Kemahli S. Clinical teaching and OSCE in pediatrics.
In addition to the more classical physical exami-
nation skills, students should also practice procedures
unique to pediatrics, such as fontanel examination,
looking for craniotabes, reflexes, meningeal irritation
signs and measurement of head circumference and
height in a newborn. These and similar procedures
should be supervised by a senior staff member (resi-
dent, chief resident or faculty). This is not only for
the sake of the patient but also for the students’
proper training. We know that not all our students are
able to take a reliable history or perform a competent
physical exam. This issue has been addressed in a
study conducted by Ahmed and Hughes .1 They iden-
tified 42 core conditions and 20 core skills to be per-
formed by students during their pediatric clerkship,
and assessed students’ clinical experience and end-
of-attachment performances. Five of the clinical
skills designated to be compulsory were performed
by over 90% of students. However, 23 of the 42 core
conditions had practice rates less than 85%, and 13 of
the conditions had rates less than 70%. Some condi-
tions had practice rates as low as 30-50%. Five per-
cent of the students did not perform any newborn
checks, while only 40% performed more than five
checks.1
A solution to these problems is to use standard-
ized patients and models for some examination skills
and for history taking. However in many countries
this is not yet possible, the reason being the lack of
standardized patient programs and the high cost of
models. The only other alternative is to use real pa-
tients. Using checklists to teach students these skills
and supervising them according to these checklists is
also a possibility. Checklists can and should be used
in this context to teach students clinical skills and to
supervise them. Checklists have been developed for
many skills including physical examination.
The feedback provided to the student would be
an invaluable motivation for better performance.
Lane and Gottlieb2 proposed such a “structured clini-
cal observations” scheme in pediatric clerkship. They
provided short observation opportunities and feed-
back for the students during the 3rd year pediatric
clerkship. The innovation was welcomed by the stu-
dents and by the faculty as well. They concluded that
this strategy is a feasible, inexpensive and qualita-
tively effective method of teaching clinical skills.
This can be a good model for other medical schools
in the teaching of clinical skills.
Thus, observing students when practicing physical
examination and giving them feedback is of utmost
importance.
Med Educ Online [serial online] 2001;6:10. Available from URL
http://www.med-ed-online.org
The Site of Clinical Training
The setting where the students practice clinical
skills is another important issue. One of the most
striking findings in the previously mentioned study
by Ahmed and Hughes 1 addresses this issue. Students
were exposed to more core conditions and performed
more core skills at the hospitals with fewer students.
The authors suggest that the best setting for the train-
ing of students can be a district hospital with a large
workload of general patients, rather than tertiary care
hospitals, where the students have the least exposure
to neonates .1 Similar views are expressed by Da-
vies3, who also suggests that, in addition to Univer-
sity hospital and the community, teaching should also
take place in district general hospitals in order for the
students to do more “clerking.” All three sites have
distinct advantages for the students. The distribution
of students to these sites and the time allocated for
each site should be balanced to ensure that students
are exposed to a good variety of core clinical condi-
tions and practice core skills. Additionally, each type
of site has its own unique patient population to which
students should be exposed.
Assessment and Evaluation
The steering effect of examinations is well
known. “Steering effect” means that students learn
best those subjects on which they expect to be exa m-
ined.4-7 This effect should be taken into account when
designing a clinical clerkship.
It has been widely accepted that both assessment
of student performance and clinical competence,
along with the measurement of knowledge, should
contribute to the students’ overall evaluation. The
traditional methods of examinations such as multiple
choice questions, written essay and bedside oral ex-
ams do not adequately measure the clinical comp e-
tency of examinees. In these methods the examinee is
“presumed” to have performed the necessary history
and physical examination and the examiner sees only
the results of that history and physical examinations
on paper. It is not uncommon that a student cannot
perform a properly focused physical examination of
the patient, even if he or she claims to have done a
complete physical examination. For this reason it is
necessary to directly measure competencies through
performance examinations.
Since students are not examined systematically
on core procedures in bedside oral or case presenta-
tion-type examinations, objective structured clinical
examinations (OSCE) should be the standard for
clinical skills assessment. The objective structured