International Journal of Basic and Applied Physiology

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Discussion: The South-East Asian medical universities are shifting their focus from knowledge based to a more competence based medical curriculum with the advent of Graduate medical education. Objective Structured Practical Examination (OSPE) was derived from Objective Structured Clinical Examination (OSCE) and modified by Harden and Gleeson13.
Since its introduction in 1975, it has emerged as a ‘gold standard’ of health professional assessment in a variety of disciplines14.However in India; the OSPE has been used as a formative assessment tool in few selected centres all over. The Medical council of India is yet to recognize and recommend OSPE as a formative or summative tool of assessment. The probable reasons could be the lack of awareness and orientation of the faculty towards the newer tools of assessment. In addition, there is also hesitancy in adapting the newer tools with lack of time and training of the faculty10.
However, National Board of Examination, Ministry of Health and Family Welfare, India has been using OSCE/OSPE for summative assessment of postgraduate students for certification in the subjects of Otolaryngology, Ophthalmology, Dermatology and Paediatrics for last few years10. Similar use of OSCE/OSPE in undergraduate curriculum is not known in Indian setup. Our objective of the study was to introduce a newer assessment tool with more objectivity, validity and reliability along with the traditional assessment method and to assess the feasibility from the faculty’s perception. While doing so, we also wanted to modernise our assessment tool and make it more competence based so that students develop more psychomotor and affective skills. For developing a good assessment tool, four criteria’s needs to be fulfilled which includes objectivity, validity, reliability and feasibility15.
Our experience with the OPSE was fruitful since it could assess all the three domains of skills effectively i.e. psychomotor domain in the form of elaborate step wise demonstration of the clinical procedures, affective domain in the form of communication skills and cognitive domain in the form of interpretations of the clinical workup which was lacking in the traditional assessment method. However it needs extensive blueprinting of the syllabus, validation and comprehensive checklists for various skills to be demonstrated which is tedious and time consuming process. In traditional assessment method, all the students are asked different questions with different difficulty levels depending on the mood and experience of the examiners which reduces uniformity and increases the biasness. This particular drawback is effectively managed by the administration of OSPE to all the students as all of them are subjected to similar questions with similar difficulty levels. In addition, there are model answers/ checklists provided to the examiners to be objective and fair to all the students. This also ensures less experienced examiners to become more objective and competent in marking the students .However studies have shown that global rating scales score given by expert examiners had a better inter-station reliability and predictive validity than the scores in checklists by OPSE 16,17.
OSCE/OSPE is a proved ‘gold standard’ for competency based examinations hence it compels the student to learn the clinical procedure in step wise and accurate manner14 .OSPE also has a high face validity as both examiners and examinee agrees with it measuring skills relevant to clinical practice18.Content validity could be ensured by rigorous blue printing of the syllabus however study done by Patil19 have shown that OSPE assesses students superficially in terms of skills demonstration. In addition, competencies like long term patient care, professionalism and ethics cannot be assessed by OSPE 20.
A similar view was put forward by Verma and Singh which stated that OSCE/OSPE can assess specific skills and is complimentary with TCE. It needs to be used in conjugation with other methods for an overall judgement of the students’ performance21. In addition, there is a compartmentalization of the skills demonstration in OSPE. Measuring skills in isolation is not equivalent to measuring a whole integrated performance20.
OSPE cannot assess all the attributes of clinical competencies effectively demanding the need to combine with other assessment methods20. OSPE is a fairly reliable assessment method provided it has large number of stations for all the specific skills demonstrations, good sampling, standardized, validated checklists and standardized subjects22. Reliability of OSPE measured by Cronbach’s alpha for 1 hour session is as low as 0.54 which can be increased to 0.8 by longer OPSE sessions of 4-8 hours which becomes practically impossible to conduct due to examiners and examinee’s fatigability10,23,24. Hence, for achieving high level of reliability, OSPE must be combined with other assessment methods20.
In addition, other factors, like practicality or feasibility of the assessment tool also needs to be considered before its implementation on a larger scale, focusing on the number of the students to be assessed, number of faculty members involved, availability of subjects, staff, time and money. In comparison to traditional assessment method, OSPE is less time consuming however it requires more time for planning, implementation and setting up. Also adequate number of stations ranging from 20-30 stations, evaluating various domains of clinical skills increases the reliability of the OSPE tool which again becomes impractical due to examiners and examinees fatigue 16,20.
All the students needs to be exposed to similar test situations and criteria to maintain and achieve high level of reliability and eliminate biasness. However it becomes tedious and difficult to arrange real, stimulated patients or standardised subjects for demonstration of various clinical skills since availability of manpower in the form of patients, standardized subjects, and support staff is not always possible. OSPE assesses all the 3 domains of clinical competence viz, cognitive, psychomotor and affective domain unlike the TCE. However, it tests the students in compartments and isolation rather than focusing on the students’ ability to look at the patient as a whole. Hence, OSPE, in-spite of being a reliable and valid tool of assessment, requires ample of time, faculty training, motivation and man power to effectively conduct and administer. It would be advisable to combine the focused approach of OSPE in assessing certain skills of the students along with the global judgement of traditional assessment method for overall evaluation of the students.

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