Jane MacKenzie
Posts: 10
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| 30/05/2007 10:27 |
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Tony, I think you said that the questions had to be objective. But I was wondering (perhaps my ignorance) about clinical judgement. Surely, there's room for assessments with a confidence rating in clinics. e.g. a scenario with patient X presenting with Y symptoms. What should the clinicians first action be: X-ray, other form of scan, observation etc. See now I sound quite dense. What do you think?
Jane |
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Tony Gardner-Medwin
Posts: 14
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| 30/05/2007 11:24 |
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Don't apologise! This type of Q is quite common in clinical exams, and I think it can be quite a big issue whether the answers are objective or subjective. Neither Nancy Curtin nor I are clinicians, so I hope there may be some around who might comment. Usually these Qs are presented as multiple-choice, or extended matching Q sets (where several Qs may share the same set of response options).
Clearly sometimes there may be options that are categorically wrong. A choice between options may also sometimes be a matter of fine clinical judgement. As far as I know, however, these Qs are usually marked with just one option being correct and all the others being marked wrong. You would need to provide a specific example to set up a debate about whether such categorical right/wrong marking is what should happen. I suppose in a lot of cases there is an implicit rephrasing of such Qs along the lines: "In this scenario, which option would generally nowadays be regarded as clinical best practice?" which makes the Q a bit more objective, albeit also a bit different. If two of the options seem almost equally acceptable, then nobody - experienced clinician or fresh student - should be expressing high confidence that the choice they eventually plump for will be the one that is marked correct. But this is really a criticism of a (possibly only hypothetical) system that treats such Qs as suitable for just right/wrong marking. There could of course be a different rubric that said that though the student must choose one option, two or more of the options may be marked correct - if there are issues of fine judgement between some of the options, then this would seem much more appropriate to me, and would enable the student once again to be confident (or not) about whether their answer was definitely consistent with best practice.
A recent clinical teacher at Imperial (Dr. Sara Marshall) interestingly mapped the C=1,2,3 decision as follows, for junior doctors when discussing a scenario:
1: I am guessing, but I think this is the correct answer
2: I am pretty sure I am correct but need advice before proceeding
3: I am happy to proceed
The real penalties for (3) in combination with a wrong judgement can be a lot worse than -6. But apparently this approach struck a useful chord with the junior doctors.
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Jane MacKenzie
Posts: 10
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| 30/05/2007 15:52 |
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Hi Tony, yes it would be useful to have an example. It just seems to me that when talking to clinicians the clinical 'judgement' is fundamental to the learning process. However, at uppers levels (ie. the year or two before a clinician qualifies) a lot of the learning and assessment happens in clinics and the assessment might be highly subjective (don't tell any clinicians I said that). I think the concept of confidence rating might be very useful to clinical supervisors even if used quite informally. Maybe they do already?
Jane |
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Tony Gardner-Medwin
Posts: 14
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| 30/05/2007 17:38 |
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Thanks Jane. You wonder if maybe clinicians already use a form of CBM thinking informally, when assessing students in the clinic. I think yes, that's bound to be true. Part of the idea of CBM in objective testing is to regain part of what is normally lost without direct interaction between student and assessor. In a face to face viva or conversation we are always picking up subtle cues about whether the other person is hesitant or confident of their position. When we aren't sure, we challenge: 'You seem a bit unsure' or 'Really?', etc. to see what happens. A student who has not prepared his/her ground can easily be forced to admit it, or else feel the noose tightening as they are forced into a confident sounding error.
Doctors know that tricky clinical judgements require a sound knowledge base and an acute awareness of where one's knowledge reaches its limits. Partly I think because of this CBM element, vivas (oral assessments) are about the most effective assessments for getting students to do their homework beforehand. They are good for probing whether a student really knows the topic they are discussing. They are very good at establishing whether a student's written work has been plagiarised. But of course they are expensive and necessarily short, so tend to be unreliable at assessing breadth of knowledge.
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