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Section 1: the knowledge components

Develop a question and ideal student response for each of the following types of question: testing facts, testing knowledge of a procedure, testing knowledge of a principle, testing knowledge of a concept. These should be presented in the table and will be informed by your formative feedback.

Testing

Question example

Ideal answer

Knowledge

Procedure

Concept

Principle

For each question analyse why your suggested question and response test what they set out to test.

Consider an MCQ exam. 

i) How would you determine whether if it was a valid assessment? Paste the following table into your assignment and complete:

Type

Describe each type of validity

Describe how you would determine each type of validity using your MCQ as an example

Construct

Face

Content

Concurrent

Predictive


ii) Reflect on the importance of validity to the assessment process.

Important: Please indicate at the top of your essay which option you have chosen, e.g. Option 2.

  • Identify a recent MCQ or OSCE exam with which you have been involved.
  • Select an appropriate standard-setting method, giving reasons for your choice, e.g. modified Angoff.
  • Apply the standard-setting method to the exam, giving information about any difficulties encountered. 
  • Identify the pass mark.
  • How many students passed/failed, according to your standard-setting method?
  • How many passed/failed, using your usual standard and/or a 50% pass mark?
  • Reflect on the implications of the use of the standard-setting approach you selected.
  • Briefly describe a course with which you are involved or have experience which has either The OSCE or MCQs as its assessment.
  • Evaluate the different standard-setting methods that might be used in this assessment process, for example Borderline, Angoff, etc. (no more than 5).
  • Select the most appropriate method(s) for use in this process, giving reasons for your choice.
  • Identify any barriers to implementation and suggest how you might overcome them.
  1. Construct a self-assessment toolthat your students or trainees could use to self-assess their own performance. Discuss its potential merits. Show how the student would use the tool, and discuss any problems that might be associated with its use.

  2. Construct a self-assessment toolthat you could use to self-assess the quality of your own teaching. Discuss its potential merits. Show how you would use the tool and discuss any problems that might be associated with its use.

  3. Briefly reflect on the importance of feedback in the self-assessment process.

Think about two recent, but different, experiences when you were involved in offering feedback (within a learning relationship). At least one of the examples should be of one-to-one, in-person feedback.

Describe the events and then analyse the process and skills you used during these experiences with reference to the content of the module. How would you change your behaviour in the light of this reflection? 

Testing Questions and Student Responses

Section 1: the knowledge components

Testing

Question example

Ideal answer

Knowledge

 What is the normal range of blood pressure in an adult?

 Systolic blood pressure of between 90 to 120 mmHg and diastolic blood pressure of between 60 to 90 mmHg

Procedure

What is the procedure of measuring blood pressure in an adult?

Get the equipment ready and have the patient seated in a relaxed manner in a quiet room.

Introduce yourself to the patient and gain consent to take his blood pressure.

Wrap a properly sized cuff of the sphygmomanometer around the upper arm with the lower edge of the cuff 5 cm from the cubital fossa.

Palpate for the brachial artery pulse then lightly press the bell of the stethoscope on the brachial artery at the lower edge of the cuff.

Inflate the cuff rapidly to around 200 mmHg until the brachial artery pulse is no longer heard using the stethoscope.

Slowly release air from the cuff at a rate of around 3 mm per second.

Listen keenly with the stethoscope as you observe the sphygmomanometer. The first Korotkoff sound corresponds to the subject's systolicblood pressure. The diastolic pressure corresponds to the disappearance of the last Korotkoff sound.

Document the pressure in both arms and calculate the difference; repeat the procedure with the patient in supine position and standing position.

Measure the blood pressure for two additional times if the subject’s blood pressure is elevated, waiting for around ten minutes between measurements.

Concept

What are the dangers of chronic high blood pressure?

 Dangers of high blood pressure include cerebrovascular accidents due to rapture of cerebral microvasculature, accelerated artherosclerosis and arteriosclerosis, renal failure, heart failure, hypertensive retinopathy

Principle

 Explain why blood pressure measurement in different positions yield different results.

Blood pressure discrepancies with varying positions are caused by inputs from compensatory mechanisms from the autonomic nervous system and baroreceptors to maintain the blood pressure within the normal range.

The knowledge question simply requires the student to state the normal blood pressure range, which is a universal fact that can be obtained from published literature. The student is not required to think but to only remember the information and answer the question.

The second question on the procedure requires the student to outline the steps that are to be followed in order to take blood pressure of a person. The student in this case is expected to be systematic and chronological in outlining the steps as well as keep in mind the rationale informing every step in the procedure.

The third question on concept requires the student to have read and create links in knowledge on the pathophysiology of complications of uncontrolled hypertension. Hypertension plays a major role in the pathogenesis of vascular disease such as arteriosclerosis due to hyalinization of the arterial and capillary walls and acceleration of formation of atheroma in atherosclerosis due increased endothelial injury that favors the fibrogenic processes. The complications of hypertension mainly involve end organ damage such as nephropathy, retinopathy, heart failure and stroke. Hypertensive nephropathy is secondary to hyalinization of capillaries in the glomerulus, inhibiting the process of ultrafiltration. Hypertensive retinopathy is secondary to rapture of capillaries in the retina leading to haemorrhage in the retina and eventual loss of vision. Hypertensive heart disease is caused by elevated systemic blood pressure that makes the heart to pump harder to counter the systemic pressure. This eventually leads to increased metabolic demands of the myocardium giving rise to ischemic heart disease and remodeling of the left ventricle that decreases the stroke volume leading to the signs and symptoms of heart failure. long standing hypertension can also cause haemorrhagic stroke due to rapture of vessels in the brain such as the middle cerebral artery. This leads to haemorrhage into the brain and eventual infarction of the areas of the brain that are supplied by the affected artery and pressure effect caused by the haematoma. This will manifest clinically with abnormal findings on neurological examination.

The fourth question on principle requires the student to understand the physiologic basis of variation in blood pressure with position and the mechanisms of short term regulation of blood pressure. In this question, the student has to remember that changing positions varies regional flow of blood which in turn affect inputs from the autonomic nervous system and the baroreceptor mechanisms to maintain the blood pressure within the normal ranges.

Validity Testing Techniques for MCQ Exams

Consider the following MCQ:

 The following statement is false as regards head injury patients

  1. Patients with acute subdural hematoma present with loss of consciousness

  2. Nasogastric tube insertion is contraindicated in patients with suspected fracture of base of the skull

  3. Skull fracture is a predisposition for epidural hematoma

  4. Radiograph of the skull is the investigation of choice in a patient with reduced level of consciousness

  5. The normal range of intracranial pressure is between 10-30 mm Hg

The correct answer is d

Type

Describe each type of validity

Describe how you would determine each type of validity using your MCQ as an example

Construct

 Construct validity refers to the degree to which an assessment covers a particular trait by demonstrating the consistency of test score interpretations with nomological network entailing observational and theoretical terms (Cronbach & Meehl, 1955).

 This MCQ overs the basic concepts that a medical student should understand as regards the physiology, pathophysiology, investigations and management of patients who present with head injury.

Face

 Face validity answers the question of whether a test appear to assess what it claims to. The purpose of the test should be clear even to naïve responders.

 This MCQ has a high face validity because it aims to test for the student understanding of principles of management of head injury patients. For instance, the patient should know that insertion of a nasogastric tube is an absolute contraindication in patients with suspected base of skull fracture because the tube can divert to the brain instead of the stomach and lead to very serious complications when it is used to administer fluids and for aspiration. Furthermore, the investigation of choice for a patient with a lucid interval is a CT scan or MRI and not a plain radiograph of the skull. The MCQ is testing the student’s understanding of head injury and not any other topic.

Content

 This refers to the degree to which an assessment measures the scope of the subject. The questions asked should be properly chosen for the level of students as well as the content under examination.

This MCQ has content validity because it tests the minimum basic knowledge that an undergraduate student is expected to have regarding head injury. The options are within the confines of the medical student knowledge and not that of a neurosurgeon.

Concurrent

 This refers to the extent of relationship between a test and an established standard that is existing concurrently.

 This MCQ has concurrent validity because it tests on the standard published principles of management of patients with head injury. The correct options are in agreement with existing protocols that have been published to guide management of head injury patients and prevent unnecessary costs and life threatening complications.

Predictive

 This refers to the level to which an assessment accurately presages future occurrence of a criterion.

 Students who score this question correctly are likely to perform better in Emergency department and intensive care because they understand the principles of recognition and management of head injury patients.

Construct validity posits a test to cover as much of the essentials of the subject matter extensively in order to give a clear picture of the students understanding of the content of the subject under examination. From the example of the above MCQ, the question seeks to test different aspects of diagnosis and management of head injury patients.

Regarding face validity, the question tests basic principles of head injury management that are contained in the undergraduate curriculum for medical students hence it will be fair for their level of knowledge.

The content of the subject being covered in the question is within the scope of what the medical student is taught and is required to demonstrate mastery hence the question has content validity.

As regards concurrent validity, the correct options in the MCQ are in congruence with the latest publications on diagnosis and management of head injury patients.

Students who are able to score this MCQ correctly are more likely to do well in traumatology, emergency medicine and intensive care courses as well as professional practice because they demonstrate mastery of principles of evaluation and management of head injury patients.

Ear, nose and throat (ENT) surgery clerkship in the bachelor of medicine and bachelor of surgery (MBChB) course is aimed to impart to the medical students the requisite knowledge and competence in skills that are essential in diagnosing, managing and preventing otorhinolaryngological diseases. The medical student undertaking this course is expected to demonstrate knowledge as well as competence through making definitive diagnosis, analysis of clinical data and develop an elaborate management plan entailing either surgical or non-surgical options, or both. Assessment for this course involves both written MCQs and OSCE examination at the end of the clinical rotation. The scope of the examination cuts across otology, rhinology, laryngology to upper aero digestive tract topics as well as different equipment used in the ENT specialty.

Standard setting in an examination context refers to the process of deciding the pass mark or cutoff points that determines people who pass and those who fail the test. For a test to be standard, it should not be so hard that students who could have passed end up failing or so easy that those who were to fail end up passing. The aim of standard setting process is to ensure that students who pass the test have demonstrated mastery of the core knowledge of the course as well as the competencies that are being assessed in the examination. Standard setting methods that can be employed in assessment of ENT surgery course include modified Angoff, Borderline, Hofstee and Ebel.

Feedback Techniques for Effective Learning

The modified Angoff technique of standard setting was developed by Agoff in 1971 to facilitate decision making in multi-component tests such as MCQ examinations that form an essential component of assessment of medical students. In this technique, the examiners are additionally served with the exact test scores of previous tests to enable them to determine the chances of a borderline students answering a particular question accurately. This comparison with previous results of the same test enables the examiners to become more realistic and reconsider the pass mark for the test making it evidence based. This also makes the test more trainee-centered than examiner-centered one hence increasing its face validity.

For the MCQ examination of ENT surgery course, the examiners should imagine and discuss the abilities of a borderline candidate and reach a consensus. Each examiner should then consider each MCQ item, one after the other then score the borderline candidate between 0 to 1 based on the probability of borderline candidates getting the right answer. The probabilities of each examiner are totaled then divided by the number of MCQs to determine the mean probability per examiner. The means of all examiners are summed up then divided by the total number of examiners to give the provisional mean pass mark for the whole test. Examiners are then provided with the actual results from previous test to reconsider, where necessary, their original probability estimates in the light of previous results provided and recalculate the pass mark for the entire MCQ examination.

According to Mogapi (2012), the Angoff technique has three primary elements: formulation of the borderline candidates of a test, identification of specific assessment questions, and the employment of experts to determine whether a borderline candidate will appropriately perform each of the assessment components. The merits of modified Angoff technique are many. First and foremost, modified Angoff technique has a high face validity since it focuses on the difficulty of the content of the examination and the level of competence that is required of the examinee to pass. Secondly, the technique is recyclable in that if a question is repeated in a different examination with the same context, the previously predicted difficulty can be re-used saving on time required to make fresh judgements. Thirdly, the modified Angoff technique has been highly studied and there are many publications on the same making it more justifiable for employment in high stakes examinations, like ENT surgery that involves the lives of patients, hence holds up when questioned in court. The disadvantages of this technique include inconsistency in defining the borderline candidate by the examiners. This requires the examiners to be experts in their specialty in order to distinguish the borderline from the average candidate. Secondly, the technique is labour intensive and time consuming since the judges have to look at every assessment item. This can encourage the examiners to rush through the process when they become fatigued and impatient. Thirdly, sample bias can negatively impact the accuracy and reliability of the assessment set using this modified Angoff technique. A large sample of examiners of different ages, levels of seniority, genders and ethnicities are required for the success of this technique making it hard to get examiners who meet these specifications. Finally, this technique relies on back-up from a criterion-referenced technique such as borderline regression since it does not use real examination data to estimate the pass mark.

The borderline regression technique is an examinee-centred method of standard setting that is applied mainly in OSCE. In this technique, the candidate is awarded a “global score” for each station in a circuit by the examiner at the end of the assessment after actual marks have been awarded based on the assessor’s judgment on the overall performance and ability of the student in that particular station. The scale for the global score ranges from three to five options, where the examiner choses the most appropriate score for the candidate for example, pass, borderline pass, borderline fail, and fail.  Advantages of using borderline regression technique include reliability, as the technique uses real test data to calculate the pass mark for a station using a single test, or many tests if available. The technique can also be assessing the effectiveness of an OSCE station by identifying problems encountered by the examinees in that particular station such as unbalanced marking scheme that can be pointed out by poor discrimination in the borderline regression graph. Borderline regression technique is easy to use by the examiners because it is not time consuming to award a global score for each candidate when proper training has been conducted. Finally, the technique is fundamental in backing up other standard setting techniques such as Angoff method. Disadvantages of using borderline regression technique include difficulty in understanding the definition of borderline candidates hence necessitating the need to conduct intensive examiner training that is costly and time consuming. Secondly, the technique encourages box ticking of the overall candidate’s competence in a station at the expense of counting marks scored. Finally, the technique requires large number of candidates and examiners for reliability making it unsuitable for examinations with low enrollment.

Hofstee method is a test-centred method of standard setting whereby the examiners estimate the lowest acceptable failure rate, the highest acceptable failure rate, the minimum pass mark, even if all candidates fail, and the maximum pass mark in case all examinees passed. The average of the four estimates is calculated by the examiner then superimposed on a graph of actual test scores. A rectangle is created by the examiner estimates, which the actual examinee test score curve bisects. In the event the rectangle falls outside the curve, another standard-setting method has to be resorted.

In Ebel (1972), examiners categorise examination items into three main categories: “essential”, “important” and “indicated” (Case & Swanson, 1998). The proportion of borderline examinees who are able to correctly answer question in each category is estimated by the examiners. The average of estimated proportion in each category is multiplied by the corresponding number of questions to arrive at the cutoff for the specific category. The pass mark for the whole test is obtained by summing the cutoffs for each category. The disadvantage of this technique is that the examinees can pass highly in one category then fail massively in a category with essential questions implying that the student will pass the test despite having no grasp of the basics of the course. 

I believe the modified-Angoff technique is the best method to standard the assessment for ENT surgery course because it gives input from both the tutor and backs up the estimates of the borderline candidates with evidence from previous results tests. This improves the validity of the test because each question is analysed thoroughly for suitability for the level of education of the students. Again, it ensures that students who are competent pass the exam whereas those who are incompetent fail the exam. The technique also boasts of reduced level of bias amongst examiners which assists in determining a clear fail.

The major barrier to implementing modified-Angoff technique is that it is based on the examiner who is an expert in the field being tested in comparison to the student who might be having limited knowledge gained from the few weeks of rotation in the ENT surgery field. Furthermore, the previous results used in moderating the pass mark are from a previous cohort that might have been taught well than the current candidates being examined. To mitigate these hitches in implementing the modified-Angoff technique, the examiners should also factor in the scope of knowledge that has been covered by the current cohort of candidates to standard the examination. To solve the problem of knowledge gap between the expert and the students, the curriculum of the ENT surgery course should be used in selecting questions for the examination.

Self-assessment refers to the process of evaluating your own progress and comparing the results obtained with what is expected of you. According to Adams et al (2016), self-assessment first entails self-grading then followed by understanding what is considered as excellent work in a learning exercise.

A self-assessment tool is composed of items that seek to analyse of one’s strengths and weaknesses, personality, preferences as well as biases that enables the person to become aware of their innermost desires, volition and belief systems.

To put this process of self-assessment into perspective, appendix 1.0 shows a sample of a checklist that is meant to be used to enable fourth year medical students to do a self-assessment of how they conduct themselves during their clerkship in the medical rotation. The merits of this questionnaire include: the students are able to identify and investigate their needs, priorities, perspectives, priorities and preferences which are key to their learning in the clinical area; the students are able to easily analyse how they spend time on different activities during their rotation; it can be used to address sensitive topics that the student might be afraid to express to the lecturers; the students have adequate time to think and respond to the items in the checklist at their own desired pace and time and the students are also able to identify their strengths, opportunities, weaknesses and threats to their learning in the clinical areas. The student will assess their performance in different aspects influencing their learning and award a single mark for every option. The scores will be summed up at the end and calculated as a percentage to give the overall self-assessment score for the candidate. A score below 50% will imply that the student has to work on their strengths and weaknesses immediately to salvage their performance in the clinical areas. The problems associated with use of the checklist include inability to rate qualitative data such as one’s perspective on how to improve their attitude towards clinical work and the reasons as to why they are lagging behind. Another problem will be on the limited amount of data collected will make it harder to get a statistically significant result that the student can work on to improve their learning in the clinical area.

Appendix 2.0 shows a checklist I would use to assessment my own style of teaching. The merits of the checklist are that it has handled diverse techniques that should be employed in teaching of medical students effectively. The checklist has also included sections for teacher-student relationship, time management, mastery of the course content, feedback through assessment and asking and answering questions which are key to learning and success of students. The challenges with using the checklist includes inability to honestly rate the good and bad habits that are employed during instruction.

Feedback in self-assessment is of crucial importance. Firstly, it boosts the morale of the student. This enables the student to adopt good study habits that eventually result in improved performance. Secondly, effective feedback in self-assessment reinforces the trainee’s professional and personal confidence. This encourages the learner to work harder given that they now believe in their potential. Feedback in self-assessment enables the learner to identify areas of weakness and make necessary improvements before participating in summative assessment. This ensures that the student gives more efforts towards polishing the areas of weakness which in turn improves their overall performance.

Feedback forms the cornerstone of any learning activity. Giving feedback enables the tutor to understand the needs of the trainee and challenge the trainee to reflect of their achievements and change their behavior for the better hence helping them to build their personal and professional lives. In this section, I am going to give examples of how I offered feedback in two different scenarios during my rotations in the clinical set up.

In the first scenario, I was charged with the mandate of mentoring my junior colleague who was fresh to the clinical years from preclinical training. He was required to take comprehensive medical histories as well as conduct complete physical examination of all patients under his care. However, he had problems when it came to performing a respiratory examination and called upon me to chip in as his mentor. The following was our dialogue with him during the entire process:

Me: Hello Mike. How may I assist you please?

Mike:  I have been having problems with examining patients especially the respiratory system. I just do not understand how to go about it to the extent that I usually guess findings whenever I clerk my patients.

Me:  I can read the read the frustration from your face but I am here to help you cope with transitioning from the preclinical years to clinical clerkships. I would like you to demonstrate to me how you usually perform your respiratory examination on one of your patients. Are you okay with that?

Mike:  It is okay.

Me:  What is the standard procedure of conducting a respiratory examination?

Mike:  You start with looking at chest expansion, percuss the chest wall then finish by listening to breath sounds.

Me:I beg to disagree with you. First and formost you need to clean your hands, introduce yourself to the patient then obtain a consent from him to examine his respiratory system. Secondly, you then have to position the patient in a supine position at about 45 degrees as you inspect around him for any clues of respiratory disease such as salbutamol inhaler, sputum pot then proceed to inspecting the chest wall. It is after that when you will systematically move to palpation, percussion then auscultation. Ensure that you document all your findings accurately. Can you now do that?

Mike: That is way too complicated given the short time I have at my disposal. My summarized procedure is straightforward and saves a lot of time. That is how I have been surviving all along.

Me: I am sorry that you will have to repeat the whole year if you dare do that before any consultant. That is equivalent to killing the medical profession and replacing it with witchcraft.

Mike: (laughing) I am sure you also do that. You are just pretending right now because you are my senior. That is what everybody is doing in the ward.

Me: (annoyed) you need to get serious young man lest you will have another year to learn how to do physical examination. You have to read and practice the right techniques on every patient. That is my simple advice to you. You either take it or leave it. See you when you are ready to learn.

From the above conversation, it is evident that the feedback was not helpful at all. In fact, it ended up being a supremacy battle between me and my mentee. I started off well by describing what was required to my mentee and making him to take the lead as I offer guidance. Unfortunately, I ended up telling the consequences of being sloppy in clinical work.

To make the feedback helpful to my mentee, I could have employed the describe, express, suggest, and consequences (DESC). First and foremost, I should have described to my colleague that he was doing well with examination of other systems but he was casual when it came to examining the respiratory system because he did not understand the standard technique that is used in conducting physical examination of the respiratory system. After describing what the problem was, I should have gone further to explain to him why a complete examination of the respiratory system was as essential as that of the other systems especially when it comes to management of patients with respiratory diseases and emergency patients. Afterwards, I should have gone ahead to explain to my colleague that only practice of the correct techniques would save him from the harassment by consultants and the extra cost of redoing the medical rotation. Finally, I should have encouraged him to read about examination of the respiratory system and make notes. He should also have conducted respiratory examination on his friends and document findings for our discussion.

In the second scenario, I was tasked with giving feedback on histopathology results to a patient in the outpatient ENT clinic by my lecturer. The patient had been suspected to have nasopharyngeal carcinoma around three weeks ago which was to be confirmed by histopathologic examination of a biopsy that was taken during her last outpatient clinic visit. Here is my dialogue with her:

Me:  Good morning Mrs. Jane?

Mrs. Jane:  Good morning too young medic.

Me: I am Kendrice, a sixth year medical student from Dundee Medical School. I would like to explain to you the results of histopathological examination of a biopsy that was taken from you three weeks ago.

Mrs. Jane:Yes, I am eager to know the findings.

Me:Okay Mrs. Jane. The results from the pathologists indicate that you have cancer of the nasopharynx, a space behind the nose and above the throat. There is a mass at that location that has grown and is blocking the airway and impinging on the adjacent structures such as the Eustachian tube and the soft palate hence causing your symptoms of pain, ear fullness, welling of the neck and difficulty in breathing.

Mrs. Jane: That is absolutely bad news. So what am I going to do? It seems to be the end of life to me. Help me my son.

Me: Do not worry Mrs. Jane. Your tumour is currently at stage 2. This implies that you can undergo radiotherapy and recover from the disease. You will have to undergo thirty radiotherapy sessions divided into six sessions per week.

Mrs. Jane: My friends who have been diagnosed with the same problem did not recover and ended up wasting a lot of money. Why will my case be different?

Me: I understand your concerns mum. The difference is that their tumours might have been advanced in stage, that is stage 3 or stage 4 hence could not be cleared by radiotherapy. You have over 70% chance of recovering from the disease. All you need to do is to start your radiotherapy sessions immediately to avoid the tumour from advancing to higher stages that will be hard to treat. Many people have been treated with the disease at the same stage as yours and they have attained complete cure from the disease. We will write you a referral letter that you will hand over to the radio-oncologist who will be taking care of you during the radiotherapy sessions.

Mrs. Jane: Thank you for your information. It is my hope that you will grow up to become a very good doctor so that you can treat us in future.

Me: Appreciated mum. I wish you all the best.

In this case, I employed the DESC model of giving feedback which made the patient to appreciate the feedback as being useful. However, I could have improved on explaining the medical jargon in a simpler language that the patient could understand better.

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