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Objective-structured clinical examination in cardiovascular system for the assessment of internal medicine postgraduates amidst the Covid-19 pandemic
[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).
| 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.
| 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
| 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.7–10 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.16–18 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 |
