PRACTICING IN THE OBJECTIVES ASSESSMENT GUIDANCE OF THE ORTHOPAEDICS AND TRAUMATOLOGIC EXAMINATION

PREFACE

 “Is the Candidate mark objective and transparent, valid and reliable in Orthopaedics and Traumatologic examination without prejudices and disparities?”

I always reflect this interesting examination question during ten years’ experience in the Indonesian National Board Orthopaedics and Traumatologic Examiner. Because of the Examiners are able to initiate an interesting topic knowledge or skill question of the scenario independently.  This question stimulates me to solve the problem. Therefore, I think all the Examiners should be able to make a similar perception to evaluate the learning objectives of the examination.

I attempt to design the objectives examination assessment guidance of the Orthopaedics and Traumatologic examination including:

1.      Part A: The objectives evaluation of the history taking, physical examination and investigation findings data collection for some possibilities or accurate diagnosis determination

2.      Part B: The objectives examination evaluation of the patient’s problem, management and complications   

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

4.      Marks every objective depends on the Examiners consensus meeting before Orthopaedics and examination. Example total marks of part A is 30 because of knowledge and skill of general physician competence; part B is 60; its more orthopaedics and traumatologic specialized and part C is 10. Therefore the total Candidate marks is part A + part B + part C

I hope my suggestion is to provide a framework of the Examiners evaluation in Orthopaedics and examination of the Candidate for achieving the same perception. I also appreciate Indonesian Orthopaedics and Traumatologic Collegium Course to effort the similarity of mark value evaluation in Candidate examination without prejudice or disparities. The aim of this draft is to improve the Candidate marks in examination and for improvement of objectives assessment by the Examiners.

I believe this draft is still minimal information and also some statements which I wrote are disagreed because of bias or errors and limitation in education information. Therefore, I invite some suggestions or comments and constructive criticism for improving Candidates Evaluation of the Orthopaedic and Traumatologic Examination objectively.

Jogjakarta, June 2015

Prof. Armis

Profesor in Orthopaedics and Traumatology

Faculty of Medicine, UGM

CONTENTS:

1.     Preface

2.     Contributors

3.     Acknowledgement

4.     Introduction

5.     Orthopaedic and Traumatologic examination

6.     Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or diagnosis determination

7.     Part B: The objectives examination evaluation of the patient’s problem, management and complications  

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

9.     Case of Orthopaedics and Traumatologic Examination (Real Case):

a.      Rotator cuff Tear Arthropathy (RTA)

b.     Osteoarthritis of the knee (Knee OA)

c.      Osteomyelitis and Non-Union of the lower leg

10. Scenario or Clinical Signs/Investigation Data of Orthopaedic and Traumatologic Examination:

a.        Septic arthritis of the knee joint

b.       Knee dislocation

c.        Intertrochanteric femur fractures

d.       Developmental dysplasia of the hip (DDH)

11. Summary

ACKNOWLEDGEMENT

To my family: Nyoman Rapiani Armis (may wife), Andrianti (Agung her husband), Ratih Yulianti (Didit her husband). Arief Prasetyo (Susan his wife), Khresna Adi S (Rieke his wife) and my grandchildren: Sekar, Rafid, Safa, Rafa, Nanya and Sofia thank you for permitting our time to support this concept

To Prof. Bill Cumming, Ptof. Joe Ghabrial, from Australia, Prof. Bala Subramanian from Singapore, They are may teachers, mentor and role model and got me started, thank you for inspiration and your support.

INTRODUCTION

A Candidate of Orthopaedics and Traumatologic always makes an effort to have an excellent mark in musculoskeletal system examination. The challenge is still the examiner’s subjectivity of the examination of the candidate’s competence evaluation, according to Orthopaedics and Traumatologic curriculum. Competency measurement during Orthopaedics and Traumatologic education is expected to become the candidate’s ability for future practice or to be adequate the requirement for higher degree education, and meet knowledge, skill, attitude and professionalism of learning objectives. A successful candidate’s marks in the examination should be correlated with educational institution curriculum in teaching.   Therefore, how does the examiner achieve the objective assessment in Orthopaedics and Traumatologic examination?

A Candidate should focus on the materials of Orthopaedics and Traumatologic learning and the educational institution should prepare the objectives in details and clearly specify the content of the assessment. It’s correlated with the learning competent education and feasible to be carried out and the assessment of Orthopaedics and Traumatologic examination should be objective and transparent, valid, reliable and feasible. 

Definition of objectives is a marks decision without influenced by examiner personal, feelings, interpretations, or prejudice. The marks based on facts and unbiased. Transparent assessment means opened, clear and accountability of the final decision making of the Candidate’s mark and because of those objectives contents of the education learning are essential in Orthopaedics and Traumatologic examination.

Valid assessment is the highest priority of the musculoskeletal system examination but invalid evaluation will not represent the contents of the learning objective issues in the Orthopaedics and Traumatologic curriculum education. Subjective evaluation can result in bias musculoskeletal system examination decision and will not evaluate the important knowledge and skill of the musculoskeletal system that can lead to be an invalid decision regarding a Candidate passing the examination. Concerning, ambiguity or unclear questions can affect the marks of the assessment’s decision in examination.

Reliable assessment of Orthopaedics and Traumatologic examination should be achieved by the examiner staffs experiences. The reliable assessment of the orthopaedics and traumatologic should be consistent and indicates precision the marks are similar from a different examiner or other various conditions. The reliability is varied and depends on the assessment format and marking quality. Because of that, Indonesian National Board Examination of the Orthopaedic and Traumatologic should decide the number of examiner staffs, severity of patients, places, organizing team, transportation and cost needed at Orthopaedics and Traumatologic examination.

The Examiner staffs must be an excellent Orthopaedics and Traumatologic clinical educator at educational institution and they are as a role model in teaching. The examiner staffs are also an expert in teaching method, long-life learner, having responsibility to their residents. The examiner is always focused on the best learning method of the residents and provides health services for patient and community. The examiners staffs are also an effective communicator, facilitator, and reviewer for their residents and patients. Clinical teachers are as a role model and professional who always implement the medical ethics including: (1) respect the decision of others health providers and patient’s decision, (2) beneficence intervention for patient and always avoids malaficence, and (3) social justice in health care services. Clinical teachers are also expected to decrease the health care services cost per capita and have a sufficient sense of humor. The role model of the Orthopaedics and Traumatologic examiners should be oriented to include:

• Orthopaedics and Traumatologic content for residents.
• How to teach the Orthopaedics and Traumatologic content.
• The person who will teach.
• The clinical teachers know whether the residents understand the Orthopaedics and Traumatologic content in learning.

Therefore, the Orthopaedics and Traumatologic assessment guideline is really needed to know how well the acquisition of the musculoskeletal system competency is achieved during the learning process.

The problem is the examiner staff’s off of always focused on the knowledge only and they are subject to tendency of subjective assessment. Validity and reliability assessment remain controversial or bias. The examiners objectivity varies and often fails to observe the candidate’s communication ability and professional-attitude. Therefore, the question will be how many examiners and patients needed to improve the performance and feasibility of the objective examination.

Now, according to above problem I attempt to make the objectives evaluation of the examiner of the Orthopaedics and Traumatologic examination guidance and material content in details and well stated to achieve objectives and transparent, valid, reliable, objective outcome without prejudice and disparities.

ORTHOPAEDICS AND TRAUMATOLOGIC EXAMINATION

There are two versions of the Orthopaedics and Traumatologic examination:

1.         A real case of exam.

After Orthopaedics and Traumatologic case selection by the examiners team; the Examiner asks the Candidate to collect the history taking and collect physical examination data of the Orthopaedics and Traumatologic patient for analyzing and making the possibilities diagnosis. The Candidate should be able to select the important information and the reasoning of the investigations before presenting the summary

2.        Scenario or clinical signs or investigation findings exam.

The Examiner is able to select the scenario or clinical signs or radiographs of x-ray or laboratory of the patient and then the Candidate is able to ask some key of information in history taking, important data of the physical examination and investigation findings. These information and key data are able to support the differential diagnosis or possibilities of the illness on the scenario or clinical signs or abnormalities of the investigation finding.

Because of that, good scenario problems are essential and have an important objectives competent examination goal. The problems must stimulate the Examiner to discuss independently and may vary and maybe design at different level of the illness condition for discussion. Patient’s problems should be able to have a specific format which starts by identifying and lists all of patient’s complaint (including medical and social)

The Examiners can discuss at any point of the interesting possibility and then extend basic medical and clinical sciences questions freely for example: extend anatomy, physiopathology, history taking, diagnosis and management, and complications of the illness questions.

Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis determination

Learning Objectives Evaluation in Examination

The Examiners should be able to evaluate:

                               I.            The Candidate ability of the history taking information collection:

1.       Patient identification, complaint, history of the illness and risk factors. The Candidate should be able to present the identity and complaint problem of patient as the reason why patient comes to consultation and he/she also narrates the history of the illness and risk factors. The symptom of the Orthopaedics and Traumatologic includes pain, activity limitation, swelling and stiffness (PASS). Other possibilities relevant symptoms are color changes, altered sensation, systematic illness, fatigue, sleep disturbance, depression and fear. The Candidate should be able to decide the type of symptom, its site and distribution, chronology, associated symptom, the response to health intervention, previous factors and its impact. The Candidate also should be able to identify about the pain, radiation, related to quality (inactivity, rest or at night), aggravating and relieving factors, response to treatment and its impact. The causes of pain problem may be from bone, joint, and soft tissue/periarticular or referred or neurologic. There are five methods to measure the quality of pain includes: likert scale, visual analog scale, numerical rating scale, continuous chromatic analog scale and pain faces for children. The severity of pain relate to activity and analgesic drugs (table 1)

Table 1 The severity of pain relate to activity and analgesic drugs

No pain	Degree of pain	Relating to activity	Relating to analgesics
	I	Pain on vigorous activity	Over counter drugs
	II	Pain walking outdoors	NSAIDs	·         Dosage ·         Efficacy ·         Side effect
	III	Pain walking indoors	Combination analgesics
	IV	Pain at night	No response to analgesics only Opiates alone
	V	Pain all the time

2.      Past medical illness, comorbidities and allergy history. The Candidate should be able to determine past medical history and comorbidities of the patient’s illness when, how and who makes the diagnosis, management and progress. He/she also tells the pregnancy history of the female patient if relevant with the present illness or organ function evaluation. The Candidate should be able to decide the history of allergy and severity of the abnormality, if relevant with the present illness.

3.      Family, social and culture and occupation history. The Candidate should be able to describe the family history of illness because there are some conditions which may have a familial predilection. History of social and culture are important to explore because it influences the process of disease; for example healing process of fracture may be influenced by smoking patient. Occupational history of patient can determine the management, for example a pianist should be treated with adequate reduction of the phalanx fracture and so on.

                              II.            The Candidate ability of the physical examination data collection: 

1.      General condition/general appearance, ambulatory or non-ambulatory patient or crutch/cane or wheelchair use. The Candidate should be able to assess the gait for ambulatory patient and vital signs such as: temperature, blood pressure, respiration rate, pulse and body mass index (gait, arms, legs and spinal or GALS screening).

2.      Local examination data collection

·         Look: the Candidate should be able to tell the local abnormalities such as : symmetricity, deformity, open wound, skin defect, rashes, blister, burn, laceration or other sequelae. If fracture should identify: tenting and protruding of the fragments fracture, muscle atrophy and so on.

·         Feel: the Candidate should be able to explain the data collection including, local tenderness, crepitation or step-off and swollen/lump or swollen at the lesion site. In case of tumor suspicion; he/she should be able to evaluate the size, surface, margin, consistency and mobility to the bone or the soft tissues around the lesion. The Candidate should be able to decide the level of tenderness of the spine palpations, curvature, spine processes, step-off, and prominence. Costovertebral tenderness is an indication of organic back pain diagnosis caused by renal abnormalities. Tenderness on para-spinal muscle indicated (indicates) fracture, infection or tumor of the spine, and other possible diagnosis. Tenderness on sacroiliac joint or positive FABER maneuver is a sacroiliac sign indication but intervertebral tenderness combined with seronegative spondylopathies (is suspicious) can be a suspicion of a rheumatoid arthritis.

·         Move: The Candidate should be able to demonstrate the measurement of range of motion (ROM) of joints actively and passively. It could be full, fixed or limited result compared to the normal side. The Candidate should also be able to ask the patient to perform forward flexion, extension, lateral binding and rotation of the spine movement examination. Limited spine motion without pain, it could be a degeneration process or ankylosing spondylitis. Movement of the cervical spine region should be carefully performed because it can cause an iatrogenic injury.

·         Neurovascular evaluation: The Candidate should be able to assess the sensation and vascularity (capillary refill test at the finger/toe pads) and the Candidate explains the physiology and pathology reflex and upper and lower extremity, sensation of the radial, ulnar, median, femoral, tibial and peroneus nerves in carefully. The Candidate should also be able to evaluate the peripheral nerves (table 2)

Table 2 Evaluation of peripheral nerves

Nerve	Muscle	Sensory
Upper extremity
Axillary	Deltoid-shoulder abduction	Lateral aspect arm
Musculoscutaneous	Biceps-elbow flexion	Lateral proximal forearm
Median	Flexor pollicis longus-thumb flexion	Tip of thumb, volar aspect
Ulnar	First dorsal interosseous-abduction	Tip of little finger, volar aspect
Radial	Extensor pollicis longus-thumb extension	Dorsum thumb web space
Lower extremity
Obturator	Adductor-hip adduction	Medial aspect, midtight
Femoral	Quadriceps-knee extension	Proximal to medial malleolus
Peroneal Nerve
Deep branch	Extensor halluces longus-great toe extension	Dorsum first web space
Superficial branch	Peroneous brevis-foot eversion	Dorsum lateral foot
Tibial	Flexor halluces longus-great toe flexion	Plantar aspect foot

·         Muscle power grading (scale: 0-5). The Candidate should be able to determine the muscle of the extremities such as:

0.      No visible of palpable muscle/tendon contraction

1.      Any flicker of motion or visible and/or palpable muscle/tendon contraction

2.      Full range of movement out of plane of gravity

3.      Full range of motion against gravity only

4.      Full range of motion against some resistence, but weaker than expected

5.      Normal strength

3.      The special clinical test ability, for example apprehension test of the shoulder for detection of recurrent dislocation, Drawer test of the knee for anterior/posterior cruciate ligaments integrity or other maneuver evaluations.

                                     III.            The Candidate ability to explain the reason investigation ordering and determining relevant investigation with interpreting the results and then analyze, investigate, interpret the key data collection and assess the risk factors for accurate diagnosis or formulating a limited differential diagnosis. The Candidate should be able to describe radiographic (x-rays, CT scan, MRI, ultrasound, and Nuclear medicine scan) and laboratory data (complete blood count, basic metabolic panel, blood type and screening, and the basic coagulation tests, prothrombin time and partial thromboplastin, synovial fluid analyses and urine pregnancy for woman of child bearing age) to support the diagnosis and management plan. A good Candidate in clinical experience knows how to ask the same question in several ways and use appropriate different terminology to patient.

                                        IV.            Achieve the accurate diagnosis maybe using the analyzing or interpretation the key data relate to the systematic knowledge of each possible patient illness that includes prevalence, patient presentation, risk factors and or others clues. There are several possibilities or differential diagnosis based on acute or chronic complaint or trauma and non-trauma of the musculoskeletal system (illustration 1 &2) 

Illustration 1: Acute condition of the musculoskeletal system illness

Illustration 2. Chronic condition of the musculoskeletal illness

The Candidate can easily establish a diagnosis in acute trauma patient but concomitant signs such as weakness or paralysis; paresthesias or pulselessness is a fracture complications. Furthermore, complaint of pain at the right knee in a patient suffering from Crohn’s disease and under chronic use of corticosteroid may not have knee abnormality at all. The pain maybe referred from avascular necrosis of the ipsilateral head of the femur. Other example, a left knee pain and fever maybe a sign septic joint infection and so on.

Table 3. List of part A evaluation

Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis determination	10 Complete & correct presenta-tion statement	6 Incom-plete presenta-tion or Correct response to stimula-tion question	0 Inco-rrect response or no response	Marks
a.       Ability to gather information of the history taking includes: ·      Identity and patient’s complaint, history of the illness and risk factors,  ·      Past medical history or comorbidities (when, how and who makes the diagnosis), allergy, severity of the abnormalities, ·      The information of the family, social, culture and occupation history, and  pregnancy history (if relevant to the present illness), management and progress or organ function evaluation
b.      Ability to collect the physical examination such as: ·         The data of the  general condition, ambulatory or gait evaluation(crutch/cane/wheel-chair using), and body mass index, ·         Local examination (look, feel, move and ·         Muscle power & neurovascular, the special  clinical test or maneuver evaluation and the investigations
c.    Investigation reasoning Interpret, analyzing key data for some possibilities  or accurate diagnosis determination determination
Total marks  part A

MARKS OF PART A:

§  Mark 10: Candidate presents: (a) the history taking or (b) physical examination or (c) investigation and analyze key data for some possibilities or accurate diagnosis determination in discussion completely and correctly

§  Mark 6: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting (a) history taking or (b) physical examination and (c) investigation needed or a mistake analyzing data for some possibilities or accurate diagnosis determination in discussion correctly.

§  Mark 0: Candidate’s response is  not correct or he/she does not respond to the examiner’s stimulation question of (a) history taking, (b) physical examination, (c) investigation and analyzing of the key data for some possibilities or accurate diagnosis determination in discussion

§  Maximal marks of part A is 30

OTHER ALTERNATIVE EVALUATION LIST

Part A. The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis

 Learning Objectives Evaluation in Examination

The Examiner should be able to assess

The Candidate ability to recognize the system musculoskeletal abnormality joint scenario

Discussion between the Examiner and the Candidate is how the Candidate make the most likely diagnosis of the system musculoskeletal abnormality based on the key data in the scenario (history taking, physical examination and investigation finding) to support diagnosis and how he/she integrates and of analyze all data  and last is problem issues of the system musculoskeletal abnormality patient (table 4). The Examiner questions are varying depends on the Examiner experience for achieving objective, valid and reliable marks.  

Table 4: List of the evaluation marks of part A

CONTENTS OF EVALUATION	Marks
Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis determination	30 Complete & correct presentation	20 Incomplete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to collect the key data of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis determination in discussion

MARKS:

§  Marks 30: Candidate presents the history taking, physical examination and investigation and analyze key data for some possibilities or accurate diagnosis determination completely and correctly

§  Marks 20: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting history taking or physical examination, investigation needed and analyzing data for some possibilities or accurate diagnosis determination correctly.

§  Marks 0: Candidate’s response is  not correct or he/she does not respond to the examiner’s stimulation question of history taking, physical examination, investigation and analyzing of the key data for some possibilities or accurate diagnosis determination.

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 hypostatic pneumonia, 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 B evaluation

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 to decide 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 prediction in discussion completely and correctly.

§  Mark 15: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting of (a) the acute and long-term problem determination or (b) management planning or (c) complications prediction in 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 planning or (c) complications prediction during discussion.

§  Maximal marks of part B is 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 & correct presentation	45 Incomplete 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 abnormality in discussion

MARKS:

• Marks 60: Candidate presents the acute and long-term problem, the management and complications prediction planning of the system musculoskeletal abnormality completely 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 planning and complications prediction determination of the system musculoskeletal abnormality correctly.
• 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, and complications prediction of 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):

The candidate attitude: 

·         What is the Candidate’s focus on communication with the patient? Does the Candidate rarely interrupt patient’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 malaficence in 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 consideration to 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

The professionalism of Candidate:

·         Professionalism Candidate should enhance the quality of medical care delivered based on biopsychosociol-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 show a good attitude (a) and basic medical and clinical knowledge to decide management based on evidence or (b) professionalism in health care services in discussion

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

§  Mark 0: Impolite attitude and Candidate is also a bad attitude (a) basic medical and clinical knowledge without evidence management decision in health care services or bad professionalism (b) in discussion  

§  Maximal marks of 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 & correct presentation	6 Incomplete 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 clinical knowledge 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 services of 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:

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