AMEE Medical Education Guide No. 9. Assessment of clinical competence using the Objective Structured Long Examination Record (OSLER)

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Abstract
Much criticism has been directed at the assessment of clinical competence and at the long case in particular an recent years. In the traditional long case candidates spend one hour with a patient from whom they take a history and whom they examine. An examiner is not present. The student is then examined by a pair of examiners over a 20–30 minute period. This has been to the extent that the problems associated with the long case in terms of objectivity, validity and reliability are such that some critics have suggested that it should be abandoned altogether. Others would take the view that before we dispense with this method we should attempt to remodel and improve it. Furthermore, tradition and practically would suggest that the long case will be with us for some time to come. The justifiable criticism of the long case is directed on a number of fronts, a major one being that the history-taking process is not observed by the examiners. Bearing these criticisms in mind, the Objective Structured Long Examination Record (OSLER) has been developed. The OSLER is a 10-item analytical record of the traditional long case which attempts as far as is possible within the limits of practicality to improve the objectivity, validity and reliability of existing practices. All candidates are assessed over 20–30 minutes by the examiners on the same 10 items, thus improving reliability and items are included that are representative of what would be regarded as having an acceptable degree of construct or face validity with regard to the long case. Attention is paid to communication skills and the history-taking process in particular. In attempting to standardize the long case and minimize the 'luck of the draw' aspect, examiners are requested to formally document the difficulty of the case. The figure of 10 with regard to the number of items assessed is not coincidental and is a deliberate act to include a minimum of the essential in terms of what should be assessed. This allows examiners to concentrate on the candidate's performance with a structured guide that is not so intrusive as to interrupt the examiner's concentration. The four items on history include pace and clarity of presentation, communication skills process, systematic approach and establishment of the case facts. Three items on physical examination include systematic approach, examination technique and establishment of the correct physical findings. During these activities the candidate's affective behaviour is also assessed. The remaining three items include construction of appropriate investigations in a logical sequence, appropriate management and final clinical acumen. The latter item draws on the previous nine to assess candidates' ability to identify and solve problems. The initial assessment is essentially criterion referenced through a P+, P, P- system which is followed by the selection of an appropriate mark, each of which has its own written descriptive profile. The perfect method for long case clinical assessment has yet to be established. Indeed perfection may be no more than a pious hope bearing in mind that any method will always be a compromise between objectivity, validity and reliability on one hand and practicality on the other. while the search for the perfect long case method continues, the OSLER is suggested as a practical approach to what is universally recognized as an ongoing assessment challenge.