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Cover page of the Journal of Health Sciences

 Table of Contents  
Year : 2022  |  Volume : 15  |  Issue : 2  |  Page : 107-109

Workplace-based assessment for improving clinical performance: A shift from assessment of learning to assessment for learning in medical education

Department of Community Medicine, J. N. Medical College, Belagavi, Karnataka, India

Date of Submission11-May-2022
Date of Acceptance17-May-2022
Date of Web Publication24-May-2022

Correspondence Address:
Dr. Deepti M Kadeangadi
G-01, Nitya Deep Comfort. Opp. KPTCL Community Hall, Shiva Basava Nagar, Belagavi, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kleuhsj.kleuhsj_412_22

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How to cite this article:
Kadeangadi DM. Workplace-based assessment for improving clinical performance: A shift from assessment of learning to assessment for learning in medical education. Indian J Health Sci Biomed Res 2022;15:107-9

How to cite this URL:
Kadeangadi DM. Workplace-based assessment for improving clinical performance: A shift from assessment of learning to assessment for learning in medical education. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2023 Jan 28];15:107-9. Available from: https://www.ijournalhs.org/text.asp?2022/15/2/107/345834

“Assessment drives learning” is a well-known fact in medical education. Physicians' graduates from medical colleges in India are not competent enough to practice in real life due to a lack of skills in lifesaving, communication, team skills, and professionalism. Conventional assessment methods did not observe the clinical performance directly in day-to-day practice and if observed, were not accompanied by any feedback. These assessment methods lacked in uniformity, context specificity, and objectivity for every student. Conventional assessment methods were implicit and nonstandardized and were based on subjective judgments by experts. Hence, it is important to assess the clinical performance of all trainees as a part of a formative assessment or assessment for learning. This can be done by the inclusion of the assessments of performance in the workplace, rather than relying on formal and infrequent high-stakes examinations alone.

“Workplace-based assessment” refers to the assessment of day-to-day practices undertaken in the working environment. Workplace-based assessment (WPBA) is an assessment of what doctors actually do in practice. It is also called in-training assessment, continuous assessment, or internal assessment.[1],[2] The research literature on workplace-based formative assessment and feedback suggests that it is a powerful means for changing the behaviour of learners.[3]

The three cardinal features of WPBA are direct observation of performance, conducted at the workplace, and provision of feedback to the trainee.[1] The critical element required to achieve this is the provision of feedback from assessor to trainee, enabling the trainee to steer his or her learning toward desired outcomes.[3]

The Postgraduate Medical Council Board has published a guidebook for the implementation of WPBA methods and the General Medical Council of the United Kingdom and the American College of Graduate Medical Education (USA) assessment guidebook, and the American Board of Internal Medicine have recommended the use tools of WPBA for formative assessment: mini-Clinical Evaluation Exercise (mini-CEX) for assessing clinical skills, direct observation of procedural skills (DOPS) for patient care, procedural skills, case-based discussion (CBD) communication skills, and professionalism chart-stimulated recall (CSR) for assessing record-keeping skills, and mini-peer assessment tool (mini-PAT) for team skills for postgraduate and undergraduate medical education.[2],[4],[5],[6]

Postgraduate Medical Education Regulations 2021 by the National Medical Council (NMC) of India have specified that formative assessments should be continuous and should assess medical knowledge, patient care, procedural and academic skills, interpersonal skills, professionalism, self-directed learning, and ability to practice in the system on a day-to-day basis. Patient-based learning and skill-based training and self-directed learning methods are recommended teaching-learning methods. NMC has suggested the WPBA assessment methods to evaluate undergraduate clinical internal assessment and also other methods such as DOPS for, mini-CEX for, multisource feedback (MSF) records maintenance, and attitudinal assessment in undergraduate medical education.[7],[8]

There are many WPBA tools used across the world; the most commonly used tools WPBA can be divided into four categories.

  1. Observation of clinical activities ‒ min CEX and DOPS
  2. Discussion of clinical cases ‒ such as CSR and the CBD
  3. Documentation of work experience through logbooks ‒ such as clinical encounter cards
  4. Feedback from peers, coworkers, and patients ‒ MSF/360° mini-PAT, team assessment of behaviors, and the patient satisfaction questionnaire.[9]

  Rationale for Using Workplace-Based Assessment Top

Workplace-based assessment conforms to the highest level of Miller's pyramid

The base of Miller's pyramid (knowledge) is like a concrete foundation on which all other layers of the pyramid are built. Medical education literature distinguishes between competence (ability to do) and performance (actually doing). In terms of Miller's pyramid, competence would fall under the “shows” category, whereas performance falls under “does.”[1],[8] The trainees competent in controlled situations such as OSCE, may not be performing the same way on the ground.[3] Hence, WPBA provides trainee with real-life situations with good sample of the situations that the trainee will actually encounter after completion of training.

Focuses on clinical skills

Focuses on clinical skills assessment in real life with the inclusion of soft skills assessment such as communication, professionalism, behavior, attitude, and ethics which are the key components of physician‒patient interaction, and these were not assessed explicitly in traditional assessment methods. WPBA methods have these soft skills inbuilt within the assessment rating scale. Hence, the assessors will not miss the opportunity to assess soft skills assessments and hence can identify those who might need particular educational support early in training.[1]

Observation and feedback

“Learners need endless feedback more than they need endless teaching.” Hattie established the fact that feedback is the most important contributor to learning and it is said to be the heart of medical education. Feedback is more effective when it is given after a specific task, which is inbuilt in WPBA. Feedback provides an opportunity for the trainee and teacher to reflect on his/her clinical behavior and encourages reflective practice. However, the opportunities for assessment by direct observation and feedback are underutilized in traditional methods of assessment.[1],[3]

Context and content specificity

Physicians perform differently on different patients in different contexts such as outpatient department, inpatient department, intensive care unit, and casualty and emergency departments. WPBA uses the clinical patients seen by the trainee at these different settings and those are the same patients, which they will be seeing tomorrow in his real-life practice also. Learning at workplace is triggered by specific problems encountered with patients, known as “on spot learning.” The first step in the development of curricular content areas is based on local needs analysis. WPBA caters to the same content areas what trainees see in actual local context.[1],[9]

The utility of any assessment depends on many attributes, namely validity, reliability, acceptability, feasibility, and educational impact. An assessment low on any one of these attributes can compensate by being high on others.[10]

(Van der Vleuten's and Schuwirth Conceptual Model)

Utility = validity × reliability × feasibility

× acceptability × educational impact.[1],[9],[10]

OSCE is said to be high on reliability, but low on validity and educational impact. It means that assessing what trainees do in a real-life setting is likely to be more authentic than in a controlled situation. Hence, a better predictor of future performance compared with assessment in a controlled situation such as Objective structured clinical examination (OSCE). WPBA stands very high on validity due to the authenticity of assessment in real life and its future educational impact on society. Acceptability and feasibility from both trainee and trainer have been demonstrated in few studies in India.[1],[9],[10]

  Challenges for Implementation of Workplace-Based Assessment in India Top

Many institutions across the country have implemented WPBA methods in isolation or as a program. Such programs demonstrate the feasibility of implementation to others, especially as a part of formative assessment methods.

Sensitization of faculty and trainers by various faculty development programs can overcome the initial resistance to implement WPBA methods. Most of the time, the feedback relies on student self-assessment and improvement than remedial measures or any action planned by faculty. Faculty training to improve the quality of assessment and feedback is crucial. Faculty plays a key role in the implementation of any formative assessments such as WPBS. Poor faculty participation and feedback strategies are the reasons for its poor implementation. This can be overcome by educational recognition and incentives given to faculty who are involved in the implementation of WPBA methods.[1],[3]

Conventional assessment methods did not observe the clinical performance and obtain feedback in day-to-day practice. Whereas, WPBA has features of direct observation of performance, conducted at the workplace, and provision of feedback to the trainee are obtained to overcome the limitations of conventional assessment methods. WPBA can improve the quality of undergraduates' and postgraduates' clinical performance, if implemented as a whole program, and ensures the quality of care to patients in future.

  References Top

Singh T, Modi JN. Workplace based assessment: A step to promote competency based postgraduate training. Indian Pediatr 2013;50:553-9.  Back to cited text no. 1
GMC Assessment in Undergraduate Medical Education. Available from: https://www.gmc-uk.org/-/media/documents/Assessment_in_undergraduate_medical_education___guidance_0815.pdf_56439668.pdf. [Last accessed on 2022 Mar 08].  Back to cited text no. 2
Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach 2007;29:855-71.  Back to cited text no. 3
PMETB Assessment Committee. Developing and Maintaining an Assessment System – A PMETB Guide to Good Practice. Postgraduate Medical Education and Training Board. London; 2007. Available from: http://www.gmc-uk.org/Assessment_good_practice_v0207.pdf_31385949.pdf. [Last accessed on 2022 Apr 11].  Back to cited text no. 4
Holmboe ES, Iobst WF. ACGME Assessment Guidebook. Available from: https://www.acgme.org/globalassets/PDFs/Milestones/Guidebooks/AssessmentGuidebook.pdf. [Last accessed on 2022 Apr 25].  Back to cited text no. 5
PG Curricula | NMC. Available from: https://www.nmc.org.in/information-desk/for-colleges/pg-curricula-2/. [Last accessed on 2022 Apr 05].  Back to cited text no. 6
Competency Based Undergraduate Curriculum for the Indian Medical Graduate NMC Module 3 Assessment Module for Undergraduate Medical Education; 2019. Available from: https://www.nmc.org.in/wpcontent/uploads/2020/08/Module_Competence_based_02.09.2019.pdf. [Last accessed on 2022 May 21].  Back to cited text no. 7
Competency Based Undergraduate Curriculum for the Indian Medical Graduate Module 5. Available from: https://www.nmc.org.in/wp-content/uploads/2020/08/Skill-Module_23.120.2019.pdf. [Last accessed on 2022 May 08].  Back to cited text no. 8
Singh T, Sood R. Workplace-based assessment: Measuring and shaping clinical learning. Natl Med J India 2013;26:42-6.  Back to cited text no. 9
Singh T, Anshu. Principles of Assessment in Medical Education. 1st ed. New Delhi: Jaypee Publishers Brothers Medical Publishers (P) LTD.; 2012.  Back to cited text no. 10


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