Objective standardized clinical assessment with feedback: Adapting the objective structured clinical examination for postgraduate psychiatry training in India

Indian Journal of Medical Sciences, Jun 2009 by Chandra, Prabha, Chaturvedi, Santosh, Desai, Geetha

Introduction

The objective structured clinical examination (OSCE) format has been conventionally used for assessing medical students in various undergraduate and postgraduate settings. [1] OSCEs have also been used in several specialties, including surgery, medicine, pediatrics and rehabilitation. [2],[3],[4],[5],[6] However, there are only a few reports about using them for training purposes.

Brazeau et al.[7] used the OSCE as a teaching tool following a request from the faculty and students, who wanted more direct observation and feedback on performance in various clinical scenarios. Following the use of the OSCE format for training, they concluded that the OSCE as a teaching tool was an efficient use of teaching resources. In addition, there was positive feedback from students about the opportunity to have constructive discussions on their strengths and weaknesses in clinical encounters and observe a variety of doctor-patient interaction styles, in addition to practicing for future OSCE-type examinations. Faculty members also reportedly enjoyed this teaching format and found the process of students giving feedback to their peers educationally useful. The teaching using OSCE was also extremely well rated in the end-of-rotation evaluations.

The OSCE as a training tool in the above exercise was adapted from the classic OSCE format and aimed at assessing the trainees and providing immediate feedback on various components of a clinical interview. Kligler et al.[8] used competency-based direct-observation tools in training family medicine residents to use an integrated medicine model in communication, and found the direct-observation checklist to be a useful tool for feedback. Parish et al.[9] used a five-station OSCE for training with different substance-use disorders and found that the perceived educational value of the OSCE with feedback as a training tool was high, and feedback improved subsequent performance.

In psychiatry, while there are reports about the use of OSCEs in postgraduate examinations, their use in training has not been discussed even though several studies have reported that feedback after the examinations using the OSCEs is beneficial. In an opinion survey, Hodges et al.[10] reported that Canadian psychiatry residents were uncomfortable about using OSCEs for examinations but felt that they would like the experience of using OSCEs as a part of their training.

In India, OSCEs are not commonly used as part of postgraduate evaluations though these have been used in undergraduate examinations. At the end of the 3 years of postgraduation training, trainees are examined by the conventional long and short cases in psychiatry, based on recommendations by the Medical Council of India. [11] OSCEs have not yet been introduced in the examinations for postgraduate psychiatry.

The current paper describes an adaptation of the OSCE method for training purposes in postgraduate psychiatry in India. This paper focuses on two aspects - the methodology of adaptation; and an analysis of the performance of trainees in different dimensions of the clinical tasks based on 34 case scenarios.

Materials and Methods

Setting

The institution where the current study was done is a premier postgraduate training center for psychiatry in India. Every year 20 postgraduate trainees enter the psychiatry residency program. While OSCEs are not used for examinations, as mentioned above, several faculty members of this institute, including the first two authors of this paper, have been trained in OSCEs as used in the UK for the MRCPsych.

It was felt that the OSCEs if adapted for use in training would be of considerable benefit in improving communication and assessment skills of trainees in the Indian setting.

Adaptation of the OSCE format as OSCAF for training

Several changes had to be made for use of the OSCE format as OSCAF (objective structured clinical assessment and feedback) for training purposes and for it to be culturally relevant. This included, firstly, the adaptation of various OSCE vignettes to the Indian setting, i.e., modifying content of the existing OSCEs used in the UK for MRCPsych examinations and adding a few components that were relevant to Indian psychiatric practice. For example, case scenarios such as 'discussing the illness with family members' were added because this is a frequently encountered situation.

The selection of clinical scenarios and adaptation was based on consensus between three psychiatric trainers. These clinical scenarios were then assessed for suitability in relation to content, timing and adaptability to roleplaying and used for the study. The case scenarios were chosen to cover a wide spectrum of subjects. Some of them included assessment of psychopathology (depression, thought disorder, suicidal ideation, insight); cognitive function assessments; different clinical conditions, such as substance use, eating disorders, sleep disorders; and different communication and interviewing challenges (education about Clozapine, educating a family member about schizophrenia, discussing compliance, breaking bad news). The case scenarios were based on commonly encountered situations in the inpatient, outpatient and emergency settings. Some OSCEs, such as assessing sexual problems, were not selected due to cultural issues about roleplaying certain topics in front of a peer group.