ASSESSMENT IN MEDICAL EDUCATION IN THE 21ST CENTURY

Junaid Sarfraz Khan, John SG Biggs, Saima Tabasum

Abstract


Definition and Context
The Oxford Dictionary1 defines assessment as ‘the
action of assessing’. Here ‘assessing’ implies evaluating
the nature, ability or quality of someone or something.
Evaluation, on the other hand, is defined as ‘forming an
idea of the amount, number or value’. It follows, that the
purpose of assessment is to determine the worth or value
of something.2 In the context of medical education,
assessment could be defined as determining the
competence of the product, that is, the Health
Professional. It would also reflect on the quality of the
medical education program itself and the standard of the
teaching/ learning methodologies applied in the medical
education program.
Oxford dictionary defines context as, ‘the
circumstances that form the setting for an event,
statement, or idea, and in terms of which it can be fully
understood’. Assessment in terms of medical education
has to be relevant to the context and the setting in which
it is applied. Traditionally, assessment has been divided
broadly into either formative or summative. Whereas
the purpose of formative assessment is to provide
feedback to one or more stakeholders concerned,
summative assessment is largely used to define the
value of the product in relation to standardised criteria
and goals.3 Research in education including medical
education has proved the worth of providing feedback to
the stakeholders, which in the context of medical
education would include the administrators, the
students, the program developers and the public. These
stakeholders use feedback including the outcomes of
formative and summative assessments in different ways
and for different purposes relevant to their own context.
To the administrator, the results of the
assessment, either formative or summative, provide data
that will help establish current policies or bring changes
in them. To the program developers, the same results
establish the worth of the program or otherwise. To the
trainee, the scores or feedback help in understanding his
deficiencies in relation to the clearly predefined goals
and objectives of the educational program. Naturally,
the public places great emphasis on the nature of
assessment and the outcomes related to it since it is the
public that is going to use the product of the medical
education programs and confidence in the product will
be related to their acceptability of the assessment and its
outcomes.4
An effective assessment that meets the
requirements of all stakeholders must be valid, reliable,
consistent and feasible, so that, it has a direct positive
effect on all stakeholders and is able to enhance the
educational experience. When the assessment meets all
these criteria, it will be found to be acceptable to all
stakeholders.4,5
The Evolution of Assessment
Assessment has been part and parcel of medical
education from time immemorial.6 From the time of
Hippocrates, assessment of cognitive, affective and
psychomotor domains have formed the pillars of
assessment goals.7 However, these three domains were
explained scientifically only recently by Bloom in
1956.8 Research in assessment has largely helped the
shift from categories and domains of assessment to
techniques and elaborating these domains in
understanding the context validity of assessment. This
has extended from the need to revise the medical
education curricula into more competency-based
product and outcome oriented curricula.9 These shifts
have been driven by the need to redefine the product of
medical education to a bio-psychosocial healthcare
provider.10 Central to this shift have been the
development of strategies worldwide, modelling the
health professional into a self-directed, life-long
learner who is an excellent team-worker and does not
hesitate to take initiatives to overcome new challenges
that hinder his progress. The context of assessment
therefore, has changed over the last half century,
keeping pace with the changing context of Medical
Education world-wide.
Medical Assessment in the 21st Century
Interestingly, evolution in medical education presently
has turned the entire assessment pyramid upside down.
A brave initiative in the 1960s at McMaster University
took the power of assessment away from the teachers.11
By doing so they showed the rest of the world how this
shift of power can wake up the students from their
passive role as learners to individuals who are able to
guide their own teaching and learning strategies to meet
the program goals. In doing so, these students actively
learned the skill of self-directed life-long learning; so
essential for health professionals.
The domains of assessment have remained
unchanged. Assessment still focuses on knowledge,
attitudes and skills, against predefined program goals in
any educational program. However, the changing
context of goals and their assessment have necessitated
innovations in assessment techniques and
methodologies. In the 21st century, assessment in
medical education in all three domains focuses on
application, problem-solving and integration, rather than
J Ayub Med Coll Abbottabad 2010;22(3)
4 http://www.ayubmed.edu.pk/JAMC/PAST/22-3/Junaid.pdf
facts and basic skills.12 Trainees are more commonly
being assessed in ‘real’ professional environments either
in vivo or in vitro. Use of task-based, work-based,
patient and community oriented assessment in all three
domains makes the process of assessment more realistic
and acceptable to all stakeholders.
Need-based Assessment
Assessment drives education.4 Changes in health-care
delivery over the years have required changes in
medical education programs, producing professionals
that can cope with greater demands with an increased
working speed in a technologically expanding,
evidence-based environment centred around the patient
and the community. This has stimulated development
of assessment techniques relevant to this context of
medical education. Problem-based and task-based
assessment using simulation or real-time, health-care
environments assessing students in psychomotor,
affective and cognitive domains, are gaining
acceptability around the world amongst the health-care
profession educationalists because these techniques
have shown to increase validity and reliability of
assessment, are relevant to the context of medical
education, are capable of enhancing and supporting
education, provide near-equivalent everyday healthcare experiences and deliver consistently accurate
outcomes. Depending on the use of simulations or
‘live’ environments these techniques are feasible and
cost-effective whether used in the developing or
developed world.
Redirecting Limelight
There are numerous resistors to change. Status-quo is
easy to maintain. Educators especially those involved in
medical education are bogged down by the weight of
tradition. These educators therefore, perceive change as
a threat to what they hold most dear in medical
education, that is, their traditions.13 Mostly, they argue
that they and their fathers and grandfathers before them
have been taught and assessed by time tested age-old
model. Finding faults and bringing change to this model,
is sometimes perceived as challenging ones own
existence as a health professional. At the other extreme,
those who romanticize change, seek change for the sake
of change.13 They commonly do not understand the
need for change nor do they follow the effect of change.
In some developing countries, as well as in
more developed ones, denial and resistance to change
are often encountered. Mostly the reasons provided are
lack of human and physical resources, lack of adequate
infrastructure, non-availability of proper staff training
and absence of value-added student selection processes.
Nevertheless, the changes in the curricula have
been brought about over the last century in order to
improve the provision of healthcare at the grass-root
level. Making the patient and not the disease and the
slide as the focus of education can only improve the
understanding of the trainees of the patient as a holistic
challenge in relation to all three domains of competence.
Since assessment is the ‘tail that wags the dog’, unless
evaluation techniques are made to focus on the patient
in all three domains and not simply on the disease, the
change in curricula or teaching methodology is not
likely to have the desired effect.

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