SECTION 6
2. Current and future concerns Philip Tombleson, MBE, FRCGP SUMMARY: Three areas offuture concern for the Examination Board are identified and discussed: the problem of gaining a reliable insight into the true behaviour of candidates when face to face with patients; the effect of the examination on general practice training and those involved in it; and the need to explore the potential of a wider educational role for the examination.
licensing a 30-station OSCE is used, when 72 candidates are examined over two days with high reliability (alpha coefficient 0.86) (Cohen et al., 1988). Some examinations have dispensed with examiners and trained the patient to make the assessment at the stations where clinical encounters take place (Stillman et al., 1980). Unfortunately, the College's experience in pilot trials of OSCEs (18 stations) held in the winter of 1989/90 was that a series of short stations evaluating single skills or attributes was poorly accepted by examiners as being unrepresentative of 'real world' general practice (Mulholland and McAleer, 1988). Indeed a study of 35 family physicians in Hamilton, Ontario, using five assessments including OSCE, found high inter-rater and subtest reliability for all components but the OSCE. It was concluded that the disappointing performance of the OSCE possibly reflected the fact that it was a useful discriminator at junior levels but not for assessment of (mature) physician performance (Norman et al., 1988). Longer scenarios have been used elsewhere in the assessment of family practitioners, such as a pilot study described in New Zealand (O'Hagan et al., 1986), the structured office orals (SOO) of the College of Family Physicians of Canada, and the simulated office with standardized patients (SOSP) used in the McMaster University physician review programme. This latter uses a well equipped consulting room with a one-way mirror and a video camera; the consultation with simulated patients lasts up to 20 minutes and is marked by two observing examiners. This overcomes a further objection to the pilot studies held by the RCGP Examination Board, namely that moving from station to station was disruptive to the candidate and artificial. There is a problem, however, that longer stations may incur less overall sampling and thus lower reliability. It has been estimated that ideally 30 stations of the structured office oral would be needed to estimate reliably a candidate's ability to manage health problems, and 10 to 15 to judge interviewing skills. Nevertheless, the Examination Board feels further research into 'simulated surgeries' to be important, as this form of evaluation of clinical competence looks highly promising (Mulholland and McAleer, 1989).
Introduction
THE membership of the College owes a great debt to the original founders of the examination. An indepth investigation has shown adequate reliability and, apart from the removal of the essay paper, little need for urgent change. Content validity of the multiple choice question paper has been improved by a temporarily high (30%) rate of newly devised questions, sampling in the modified essay question has been widened, and the role of the oral examination defined more clearly by the use of marking grids and greater standardization of examiner behaviour.
Clinical component One area that gives most cause for concern is the lack of a clinical component - examiners actually viewing the candidates face-to-face with the patient. The important feature of any such direct assessment is the appreciation of the 'content specificity' of problem-solving skills in that a doctor's performance varies considerably and non-systematically from one clinical situation to another (Barrows et al., 1978; Elstein et al., 1978; Swanson et al., 1982). This means that extensive sampling of the candidate's abilities is necessary to achieve a true judgement. The traditional 'clinical' examination with 'real' patients, for example one long case with four short cases, cannot therefore reach any degree of reliable judgement about a candidate (and without reliability there cannot be validity). Other factors such as contamination (leakage of information to the candidates), inter-rater reliability (examiners marking for different skills and attributes from each other) contribute to the unacceptability of such a test instrument. The use of simulated tasks presented to the candidate at 'stations' in the objective structured clinical examination (OSCE) (Harden and Gleeson, 1979) has given assessors an instrument whereby such a direct measurement of clinical skills can reliably be made. The OSCE has been taken up with particular enthusiasm in North America, and in Canada, for example, for foreign entry
43
44
Assessment and learning The place of assessment in directing learning behaviour is a sensitive and controversial topic. Traditionally, a learning curriculum is set up by the teachers concerned, and the contents assessed either during the educational process as a feedback to the student (formative assessment) or at a set point in the training to establish a rank ordering of the candidates (summative assessment). Much interest has been generated in the last decade on the effect of assessment on students' learning behaviour. This may be particularly marked where the assessment (e.g. a degree examination) is seen to be little more than recall of factual information (Beard and Senior, 1980). Not only the content of the learning but the learning style may be influenced by the assessment, the students adapting their way of learning to their concept of what is required of them (Entwistle, 1981). Thus two broad strategies of learning, 'surface' and 'deep', are described (Marton and Saljo, 1976a). The surface approach is adopted when the student merely identifies and memorizes important facts and ideas without appreciating the structure and principles involved; the intention is to reproduce the material likely to be set in the assessment. The preferred deep approach on the other hand is characterized by the student's intention to understand material of the subject. Interestingly, those adopting this approach not only had a more complete understanding in one study, but were also able to recall more factual details, both immediately and several weeks later (Marton and Saljo, 1976b). Also described is the strategic approach of the student motivated by a sense of competition; in his quest for high grades he may use either deep or surface approaches in a calculated way to win the examination 'game' (Newble and Entwistle, 1986). One factor that has become evident in the review of the MRCGP examination is the need to test a wide range of skills, as well as testing for an adequate knowledge base. Unfortunately the examination is perceived by some candidates as having a high factual bias (in fact, the multiple choice question paper represents only one fifth of the overall mark and is highly specific to family practice), and this effect has caused resentment among some trainers who complain that the trainee in his final months spends too much time reading textbooks preparing for the examination, thus interfering with his educational programme. (In view of this perceived disruption to training, Council of the College debated the issue in January 1990 but decided to retain the status quo.) Indeed this false concept, if held, that factual knowledge is of paramount importance in the MRCGP examination is alarming and needs to be firmly denied. In one study, where the final examination for medical students has become predominantly multiple choice tests, staff became concerned that students, instead of spending all of their time in the wards (four weekly ward-based assessments had also been introduced) were increasingly to be found studying in the library and requesting didactic lectures (Newble and Jaeger, 1983). Such an effect on the behaviour of candidates for the MRCGP examination would be most unwelcome and closer links with the
trainers themselves need to be forged to ensure an appropriate and acceptable assessment of their educational goals (Leeder et al., 1979). Nevertheless, the presence of a goal such as the MRCGP examination may in itself be a powerful stimulus to learning. Motivation and performance are strongly related and there is evidence that individuals work more closely to their capacities where an assessment exists (Scottish Education Department, 1977). A study of 400 trainees showed that the two most important reasons for taking the examination were to help in getting a job (significantly more women than men) and as a personal hurdle or discipline (Tombleson and Wakeford, 1989). Is there, then, a case for utilizing the examination to influence learning behaviour in an area the College considers needs greater emphasis? The case has been put for assessment procedures to provide a guide to student learning (Fritts and Posner, 1978). Since what and how a student learns will be markedly influenced by how he is assessed, the argument runs that the form or procedures used are clearly related to learning requirements. Such assertions suggest that the MRCGP examiners must act with great sensitivity in defining educational goals with trainers yet at the same time reflect the College's forward-thinking ideas. Thus just as the introduction of cardiopulmonary resuscitation certification and implementation of the critical reading question paper are examples of perceived ideas being highlighted by the examination itself, so prior certifiction by trainers in areas such as research and audit (as in the Canadian College examination) is another avenue worth exploring.
Continuing learning and assessment The MRCGP examination has always been offered without charge to those members who have previously gained the examination. This form of assessment, however, is limited to the exceptionally motivated (and courageous). It is of interest to review the way some of our sister Colleges approach this area. Mandatory assessment packages are required to be taken by members of the Canadian College of Family Physicians every five years; the distance learning package has abstracts and references included and there is confidentiality of marking. In Australia the CHECKUP programme is used by the 2000 trainees in the family medicine programme and from February 1988 about 500 family doctors (Marshall, 1989). Because of the vast size of the country a programme of home-based video text programmes is used, with a bank of true/false, patient management and modified essay questions. A printout of performance feedback, which identifies areas of knowledge that need to be improved, is forwarded confidentially to the individual. Similar programmes exist in several other countries, but in the United Kingdom distance learning programmes have mainly been content specific, such as the ones the College issues in conjunction with the Centre for Medical Education, Dundee - the CLIPP and CASE projects. The College's own fellowship by assessment is a practice-based assessment with specific management
45 and organizational criteria plus video evaluation but no broad-based evaluation of skills or knowledge. It does appear that there might be room for a distance learning/assessment package in the College. Such a programme could be co-ordinated by an expert medical educator who would then be the pivotal figure in the College's educational and examination domains. Conclusion
The study of clinical competence has been described as a 'battered child': 'child' because it is a relatively new topic of interest, 'battered' because it is maltreated by some researchers (Neufeld, 1985). The MRCGP examination is fortunate in having a solid foundation of well proven components, enthusiastic and talented examiners, and a supportive College. It is important that these features should not be lost by responding to fashionable psychometric influences which would remove its true validity, nor by adjusting the content to the detriment of the candidates' learning styles. Work will continue to move towards criterion-referenced assessment, and to answer some of the deceptively simple questions that an examination can raise, such as estimating the relative standards of candidates between one diet of the examination and another. The spirit of openness engendered by the assessment of colleagues by colleagues will in the meantime ensure that as much feedback of personal performance as possible will be given to individual candidates, and of overall performance of the examination in the annual report to Council, published in the RCGP Members' Reference Book. Criticisms of "excessive secrecy shrouding the examinations of the Royal Colleges" (Lancet, 1990) will, it is hoped, never be justifiably directed at the membership examination of the Royal College of General Practitioners. References Barrows H S, Feightner J W, Neufeld V R et al. (1978) Analysis of the Clinical Methods of Medical Students and Physicians. Report submitted to the Province of Ontario Department of Health and Physicians Services Inc. Foundation. Beard R M and Senior J L (1980) Motivating Students. London, Routledge and Kegan Paul. Cohen R, Rothman A I, Ross J et al. (1988) A comprehensive assessment of graduates of foreign medical schools. Annals of the Royal College of Physicians and Surgeons of Canada 21, 7, 505-9. Elstein A S, Shulman L S and Sprafka S A (1978) Medical Problem Solving - an Analysis of Clinical Reasoning. Cambridge, Massachusetts, Harvard University Press.
Entwistle N (1981) Styles of Learning and Teaching. Chichester, John Wiley. Fritts P M and Posner M I (1978) Human Performance: 'Assessing Health Workers' Performance'. London, Prentice Hall. p. 27. Harden R M and Gleeson F A (1979) Assessment of clinical competence using an objective structured clinical examination (OSCE). Medical Education 13, 41-54. Lancet (1990) Examining the Royal College examiners. Editorial 335, 443-4. Leeder S R, Feletti G I and Engel C E (1979) Assessment help or hurdle. Programmed Learning and Education Technology 16, 309. Marshall J (1989) CHECKUP: Computerised Home Evaluation of Clinical Knowledge Understanding and Problem Solving. Teaching and Learning in Medicine 1, 38-41. Marton F and Saljo R (1976a) On qualitative differences in learning. I - Outcome and process. British Journal of Educational Psychology 46, 4-11. Marton F and Saljo R (1976b) On qualitative differcnces in learning. II - Outcomes are a function of the learner's conception of the task. British Journal of Educational Psychology 46, 115-27. Mulholland H and McAleer S (1988) Report to the Examination Board of the Royal College of General Practitioners. Dundee, Centre for Medical Education. Unpublished. Mulholland H and McAleer S (1989) Report to the Examination Board of the Royal College of General Practitioners. Dundee, Centre for Medical Education. Neufeld V R (1985) Perspectives on clinical competence. In Neufeld V R and Norman G R (Eds) Assessing Clinical Competence. New York, Springer. pp. 39-50. Newble D I and Entwistle N J (1986) Learning styles and approaches: implications for medical education. Medical Education 20, 162-75. Newble D I and Jaeger K (1983) The effect of assessments and examinations on the teaching of medical students. Medical Education 17, 165-71. Norman G R, Davis D A, Painvin A et al. (1988) Comprehensive assessment of clinical competence of family/general physicians using multiple measures. Presented at 27th Conference on Research in Medical Education, Washington DC. O'Hagen J, Davies J and Pears R K (1986) The use of simulated patients in the assessment of actual clinical performance in general practice. New Zealand Medical Journal 99, 948-51. Scottish Education Department (1977) Assessment for All. Dunning Report. London, HMSO. Stillman P L, Rugill J S, Rutalla P J et al. (1980) Patient instructors as teachers and evaluators. Jouirncal of Medical Education 55, 186-93. Swanson D B, Barrows H S, Friedman C P et al. (1982) Issues in assessment of clinical competence. Professions Ediucation Research Notes 4, 2. Tombleson P and Wakeford R (1989) Why do trainees take the MRCGP examination? Letter. Jouirnal of the Royal College of General Practitioners 39, 168-71.
2. Current and future concerns Philip Tombleson, MBE, FRCGP SUMMARY: Three areas offuture concern for the Examination Board are identified and discussed: the problem of gaining a reliable insight into the true behaviour of candidates when face to face with patients; the effect of the examination on general practice training and those involved in it; and the need to explore the potential of a wider educational role for the examination.
licensing a 30-station OSCE is used, when 72 candidates are examined over two days with high reliability (alpha coefficient 0.86) (Cohen et al., 1988). Some examinations have dispensed with examiners and trained the patient to make the assessment at the stations where clinical encounters take place (Stillman et al., 1980). Unfortunately, the College's experience in pilot trials of OSCEs (18 stations) held in the winter of 1989/90 was that a series of short stations evaluating single skills or attributes was poorly accepted by examiners as being unrepresentative of 'real world' general practice (Mulholland and McAleer, 1988). Indeed a study of 35 family physicians in Hamilton, Ontario, using five assessments including OSCE, found high inter-rater and subtest reliability for all components but the OSCE. It was concluded that the disappointing performance of the OSCE possibly reflected the fact that it was a useful discriminator at junior levels but not for assessment of (mature) physician performance (Norman et al., 1988). Longer scenarios have been used elsewhere in the assessment of family practitioners, such as a pilot study described in New Zealand (O'Hagan et al., 1986), the structured office orals (SOO) of the College of Family Physicians of Canada, and the simulated office with standardized patients (SOSP) used in the McMaster University physician review programme. This latter uses a well equipped consulting room with a one-way mirror and a video camera; the consultation with simulated patients lasts up to 20 minutes and is marked by two observing examiners. This overcomes a further objection to the pilot studies held by the RCGP Examination Board, namely that moving from station to station was disruptive to the candidate and artificial. There is a problem, however, that longer stations may incur less overall sampling and thus lower reliability. It has been estimated that ideally 30 stations of the structured office oral would be needed to estimate reliably a candidate's ability to manage health problems, and 10 to 15 to judge interviewing skills. Nevertheless, the Examination Board feels further research into 'simulated surgeries' to be important, as this form of evaluation of clinical competence looks highly promising (Mulholland and McAleer, 1989).
Introduction
THE membership of the College owes a great debt to the original founders of the examination. An indepth investigation has shown adequate reliability and, apart from the removal of the essay paper, little need for urgent change. Content validity of the multiple choice question paper has been improved by a temporarily high (30%) rate of newly devised questions, sampling in the modified essay question has been widened, and the role of the oral examination defined more clearly by the use of marking grids and greater standardization of examiner behaviour.
Clinical component One area that gives most cause for concern is the lack of a clinical component - examiners actually viewing the candidates face-to-face with the patient. The important feature of any such direct assessment is the appreciation of the 'content specificity' of problem-solving skills in that a doctor's performance varies considerably and non-systematically from one clinical situation to another (Barrows et al., 1978; Elstein et al., 1978; Swanson et al., 1982). This means that extensive sampling of the candidate's abilities is necessary to achieve a true judgement. The traditional 'clinical' examination with 'real' patients, for example one long case with four short cases, cannot therefore reach any degree of reliable judgement about a candidate (and without reliability there cannot be validity). Other factors such as contamination (leakage of information to the candidates), inter-rater reliability (examiners marking for different skills and attributes from each other) contribute to the unacceptability of such a test instrument. The use of simulated tasks presented to the candidate at 'stations' in the objective structured clinical examination (OSCE) (Harden and Gleeson, 1979) has given assessors an instrument whereby such a direct measurement of clinical skills can reliably be made. The OSCE has been taken up with particular enthusiasm in North America, and in Canada, for example, for foreign entry
43
44
Assessment and learning The place of assessment in directing learning behaviour is a sensitive and controversial topic. Traditionally, a learning curriculum is set up by the teachers concerned, and the contents assessed either during the educational process as a feedback to the student (formative assessment) or at a set point in the training to establish a rank ordering of the candidates (summative assessment). Much interest has been generated in the last decade on the effect of assessment on students' learning behaviour. This may be particularly marked where the assessment (e.g. a degree examination) is seen to be little more than recall of factual information (Beard and Senior, 1980). Not only the content of the learning but the learning style may be influenced by the assessment, the students adapting their way of learning to their concept of what is required of them (Entwistle, 1981). Thus two broad strategies of learning, 'surface' and 'deep', are described (Marton and Saljo, 1976a). The surface approach is adopted when the student merely identifies and memorizes important facts and ideas without appreciating the structure and principles involved; the intention is to reproduce the material likely to be set in the assessment. The preferred deep approach on the other hand is characterized by the student's intention to understand material of the subject. Interestingly, those adopting this approach not only had a more complete understanding in one study, but were also able to recall more factual details, both immediately and several weeks later (Marton and Saljo, 1976b). Also described is the strategic approach of the student motivated by a sense of competition; in his quest for high grades he may use either deep or surface approaches in a calculated way to win the examination 'game' (Newble and Entwistle, 1986). One factor that has become evident in the review of the MRCGP examination is the need to test a wide range of skills, as well as testing for an adequate knowledge base. Unfortunately the examination is perceived by some candidates as having a high factual bias (in fact, the multiple choice question paper represents only one fifth of the overall mark and is highly specific to family practice), and this effect has caused resentment among some trainers who complain that the trainee in his final months spends too much time reading textbooks preparing for the examination, thus interfering with his educational programme. (In view of this perceived disruption to training, Council of the College debated the issue in January 1990 but decided to retain the status quo.) Indeed this false concept, if held, that factual knowledge is of paramount importance in the MRCGP examination is alarming and needs to be firmly denied. In one study, where the final examination for medical students has become predominantly multiple choice tests, staff became concerned that students, instead of spending all of their time in the wards (four weekly ward-based assessments had also been introduced) were increasingly to be found studying in the library and requesting didactic lectures (Newble and Jaeger, 1983). Such an effect on the behaviour of candidates for the MRCGP examination would be most unwelcome and closer links with the
trainers themselves need to be forged to ensure an appropriate and acceptable assessment of their educational goals (Leeder et al., 1979). Nevertheless, the presence of a goal such as the MRCGP examination may in itself be a powerful stimulus to learning. Motivation and performance are strongly related and there is evidence that individuals work more closely to their capacities where an assessment exists (Scottish Education Department, 1977). A study of 400 trainees showed that the two most important reasons for taking the examination were to help in getting a job (significantly more women than men) and as a personal hurdle or discipline (Tombleson and Wakeford, 1989). Is there, then, a case for utilizing the examination to influence learning behaviour in an area the College considers needs greater emphasis? The case has been put for assessment procedures to provide a guide to student learning (Fritts and Posner, 1978). Since what and how a student learns will be markedly influenced by how he is assessed, the argument runs that the form or procedures used are clearly related to learning requirements. Such assertions suggest that the MRCGP examiners must act with great sensitivity in defining educational goals with trainers yet at the same time reflect the College's forward-thinking ideas. Thus just as the introduction of cardiopulmonary resuscitation certification and implementation of the critical reading question paper are examples of perceived ideas being highlighted by the examination itself, so prior certifiction by trainers in areas such as research and audit (as in the Canadian College examination) is another avenue worth exploring.
Continuing learning and assessment The MRCGP examination has always been offered without charge to those members who have previously gained the examination. This form of assessment, however, is limited to the exceptionally motivated (and courageous). It is of interest to review the way some of our sister Colleges approach this area. Mandatory assessment packages are required to be taken by members of the Canadian College of Family Physicians every five years; the distance learning package has abstracts and references included and there is confidentiality of marking. In Australia the CHECKUP programme is used by the 2000 trainees in the family medicine programme and from February 1988 about 500 family doctors (Marshall, 1989). Because of the vast size of the country a programme of home-based video text programmes is used, with a bank of true/false, patient management and modified essay questions. A printout of performance feedback, which identifies areas of knowledge that need to be improved, is forwarded confidentially to the individual. Similar programmes exist in several other countries, but in the United Kingdom distance learning programmes have mainly been content specific, such as the ones the College issues in conjunction with the Centre for Medical Education, Dundee - the CLIPP and CASE projects. The College's own fellowship by assessment is a practice-based assessment with specific management
45 and organizational criteria plus video evaluation but no broad-based evaluation of skills or knowledge. It does appear that there might be room for a distance learning/assessment package in the College. Such a programme could be co-ordinated by an expert medical educator who would then be the pivotal figure in the College's educational and examination domains. Conclusion
The study of clinical competence has been described as a 'battered child': 'child' because it is a relatively new topic of interest, 'battered' because it is maltreated by some researchers (Neufeld, 1985). The MRCGP examination is fortunate in having a solid foundation of well proven components, enthusiastic and talented examiners, and a supportive College. It is important that these features should not be lost by responding to fashionable psychometric influences which would remove its true validity, nor by adjusting the content to the detriment of the candidates' learning styles. Work will continue to move towards criterion-referenced assessment, and to answer some of the deceptively simple questions that an examination can raise, such as estimating the relative standards of candidates between one diet of the examination and another. The spirit of openness engendered by the assessment of colleagues by colleagues will in the meantime ensure that as much feedback of personal performance as possible will be given to individual candidates, and of overall performance of the examination in the annual report to Council, published in the RCGP Members' Reference Book. Criticisms of "excessive secrecy shrouding the examinations of the Royal Colleges" (Lancet, 1990) will, it is hoped, never be justifiably directed at the membership examination of the Royal College of General Practitioners. References Barrows H S, Feightner J W, Neufeld V R et al. (1978) Analysis of the Clinical Methods of Medical Students and Physicians. Report submitted to the Province of Ontario Department of Health and Physicians Services Inc. Foundation. Beard R M and Senior J L (1980) Motivating Students. London, Routledge and Kegan Paul. Cohen R, Rothman A I, Ross J et al. (1988) A comprehensive assessment of graduates of foreign medical schools. Annals of the Royal College of Physicians and Surgeons of Canada 21, 7, 505-9. Elstein A S, Shulman L S and Sprafka S A (1978) Medical Problem Solving - an Analysis of Clinical Reasoning. Cambridge, Massachusetts, Harvard University Press.
Entwistle N (1981) Styles of Learning and Teaching. Chichester, John Wiley. Fritts P M and Posner M I (1978) Human Performance: 'Assessing Health Workers' Performance'. London, Prentice Hall. p. 27. Harden R M and Gleeson F A (1979) Assessment of clinical competence using an objective structured clinical examination (OSCE). Medical Education 13, 41-54. Lancet (1990) Examining the Royal College examiners. Editorial 335, 443-4. Leeder S R, Feletti G I and Engel C E (1979) Assessment help or hurdle. Programmed Learning and Education Technology 16, 309. Marshall J (1989) CHECKUP: Computerised Home Evaluation of Clinical Knowledge Understanding and Problem Solving. Teaching and Learning in Medicine 1, 38-41. Marton F and Saljo R (1976a) On qualitative differences in learning. I - Outcome and process. British Journal of Educational Psychology 46, 4-11. Marton F and Saljo R (1976b) On qualitative differcnces in learning. II - Outcomes are a function of the learner's conception of the task. British Journal of Educational Psychology 46, 115-27. Mulholland H and McAleer S (1988) Report to the Examination Board of the Royal College of General Practitioners. Dundee, Centre for Medical Education. Unpublished. Mulholland H and McAleer S (1989) Report to the Examination Board of the Royal College of General Practitioners. Dundee, Centre for Medical Education. Neufeld V R (1985) Perspectives on clinical competence. In Neufeld V R and Norman G R (Eds) Assessing Clinical Competence. New York, Springer. pp. 39-50. Newble D I and Entwistle N J (1986) Learning styles and approaches: implications for medical education. Medical Education 20, 162-75. Newble D I and Jaeger K (1983) The effect of assessments and examinations on the teaching of medical students. Medical Education 17, 165-71. Norman G R, Davis D A, Painvin A et al. (1988) Comprehensive assessment of clinical competence of family/general physicians using multiple measures. Presented at 27th Conference on Research in Medical Education, Washington DC. O'Hagen J, Davies J and Pears R K (1986) The use of simulated patients in the assessment of actual clinical performance in general practice. New Zealand Medical Journal 99, 948-51. Scottish Education Department (1977) Assessment for All. Dunning Report. London, HMSO. Stillman P L, Rugill J S, Rutalla P J et al. (1980) Patient instructors as teachers and evaluators. Jouirncal of Medical Education 55, 186-93. Swanson D B, Barrows H S, Friedman C P et al. (1982) Issues in assessment of clinical competence. Professions Ediucation Research Notes 4, 2. Tombleson P and Wakeford R (1989) Why do trainees take the MRCGP examination? Letter. Jouirnal of the Royal College of General Practitioners 39, 168-71.
