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Commentary
A long case in perfect health
The reports of my death have been greatly exaggerated.
Mark Twain, 1835-1910
Today, most doctors given the responsibility for making
high stakes decisions of clinical competence agree that
oral examinations following an unobserved long case
clinical encounter are fraught with problems. Almost
fifty years ago[1,2], Harden and his Glasgow colleagues
having showed the lack of precision of examining with
their finals’ long cases, set about producing another
method of examining which they called the objective
structured clinical examination (OSCE). [3] Similar
observations were happening elsewhere.[4]
Let us be clear, the OSCE may be objective, fair and
ostensibly reliable, but it is not real life. Whereas,
OSCEs are an effective way to monitor the acquisition
of clinical skills by undergraduate medical students,
postgraduate trainees need another metric with better
face validity. The Saudi Med Framework cites 166
clinical presentations, and it is clear for any graduating
student that their performance on all will never be
uniform, and yet their right to graduate and practice
medicine may be based on the examination of just
one. Then there are other factors that may distort the
measurement: examiner reliability or inconsistencies,
patient variability and not least the candidate-patient
relationship, and the stories around that are almost
mythical.
However, as Geoff Norman points out about medical
education, few self-evident truths are true.[5] Because
along came the examiners at St Thomas’ Hospital,
London, and observing 214 candidates taking their
‘finals’, conducted a comparison between two long
cases, observed and marked with a structured mark
sheet and a twenty station OSCE rated with checklists
only.[6] The reliability of the two long cases turned out
to be 0.84 versus the OSCE reliability of 0.74. The
conclusions were obvious. So, what is wrong with
the long case? First and foremost we must observe the
candidate-patient interaction and secondly a structured
and systematic checklist as well as some form of global
rating must be used to grade each performance, and
lastly the examiners must be prepared for their task
with a short orientation. But, doesn’t that sound familiar
today?
126
Almost a whole industry has grown up based on
workplace-based assessment, essentially using the
candidate-patient interaction for the judgments
made about the candidate’s (developing) clinical
competence. [7] Other variants have been reported,
such as the direct observation clinical encounter
examination (DOCEE), objective structured long
examination record (OSLER), direct observation of
procedural skills (DOPS), mini-clinical evaluation
exercise (Min-CEX) and more, but all of them are
predicated on a real life case or patient-candidate
interaction. So, back to the long case and its long
supposed death. We all would agree that the real thing
is better than a simulation, although there are certain
clinical competences that can only be observed on a
simulation or in a simulated setting. Yet all actually
take place where clinical medicine is practiced.
Thus, when a postgraduate supervisor observes and
evaluates a resident performing a task, such as the
emergency admission of a patient, and then completes
an in-training evaluation report (ITER) form he is
essentially conducting a long case exam, with one
important difference, the feedback given making
it both an assessment and teaching opportunity.[8]
What must now happen is that every resident shall be
assessed with at least nine such cases, evaluated by
3 - 4 different supervisors during any 12 month period.
The results of this will satisfy the most eloquent critics
of the long case.
The Saudi Commission recognises the importance
and validity of workplace-based examining when
determining a resident’s clinical competence and is
stressing the importance of in-course evaluations. An
OSCE will always be a surrogate for the real thing, but
nevertheless will still contribute useful information
about the skills of those candidates observed; however,
not as a replacement for the long case in postgraduate
training.
James Ware, Imran Siddiqui
Department of Medical Education and Postgraduate Studies, Saudi
Commission for Health Specialties, Riyadh, Saudi Arabia
Address for correspondence:
Prof. James Ware,
Department of Medical Education and
Postgraduate Studies,
Saudi Commission for Health Specialties,
Riyadh, Saudi Arabia.
E-mail: [email protected]
Journal of Health Specialties / July 2014 / Vol 2 | Issue 3
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Ware and Siddiqui: A long case in perfect health
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How to cite this article: Ware J, Siddiqui I. A long case in perfect health. J
Health Spec 2014;2:126-7.
Source of Support: Nil, Conflict of Interest: None declared.
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