To the Editor: I am disappointed that Epstein's review of assessmentin medical education (Jan. 25 issue)1 does not include the shortcase, which is an excellent instrument used in many educationalsettings.2 In the short case, the student is asked to performa supervised focused physical examination (e.g., of only theabdomen) of a real patient, with little knowledge of the patient'shistory, and is then assessed on the basis of the techniqueof the examination and the ability to elicit physical signsand interpret these findings correctly. Several cases are usedto improve validity and reliability.
By making physical examination an integral part of trainee evaluation,the short case represents a tool for curtailing the declinein physical-examination skills.3 Furthermore, the short caseuniquely prepares a trainee to perform an accurate assessmentand place physical findings in context. These skills are especiallyvaluable in the current era of duty-hour restrictions and increasingshift work,4 since a house officer is likely to be called toevaluate a patient he or she hardly knows.
Kapil Parakh, M.D., M.P.H. Johns Hopkins University School of Medicine Baltimore, MD 21224 kparakh1{at}jhmi.edu
References
Epstein RM. Assessment in medical education. N Engl J Med 2007;356:387-396. [Free Full Text]
Fowell SL, Maudsley G, Maguire P, Leinster SJ, Bligh J. Student assessment in undergraduate medical education in the United Kingdom, 1998. Med Educ 2000;34:Suppl 1:1-49. [Web of Science][Medline]
Jauhar S. The demise of the physical exam. N Engl J Med 2006;354:548-551. [Free Full Text]
Fletcher KE, Underwood W III, Davis SQ, Mangrulkar RS, McMahon LF Jr, Saint S. Effects of work hour reduction on residents' lives: a systematic review. JAMA 2005;294:1088-1100. [Free Full Text]
To the Editor: In his review of assessment methods, Epsteinmisses an opportunity to discuss the importance of providingconstructive feedback to the trainee. This failure is painfullyillustrated by the video that accompanies the article. The videoshows two students separately examining a standardized patient.The students are subsequently confronted with (long lists of)their shortcomings and mistakes. If the assessment does notprovide clear, positive feedback and reassurance and does notfocus on specific points to improve, students may fail to learnfrom their mistakes, lose motivation to engage in assessmentin the future, and develop a disproportionate fear of failurein their contact with real patients.1 Moreover, although insubsequent examinations, students may show improvement in areasin which they previously received a negative assessment, theymay fail in areas in which they performed well earlier but withoutpositive feedback.
The purpose of assessment is to improve the clinical skillsof trainees and produce competent physicians who can providehigh-quality care. This requires formative feedback that encouragesself-reflection, actively reinforces good medical skills, andprovides specific strategies for improving performance.2
Bastiaan E. de Galan, M.D., Ph.D. Petra J. van Gurp, M.D. Paul M. Stuyt, M.D., Ph.D. Radboud University Nijmegen Medical Center 6500 HB Nijmegen, the Netherlands b.degalan{at}aig.umcn.nl
References
Kilminster S, Jolly B, van der Vleuten CPM. A framework for effective training for supervisors. Med Teach 2002;24:385-389. [CrossRef][Web of Science][Medline]
Brukner H, Altkorn DL, Cook S, et al. Giving effective feedback to medical students: a workshop for faculty and house staff. Med Teach 1999;21:161-165. [CrossRef][Web of Science]
To the Editor: As Klass notes in the editorial1 accompanyingthe review by Epstein, current assessment systems do not performacceptably for evaluating physicians in practice. We need tomove away from hours of continuing medical education or attendanceat meetings or symposia and allow practice members to designtheir own continuing education on the basis of specific practicecharacteristics. All members of a practice, rather than individualphysicians, should be held accountable for the progress of thepractice's population. When electronic medical records are widelyavailable, practice assessments could be developed, evaluated,and adjusted annually on the basis of the practice demographics(e.g., the numbers of patients in the practice according todiagnosis and health status).2 We also need to move away frommeasures focused strictly on process to an emphasis on patientoutcomes. For example, the Health Plan Employer Data and InformationSet (HEDIS) looks at data for the proportion of eligible patientswho have been immunized, but the system currently includes informationonly about shots given, not about immunization schedules completed.Similarly, the proportion of visits for hypertension can beanalyzed, but individual outcomes (e.g., control of blood pressure)cannot. This assessment system would be greatly enhanced bybetter training in epidemiology for all physicians.
Christopher M. Buttery, M.B., B.S., M.P.H. Virginia Commonwealth University Richmond, VA 23298 cbuttery{at}vcu.edu
References
Klass D. Assessing doctors at work -- progress and challenges. N Engl J Med 2007;356:414-415. [Free Full Text]
Buttery CMG. Clinical investigation in general practice: the use of a simplified data-recording system. South Med J 1963;56:650-653. [Medline]
To the Editor: Though Klass states that "little attention hasbeen paid to the assessment of doctors who are already in practice,"24 member boards of the American Board of Medical Specialties,including the American Board of Internal Medicine (ABIM), offermaintenance of certification — a process for assessingphysician competence that promotes lifelong learning and high-qualitycare. Recent articles in the Journal1,2,3 describe the program'simportance and value.
Through certification and maintenance of certification, ABIMassesses physician competence throughout a lifetime of practice.ABIM's secure examination tests medical knowledge and assessesthe clinical reasoning and judgment required of an excellentinternist. Our self-evaluation modules allow physicians to examinetheir clinical knowledge and performance in practice and touse these data to direct improvements in patient care.
Maintenance of certification is a rigorous mechanism for assessingphysicians in practice. It addresses the important need thatKlass identifies. Unfortunately, participation is not universal.Perhaps that is the issue to which too "little attention hasbeen paid."
Christine K. Cassel, M.D. American Board of Internal Medicine Philadelphia, PA 19106
References
Baron RJ. Personal metrics for practice -- how'm I doing? N Engl J Med 2005;353:1992-1993. [Free Full Text]
Brennan TA. Recertification for internists -- one "grandfather's" experience. N Engl J Med 2005;353:1989-1992. [Free Full Text]
Steinbrook R. Renewing board certification. N Engl J Med 2005;353:1994-1997. [Free Full Text]
The author replies: The short case may hold promise as a methodfor assessment of clinical skills and may prove to be a robustand economical alternative or adjunct to long cases and standardizedpatient examinations. However, a Medline search with the searchterms "short case" and "education" or "assessment" yielded noarticles describing and validating its use in English-speakingor Western European countries. Three articles mentioned itsuse.1,2,3 An article from Kuwait indicated that the performanceof the short case compared favorably with that of the long case.4A word search of the study by Fowell and colleagues5 cited byParakh showed that the short case was simply included in a listof assessment methods commonly used in the United Kingdom; therewas no further description. I am certain that there are manyother assessment methods that will ultimately prove to havemerit, but just as with diagnostic tests in clinical medicine,we must await empirical validation before promoting their use.
I agree with de Galan and colleagues that feedback must be balanced,timely, and accurate. The purpose of feedback is to promotean organized approach to reflection and remediation of clinicalskills. Feedback should lead to greater mindfulness, attentiveself-observation, and critical curiosity during actual clinicalpractice and should enhance the motivation for change. The listof deficiencies in the video that accompanies the article wasintended to emphasize the kinds of skills that can be observedin simulated settings; it was not intended to suggest that allthose items should be presented to the student. In real-lifesettings, feedback should be based on respect and trust, shouldbuild on strengths, should be given in bite-size pieces thatcan be assimilated, and should be framed to increase self-confidence,skills, and autonomy. Feedback should be embedded in longitudinalmentoring relationships, which are all too rare in clinicalteaching and in medical education in general. Otherwise, thefeedback runs the risk of being haphazard and will be less likelyto build incrementally on the trainees' emerging skills andcompetence.
Ronald Epstein, M.D. University of Rochester School of Medicine and Dentistry Rochester, NY 14610 ronald_epstein{at}urmc.rochester.edu
References
Wass V, Van der Vleuten C, Shatzer J, Jones R. Assessment of clinical competence. Lancet 2001;357:945-949. [CrossRef][Web of Science][Medline]
Singh R, Gupta P, Singh K, Koirala S. Undergraduate pediatric education at BPKIHS integrated with an innovative curriculum. Indian Pediatr 1999;36:43-50. [Medline]
Mekasha A. Assessment methods in medical education. Ethiop Med J 2004;42:63-71. [Web of Science][Medline]
Hijazi Z, Premadasa IG, Moussa MA. Performance of students in the final examination in paediatrics: importance of the "short cases." Arch Dis Child 2002;86:57-58. [Free Full Text]
Fowell SL, Maudsley G, Maguire P, Leinster SJ, Bligh J. Student assessment in undergraduate medical education in the United Kingdom, 1998. Med Educ 2000;34:Suppl 1:1-49. [Web of Science][Medline]
The editorialist replies: I agree with the comments of bothButtery and Cassel. I would add to what Buttery says that althoughthe task of making valid judgments about practices on the basisof outcomes is an important objective, it must be undertakencarefully because of the tortuous and poorly understood relationshipsbetween process and outcome in most medical situations. AndI should apologize to Cassel if my suggestion of a relativelack of attention to assessments in practice over time disparagedthe efforts of many organizations to address this discrepancy.In particular, the leadership of John J. Norcini and F. DanielDuffy (former and current staff members, respectively, at ABIM)in this area is notable. Editorial constraints limited my abilityto be more complete in attribution, so I thank Cassel for usingthis venue to draw attention to the important work in this areaby ABIM and also by the American Board of Medical Specialties.
Daniel Klass, M.D., C.M. College of Physicians and Surgeons of Ontario Toronto, ON M5G 2E2, Canada
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