Orthopaedics and Traumatologic Examination : Part B and Part C

Part B: The objectives examination evaluation of the accurate diagnosis determination or possibilities of the abnormalities, patient’s problem, management and complications  

Learning Objectives Evaluation in Examination

The Examiner should be able to evaluate the Candidate ability to:

1.       To decide the problem determination (acute and long-term) of the patient

After the Candidate determines the diagnosis, he/she should be able to consider the impact of the problem on the individual or the severity of the illness process or “how bad” that disease. Example severity of fracture or dislocation must be classified into stable or unstable or other classification system. Unstable fracture of the lower extremity can contribute shortening or malunion and degeneration process of the bearing joint become happened at the long time.The risk factors of 4 parts of the humeral head fracture or femoral neck fracture in elderly condition can lead to avascular necrosis of the head humerus or femur.

2.     To plan the management and outcome

“What is the best therapy?” The answer to this question has to be preceded by a correct diagnosis and evaluation of the condition’s severity, and then the Candidate must understand the appropriate therapy and evidence. Hemiarthroplasty of femoral neck fracture in elderly should be performed directly caused by avascular necrosis complication of the femur head but open reduction and internal fixation is indicated for young patient.

The Candidate should be able to explain conservative methods and surgery technique of orthopaedics and traumatologic clearly and to predict the prognosis of the patient and relates it to the severity of the illness directly.

·         Non operative therapy or conservative methods for example: casting and splinting, bracing, traction, and modification activity daily living and so on.

·         Operative treatment for example: open reduction and internal fixation (ORIF) or open reduction and external fixation (OREF), intramedullary nailing, percutaneous pinning, arthroplasty, arthroscopy and so on.

The Candidate should also be able to follow management response after treating the patient and to discuss the adverse outcome of treatment (delayed or non-union). The question is how to “measure” the response. It means the Candidate should be able to monitor and record in documentation. The record could be in a patient subjective pain, activity level, range of motion and strength. The Candidate should understand how to avoid the subjective data in a biased and standardized manner.

3.    To predict the complications

The clinical experience of the Candidate must recognize the complications of the musculoskeletal diseases by applying knowledge of the consequences of pathologic process, therefore the Candidate will understand how to follow and monitor that patient. For example: Forearm/radius-ulna fractures caused by traffic accident is at significant risk for developing of compartment syndrome in short time, as well as leading to synostosis or Volkmann ischemia in a long time. Open reduction and internal fixation by plate and screws has some complications such as: infection, nonunion, malunion, post-traumatic synostosis and neurovascular trauma.Therefore the Candidate should be able to decide the potential of complication arising from certain condition or injuries. Conclusion: knowledge of complications after non-operative and operative intervention for a variety of orthopaedics and traumatologic conditions is paramount. For example, the Candidate should be able to predict a closed fracture complication includes soft tissues damage (internal/external bleeding), oligaemic shock, infection, electrolyte imbalance, protein breakdown and other metabolic response of injury. Prolong immobilization complications are hypostaticpneumonia, pressure sores, deep venous thrombosis, muscle atrophy, skeletal decalcification and urinary tract calculi and urinary tract infection. Post-operative complications include atelectasis and pneumonia (anesthesia), blood loss and wound infection. Fracture complications are stiffness, sundeck’s atrophy, avascular necrosis, myositis ossificans, osteomyelitis, vascular and tendon complications and fat embolism and implant complications. Other complications are compartment syndrome and hypovolemic shock.

The Candidate should also be able to avoid the risk factors of the musculoskeletal diseases for promotion and prevention issues for patient and community. For example compartment syndrome risk of the comminuted fracture of the forearm (radius and ulna fractures) needs to monitor every few hours. A basic knowledge of complications after non-operative and operative management should be discussed with the patient and patient’s family before making decision.

Table 5.List of part Bevaluation

Part B: The objectives examination evaluation of the patient’s problem, management and complications	20 Complete presentation& correct statement	15 Incomplete presentation or Correct response to stimulation question	0 Incorrect response or no response	Marks
a.       Ability todecide the acute and long-term problem of the patient in discussion
b.      Ability to  plan the management of the patient and outcome in discussion
c.       Ability to to predict complications in discussion
TOTAL MARKS of Part B

MARKS OF PART B:

§  Mark 20: Candidate presents: (a)the determination of acute and long-term problem or (b) management planning,or(c) complications predictionin discussion completely and correctly.

§  Mark 15: Incomplete data presentation or the Candidate is abletorespondthe examiner’s stimulation question about a mistake or omission of the interestingof (a) the acute and long-term problem determination or(b) management planningor(c) complications predictionin discussion correctly.

§  Mark 0: Candidate’s response is not correct or he/she does not respond to the examiner’s stimulation question of (a) the acute and long-term problem determination, or (b) management planningor(c) complications prediction during discussion.

§  Maximal marks of part Bis 60

OTHER ALTERNATIVE EVALUATION LIST (table 6)

Part B. The objectives examination evaluation of the accurate diagnosis determination or possibilities of the abnormalities, patient’s problem, management and complications

Learning Objectives Evaluation in Examination

The Examiner should be able to assess

1.      The Candidate capability to decide the acute and long-term problem of the system musculoskeletal abnormality. The Candidate should be able to explain the problem of the system musculoskeletal abnormality. The Examiner questions are varying depends on the Examiner experience for achieving objective, valid and reliable marking.

2.      The Candidate ability to plan the management decision of the system musculoskeletal abnormality based on evidence (treatment algorithm)

The Candidate should be able to understand that the based on treatment depends on accurate diagnosis, treatment options according to evidence of medicine, patient need and facilities. The Examiner questions are varying depends on the Examiner experience for achieving objective, valid and reliable marking.

3.      The Candidate ability to predict the common complication of the system musculoskeletal abnormality, promotion and prevention issues

The Candidate should be able to explain complication of the system musculoskeletal abnormality, management complications, promotion and prevention of the system musculoskeletal abnormality patient. The Examiner stimulates a few questions for achieving objective, valid and reliable marking.

Table 6: List of the evaluation marks of part B

CONTENTS OF EVALUATION	Marks
Part B: The objectives examination evaluation of the patient’s problem, management and complications	60 Complete & correctpresentation	45Incomplete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to determine acute and long-term problem, select the best option of the management  and to decide the complication of the system musculoskeletal abnormalityin discussion

MARKS:

• Marks 60: Candidate presents the acute and long-term problem,themanagement and complications predictionplanningof the system musculoskeletal abnormalitycompletely and correctly
• Marks 45: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting of the acute and long-term problem, management planningand complications predictiondeterminationof the system musculoskeletal abnormalitycorrectly.
• Marks 0: Candidate’s response is not correct or he/she does not respond to the examiner’s stimulation question of the acute and long-term problem determination, management planning,andcomplications predictionof the system musculoskeletal abnormality.

Part C: The objectives examination evaluation of a good candidate’s attitude and professionalism.  .

Learning Objectives Evaluation in Examination

The Examiner should be able to evaluate (table 7):

a.       The candidate attitude:

·         What is the Candidate’sfocus on communication with the patient? Does the Candidate rarely interruptpatient’s story during history taking? Meaning;“The Candidate is a good listener”or “Is the Candidate a good communication with the Examiner during discussion?”

·         What is Candidate’s plan on the beneficence management orientation and avoid malaficencein the health care intervention on discussion in section B? Meaning; The Candidate should be able to plan the management based on Evidence Based Medicine (EBM) and biopsychosocial-culture.

·         What is the Candidate social justice in health care services? Candidate should ask several questions to patient that he/she may show prejudice and discrimination in health care management. What is Candidate’s perspective in considerationto health care disparities to the patient?

·         How the candidate tries to improve communication and awareness regarding health care disparities through cultural competency education that can lead to better racial and ethnic harmony in health care to patient

b.      The professionalism of Candidate:

·         Professionalism Candidate should enhance the quality of medical care delivered based onbiopsychosociol-cultural knowledge for patient in discussion section.

·         Professionalism Candidate always has to make decision of which care service is the best management based on EBM, decision making of the priority management among some options based on the evidence based medicine (EBM). What is the candidate management decision in health care and the reasoning of explanation mechanism, advantages and disadvantageous clearly and knowledgeable to the patient in discussion?

·         Is the Candidate able to decrease health care cost per capita in discussion?

Note: Questions discussion of the Examiner depend on his/her experiences for getting the objective, valid and reliable marks.

Table 7: List of part C evaluation

PARTC: The objectives examination evaluation of a good Candidate’s attitude and professionalism.	5 Complete presentation& correct statement	3 Incomplete presentation or Correct response to stimulation question	0 Incorrect response or no response	Marks
a.       Ability to show a good attitude in communication (in discussion)
b.      Ability to show a good professionalism in discussion
TOTAL MARKS of Part C

MARKS:

§  Mark 5: Candidate ability to showa good attitude (a) and basic medical and clinicalknowledge to decide management based on evidence or (b) professionalism in health care services in discussion

§  Mark 3: Impolite attitude in discussion between Candidateand patient/Examiners but the Candidate is a good attitude (a) basic medicaland clinical knowledge and management decision based on evidence in health care services or (b) professionalism in discussion.

§  Mark 0: Impolite attitude and Candidateis also a badattitude (a) basic medical and clinical knowledge withoutevidence management decision in health care services or bad professionalism (b) in discussion

§  Maximal marksof part C is 10

OTHER ALTERNATIVE EVALUATION LIST (table 8)

Part C: The objectives examination evaluation of a good Candidate’s attitude and professionalism. 

Learning Objectives Evaluation in Examination

The Candidate must have good attitude and professionalism in solution of the system musculoskeletal abnormality problem. The Examiner should be able to evaluate the Candidate attitude & professionalism based the response in the discussion above. If the Candidate responses are doubtfulness, the Examiner stimulates a few questions for achieving objective, valid and reliable marking.

Table 8: List of the evaluation marks of part C

CONTENTS OF EVALUATION	Marks
Part C: The objectives examination evaluation of a good Candidate’s attitude and professionalism.	10 Complete & correctpresentation	6Incomplete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to show a good attitude and professionalism in discussion

MARKS:

•      Marks 10: Candidate ability to show a good attitude and basic medical and clinicalknowledge to decide management based on evidence (professionalism) in health care services of the system musculoskeletal abnormality problem

•      Marks 6: Impolite attitude in discussion between Candidate and patient/Examiners but the Candidate is a good basic medical and clinical knowledge and management decision based on evidence in health care servicesof the system musculoskeletal abnormality.

•       Marks 0: Impolite attitude and Candidate is also a bad basic medical and clinical knowledge without evidence management decision in health care services of the system musculoskeletal abnormality

Conclusion total marks of the Candidate = part A + part B + part C

·         Marks 85-90 is superior ·         Marks 79-84 is excellent ·         Marks 69-78 is pass; and ·         Marks 60-68 is fail

·         Marks 85-90 is superior ·         Marks 76-86 is excellent ·         Marks 65-75 is pass; and ·         Marks ≤ 65 is fail

KEPUSTAKAAN:

1.      Abdulla MA (2012). Student’s perception of objective structured clinical examination (OSCE) in surgery at Basrah College of Medicine. Bas J surg  18: 1-6

2.      Ahmed AM (2011). Examination of clinical examinations: notes on assessment of clinical competence in our medical schools. Sudanes J Publ. Health 6: 29-35.

3.      Armis (2005). Musculoskeletal Competency: Guidelines for Medical Students, PCPs (Primary Care Physician) and Residents in Training. Unit PelayananKampus. FK UGM. Jogjakarta.
4.      Dent JA and Harden RM (2001). A Practical Guide for Medical Teachers. Churchill-Livingstone, London.

5.      Howes O (2006). The assessment of post-graduate psychiatric competence: recent developments and the implication. Inst Psych, King’s College London 59-67.

6.      Idris SA, Hamza AA, Hafiz MM, and Eltayeb AM (1014). Teachers and students perception in surgical OSCE exam: A pilot study. Open SciencEduc 2: 15-9.

7.      Kamarudin MA, Mohamad N, AwangBesar MN, et al (2011). UKM Teaching and Learning Congress 2011. The relationship between modified long case and objective structured clinical examination (OSCE) in final professional examination 2011 held in UKM Medical centre. Procedia-Social and Behavior Sciences 60: 241-8.

8.      Meekin SA, Klein JE, Fleischman AR and Fins JJ (2000). Development of a Palliative Education Assessment Tool for Medical Student Education. Acad med. 75: 986-52.

9.      Mirghani OA and Elsanousi M (1014). The clinical examination-long case the most valid test in a medical school. Gez J health Scienc 5: 1-14.
10.  Pitt D, Rowley DI and Sher JL (2005). Assessment of performance in orthopaedic training. JBJS (B): 87 (9): 1187-91.
11.  Sherbino and Frank (2011). Educational Design a CanMEDS guide for health professions. The Royal Colleage of physician and Surgeon of Canada. Ottawa

12.  Sood R (2001). Long Case Examination – Can it be Improved?.J Indian AcadClin Med. 2: 252-55.

13.  Toy EC, Rosebaum AJ, Roberts TT and Dines JS (2013). Case Files: Orthopaedic Surgery. McGraw Hill Education. New York.

14.  Troncon LEA, Dantas RO, Figueirdo JFC, et al (2000). A standardized, structured long-case examination of clinical competence of senior medical students. Med. Teach 22: 380-85.

15.  Wass V and van der Vleuten C (2004). The long case. Med Educ. 38: 1176-80.

16.  Wass V, van der Vleuten C, Shatzer J and Jones R (2001). Assessment of clinical competence. The Lancet 357: 945-49.