Iram Khursheed  ( Department of Family Medicine, Ziauddin Medical University, Karachi. )
Yaseen Usman  ( Department of Family Medicine, Ziauddin Medical University, Karachi. )
Jawaid Usman  ( Department of Family Medicine, Ziauddin Medical University, Karachi )

Erythema ab igne is a localized red brown reticular pigmentation, resulting from chronic, repetitive exposure to sub maximal heat, insufficient to cause burn. A study was carried out at the dermatology outpatient department of Combined Military Hospital, Abbottabad during January-April 2005 with the purpose to see frequency of erythema ab igne. Fourteen patients were identified, interviewed and examined in detail. Nine were females, eight of them housewives, and five were males. Age of the patients ranged from 9 to 60 years with a mean of 36.5 + 14.8 years. Body Mass Index (BMI) of the patients ranged from 13.5 to 33.5, six of them were in the BMI range of between 25.1 and 30. Nine patients belonged to rural areas. Erythema ab igne was not associated with thyroid disease or any other systemic or psychiatric illness.

Medical education implies assessment of students at regular intervals as a source of learning and providing the basis for enhancing the competence level. In this context, skill based assessments are of importance in addition to knowledge based tests.1

Harden introduced Objective Structured Clinical Examination (OSCE) in 1975 for assessing students' clinical competence in a more comprehensive, consistent and structured manner.2 This technique not only makes the process objective but also addresses the assessment of all three domains (cognitive, affective and psychomotor) at one point.2,3 Although OSCE seems to be more authentic even then it can not be regarded as a perfect way of assessment in terms of validity and reliability. However literature has shown that various strategies can be adopted to meet the acceptable standards.4,5

OSCE has been in practice in many parts of the world with favourable outcomes and has proven provide formative and summative assessment in various medical disciplines.6

In the early nineties College Of Physicians and Surgeons Pakistan (CPSP) introduced OSCE as an assessment technique for post graduates in the discipline of Family Medicine.7 Whereas, at undergraduate level, the Aga Khan University (AKU) and King Edward Medical College (KEMC) implemented this technique in the late nineties. Analysis of OSCE at AKU regarded it as a system of examination that can be used to evaluate affective and psychomotor domains.8 At KEMC students offered positive and constructive feedback and demanded its implementation in all clinical subjects.9

Students' feedback is regarded as a key indicator for successful implementation of the process and also provides an impulse for improvement.

Ziauddin Medical University introduced OSCE in 2004 for the assessment of clinical competencies at the undergraduate level.

This study aimed to evaluate undergraduate students' perceptions regarding OSCE to be used as a feedback to improve the assessment technique.

The department of Family Medicine, Ziauddin Medical University is imparting basic clinical skills training (history-taking, physical examination and communication skills), to the third year undergraduate medical students. They are then assessed for the clinical competencies through OSCE.

For this particular study, OSCE was designed by using 10 observed performing stations and the two resting stations. Performing stations were equipped with standardized simulators (not real patients, rather healthy volunteers trained to act/ behave according to given scenario) and the observer (examiner). The aspects of competence (history-taking, physical examination and communication skills) were assessed in a structured manner. The examination at each station lasted for five minutes and performance of the required tasks was calibrated according to specifically designed checklists, containing ten items, each with an assigned score corresponding to the key skills.

At the end of this session, students were provided with a feedback questionnaire related to OSCE to obtain their views and comments. The feedback was obtained from two consecutive batches of third year medical students and was utilized to incorporate the improvements in the process, wherever possible.

A total of 110 students out of 115 (69 from group 'A' + 41 form group 'B') responded to the questionnaire, representing 96% response rate (Table). Group 'A' was students of 3rd year during 2004 and group 'B' was 3rd year students during 2005. Students' comments were also invited for possible improvement in OSCE through an open-ended question.

The majority of students (81% from group 'A' and 88% from group 'B') agreed that the objectives of clinical rotations were covered. Similarly a significant (p-value=0.01) majority of students from group 'B' (88%) agreed that the OSCE process was known beforehand and the given tasks were clear and easily understood. Likewise a significant (p-value=0.01) majority of students from group 'B' (85%) agreed that tasks given in OSCE were demonstrated during their clinical rotations and believed that content of OSCE stations was relevant and linked to the curriculum (83% from group 'A' and 95% from group 'B'). Most were comfortable with the sequencing of stations (71% from group 'A' and 76% from group 'B'). Approximately half of the students (55% from group 'A' and 45% from group 'B') were comfortable with the time given otherwise most of them felt that it was inadequate for the tasks given. Most of the students (72% from group 'A' and 83% from group 'B') agreed that the facilitators (observers/ examiner) were cooperative and majority (80% from group 'A' and 85% from group 'B') stated that standardized simulators were cooperative. A small proportion (35% from group 'A' and 15% from group 'B') mentioned interference in at least one of the station by the facilitator. Overall 68% students felt that OSCE performance is affected by simulator's response or behaviour.

A great majority of students (93% from group 'A' and 95% from group 'B') regarded OSCE as a practical and useful assessment tool in early years of medical education while (65% from group 'A' and 80% from group 'B') found that it identified deficiencies in their clinical skills.

Overall 38 students commented to the open ended question; which included 23 comments for increasing the duration of stations, 9 for ensuring clear instructions and 2 for having real patients for the expected tasks. Four students emphasized on more training with the OSCE and emphasized its scheduling at regular intervals during 3rd year.

In this study, students appreciated OSCE and offered constructive feedback on structure and organization of the process. However, at some stations they felt that instructions were ambiguous and time allocation was inadequate for the assigned tasks. It is assumed that lack of specific training in time management skills and inadequate practice at being examined in the OSCE format might have contributed to the dissatisfaction with the time allocation. The overall feedback was very useful and facilitated a critical review of the process.

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1. Smee S. ABC of learning and teaching in medicine Skill Based Assessment. BMJ 2003; 326: 703-06.

2. Harden RM, Stevenson M, Downie WW, Wilson GM. Assessment of Clinical Competence using Objective Structured Examination. BMJ 1975; 1:447-51.

3. Shaw LMA. Effective Assessment of trainees. The Ob .& Gynae 2004; 6: 171-77.

4. Newble D. Techniques for Measuring Clinical Competence: Objective Structured Clinical Examinations. Med Edu 2004; 38: 199-203.

5. Carraccio C, Englander R. The Objective Structured Clinical Examination, a Step in the direction of Competency-Based Evaluation. Arch Pediatr Adolesc Med 2000; 154: 736-41.

6. Elahi F. Objective Structured Clinical Examination (OSCE): a practical guide book. 2nd edition, Karachi: National Teacher Training Centre, 1991.

7. Zuberi RW, Jafarey NA, Qureshi AF, Elahi F. The Diploma in Family Medicine Examination; a Scientific Exercise. J Pak Med Assoc 1993; 43: 217-20.

8. Nizami SQ, Yousuf K, Khan IA, Khan S, Shah U. Evaluation of Objective Structured Clinical Examination(OSCE) for undergraduate students at the Agha Khan University, Karachi. J Coll Physicians Surg Pak 1998; 8: 5-7.

9. Ashraf M. Introduction of OSCE at Undergraduate Level Ann King Edward Med Coll Dec 2000; 6: 383-4.