Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20

Assess Clinical Competence-An Overview R. M. Harden To cite this article: R. M. Harden (1979) Assess Clinical Competence-An Overview, Medical Teacher, 1:6, 289-296 To link to this article: http://dx.doi.org/10.3109/01421597909014338

Published online: 03 Jul 2009.

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Assess Clinical Competence -An Overview R.M. HARDEN

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R . M . Harden, M D , FRCP, is Professor o f Medical Education, Centre f o r Medical Education, The University, Dundee LID1 9SY, UK. Assessment of a doctor’s or student’s clinical competence is of key importance. T h e examiner should ask what competencies he is attempting to assess and how he can best assess them; whether, for example, by using an objective structured clinical examination (OSCE), patient management problems (PMP), supervisors’ reports, project work or assignments, or by auditing case records. He should consider the functions of the clinical examination, i n particular its role in providing feedback to the student and teacher. With regard to timing there is a place for both incourse and end-ofcourse assessment of clinical competence. Finally, in considering who should undertake the assessment, the role of the student or doctor in assessing his own competence should not be overlooked. Great importance is attached to the clinical part of the final examination in medicine in many medical schools and in examinations for postgraduate diplomas. In addition, assessment of trainees’ clinical competence is a matter of concern in vocational training programmes. Thus, most teachers, at one time or another, are concerned with the assessment of clinical competence.

Need for Improvement in Reliability and Validity

A pass in the clinical section of an examination is regarded as essential by most examining bodies, and no compensation for a performance judged inadequate is usually permitted, however well the candidate may have done in other sections. In view of the significance attached to the clinical test and of the important consequences of failure, assessment of the candidate by the examiners should be both reliable and valid. (The concepts of reliability and validity were discussed in Medical Teacher, 1979,1’49-50and 101-102.) There is good evidence from many sources that there is a need for improvement in both the reliability and the validity of the clinical examination. For example, Wilson and colleagues (1969) reported a study in which two examiners independently marked candidates in a ‘long case’ in the clinical examination in medicine, and 14 Medical Teacher Vol 1 No 6 1979

examiners independently marked the students undertaking a neurological examination as a ‘short case’. Marks awarded by one examiner differed by as much as 25 per cent from those awarded by another examiner for the same performance, and inconsistency in the same examiner was also evident. In a study of the membership examination, Fleming et al. (1 974) identified examiners whose influence appeared to favour high or low marks. For example, one examiner was identified who took part in 10 examinations and whose influence on his colleagues was such as to lower very substantially below the expected level the pass rate for the candidates he examined. Stokes (1974)has drawn attention to the problems of validity in the conventional clinical examination and has suggested that frequently what is measured is not what should be measured. More recently, an editorial in the Lancet (1978) has commented on the high failure rate (30 per cent) in a recent final examination at Guy’s, a result described by the editor of the Guy’s Hospital Gazette as “a random result largely unrelated to medical competence”. Whatever the truth, a question mark must hang over the traditional approach to clinical examinations as a method of assessing students’ clinical competence. This article discusses the assessment of clinical competence, which includes the skill in obtaining pertinent information from a patient, the ability to detect and interpret symptoms and abnormal signs, acumen in arriving at a reasonable diagnosis and judgement in the management of patients (Hubbard et al. 1965). Consideration is given to the five questions that should be answered in relation to any assessment procedure (Harden 1979). The answers to these questions will determine how one would or should set about assessing a student’s or a doctor’s clinical competence. What Should be Assessed? Knowledge of what is to be assessed is a prerequisite for any assessment, and many of the problems in relation to assessment arise because of inadequate attention to this question (Harden 1979). In an established course, the examiners have usually developed over the years an understanding of what is to be assessed, although this

289

may not be set down on any paper or document. Problems still arise, however, with new examiners, and even experienced examiners can profitably review this aspect of assessment. Particularly with new courses, a more formal statement of objectives may help in:

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1. Determining the scope and depth of the topics to be tested in the examination. 2. Choosing appropriate assessment methods. 3. Assessing the assessment procedure itself as a valid instrument.

Some of the objectives for the paediatric training required by a general practitioner are shown in Table 1 (Joint Working Party 1976). This extract illustrates the value of considering what is to be assessed before making decisions about the methods of assessment. Objective one, for example, can be tested by a written assessment while objectives two to five require more clinically orientated instruments. To assess whether or not objective two has been achieved, one needs either to watch the doctor assess a number of children or to see the results of a number of such assessments. To determine whether or not objective five has been achieved, the doctor needs to be faced with real or simulated situations where there may be a need for more elaborate or specialist investigation. Clinical Competence Required of a Doctor Some of the main tasks of a doctor are summarized in Table 2; these should be reflected in clinical examinations. The use, or construction, of such a list can help the examiner to decide whether what he is trying to measure in a clinical examination is what he wants to measure. The items on the list can be expanded. For example, in relation to collection of information, does the student: 1. Try to elicit the relevant information from the history and carry out the relevant examinations and tests? 2. Use the proper technique in so doing? 3. Obtain the correct answers? 4. Omit unnecessary investigations and examinations?

Table 1. Objectives for the paediatric training required by the general practitioner (Joint Working Party 1976). In relation to human development, at the completion of his training, the doctor should be able to demonstrate that: 1. He has knowledge of the important norms of physical, intellectual, emotional and social development at different ages 2. He can carry out the basic methods of assessment of these modes of development from birth up to and including, adolescence 3. He can recognize common deviations from the normal 4. He understands the role of the health visitor in developmental assessment 5. He can recognize when there is a need for referral for more elaborate or specialized assessment.

290

Table 2. Clinical competence required of a doctor. Collection of relevant information 1. History taking 2. Physical examination 3. Use of instruments, e.g. ophthalmoscope 4. Laboratory and special investigations, e.g. biochemistry and radiology 5. Information from other appropriate sources, e.g. patient’s family Recording of information and interpretation 1. Recording of information 2. Integration of data 3. Recognition of medical problems 4. Making a diagnosis Management programme 1. Planning of treatment programme 2. Communication with patient 3. Using appropriate resources, e.g. health visitors 4. Evaluation of progress of treatment 5. Follow-up and continuing responsibility for patient

The doctor’s ability to make a diagnosis will depend on his ability to collect the appropriate information, recognize patterns, for example the slow-moving patient with the hypothyroid facies, and assess the probabilities of various diagnoses from the evidence available. A more sophisticated assessment might try to answer the following questions in relation to each task: 1. Does the student or doctor know what he should do? This mainly reflects his knowledge. 2. Is he able to do it? This involves psychomotor and interpersonal skills and the application of knowledge. 3. In practice, does the student or doctor choose to do it when confronted with a situation? This, at least in part, reflects his attitudes and is the most difficult to assess.

A clinical examination should be more concerned with a student’s application of knowledge in relation to a patient and with his clinical skills and attitudes than with the extent of his knowledge per se. That we do not always succeed in doing this in relation to our undergraduate examinations is witnessed by the fact that students who have the best record in undergraduate examinations frequently do not make the best house physicians or surgeons, while other students, who have an average performance in examinations, not only make excellent house staff, but also have a very successful career in medicine.

How Should Clinical Competence be Assessed? Stokes (1974) has reviewed the traditional British approach to clinical examinations. In the ‘long case’ the candidate has about an hour to take a history and examine the patient, and following this he is asked to report his findings to the examiner who, on the basis of this, assesses the candidate’s clinical ability. In the ‘short case’ the candidate is asked to make a diganosis or to report his findings after a brief examination of a patient. Medical Teacher Vol 1 No 6 1979

Alternatively, he may be asked to undertake a physical examination of a patient under the observation of the examiner. To improve the reliability of the assessment, examiners usually work in pairs, and each examiner should mark the student independently before discussing his performance with his colleague. With this traditional approach to clinical assessment:

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1. Only a small sample of competencies can be tested in the time available. 2. Patients who can be used are of a limited type. 3. Different patients are used with different students. 4. There is a variability in marking between examiners. Is there an alternative to the traditional clinical examination? The answer is probably ‘yes’. Certainly, a number of approaches to the assessment of clinical competence have been developed which are worthy of consideration. These include: 1. The objective structured clinical examination (OSCE). 2. Patient management problems, including the modified essay question. 3. Audit of cash records and work. 4. Supervisors’reports. 5. Project work and case studies.

stations, spending 4i minutes at each. All students rotate through the same stations. 2. Each station is designed to test a component of the student’s clinical competence. An example of the range of topics covered in a recent OSCE is shown in Table 3. 3. At some stations (procedure stations) the student is given a task to perform; for example, he may be asked to take a history from a patient with a specified complaint such as haematuria, or to carry out one aspect of an examination, e.g. the examination of a patient with a , lump in the breast. Table 3. An 18-station objective structured clinical examination (E = examiner present). Station 1

3. Station 5.

2

Station 3

3.

Examine neck Questions on Station 1 Take history from patient with abdominal pain

Station 4

Questions on Station 3

Station 5

Neurological examination of legs

5.

3. Station 3. Station 3.

Before these approaches are described two points should be emphasized. First, the assessment method adopted should be chosen to meet the requirements of the particular situation. For example, a different approach will be required in the assessment of undergraduate medical students compared to trainee general practitioners. Second, it is likely that in most situations no one approach will by itself be satisfactory. For example, the surgery final examination at the University of Dundee includes:

Station 8

1. An objective structured clinical examination at the end of the 5th year; this includes patient management problems. 2. A ‘long case’ during the student’s attachment to a surgical unit in the 5th year. 3. Clinical assessment of the student during each of the six terms in the 3rd and 4th years of the course.

Station 10

Read written summary of patient’s history and patient’s chest radiograph and answer questions

Station 11

Look at ward drug prescription chart and answer questions

The Objective Structured Clinical Examination (OSCE) The objective structured clinical examination is so called because it is more objective and thus more reliable than the traditional examination, the examination is structured in such a way that the content of the examination and the standards required of the students can be planned by the examiners in advance, and the examination tests clinical competence. The precise details of how the examination is organized vary from centre to centre, but the following general features usually apply: 1. Each student has an examination lasting about 100 minutes, during which time he rotates around 20

Medical Teacher Vol 1 No 6 1979

6

Questions on Station 5

7

Examine chest

5.

Station 9

3.

3. Station 12

3. Station 13

3. Station 14

3.

Station 15

4 Station 16

3.

Station 17

3.

Station 18

Questions on Station 7 Inspect photographs of patients and answer questions

Look at written history of patient and fluid balance chart and answer questions Take history from patient with haematuria

(El

Questions on Station 13 Take history from patient with acute onset of dyspnoea (El Questions on Station 15 Examination of patient’s breast

(E)

Questions on Station 17 291

4. At other stations the student is asked questions in

writing (these may be in a multiple choice format or of the completion type). The questions may relate to the patient the student has examined at the previous station, or to information presented to him at the same station in the form of a patient management problem, photographs of a patient, or laboratory or specialized investigations. 5. An examiner is stationed at each procedure station and marks the student’s performance using a checklist. An example of a checklist is shown in Figure 1. 6. Where appropriate, simulated patients can be substituted for real ones.

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This approach, together with practical details of its

implementation, has been fully described in ar Association for the Study of Medical Education Booklet* (Harden and Gleeson 1979), and the experience gained in a surgical final examination has been described by Cuschieri and colleagues (1979).

Patient Management Problems (PMPs) In patient management problems the doctor or student is given information about a patient and is required to make decisions in the simulated situation about further *Copies available from ASME Office, 150b Perth Road, Dundee, Scotland.

Figure 1. Example of checklist used by examiner at one station in an o bjectiue structured clinical examination. Student’s name and initials:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.........................................

Instructions to student: This patient has been admitted for investigation of abdominal pain. Obtain a history

e appropriate boxes. ere is no tick it will be assumed

B. History taking technique Please mark out of 10 the student’s history taking technique, taking account of: -dates established -correct phrasing of questions -attention paid to answers -answers followed up appropriately -systematic approach -effective use of time 8 - 10 7-

654-

3 or less

Distinction Verygoodpass Pass Barepass Fail Bad fail

C . Student 5 attitude to patient Please mark out of 10 the student’s relationship with the patient, taking account of

-no unnecessary discomfort to patient -consideration of patient’s feelings -attempt to establish rapport with patient 8- 10

76543 or less

292

Distinction Verygoodpass Pass Barepass Fail Bad fail

u

c

Medical Teacher Vol 1 No 6 1979

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investigations and the patient’s diagnosis and management. In some problems the results of his actions or decisions are revealed immediately to the student. This is achieved by scraping away a covering over the print on the paper, by using a red mask or a red felt tip pen with coloured scrambled print or by using a latent image printing technique (Rogers et al. 1979). Latent image printing is a technique whereby information is printed which is invisible until treated by the reader in some way, for example by rubbing a special pen over the area. In this way the candidate can obtain further information about the patient as he proceeds, and his actions can be recorded and scored; a plus score for a response that was indicated, a negative score for a contraindicated response and nothing for other responses. Instead of the candidate being asked simply to select the appropriate course of action from a list, he may be asked to grade various courses of action on a five-point scale ranging from 1 for something that should be definitely avoided or was definitely wrong, to 5 for something that should definitely be done or was definitely correct (Harden et al. 1979). An example of this approach is shown in Figure 2. The Modified Essay Question (MEW is one type of sequential or linear patient management problem in which the candidate has to note on paper, as the problem unfolds, his actions and decisions (Knox 1975). In a patient management problem the information about a patient may be presented in a number of ways: printed on paper, on slides for projection, or even on overhead projector transparencies and audio tape (Biran et al. 1978). The construction and use of patient management problems has been described by Barrows (1973) and McGuire et a1 (1976). and will be discussed in depth by Christine McCuire in a future issue of Medical Teacher. Patient management problems do not test a candidate’s interpersonal skills or skills of physical examination but are useful in the assessment of clinical problem solving and decision making.

Audit of Case Records and Work Patients’ medical records can be used as a tool for assessment purposes. Although medical audit has received much attention recently, the concept is not a new one, and Zussman and Slawson (1972) described how, in 1912, Codman reviewed the case records of every patient he admitted to hospital between 1912 and 1916 and classified the results of his treatment as ‘favourable’ or ‘unfavourable’. He assigned responsibility for ‘unfavourable’ results to errors in diagnostic ability, poor treatment, refusal of the patient to accept treatment, ‘acts of God’ and the like. More recently the use of problem-orientated records has focussed attention on the educational potential of the case record (Weed 1968; McIntyre et al. 1976), and such records can form the basis of an assessment of clinical competence. The use of the case records for assessment purposes has a number of problems about which the assessor should know : Medical Teacher V ol l No 6 1979

The user has to rate the decisions on a 1 to 5 scale where 5 = definitely correct and 1 = definitely disagree.

Margaret Williams, a 59-year-old shop assistant, consults you one morning, anxious because she has been becoming progressively more breathless over the previous two months. She is now feeling breathless after moderate exertion. She was widowed three years ago, her husband having died of a bronchial carcinoma. She grieved for slightly longer than average and she has lived a lonely life since then. She no longer smokes, having given up the habit after the death of her husband. She has two married sons aged 30 and 27 who both live some distance away, have young children and whom she sees about twice a year. Her height is 5’ 5“ and she weighs 9 stones. You examine her and the only positive findings are a blood pressure of 220/110 and fundi showing only marked A/V nipping, but no haemorrhages or exudates. Urinalysis is negative. You have no previous blood pressure recordings in your notes and you arrange for her blood pressure to be taken over the next few days. Her blood pressure settles to a mean of 200/105. Grade the usefulness of the following investigations in terms of the information each is likely to provide as part of your initial diagnostic work-up for Margaret Williams. 1. ECG 2. Chest radiograph 3. Bloodurea 4. Electrolytes 5. IVP 6. MSU culture 7. Haemoglobin and absolute values 8. Serum creatinine. The x-ray showed a slight prominence of the left ventricle. At this stage what treatment would you consider for Margaret Williams? 1. Methyldopa (e.g. 250 mg b.d.) 2. A &blocker (e.g. propranolol e.g. 80 m g b.d.) 3. No treatment meantime, but continue to monitor 4. Clonidine(e.g.0.1mgt.i.d.) 5. A diuretic (e.g. bendrofluazide 5 mg daily) 6. Refer to hospital outpatient department 7. Diazepam (e.g. 2 mg t.i.d.) 8. Digoxin (e.g. 2 mg b.d.) 9. No treatment, no follow-up and reassure patient that her prognosis is good 10. Guanethidine (e.g. 5 mg b . d . ) 11. A diuretic with a potassium supplement Which of the above is your preferred treatment? *A limited number of copies of the complete programme are available on request.

Figure 2. Extract * f r o m patient management problem (Harden et al. 1979) 1. A study of case records may give a more accurate impression of the record keeping ability of the doctor or student than of his clinical practice. 2. Sketchy records with missing notes (a not uncommon situation) may give a poor indication of actual practice. 3. Aspects that one may wish to study are frequently not mentioned in notes, e.g. patients’ attitudes. 293

4. What is described in the notes may not be what actually happened.

Despite these difficulties, case records have much to offer in assessment. Other valuable records which can be used as a basis for audit in general practice are the prescriptions written by a practitioner (Crooks 1978).

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Superuisors’ Reports Reports by senior staff or junior colleagues on students with whom they are in close contact in their clinical work, and reports by general practitioner trainers on their. trainees, can provide useful measures of clinical competence. Wiener and Nathanson (1976) described how interns and residents were required to do a 15-minute interview and examine an unknown patient in front of the remainder of the group during a ward round. During these sessions a number of errors in interviewing and physical diagnosis were observed. The commonest were errors in technique. For example, patients were often over questioned rather than allowed to tell their own story: poorly defined complaints such as ‘cold’and ‘fever’ were accepted without further clarification; and there was incomplete characterization of major symptoms such as the relieving and exacerbating circumstances. The main problem when such observations and reports are used in formal assessments is that they are subjective. Thus, standards may vary from observer to observer, and the personal bias of the observer will be a factor in the final assessment. Graham (197 1) has described the use of descriptive checklists to improve objectivity. Terms are placed in several columns with positive and negative descriptions at the top and bottom of each column. The terms described general personality characteristics, treatment planning, clinical judgement, ethical behaviour and student-patient interaction. A term was ticked off on each column to describe any given student. Narrative sections were also included in which the ob-

server described situations efficiently or ineffeciently tackled by the doctor or student. An example of a rating scale to assess general practice trainees’ clinical problemsolving skills is shown in Table 4 (Byme 1976). In addition to assessing the trainee’s ability and skill in using information to develop a diagnosis and support clinical activity, Byrne (1976) devised rating scales to assess eight other criteria of clinical competence: information gathering, clinical judgement, relationship to patients, continuing responsibility, emergency care, relationship with colleagues and professional values. The rater was asked to place a vertical line on a 12-point scale to represent his rating of the trainee. As well as the use of checklists or rating scales, reliability is improved as the number of raters is increased. The use of several observers to assess clinical competence helps to cancel individual observer variation.

Project Work and Case Studies As part of their clinical work, students or trainees might be required to undertake a small project or assignment which contributes to their assessment. This might be the documentation of a patient or patients, including the follow-up and a discussion, or a study of some aspect of clinical practice, e.g. a survey of patients with anaemia. Such activities can help provide an estimate of a candidate’s capacity for independent work, critical thinking and ability to make use of information sources. As with observers’ reports, the reliability of such assessments may cause some concern and can be improved by the use of more than one marker.

Why assess Clinical Competence? In general, the functions of a clinical assessment do not differ from other assessments (Harden 1979). These are: 1. To pass or fail the student. 2. T o grade the student.

Table 4. Example of rating scales used to assess general practitioner trainees’ clinical problem solving skills (Byrne 1976). The Acceptable Trainee

The Unacceptable Trainee Does not fully realize the implications of the data which he collects.

He is unable to interpret the unexpected result, which he may often ignore, and his thinking tends to be rigid and unimaginative and impedes his recognition of associated problems. His general shortcomings-rigidity of thought and lack of capacity to range round flexibly, i.e. to diverge when thinking over a particular problem - inhibit his effectiveness.

Realizes the importance of unexpected findings and seeks to interpret them. He understands the nature of probability and uses this to assist his diagnosis and decision making. He considers all data before making a decision and routinely tests alternative hypotheses. He thinks effectively, i.e. he has the capacity to range flexibly, or ‘diverge’, in the search for relevant factors in connection with the particular problem in hand. He also has the capacity to focus or ‘converge’ his thinking on whatever factors have been decided upon as relevant.

Rating

01

02 Poor

294

03

04 05

06

Marginal

07

08

Good

09

10

11

12

Excellent

Medical Teacher Vol 1 No 6 1979

3. To provide feedback to the student.

required. If this thesis is adopted, then it is important to have a check on the extent of its success through feedback from examinations to teachers. If a significant number of students show a deficiency in an important aspect of clinical practice, then the teacher should look again at the training programme.

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4. To provide feedback to the teacher. 5 . To motivate the student.

A student or doctor passing a clinical examination is certified as having the clinical skills claimed to be tested by the examination. Thus, the public can be assured that a qualified doctor has certain basic competencies which allow him to practise clinically, albeit at first largely under supervision. Those responsible for the examination must determine what are the minimum standards necessary for a candidate to pass the examination and in what circumstances the verdict should be ‘failed’ or ‘not yet reached the required standard’. Such decisions are not easy and usually involve judgements on the part of the examiners, particularly where a candidate’s performance is satisfactory in some areas and unsatisfactory in others. In reaching a conclusion about an individual student, examiners can be helped by a breakdown of the student’s marks in different areas, e.g. history taking, physical examination, interpretation and problem solving and patient management (Cuschieri et al. 1979). Examinations along the lines of the OSCE make it easier to set about establishing minimum standards. Examinations can be designed, the purpose of which is to select candidates with particular ability, as has been suggested in relation to the examination for the Membership of the Royal College of Physicians (Whimster 1978). In such examinations the emphasis may be on including measures which discriminate most effectively between the less and more able candidate, although even here some measure of minimum competence is required.

When Should Students be Assessed? There are strong arguments for a combination of incourse and end-of-course assessment of clinical competence, and the General Medical Council Survey of Basic Medical Education (1977) reported that this is the practice in a number of UK medical schools (Table 5 ) . In-course assessment encourages assessment of day-to-day clinical work and provides feedback to staff and students. For example, Wiener and Nathanson (1976) reported assessment of clinical competence of junior medical staff during ward rounds. End-of-course assessment looks at the student’s clinical competence at the end of the course. In Dundee students have a mixture of in-course and end-of-course assessment. During their first two clinical years students have six clinical assessments and are awarded for each a grade A to F. In their final assessment at the end of the 3rd clinical year, examiners, in coming to a decision about a candidate, take into account the candidate’s earlier grades. Who Should Undertake the Assessment? Within a medical school the clinical examinations are mainly under the control of heads of the departments whose disciplines are involved, often with the safeguard of one or more external examiners from other schools. Recently, a national examination has been suggested to resolve some of the problems besetting universityadministered final MB examinations (Lancet 1978). National examinations already exist in the USA (National Board of Medical Examiners), in Canada and in some European countries. Unfortunately, as Newble and Elmslie (1978) have pointed out, many such national examinations, by excluding the clinical component of the examination in the interest of reliability, have impaired the examination as an assessment of clinical competence. The objective structured clinical examination approach does, however, offer the possibility of the organization of similar clinical examinations simultaneously in several centres, and work along these lines is already proceeding. Responsibility for the assessment of an individual could

Feedback Function

Assessments of clinical competence should be seen also as having an important feedback function -feedback both to the candidate and to the examiner. As with playing golf, continued practice is not by itself a guarantee of improved performance and assessments should be used to provide feedback to students in the form of ways in which improvements in their clinical skills are possible. In the same way, good practice can be reinforced. In examinations for diplomas in music and dancing, the examiners have to comment in writing on aspects of the candidate’s performance, and this information is given to the candidate whether he passes or fails. This practice could be usefully extended to clinical examinations in medicine. Perhaps in the past it has been felt that too small a sample of the student’s skills were examined to allow the examiner to comment in this way, or that such commentaries might encourage students who have been deemed to have ‘failed’ the examination to query the decision. However, neither explanation stands up to close inspection. Feedback of information to students about examination performance is an area which could be further explored. Clinical training is often a haphazard or unplanned affair, the assumption being that the students or doctors attached to a clinical unit or teaching practice for a specified period of time will gain the competencies Medical Teacher V o l l No 6 1979

Table 5. Assessment of clinical competence in UK medical schools (GMC Survey of Basic Medical Education 1977). Number of schools

Timing of assessment ~

~

~

~~

End-of-course only Mainly end-of-course but also in-course End-of-course and in-course Mainly in-course In-course only

~~

15 11 8 0 1

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be delegated to the person who is in day-to-day contact with the person being evaluated. This may be the trainee's trainer or the student's clinical supervisor. This assumes, however, both an impartiality on the part of the assessor and appropriate briefing or training. Finally, the student or doctor should be encouraged to accept some responsibility for assessing his own competence. Patient management problems are particularly effective in this respect (Harden et al. 1979). With regard to skills in history taking and the physical examination, students may be given checklists which will allow them to evaluate their own performance and to identify problem areas (Graham 1971).

Stokes, J. F., The Clinical Examination - Assessment of Clinical Skills, ASME Booklet No. 2, Association for the Study of Medical Education, Dundee, 1974. Weed, L. L., Medical records that guide and teach, New England Journal ofMedicine, 1968.278, 593-600. Whimster, W. F.. The MRCP 1977, British Medical Journal, 1978, 1,217-220. Wiener, S. and Nathanson. M.. Physical examination: frequently observed errors. Journal of the American Medical Association, 1976, 236,852-855. Wilson, G. M., Level, R., Harden, R. M., Robertson, J. B. and MacRitchie, J., Examination of clinical examiners, Lancet, 1969. i, 3740. Zussman. J . and Slawson, M. R., Service quality profile: development of a technique for measuring quality of mental health services, Archives of General Psychiatry, 1972.27.692-698.

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Teaching Package on Child Abuse Child abuse is responsible for the deaths of up to 110 young children in the U K each year and for about 7,700 non-accidental injuries. With these figures in mind, the Open University and Newcastle upon Tyne Polytechnic have jointly produced a teaching package which provides a multidisciplinary overview of the subject for anyone in contact with children under threat: It is aimed at social workers, health visitors, doctors, police officers, teachers, and other professionals and non-professionals, many of whom are trained without an awareness of other disciplines. The contributors are equally wide ranging. The package comprises a Reader, a Study Text and a Teaching Pack, which can be used singly or together. It provides practical information and techniques for predicting problems and rehabilitating families, and it covers emotional, sexual and psychological, as well as obviously physical damage. The two books in the package are Child A b w e - A Study Text (€4.95), edited by Dr Vida Carver, Senior Lecturer in the Oxford University Post-Experience Unit, and Child Abuse-A Reader and Source Book (25.50) edited by Miss Constance M. Lee, Principal Lecturer in Health Studies at Newcastle Polytechnic. The Study Text provides a programmed learning approach to the subject: topics covered include recognition and diagnosis, crisis intervention, and methods and techniques for the professionals. The Reader deals with the complex, multidisciplinary theoretical background and describes practical actions for prevention and intervention. The Teaching Pack (E20), edited by Richard Fothergill, Principal Lecturer, Educational Development Unit, Newcastle upon Tyne Polytechnic, and Susan Hurley, Senior Counsellor, Open University Northern Region, supports the two books by providing material for group work and is suitable for use in, for example, a postgraduate centre. The three parts of the package are available from: Open University Educational Enterprises Ltd, 12 Cofferidge Close, Stony Stratford, Milton Keynes, Buckinghamshire, UK.

Medical Teacher Vol 1 No 6 1979