Clinical Skills at the Undergraduate Level: What are we trying to assess?
Authors: Asad Munazza ,   Al-Nafees Medical College and Hospital, Isra University, Islamabad Campus, Islamabad
Published: July 2024

The attainment of clinical skills is essential for the development and achievement of competence as a clinician. Transparency about what is being assessed and how and what should be assessed authenticates the development of any assessment process, and its purpose supports the required format of assessment taken.1 Clinical skills involve facts gathering through physical examination, history taking, and interpretation of data by applying conceptual knowledge, critical thinking, reasoning, and communication of information to the patient with the performance of a procedure.2 The acquisition of competence is the goal of teaching and learning in medical education. Over the past few years, medical colleges and regulatory authorities have made great efforts to plan valid and reliable assessment methods to assess the clinical competence of graduating doctors for future learning.3 various assessment methods are utilized to assess different components of competencies, and these methods have their own strengths, uses, and limitations.1 To assess the “shows how” level of Miller’s pyramid, competency assessments are required. Assessment not only confirms the required standards of knowledge and skills but also provides constructive feedback on the impact of teaching and learning on stakeholders. For performance assessment to have any real impact on learning, it must be context-relevant and sample widely.3 Establishing credible, defensible, and acceptable passing scores for performance-type examinations in real-world settings is a challenge for health professions educators. Van der Vleuten has described five criteria for assessing the effectiveness of the assessment method. Reliability: the extent to which the method is reliable and reproducible. Validity: how assessment measures what it declares to measure. Impact on future learning. Acceptability to students and faculty, and Cost effectiveness.4 Student learning mainly depends on how they think they will be assessed. At the start of the academic year, a clear timeline for gaining competencies and a separate graph for the acquisition of individual skills could be maintained for each student so that, at the end of the year, both the faculty and students know where they stand. If the assessment tasks are relevant and important, students will put in more effort to complete them. Timely, specific, and detailed feedback and guidance helps in the improvement of subsequent skills. 2 The major principles of a performance exam are ‘objectivity and structure'. Objectivity reflects the standardized scoring rubrics, and structure refers to a standardized station assessing a specified blueprinted task given in the curriculum. Training of examiners on the development of stations and assessment rubrics, marking criteria, standardizing patients, and quality assurance with reflective writing on cases is essential. Marking rubrics must be well explained, clear, and linked with student feedback.5 At the undergraduate level, for the development of competency-based assessment stations, a framework of references must be followed. The purpose of the assessment is aligned with the blueprint showing the required learning outcomes and the choice of method chosen. Whatever we intend to assess, the learning outcomes and assessment process must show defined alignment with each other, domains of performance and compensation between various domains must be clearly defined, and this facilitates the learner to demonstrate that they have achieved the required standards. Assessments involving more than basic clinical skills like professionalism, clinical reasoning, teamwork, and decision-making. The scoring criteria should be relevant to the given course outline and the learning level being assessed. Difficulty level of individual and linked stations, with standardization of scores provided to the candidates along with constructive feedback. Direct interaction with faculty; clinical encounters that include real patients with physical findings. Use experts to test the pass/fail judgment on standards that reflect developmental levels. In the end, a reflective report on the analysis of the assessment process and feedback from students and faculty could be utilized for improvement purposes.3,4 This approach will encourage the students and provide assessors with the chance to drive learning through assessment. Although assessment of learners in clinical settings is a difficult task, to overcome the psychometric challenges, a framework of reference for the evaluation of learners and to trust our learners to work independently in the clinical workplace is necessary. Continuously updating this framework by reflecting on the strengths and weaknesses of the framework is extremely effective. 3 The possibility of errors in OSCE marking can be decreased by evaluating OSCE scores to check standardization of stations and experienced and novice examiners judging on predetermined criteria. Numerous studies have shown that examiners were more accurate in assessing a strong student performance than a mediocre one. They concluded that a major factor influencing the candidates' results was the examiner's partiality. The examiner's narrow range of scores, leniency, consistency, and the "halo effect" are the four aspects that influence their marking. 6 Accurate exam results may be obtained by properly training examiners and making them aware of these biases before the exam.7, 8 Considering the challenges faced by assessment, it must motivate the students for future learning and give direction to improve the acquisition and application of knowledge, skills, and professionalism. Organize the assessment by using ongoing, contextual, and complex real-life situations that require clinical reasoning, expert judgment, and direct observation of behavior. Clearly defined criteria for pass/fail with timely constructive feedback and mentoring. Ideally, longitudinal assessments with the use of various assessment methods to assess learners’ needs and rectify suboptimal performance could be adopted.