WORKPLACE-BASED ASSESSMENT IN POSTGRADUATE MEDICAL TRAINING: SCOPE AND CHALLENGES
Abstract
Post-graduate training programs prepare the residents to treat patients with the best possible skills without errors. The traditional training programs emphasized ensuring trainees get through the examination by scoring good marks in theory and practical; however, traditional learning often underemphasize significant domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice.1
Moving on two decades later, the majority of the postgraduate training programs are now competency-based and are focused on transferring performing skills, complemented with knowledge and attitude.2
Workplace-based assessments (WPBA) make an essential component in formative assessment in competency-based training programs. WPBA provides multiple advantages to the trainee in terms of acquiring competencies in their specialty with continuous feedback, this makes it a quality tool for formative assessment where the trainee has an opportunity to keep on improving his or her performance. The trainee undergoes several sessions of WPBA during each year of training; this not only makes him or her to be actively involved in learning but also provides an opportunity for the trainee to take responsibility for their learning. A revised approach to WPBA, with formative and summative encounters, is aimed at engaging both trainees and trainers.3 (Parry-Smith et al.,2014).
PBA focuses on assessing trainees in real work environments rather than in artificial testing situations, it is at the highest level of assessment in Miller's pyramid of trainee assessment.4 WPBA makes use of different tools like mini clinical evaluation exercises (Mini-CEX), Direct observation of procedural skills (DOPS), Consultation observation tool(COT), Audio COT, Case based discussion, Clinical encounter cards, Acute care assessment tool, Quality assessment project/Audit, Multisource feedback, Leadership feedback, Portfolio and supervisors review report and many more.5 (Wass,2011).
All these tools are structured to be objective in assessing trainee in specific learning tasks/competencies in their specialty and provide feedback either immediately or upon completion of the task. These tools are easy to use, and structured and provide a purposeful opportunity to correct the shortcomings in a performance with provision to repeat the same or a similar performance and a repeat feedback. 6
The WPBA promotes the supervisor-trainee relationship and builds trainee confidence in performing a task in the real world under direct supervision with feedback. WPBA helps the trainee to improve communication skills with patients and supervisors, as they also learn to take feedback and reflect on their performance. Upon successful completion of sessions of WPBA, the trainee can be trusted with a number of tasks safely and independently. In recent times, an electronic version or e-portfolio has increased ease of use in maintaining the trainee’s record 7.
PBA comes with challenges, the most common one being the inability of the supervisor to find time for these encounters from their busy schedules. Trainees and supervisors may not feel comfortable carrying out these sessions, but a culture of trusting WPBA is needed before implementing it. Many training institutes have a limited number of supervisors who may not have time for all the trainees and they have to take help from their consultants who may not be trained in conducting these sessions, which can affect the quality of training 8. Implementing WPBA in residency programs involves training the supervisors. Formal training of the supervisors in conducting the sessions is required to overcome the time constraint challenge.
The WPBA sessions must have a limited time, usually not exceeding 20 to 30 minutes. Tasks requiring more time may be broken down into smaller tasks to limit time for a single session. Scoring performance on checklists may generate similar results by novice and expert supervisors but qualitative analysis of performance, followed by feedback to the trainee, is better given by expert or experienced supervisors who draw more interpretations of trainee behavior during performance. Improving the behaviours and attitudes of trainees is a known challenge for supervisors involved in teaching.
WPBA, uses different patients for different trainees, as may be available at the time of assessment, leading to a lack of uniform difficulty index, this can be overcome by selection of similar types of patients for all trainees. Trust on WPBA is a challenge that can undermine the effectiveness 9. Another challenge may be the trainee's perception that supervisors are biased in giving feedback. This can be addressed by using constructive feedback techniques. In recent times inter-professional feedback has been studied in light of social identity theory which also has improved feedback 10.
The psychometric analysis of WPBA may not make it the best single tool in terms of reliability, validity and feasibility (Parr-. The student's performance is subjected to several factors that can modify or make them perform differently on the same task. Trainees may become overconfident and underperform a task in subsequent sessions. Similarly, the novice and expert assessors mark differently, with seniors usually marking strictly, making trainees try to get assessments from junior assessors 3, 11.
Most of the competency-based postgraduate programs have a place for WPBA in their curriculum. Hence, it seems only mandatory that WPBA must be implemented in the best of user-friendly manner taking input from all stakeholders, most important being the trainers and the trainees. The checklists used in these assessments must be simple. WPBA empowers supervisors to gain the respect of the trainees who value the effort put into these sessions by their supervisors.
Currently, WPBA has shown to be useful in formative assessment in improving trainee learning through reflection and feedback, it shows promise to be used in summative assessment in times to come 12. Apparently, for the regular and hardworking trainee, summative assessments using WPBA are more welcomed than assessments through OSPE or end-of-year assessments, as WPBA is conducted during day-to-day work with less anxiety. The apparent barriers to its implementation seem to be addressed, at least to an extent, to make it one of the best assessment tools in postgraduate training.
