ASSESSMENT IN MEDICAL EDUCATION IN THE 21ST CENTURY

Abstract

Definition and ContextThe Oxford Dictionary1 defines assessment as ‘theaction of assessing’. Here ‘assessing’ implies evaluatingthe nature, ability or quality of someone or something.Evaluation, on the other hand, is defined as ‘forming anidea of the amount, number or value’. It follows, that thepurpose of assessment is to determine the worth or valueof something.2 In the context of medical education,assessment could be defined as determining thecompetence of the product, that is, the HealthProfessional. It would also reflect on the quality of themedical education program itself and the standard of theteaching/ learning methodologies applied in the medicaleducation program.Oxford dictionary defines context as, ‘thecircumstances that form the setting for an event,statement, or idea, and in terms of which it can be fullyunderstood’. Assessment in terms of medical educationhas to be relevant to the context and the setting in whichit is applied. Traditionally, assessment has been dividedbroadly into either formative or summative. Whereasthe purpose of formative assessment is to providefeedback to one or more stakeholders concerned,summative assessment is largely used to define thevalue of the product in relation to standardised criteriaand goals.3 Research in education including medicaleducation has proved the worth of providing feedback tothe stakeholders, which in the context of medicaleducation would include the administrators, thestudents, the program developers and the public. Thesestakeholders use feedback including the outcomes offormative and summative assessments in different waysand for different purposes relevant to their own context.To the administrator, the results of theassessment, either formative or summative, provide datathat will help establish current policies or bring changesin them. To the program developers, the same resultsestablish the worth of the program or otherwise. To thetrainee, the scores or feedback help in understanding hisdeficiencies in relation to the clearly predefined goalsand objectives of the educational program. Naturally,the public places great emphasis on the nature ofassessment and the outcomes related to it since it is thepublic that is going to use the product of the medicaleducation programs and confidence in the product willbe related to their acceptability of the assessment and itsoutcomes.4An effective assessment that meets therequirements of all stakeholders must be valid, reliable,consistent and feasible, so that, it has a direct positiveeffect on all stakeholders and is able to enhance theeducational experience. When the assessment meets allthese criteria, it will be found to be acceptable to allstakeholders.4,5The Evolution of AssessmentAssessment has been part and parcel of medicaleducation from time immemorial.6 From the time ofHippocrates, assessment of cognitive, affective andpsychomotor domains have formed the pillars ofassessment goals.7 However, these three domains wereexplained scientifically only recently by Bloom in1956.8 Research in assessment has largely helped theshift from categories and domains of assessment totechniques and elaborating these domains inunderstanding the context validity of assessment. Thishas extended from the need to revise the medicaleducation curricula into more competency-basedproduct and outcome oriented curricula.9 These shiftshave been driven by the need to redefine the product ofmedical education to a bio-psychosocial healthcareprovider.10 Central to this shift have been thedevelopment of strategies worldwide, modelling thehealth professional into a self-directed, life-longlearner who is an excellent team-worker and does nothesitate to take initiatives to overcome new challengesthat hinder his progress. The context of assessmenttherefore, has changed over the last half century,keeping pace with the changing context of MedicalEducation world-wide.Medical Assessment in the 21st CenturyInterestingly, evolution in medical education presentlyhas turned the entire assessment pyramid upside down.A brave initiative in the 1960s at McMaster Universitytook the power of assessment away from the teachers.11By doing so they showed the rest of the world how thisshift of power can wake up the students from theirpassive role as learners to individuals who are able toguide their own teaching and learning strategies to meetthe program goals. In doing so, these students activelylearned the skill of self-directed life-long learning; soessential for health professionals.The domains of assessment have remainedunchanged. Assessment still focuses on knowledge,attitudes and skills, against predefined program goals inany educational program. However, the changingcontext of goals and their assessment have necessitatedinnovations in assessment techniques andmethodologies. In the 21st century, assessment inmedical education in all three domains focuses onapplication, problem-solving and integration, rather thanJ Ayub Med Coll Abbottabad 2010;22(3)4 http://www.ayubmed.edu.pk/JAMC/PAST/22-3/Junaid.pdffacts and basic skills.12 Trainees are more commonlybeing assessed in ‘real’ professional environments eitherin vivo or in vitro. Use of task-based, work-based,patient and community oriented assessment in all threedomains makes the process of assessment more realisticand acceptable to all stakeholders.Need-based AssessmentAssessment drives education.4 Changes in health-caredelivery over the years have required changes inmedical education programs, producing professionalsthat can cope with greater demands with an increasedworking speed in a technologically expanding,evidence-based environment centred around the patientand the community. This has stimulated developmentof assessment techniques relevant to this context ofmedical education. Problem-based and task-basedassessment using simulation or real-time, health-careenvironments assessing students in psychomotor,affective and cognitive domains, are gainingacceptability around the world amongst the health-careprofession educationalists because these techniqueshave shown to increase validity and reliability ofassessment, are relevant to the context of medicaleducation, are capable of enhancing and supportingeducation, provide near-equivalent everyday healthcare experiences and deliver consistently accurateoutcomes. Depending on the use of simulations or‘live’ environments these techniques are feasible andcost-effective whether used in the developing ordeveloped world.Redirecting LimelightThere are numerous resistors to change. Status-quo iseasy to maintain. Educators especially those involved inmedical education are bogged down by the weight oftradition. These educators therefore, perceive change asa threat to what they hold most dear in medicaleducation, that is, their traditions.13 Mostly, they arguethat they and their fathers and grandfathers before themhave been taught and assessed by time tested age-oldmodel. Finding faults and bringing change to this model,is sometimes perceived as challenging ones ownexistence as a health professional. At the other extreme,those who romanticize change, seek change for the sakeof change.13 They commonly do not understand theneed for change nor do they follow the effect of change.In some developing countries, as well as inmore developed ones, denial and resistance to changeare often encountered. Mostly the reasons provided arelack of human and physical resources, lack of adequateinfrastructure, non-availability of proper staff trainingand absence of value-added student selection processes.Nevertheless, the changes in the curricula havebeen brought about over the last century in order toimprove the provision of healthcare at the grass-rootlevel. Making the patient and not the disease and theslide as the focus of education can only improve theunderstanding of the trainees of the patient as a holisticchallenge in relation to all three domains of competence.Since assessment is the ‘tail that wags the dog’, unlessevaluation techniques are made to focus on the patientin all three domains and not simply on the disease, thechange in curricula or teaching methodology is notlikely to have the desired effect.