Massive Open Online Course for HPE&R

Kathmandu, Nepal

Massive Open Online Course (MOOC) has changed the way learning happens in the globe. Distance learning is becoming a norm now as internet has empowered us to do courses from the institutions and instructors of our choice without leaving the comfort and safety of our room, family and country. It might also contribute reducing the much talked/reported "brain drain" in the long term for education as these courses are "free" so far. In my opinion, two MOOC players, EdX and Coursera, are currently most active in this scenario. EdX is open-source whereas Coursera is closed-source.

 

Both of them have some excellent courses related to Health Professions Education & Research (HPE&R) but the one recently announced course in the Coursera entitled "Instructional Methods in Health Professions Education" is getting lots of attraction here in Nepal and South Asia. Many of the colleagues from the Patan Academy of Health Sciences (PAHS) and FAIMER fellows and faculty from PSG FAIMER Regional Institute (PSG-FRI) have already registered for this course within a month of getting knowledge about it through the "group mail" and "listserve" of PAHS and PSG-FRI respectively.

 

The introduction of this course says that "This course provides those involved in educating members of the health professions anasynchronous, interdisciplinary, and interactive way to obtain, expand, and improve their teaching skills."

With this course, the instructor claims that the learners will:

1. Understand educational theory as it relates to health professions education
2. Match instructional methods with desired educational outcomes
3. Learn a variety of applied teaching techniques
4. Share successful teaching strategies

It covers broad areas of HPE and I especially like the starting of the course with the adult learning theory. There is no doubt that it will provide the theoretical and practical bases for all the faculty involved in the HPE.

 

More are here: https://www.coursera.org/course/instructmethodshpe

 

The course is starting from August 5, 2013 so kindly register if you want to improve your teaching, assessment and research in HPE if it turns out to be the effective one, which remains to the judged by you later.

 

I would like to thank to the first voter/s who have voted their choice in the poll entitled "What do you want me to write (next)?" I will wait some more time and then prioritize my writing based on the "e-vox populi".

 

I am planning to write next post on "Andragogy: Adult Learning Principles".

Testing Post-partum hemorrage management skills using OSCEs

Kathmandu, Nepal

Developing and establishing Reliability and Validity of OSCE stations on PPH Management skills:

 

1. Write a checklist /series of checklists that can be assessed and feasible in 5 minutes (remember OSCE is usually of 5 minutes duration). If you want to test many things then break them down to multiple checklists to assess the "holistic" assessment of skills related to the topic. This will now become "modified OSCE".

 

2. You can take advantage of the currently available tools from articles, books, websites etc. to supplement/complement you own checklists. Make the skills and checklists "mutually exclusive" i.e. don't assess same thing on different checklists.

3. Once you develop the tools then discuss it in a team (experts in PPH management) to ensure the "content validity". Remember this will be iterative process and you will need to document the discussion in each step.

4. Give the tool/tools to review by the other content and non-content experts (GPs, Emergency Medicine, Public Health including statistician, Allied Health etc.) to ensure "face validity".

5. Think wisely if you want to use Standardized patients or real patients. You need to train them beforehand to get the "standardized" outcomes. Real patients are difficult to manage and handle (we recently faced a serious problem with our Obs/Gyn OSCE during formative exam as only 2 out of 8 volunteer patients were willing and available at the end of the OSCE circuit!).

6. Train the interviews rigorously to ensure inter-rater reliability.

 

7. Standard set each OSCE station using holistic/subjective approach i.e. use global rating along with the objective checklist ratings. These scores in combined will give you the "competency" required to pass each OSCE station using Borderline, Contrast group or Borderline Regression Method. One can also use Angoffing but it will be tedious process.

8. Once it is done, then pilot test the OSCE stations with volunteer participants (students, interns etc.) to know about the feasibility, problem in checklist and reliabilities. Use at least 10-15 volunteers in this process. Pilot test will also give you the internal construct reliability commonly known as Cronbach's alpha.

 

9. Use at least 2 raters in each station to calculate inter-rater reliability.

 

10. If you use more than 1 station then you can calculate the Generalizability (G) Coefficient which shows how much reliable the whole OSCE circuit. You need special software for this but it is available free from PERD, McMaster University, Canada.

 

11. If you also want to assess the test-retest reliability of your PPH OSCEs then run the pilot test two times using same interviewers and same candidates immediately after a break of, say, 30 to 60 minutes in the same day. If possible make sure not to contaminate your test-re-test reliability estimate i.e. don't let students refer the OSCE related resources from any references and interact on the OSCEs).

12. Modify the checklists after the pilot test if required and document them properly. Re-run the pilot test if the reliability estimates are not in the acceptable range. If they are acceptable then you are ready to run the "full fledge" OSCE on PPH management.

 

13. Calculate the relevant statistics, interpret the results, document them and publish it on MedEdPortal so that others can assess it when required.

 

This will complete all the reliability assessment for your PPH OSCEs:

I. Inter-rater reliability
II. Internal construct reliability
III. Test Re-test reliability

And remember that "Rome was not built in a day" so go slowly and document all the process. Your tool development and/or pilot testing phase can be your curriculum innovation project.

Once you run the full OSCEs then you can proceed with more complex statistical analysis to establish the "construct validity", "Predictive validity" & "Criterion validity" later ...

 

N.B. -

 

a. Same process holds true for pre-validate and/or validate the OSPE/OSCE stations properly. 

 

b. If the tool needs to be used in the local language (say Nepali) then it should be translated from English to Nepali first by a professional translator/expert bilingual followed by back-translation into English using translated Nepali tool by another professional. Then original English tool and back-translated English tool should be compared by the study team and modifications should be reflected in the Nepali tool as well. This process will also be iterative one and must be documented properly. It can be resource demanding as well.

Standard Setting in Health Professions Education

Kathmandu, Nepal

Health Professions Education (HPE) is embracing the competency based curriculum, teaching and assessment cycle, which is quite different from the conventional objective driven approach.

 

The competencies laid down in the course and/or curriculum require a criterion-referenced standard setting system for an effective and defensible student assessment. Standard setting sessions require subject matter / content experts to determine the competencies for each item such as Multiple Choice Question (MCQ), Short Answer Question (SAQ), Objective Structured Practical/Clinical Examination (OSPE/OSCE).

 

One of the most widely used criterion-reference method of standard setting in HPE is Angoff method where judges review the items in terms of its content and difficulty levels and award score between 0 and 1. The underlying assumption of this score is related with the "Minimally Competent Borderline Candidate" or simple "Borderline" candidate who are those students who "either can barely pass or fail" in any examination. These are "hypothetical" students and thus a common understanding among the judges must be obtained a priori to the actual Angoff scoring session (Angoffing).

 

When the  individual scores of the judges for an item are averaged then the resulting value becomes the "cut-off score" or pass-mark for that particular item. So, if a test consist of 50 standard set items then the pass mark of the test is obtained as sum of the Angoff score of each of the items included in the test. This shows the "competency" required to pass the test.

 

Below I present a hypothetical example for a test with 5 items where each item is judged by a "mixed" panel of  six judges. With six judges, Angoff scores become reliable further adding weight in favor of its validity.

 

Example:	Judge1	Judge2	Judge3	Judge4	Judge5	Judge6	Angoff
Item1	0.45	0.5	0.55	0.4	0.6	0.55	0.51
Item2	0.4	0.35	0.45	0.4	0.45	0.4	0.41
Item3	0.5	0.65	0.6	0.55	0.6	0.5	0.57
Item4	0.7	0.75	0.8	0.65	0.7	0.65	0.71
Item5	0.65	0.55	0.75	0.7	0.55	0.6	0.63
Pass Mark	2.70	2.80	3.15	2.70	2.90	2.70	2.83
						Pass % =	56.5

 

One of the main problem of the Angoff method is the "content expert bias" which means that when standard setting is done by a group of experts belonging to the same discipline they tend to give higher score resulting the "upward bias" in the Angoff score by shifting the pass-mark higher. It has big consequences if the test is "high stake" as adjustments in the Angoff scores are not permitted. Thus, it is recommended to use a "mixed judge" panel to balance the scores in the standard setting process.

 

Another problem occurs when Angoff score is done for the very first time and there is a little discussion on the concept and meaning of the "borderline" student. As most of the HPE courses in South Asia including Nepal uses 50% cut-score, faculty here tend to give at least 50% marks to maintain this norm. I call this a "novice bias".

 

When "content expert bias" or "novice bias" occurs then a compromised methods like Hofstee and Beuk are recommended for formative examinations. These methods use the students' actual scores and Angoff scores to determine the adjusted pass-mark after correcting these bias if present. It is actually recommended to use these methods in the initial phase of the formative student assessment until a normalization effect takes place among the judges. For summative assessment, it is recommended to standard set the items with item analysis results and/or repeat Angoffing to reduce the biases.

 

If standard setting is done correctly then a test with pre dominantly easy items will have higher pass mark whereas a test with mostly difficult items will have lower pass mark. In other words, "competency" for a test is known to the students and faculty before the test is conducted.

 

At last, a test should typically be compiled based on examination blueprint as it allows the teachers/faculty to sample the contents from different sections and of varied difficulty. It also allows the faculty to choose the knowledge and skills using appropriate methods, which in turn increase the validity of the test. As knowledge can also be assessed in varying degree of difficulty, it is always better to use the "mixed bag" approach to get the sample of curricular contents, item difficulty and assessment methods for producing technically "competent" human resources for health.

 

More can be found here:

 

1. www.kumj.com.np/issue/33/3-4.pdf

 

2. www.act.org/research/researchers/reports/pdf/ACT_RR89-2.pdf

Rest later ...

So, happy Angoffing!