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Medical Education
35 (
3
); 172-176
doi:
10.25259/NMJI-35-3-172

Objective-structured clinical examination in cardiovascular system for the assessment of internal medicine postgraduates amidst the Covid-19 pandemic

Department of Cardiology, Advanced Cardiac Centre, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
Department of Internal Medicine, Advanced Cardiac Centre, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
Department of Internal Medicine, Government Medical College and Hospital, Chandigarh, India
Correspondence to RAJESH VIJAYVERGIYA; rajeshvijay999@hotmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

[To cite: Gawalkar AA, Kasinadhuni G, Kumar HM, Lehl SS, Kumari S, Vijayvergiya R. Objective-structured clinical examination in cardiovascular system for the assessment of internal medicine postgraduates amidst the Covid-19 pandemic. Natl Med J India 2022;35:172–6.]

Abstract

Background

The Covid-19 pandemic has posed a challenge to organizing a safe clinical assessment for postgraduate degree candidates completing the residency programmes in various specialties. Although minimizing the risk of Covid-19 transmission is a priority, fulfilling the objectives of the assessment is equally important.

Methods

We conducted this study in the Department of Internal Medicine at our institute. Instead of physically examining patients, case scenarios that included history, clinical and investigational data of the cardiovascular system (CVS) were presented to the candidates. Performance was scored by both the conventional and the CVS objective-structured clinical examination (CVS-OSCE) method and compared.

Results

Clinical assessment examination of 27 candidates for the degree of Doctor of Medicine showed that the median cumulative score gained in narrating and analysing various differential diagnoses was lower compared to the mean cumulative score gained in arriving at a single correct diagnosis (50% [interquartile range—IQR 39%–64%] v. 79% [IQR 64%–100%], p<0.01). Most of the candidates agreed that case scenarios were good alternatives to the conventional physical examination amidst the pandemic.

Conclusion

CVS-OSCE-based assessment using structured case scenarios is a feasible and effective alternative for clinical skill assessment in high-stake examinations.

INTRODUCTION

The Covid-19 pandemic has posed new challenges to medical education.1 The first case of Covid-19 in India was detected on 30 January 2020. A nationwide lockdown was imposed in March 2020 to curtail the increasing number of Covid-19 cases and to prepare healthcare workers/institutes to deal with the pandemic. The outbreak and lockdowns led to delays in the final assessment examination at the completion of the Doctor of Medicine (MD) Internal Medicine (IM) residency programme. While minimizing the Covid-19 transmission within the healthcare establishments is of paramount importance, medical education and research activities also need to be continued. The clinical/practical assessment of trainees amidst the pandemic require strict adherence to infection control practices.

The assessment for the completion of a 3-year residency programme in IM has two parts. The first part is the theory examination, which does not require direct interaction with another person, while the second part is the clinical skill assessment that demands interaction between the student, patients and examiners. The conventional clinical assessment involves eliciting historical data and physical findings of a patient and the presentation of these to examiners, who then score the candidate based on the presentation, and the ability to justify the interpretations and decisions. A cardiovascular system objective-structured clinical examination (CVS-OSCE) allows for a structured and comprehensive evaluation of different aspects of clinical skills while maintaining objectivity. We present our experience of organizing the final MD examination amidst the Covid-19 pandemic and analyse the utility and applicability of a CVS-OSCE.

METHODS

We included 27 students who were completing their residency programme in June 2020. The study design and assessment strategy for conducting the clinical skill examination were approved by the institutional ethics committee. The candidates were divided into four groups (7, 7, 7, 6). Only one group was allowed to be at the examination venue at anytime. Within each group, adequate physical distancing was maintained between individual candidates. Students were briefed about the expected plan of movement during the examination. The examination was conducted in a large (71.5 m2) conference room, to avoid any risk of exposure from inpatients or other healthcare workers. All the candidates, examiners and organizers were free of medical symptoms and had not been exposed to high-risk situations near the day of the examination. All persons involved in the process of the examination wore a triple-layered medical mask.2 Hand sanitizers were used before and after handling papers by both candidates and examiners. Adequate physical distancing (at least 2 m apart) was maintained between the examiners and the candidate at all times.3

On arrival, a set of papers that contained a case scenario (Appendix 1) was handed over to the candidate. The case scenario was organized to give sequential clues, i.e. demographic details and chief complaints, detailed history of presenting complaints, family/personal history, general physical examination findings, cardiovascular examination findings and clinical findings of other systems (Appendix 1). After each section, the candidates were asked to analyse and interpret the data. The candidate’s ability to narrate the physiological basis and common causes of specific symptoms and signs were also scored. Further, their ability to narrate the steps of carrying out an appropriate physical examination was assessed. Two examiners (RV and SSL) assessed the candidate independently, and both followed the conventional method of scoring as per the institutional protocol (Appendix 2), while a third person (AG) independently scored the candidate’s response to all the questions/aspects of case analysis using CVS-OSCE (Table I). AG was blinded to the scores given by the other two examiners. CVS-OSCE consisted of a total of 30 elements providing a graded score for each element of clinical skills from 0 to 2 (maximum total score was 60). The scores by two examiners assessed by the conventional method were averaged and the mean score was then compared with the CVS-OSCE score. The students were not informed about the independent CVS-OSCE until the completion of the examination. After the clinical skill assessment, the candidates were explained about the CVSOSCE proforma and asked to give feedback on this newer model and their opinion on conducting examinations using case scenarios, instead of physically interacting and examining the patient. The scores obtained by each student in individual aspects of clinical assessment and their response to the feedback questionnaire were recorded on a 5-point Likert scale. All statistical analysis was done using IBM SPSS Statistics (Version 26) for MacOS. Variables were summarised as either mean and standard deviation or median with interquartile range (IQR).

TABLE I.: Cardiovascular system objective-structured clinical examination (CVS-OSCE) proforma used for the assessment of clinical competency in cardiovascular diseases using case scenarios
Item Score 2 Score 1 Score 0
Chief complaints and detailed history of present illness
Interpret chief complaints to localize the system involved
Extract relevant positive/negative history to rule in/rule out various common causes
Use demographics such as age/gender/place in clinical decision-making
Explain the mechanism of a symptom
Past/family/personal/treatment history
Interpret given past/family/personal/treatment history and use the same in arriving at an appropriate diagnosis
Extract relevant positive/negative history to rule in/rule out various common possible causes
Conclude after history-taking
Could reach the most appropriate diagnosis
Gives close differentials with justification for and against them
General physical examination
Integrate given important clinical findings to reach at a conclusion
Extract important positive/negative findings to help arrive at the right diagnosis or rule out a close differential diagnosis
Narrate possible other clinical findings commonly seen in the arrived diagnosis
Demonstrate or narrate the systematic method of carrying out a given method of examination
Cardiovascular system examination
Integrate given important clinical findings for arriving at a conclusion
Extract important positive/negative findings to help arrive at the right diagnosis or rule out a close differential diagnosis
Narrate possible other clinical findings commonly seen in the arrived diagnosis
Demonstrate or narrate the systematic method of carrying out a given method of examination
Examination of other systems
Integrate given important clinical findings in arriving at a conclusion
Extract important positive/negative findings to help arrive at the right diagnosis or rule out a close differential diagnosis
Investigation
Mention relevant important investigations
Justify the use of these investigations
Electrocardiogram (ECG)
Systematic description of the given ECG
Pick important findings to correlate with the clinical diagnosis
Chest radiograph
Systematic description of the given radiograph
Pick important findings to correlate with the clinical diagnosis
Diagnosis
Able to reach the correct diagnosis
Justifies clinical findings and investigations in arriving at the diagnosis
Able to make close possible differentials
Management of the patient
Appropriate medical management in a stable patient
Appropriate medical management in complications related to the disease
Relevant surgical options
Total score

Differences between the variables were analysed using paired-samples t-test. A Spearman rank order correlation test was done to assess the relationship between scores obtained by the conventional and the CVS-OSCE methods.

RESULTS

The mean score of 27 candidates in various categories of the clinical examination are summarized in Table II. The scores gained in narrating and analysing various differential diagnoses was lower compared to the mean cumulative score gained in arriving at a single correct diagnosis (50%; IQR 39%–64% v. 79%; IQR 64%–100%; p<0.01). The total score obtained by the CVS-OSCE was significantly higher compared to the conventional scoring system (35 [IQR 31–46.5] v. 34 [IQR 32–7], p<0.01). Further, there was a statistically significant and strong correlation between two scores with rs=0.705, p<0.01, where rs is the Spearman correlation coefficient. The responses to the survey carried out after the examination are summarized in Table III.

TABLE II.: Scores in various aspects of the objective-structured clinical examination (OSCE)
Assessment parameter Maximum score Mean (SD) score Mean (SD) score (%) Median (IQR) score Median (IQR) score (%)
Chief complaints and presenting history score 8 5.3 (1.6) 66.2 (19.5) 5 (4–7) 62.5 (50–87.5)
Past/personal/family history score 4 2.8 (1.1) 70.4 (26.9) 3 (2.5–3.5) 75 (62.5–87.5)
Diagnosis after history score 4 2.7 (0.8) 68.5 (20.3) 3 (2.5–3) 75 (62.5–75)
General physical examination score 8 5.3 (1.6) 65.7 (20.1) 5 (4–6.5) 62.5 (50–81.25)
Cardiovascular system examination score 8 5.1 (1.5) 63.9 (18.8) 5 (4–6) 62.5 (50–75)
Diagnosis after history and examination score 4 25 (0.9) 62 (22.3) 2 (2–3) 5 0 (50–75)
Investigation score 12 7.4 (1.8) 61.7 (15.4) 7 (6–9) 58.3 (50–75)
Diagnosis after investigation score 6 4.0 (1.3) 67.3 (20.9) 4 (3–5) 66.7 (50–83.3)
Management score 6 3.7 (1.1) 61.1 (19.0) 4 (3–4) 66.7 (50–66.7)
Cumulative score for arriving at a specific diagnosis 14 11 (2.5) 78.6 (17.8) 11 (9–14) 79 (64–100)
Cumulative score for differentials 14 7.4 (2.8) 53 (20) 7 (5.5–9) 50 (39–64)
Total score by OSCE 60 38.8 (9.5) 65 (16) 35 (31–46.5) 58 (52–78)
Total score by the conventional method 60 34.7 (4.3) 58 (7.0) 34 (32–37) 57 (53–62)

SD standard deviation IQR interquartile range

TABLE III.: Feedback obtained from the students regarding the cardiovascular system objective-structured clinical examination (CVS-OSCE) proforma and the effect of the Covid-19 pandemic on their learning
Item Strongly agree (%) Agree (%) Neutral (%) Disagree (%) Strongly disagree (%)
Time allocated was adequate 17 (63) 10 (37) 0 0 0
This structure covers most of the discussion on a given topic 15 (56) 10 (37) 2 (7) 0 0
The structured assessment helps to make up for lost scores 10 (37) 12 (44) 5 (19) 0 0
This structure gives adequate importance to all necessary domains 11 (41) 13 (48) 1 (4) 2 (7) 0
More emphasis should be given to investigation and management as in 3 (11) 11 (41) 8 (30) 5 (19) 0
contemporary practice
The structured assessment helps in deeper learning 9 (33) 12 (44) 6 (22) 0 0
OSCE assesses a candidate’s competency better than the conventional 3 (11) 14 (52) 6 (22) 4 (15) 0
method
Case scenarios were a good alternative to the conventional patient 18 (67) 7 (26) 1 (4) 1 (4) 0
examination physically amid the worsening pandemic
Covid-19 pandemic affected our learning/clinical skill training 13 (48) 9 (33) 1 (4) 4 (15) 0
The present case scenarios might have helped us gain a better score 7 (26) 15 (56) 4 (15) 0 1 (4)

The examination was carried out safely without any of the study participants showing any symptoms or signs of Covid-19 infection during a 1-month follow-up.

DISCUSSION

In this study, we used structured case scenarios as a substitute for the final assessment of the MD-IM residency programme. We also tested and compared the CVS-OSCE with the conventional method of scoring.

In April 2020, the National Medical Commission gave directions for the conduct of examinations of final-year postgraduate trainees to maintain the continuous availability of specialists to deal with the ever-increasing number of Covid-19 patients.4 It also advised various institutes to adopt alternative methods of assessment, which can reliably test the clinical skills of the candidates.5 However, there was a lack of clear guidelines on how to conduct these high-stake examinations to assess both knowledge and clinical skills of the candidates.

The OSCE was first introduced in 1975 as a model for student’s assessment.6 Since then, it has been adopted as the mode of choice for assessment of competency in clinical skills in many countries and few educational boards of India.710 OSCE improves objectivity while covering a wider range of aspects of clinical skills. The structured assessment also provides feedback about the teaching programme and measures student’s and teacher’s effort in quality education. In this study, the objective assessment revealed that the student’s ability to provide a differential diagnosis was poorer compared to the ability to arrive at a single best diagnosis (p<0.01). This brings to light a crucial aspect of their learning, as the ability to give various alternatives requires a deeper knowledge than arriving at a single best diagnosis from the given typical history. Making a close differential diagnosis reflects a methodical way of thinking and has been shown to reduce diagnostic error in clinical practice.11 This fact needs to stimulate educators to discourage the ‘one-diagnosis-only’ practice among students.12 The response of the students reflected the negative impact the Covid-19 pandemic on their training and showed that they were satisfied by the alternative tool of case scenarios. They also opined positively regarding the OSCE assessment for CVS.

Alternative methods of assessments for such examinations have also been explored by others. Pictures or videos demonstrating relevant examination findings have also been used for candidates to view and interpret.13 This method is more applicable considering the increased adoption of telemedicine and virtual visits as modes of outpatient care.14,15 Programmable mannequins have also been used for identification of abnormal findings and demonstration of physical examination skills.1618 Other options include conducting the practical assessment, using carefully chosen patients in a controlled environment.19,20

Limitations

It was a single-centre experience of 27 candidates, assessed only for CVS. We did not assess the effectiveness and validity of this modality in comparison to the standard method of physical patient examination and assessment, as practised during the pre-Covid-19 era. The present method of assessment, however, does not evaluate the candidate’s ability to elucidate physical signs, which is an essential component of patient management.

Our study will help other medical schools to adopt OSCE-based assessment for high-stake examinations. It also illustrates the utility of CVS-OSCE in unmasking the area of deficiency in student’s knowledge and skills so that the same can be reinforced in teaching programmes. The adopted proforma provides a prototype for scoring clinical skills in CVS for medical postgraduates. A similar proforma can be adapted for other systems as well.

We postulate that CVS-OSCE using structured case scenarios can become an effective, alternative method for physical examination and clinical assessment.

Conflicts of interest

None declared

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Appendix 1 Case scenario prototype

PRESENTING ILLNESS

A 32-year-old woman presented with dyspnoea on exertion (New York Heart Association-II) for the past 14 years. It got worse for the past 5 months and is associated with intermittent palpitation for the past 5 months.

## Possibilities and discussion

HISTORY OF PRESENTING ILLNESS

The patient was well until 18 years of age when she started experiencing dyspnoea on exertion, which was insidious in onset and gradually progressive. It used to relieve with rest and there was a history of occasional episodes of paroxysmal nocturnal dyspnoea and orthopnoea. Now, she can walk for only 250 m at a stretch.

She had intermittent episodes of palpitations at rest, which used to occur spontaneously for the past 5 months. There was no history of similar episodes of palpitation in the past.

There was no history of syncope, chest pain, chronic cough, haemoptysis, fever or any history of pedal oedema or right upper quadrant pain abdomen.

## Possibilities and discussion

HISTORY PRIOR TO THIS EPISODE

She had a history of hospitalization with fever and arthralgia at 6 years of age. There was no history of rashes or involuntary movements.

There was no history of squatting.

There was no history of tuberculosis in the past.

She was not a known case of diabetes mellitus or hypertension.

She gave birth to a healthy child at 25 years of age, following an uneventful pregnancy.

FAMILY HISTORY

There is no similar illness in the family.

DRUG HISTORY

She receives an intramuscular injection every 3-weekly since the onset of illness along with a few other oral drugs.

## Possibilities and discussion

GENERAL PHYSICAL EXAMINATION

She is thin built and poorly nourished.

Blood pressure was 112/72 mmHg in the right arm, in sitting posture.

Pulse is 92/minute, low volume, irregular, with no radio-radial or radio-femoral delay

Jugular venous pulsation is 5 cm above the angle of Louis at 45° angle, ‘a’ wave absent; x, v and y waves are present.

There is no pedal oedema or jaundice.

## Possibilities and discussion

CARDIOVASCULAR EXAMINATION

There is no precordial bulge.

Cardiac apex is in the left fifth intercostal space, 1 cm medial to the mid-clavicular line, localized and ill sustained. Second heart sound is palpable. A diastolic thrill is palpable in the mitral area, best in the left lateral position and during full expiration. S1 is loud, S2 is normally split, P2 is loud and there is a presence of an opening snap just after S2. There is a grade IV, low-pitched mid-diastolic rumbling murmur which is best heard at the apex, with the bell of stethoscope in left lateral position at height of expiration. There is no click, rub or other murmurs.

## Possibilities and discussion

OTHER SYSTEM EXAMINATION

The trachea is in the centre.

The chest is symmetrical with equal expansion.

Transverse chest:anteroposterior diameter=7:5.

There are no crepitations/wheeze.

The abdomen is soft and non-tender.

There is no hepatosplenomegaly.

Higher mental functions as assessed by mini-mental state examination are normal.

Cranial nerve examination is normal.

Gait is normal.

Motor and sensory examinations are normal.

## Possibilities and discussion

CHEST RADIOGRAPH

##Discussion

ELECTROCARDIOGRAPH

##Discussion

Appendix 2 Conventional assessment scoring proforma

Item The score obtained by the candidate Maximum score allotted
History 30
Physical examination 30
Diagnosis 10
Differential diagnosis 10
Investigations 5
Treatment 5
Discussion 5
Special credits/discredits 5
Total 100
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