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Sir,Objective Structured Clinical Examinations (OSCEs) have been used increasingly in recent years to assess competence in practical skills. In 1996 we adapted the system for pre-registration house officers at Frenchay Hospital, Bristol, UK, and found them extremely valuable as a learning tool and for increasing confidence and competence in practical skills. The first year after qualification is often very stressful, with young doctors being expected to undertake procedures for which they have had little training. The introduction of our clinical skills laboratory has helped enormously to bridge the gap between undergraduate and postgraduate practice.
OSCEs are arranged for the house officers mid-way through their post and all are invited to participate. Although attendance is not compulsory, in fact there has been 80% participation each time, the other 20% being on either annual leave, night duty or on-take. Using the Clinical Skills Laboratory, work stations are set up where doctors can demonstrate particular skills, for example, male catheterisation, insertion of a chest drain, interpretation of electrocardiograms, etc. The examiners are selected from appropriate consultant medical staff or specialist registrars who prepare a list of criteria against which the house officer can be marked. For instance, when examining on the preparation and administration of intravenous drugs, the house officer is expected to demonstrate ability to write a clear and concise prescription, use and knowledge of information services, good aseptic techniques and correct labelling. A possible maximum number of marks is identified and house officers are scored against this number. Ten minutes is allocated at each of the seven work stations.
The doctors' ability to break bad news is assessed using the Communication Skills Laboratory which is equipped with video cameras and recorders. An actress is employed for whom a scenario is written and the doctors are assessed on their sensitive handling of this difficult situation. The Communication Skills Laboratory is designed to enable the OSCE to be observed from an adjoining room which allows the house officer to behave in a less inhibited way. The Macmillan Nurse participates in this and gives feedback to the doctors.
Feedback on performance is given to each doctor by the Postgraduate Clinical Tutor and a certificate issued stating that the individual has been examined in the Clinical Skills Laboratory and found to be competent in the listed areas. The certificates are signed by the Director of Postgraduate Medical Education and the Director of the Clinical Skills Laboratory and become part of the doctor's CV. The house officers are not in a pass or fail situation − they are assessed purely on their competence and, where this is found to be lacking, extra tuition is given to improve the level of competence.
Feedback from the housemen is also sought and, without exception, this has been found to be extremely positive. Whilst admitting to initial nervousness, all participants thoroughly enjoyed the OSCEs and found them a valuable learning experience. They particularly valued the opportunity to spend a few minutes with a consultant having tuition on specific topics and receiving verbal feedback at the time of examination.
The introduction of OSCEs for this group of doctors has been a very successful development in postgraduate medical education and is highly recommended to other centres. We envisage compulsory assessment of competence will spread throughout medicine. In today's culture of clinical governance and litigation, it is essential that some form of assessment is developed to protect patients, medical staff and hospital trusts.
We thank our colleagues who have been so enthusiastic and helped this to happen.