with patient ratings SHEFFPAT vs SPRAT r=0.12 NS SHEFFPAT vs PATSCORE r=0.45 p<0.01

  14. Predictive and consequential validity

  15. Centralisation • Facilitates standardisation and robust QA • Facilitates movement between locations • Economies of scale • Strategies to enhance local ownership important

  16. Practicalities • Is it feasible? • Electronic vs paper • Centralised vs localised • Who assesses? • How is training organised? • Who will do the QA?

  17. Acknowledge legitimate concerns • Healthy scepticism • Resources - especially time • Conflicting demands espy CLINICAL • Need for sampling • Lack of standardisation • Training needs • Loss of local ownership

  18. Support doctors in difficulty

  19. Be patient • Op-ti-mist n • Somebody who tends to feel hopeful and positive about future outcomes • Recognise extent of cultural change • Ensure work based assessment is done as well as possible “ Every problem is just an opportunity waiting to be made use of ”

  20. Who assesses? 14.8% 19.4% 7.1% 57.6%

  21. The programme should be quality assured importance 100 % 0 % R V E C A F aspect van der Vleuten C. The assessment of professional competence: developments, research and practical implications. Advances in Health Sciences Education. 1996;1:41-67.

  22. Sampling • Content specificity • Being good at one thing doesn’t mean you are good at everything • Must sample clinical content widely • Map to curriculum - blueprint • Sources of variance • Assessors significant source of variance • Use lots of assessors

  23. Classification Scheme for Work-Based Assessment Norcini BMJ 2003

  24. Quality assurance Quality assure assessment system Modify assessment system in response to QA

  25. Effective (work based) assessment RESOURCES and CO-ORDINATION TIME FUNDING

  26. Key messages • Sampling is crucial • Consider sources of bias • Have as many different clinical problems and as many assessors as possible • Subjectivity ≠ unreliability • Train the raters Holmboe, E. S., R. E. Hawkins, et al. (2004). "Effecs of training in direct observation of medical residents' clinical competence; a randomized trial." Ann Intern Med140: 874-881.

  27. Attributes of physician: • Personality • Background • Aptitude for specialty • Attributes of training: • Post • Programme • Supervisor • Context of training: • Workload • Colleagues • Patients MSF PERFORMANCE OF PHYSICIAN • Personal pressures: • Home • Health

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