2010; 32: e443–e447

WEB PAPER

Competency-based integrated practicalexaminations: Bringing relevance to basicscience laboratory examinations

RIFFAT SHAFI, KHURRAM IRSHAD & MOBEEN IQBAL

Shifa College of Medicine, Pakistan

Abstract

Background: The practical examinations in subject-based curriculum have been criticized for lack of relevance and clinical

application. We developed competency-based integrated practical examinations (IPEs) for first two years incorporating basic

science principles with clinical relevance in our integrated curriculum.

Aim: To bring relevance to basic science laboratory practical examinations by conducting competency-based IPEs.

Methods: IPEs were developed according to competency-based blueprinting for each integrated module. Clinical scenarios were

used as triggers followed by tasks pertaining to laboratory tests, relevant physical diagnosis and ethics/professional aspects

utilizing standardized patients. Checklists were developed for standardized marking. A feedback questionnaire and two focus

group discussions were administered to a random group of students from both first and second year students. Faculty members’

feedback was also recorded on a questionnaire.

Results: Almost all the students agreed that IPE was a useful experience. Eighty-nine percent agreed that it was a fair examination

and elicited a lesser degree of psychological stress. Eighty-two percent agreed that IPE encouraged critical thinking and application

of knowledge. However, students suggested better organization and longer duration of stations. Faculty members also liked the

experience.

Conclusion: In conclusion, IPEs were well-received and valued both by students and faculty members.

Introduction

Assessment is an essential part of the teaching and learning

process (Harden 2001). Any teaching method needs to be

matched by an appropriate assessment that relates to the

objectives of the teaching. Students may or may not learn what

is in the curriculum or what we teach, but they will learn what

we assess them on, as ‘‘assessment drives learning’’ (Shimura

et al. 2004). As medical curricula around the world move from

discipline-based to integrated teaching and learning, the

integration of assessment must necessarily follow (Hudson &

Tonkin 2004). A change in instructional methods without

changing assessment will not achieve desired outcomes

(Ahmed et al. 2007). Studies have shown that such a mismatch

can eventually lead to failure of any adopted curriculum

(Ghosh & Pandya 2008).

The limitations of clinical and practical examinations have

been realized for a long time and have given rise to attempts at

improving the current scenario (Stiliman et al. 1977; Edelstein

& Ruder 1990; Newble 1991). An earlier innovation in this

regard is the objective structured clinical examination (OSCE)

later extended to the objective structured practical examination

(OSPE) described in 1975 and in greater detail in 1979 by

Harden and his group from Dundee (Harden et al. 1975;

Harden & Gleeson 1979). This method with some modifica-

tions has stood the test of time and has largely overcome the

problems of the conventional clinical examinations mentioned

earlier (Ananthakrishnan 1993). It appears that the assessment

of problem solving skills must occur in the context of a clinical

Practice points

. The integration of assessment must match the integrated

medical curriculum.

. Shifa College of Medicine, Islamabad, Pakistan moved

from discipline-based to system-based integrated

curriculum.

. IPE, a tool for assessing multiple competencies was

developed.

. Basic science knowledge was linked to clinical practice

in IPEs.

. IPEs were well received by students and faculty.

Correspondence: R. Shafi, Department of Basic Health Sciences, Shifa College of Medicine, Sector H-8/4, Islamabad, Pakistan. Tel: 92 51 460 3365;

fax: 92 51 443 5046; email: shafiriffat@hotmail.com

ISSN 0142–159X print/ISSN 1466–187X online/10/100443–5 � 2010 Informa UK Ltd. e443DOI: 10.3109/0142159X.2010.513405

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problem, yet no unanimity exists on the tools to be used

(Nendaz & Tekian 1990).

Skills assessment does not only measure the perfor-

mance but also provides an indication of the effectiveness

of learning strategies and appropriateness of the content

input. A good assessment should be valid, reliable, prac-

ticable, and should have educational value (Ahmed et al.

2007).

Miller acknowledged that no single method of assess-

ment could provide all the data required for judgment

of the delivery of professional services by a physician (Miller

1990).

The move from discipline-based to system-based inte-

grated curriculum at Shifa College of Medicine, Islamabad,

Pakistan in 2008, provided exciting opportunities to integrate

the learning of basic and clinical sciences for medical

undergraduates. After introducing integrated written assess-

ments in the form of integrated multiple choice questions

(MCQs) and short answer questions (SAQs), we aimed to

develop a competency based integrated practical examina-

tion (IPE), for the 1st and 2nd year of our 5-year

undergraduate curriculum. This type of assessment serves

as a tool for testing multiple competencies related to skills

(as in performance exercises), grounded knowledge (as in

OSPE; Howley 2004; Hudson & Tonkin 2004) and attitudes

of the students.

The objective of this study is to share our experience of

bringing relevance to basic science laboratory practical exam-

inations by conducting competency-based IPEs, and to ana-

lyze its efficacy for the students.

Methods

CanMeds framework for competencies was utilized for devel-

oping the curriculum (Mickelson & MacNeily 2008). The level

of achievement for these competencies was defined according

to the years of undergraduate education. In our 5-year

undergraduate curriculum, spirally integrated modules were

developed for two spirals delivered over a period of first three

years. First spiral aimed at system-based modules comprising

anatomy, physiology, biochemistry, ethics, professionalism,

clinical relevance, and evidence-based medicine. The modules

in the second spiral incorporated revisit of the systems with a

stress on pharmacology, community health sciences, pathol-

ogy, relevant clinical disciplines, ethics, professionalism, and

evidence-based medicine. Modules revolved around longitu-

dinal themes which were revisited with varying objectives

throughout the curriculum. The last 2 years of curriculum

revolved around clinical clerkships in the disciplines of

General internal medicine, Family medicine, Surgery,

Ophthalmology, Otolaryngology, and Obstetrics and

Gynecology.

Multidisciplinary modular teams developed objectives

using SMART (specific, measurable, attainable, relevant, and

targeted) technique linking objectives to CanMeds compe-

tency framework. Longitudinal clinical themes covering the

important clinical concepts were developed for all the mod-

ules. Appropriate learning strategies were employed, which

included small group discussions, followed mostly by a large

group wrap-up session, problem-based learning and self-

directed learning. Modular delivery involved a great deal of

stress on learning clinical skills about data gathering and

physician–patient interaction. Students were provided with

opportunity to learn skills in skills laboratory sessions. Faculty

members from both basic as well as clinical sciences facilitated

skill-related sessions utilizing models, simulations, and stan-

dardized and real patients.

In our traditional curriculum, practical examinations were

discipline based. The practical assessments revolved

around laboratory techniques for biochemical and physiolog-

ical testing with very little relevance to real life practice of a

physician.

IPEs were constructed for each module by the team

members from various disciplines including Anatomy,

Physiology, Biochemistry, General medicine, and Surgery.

Content validity was ensured by developing a blue print

and repeated discussions during planning meetings.

Competencies related to Performance Skills,

Communication Skills, Reasoning Skills, and Humanistic

Qualities/Professionalism were incorporated by developing

an IPE construction template. A rating instrument was also

developed which had these competencies listed on it. The

raters were given workshops on the rating instrument.

Students were rated on all the competencies incorporated

in an IPE on a three-category scale of unsatisfactory,

satisfactory, and superior. Practical performance and clinical

skills like history taking, physical examination, and coun-

seling skills were assessed in a clinical context. Relevant

ethical and professional aspects were also addressed. Basic

science knowledge was linked to clinical practice and high

construct validity was achieved by subjecting the draft of

each station to extensive review. Faculty members involved

in the process of assessment were briefed about the

process of assessment and rating of the students.

It was a multistation, objective, structured examination.

Case scenario, video, Images/Photograph/Model/Specimen, or

Standardized Patient were used as triggers at each station.

Three or four tasks relevant to the trigger were given. Each

module exam had 8–12 stations. Each station was given equal

time, after which the candidate was required to move on to the

next station. These stations included tasks which were both

interactive (for example, taking history or performance on

patient) and static (for example, identification of slide or data

interpretation).

A faculty member was present as an observer at

each station where performance was required. Global rating

scale was used to rate the students, using checklist as a

reminder.

Feedback

A feedback questionnaire was administered to a random

group of 44 students from first and second year classes,

and they were asked to give suggestions and to com-

ment on the IPE. Their comments were recorded.

Feedback pro forma was also administered to the faculty

members.

R. Shafi et al.

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Sample stations of IPE

Results

Likert scale was used; strongly agree and agree were merged

for the purpose of analysis and strongly disagree and agree

were also merged for analysis.

Of the students, 80–90% agreed with organization and

content of the tasks for various stations. Structure and

sequence of the IPE and the time given for each task were

the areas where less than 50% of the students agreed (Table 1).

Of the students, 70–80% agreed with the content of the

tasks in each IPE station (Table 2).

Comments of the students

Most of the students liked change from traditional to the IPE,

but thought that it needs to be organized further; they thought

that the time given for each station was not enough for the

performance of the tasks. Some of them also suggested that

the oral viva should be more extensive. They thought it was an

unbiased way of examination.

Some representative comments of the students regarding

gains and concerns are shown in Table 3.

Comments of the faculty

Faculty found IPE a good way of assessing application of

knowledge and skills of the students (Table 4).

Discussion

In our study, the feedback from students was strongly positive.

This is consistent with another study in which the multistation

IPE was ranked high by the majority of students (Abraham

et al. 2005).

The organization as well as clinical relevance in the

practical exam was highly appreciated by the students.

Eighty-two percent of the students thought that it reflected

relevance and helped create connections across various

disciplines. This is consistent with another study in

Katmandu, although this study included examination in the

discipline of pharmacology as compared to our study where

the examination was integrated. In the curriculum of

Katmandu university stations, testing skills in pharmacology

are proposed to be introduced and the attitude of students

A 40 year old male presents to the emergency room with history

of severe pain in his right loin for 2 days.

A 60 year old, chronic smoker came to the OPD with the complaint of

on-and-off episodes of coughing and breathlessness for the last 3 years.

Task 1 Task 1

Take history relevant to his symptoms (standardized patient) Perform peak expiratory flow rate on the patient (standardized patient)

Discipline represented: (Clinical skills/communication skills) Discipline represented: (physiology)

Task 2 Task 2

Identify the abnormality in the imaging study (an IVU with a stone) Identify the impressions marked on specimen (lung specimen)

Discipline represented: (Anatomy/Clinical skills) Discipline represented: (Anatomy)

Task 3 Task 3

Identify the structure under microscope and give two reasons that

favor your identification (slide under microscope)

Identify the marked structures on the chest radiograph (X-ray chest)

Discipline represented: (Anatomy) Discipline represented: (Anatomy/Clinical skills)

Task 4 Task 4

How do you relate urine microscopic findings with patient’s

presentation? (Urine microscopy)

Interpret the data (arterial blood gases report)

Discipline represented: (Biochemistry) Discipline represented: (Physiology/Biochemistry)

Table 1. Student’s feedback on module organization and structure.

Agree n (%) Uncertain n (%) Disagree n (%)

IPE was fair examination when compared with traditional practical and viva 39 (89) 2 (4) 3 (7)

IPE reflected relevance and helped create connections across various disciplines 36 (82) 7 (16) 1 (2)

IPE was well-administered 20 (70) 15 (34) 9 (20)

IPE was well-structured and sequenced 21 (48) 14 (32) 9 (20)

Clinical cases and instructions at the workstation were appropriate 24 (55) 11 (25) 9 (20)

Tasks reflected learning objectives as discussed/taught in the module 36 (82) 6 (14) 2 (4)

IPE was a useful experience 43 (98) 1 (2) 0

Time at the stations was enough for various tasks 20 (45) 9 (20) 15 (34)

Degree of psychological stress elicited by IPE was less than

any other format of exam (viva, traditional practical)

39 (89) 2 (4) 3 (7)

Integrated practical examinations

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toward this development was generally positive (Shankar &

Mishra 2002). Another study by Boon et al. (2001) conducted

at the University of Pretoria in South Africa shows that the

majority of students considered that the clinical case studies

gave them a better understanding of the relevant basic

sciences.

The majority of the students agreed that the IPE was a

better way of assessing practical skills when compared with

the traditional method of practical exam. Eighty-nine percent

thought it was a fair exam with lesser stress for the candidate.

This is consistent with the results of another study by Hudson

and Tonkin (2004), where students admitted that the previous

assessment method encouraged test-directed studying. It was

pleasing that a significant number of students thought that the

examination was clinically relevant and it was a good

preparation for later assessments and clinical practice.

Students acknowledged that the integrated practical items

had high clinical relevance.

The feedback on knowledge area covered in the IPE

was strongly positive. Eighty-two percent of the students

agreed that it covered a wide knowledge area. Seventy-

nine percent of the students appreciated that the clinical

relevance helps to clarify concepts in basic sciences. This is

consistent with another study where students found that the

clinical cases and interactions with actual patients helped

them synthesize and retain basic science knowledge,

although we used simulated patients in the IPEs (Muller

et al. 2008).

In our modules, formal teaching of important competencies

related to medical ethics, professionalism, and communication

skills which are generally ignored in the traditional curriculum

(Verma et al. 1991; Nayar et al. 1995) were also introduced,

using CanMeds framework of competencies (Mickelson &

MacNeily 2008). History taking, physical examination, profes-

sionalism, and communication skills were assessed during

IPEs. Ethics-related issues were also incorporated in written

assessment. Assessment of attitudes in IPE where it was

integrated with basic sciences knowledge was appreciated by

the faculty in this study. Students and the faculty members

both appreciated the competency-based integrated examina-

tions; however they felt that there was still room for improve-

ment in the structure and organization of IPEs, and that the

time allocated for each station was not appropriate.

Running IPE simultaneously for all the students would

certainly be the best option to ensure a fair exam, but lack of

enough space was a limitation which was overcome by

utilizing the same space for all the groups. However, the

stations and the tasks were changed for each group to ensure

privacy, although it took longer and was hectic for the faculty

and SPs. It was made sure that the students’ feedback on

organization of the module and inappropriateness of time at

each station was rectified in the forthcoming examinations.

Students study more thoughtfully when they anticipate

certain examination formats, (Hakstian 1971) and changes in

the format can shift their focus to clinical rather than theoretical

issues (Newble & Jaeger 1983). The introduction of compe-

tency-based IPE is unique in assessing the basic science

practicals in undergraduate medical curriculum which

addresses multiple competencies that are required by a good

practicing physician.

In conclusion, competency-based IPEs were well received

and valued both by students and faculty members.

Declaration of interest: The authors report no conflicts of

interest. The authors alone are responsible for the content and

writing of the article.

Notes on contributors

RIFFAT SHAFI, MBBS, Fellow College of Physicians and Surgeons of

Pakistan (FCPS). She is an assistant professor in the Section of Physiology,

Department of Basic Health Sciences. She is a curriculum coordinator at

Shifa College of Medicine, Islamabad, Pakistan.

KHURRAM IRSHAD, MBBS, Fellow College of Physicians and Surgeons of

Pakistan (FCPS). He is an assistant professor in the Section of Physiology,

Table 3. Student’s comments on IPEs.

Traditional exam vs. IPE

Favorable feedback Areas to be improved

IPE’s far better than traditional exam

Structured and fair ways of examination Time duration at individual

stations is brief

Helpful in clarifying concepts Need more organization in

terms of logisticsExcellent way of accessing practical skills

It has clinical relevance

It is interactive

Integration with clinical sciences

makes it interesting and easier

Table 4. Faculty’s comments on IPEs.

Traditional exam vs. IPE

Favorable feedback Areas to be improved

Excellent way of assessing practical skills Need more organization

Helps in clarifying the concepts

Integration between basic sciences

and clinical skills is good and useful

Good training program for

preclinical students

Tests the attitude along with

knowledge and skill

Table 2. Student’s feedback on the content of the tasks.

Agreen (%)

Uncertainn (%)

Disagreen (%)

Wide knowledge area

was covered

36 (82) 5 (11) 3 (7)

IPE encouraged critical thinking

and application of knowledge

36 (82) 6 (14) 2 (4)

IPE provided opportunities to learn

and clarify concepts further

35 (79) 6 (14) 3 (7)

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Department of Basic Health Sciences, Shifa College of Medicine, Islamabad,

Pakistan.

MOBEEN IQBAL, MBBS, Fellow American College of Chest Physicians

(FCCP). He is a professor of Medicine and associate dean of Medical

Education at Shifa College of Medicine. He is a consultant, Pulmonary and

Critical Care Medicine, at Shifa International Hospital, Islamabad, Pakistan.

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