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The case records exam was more useful in detecting the next winner of the Booker prize for fiction. The occupational and lighting exam an oddity. I was asked 'why aren't fire engines yellow?' I responded that they would attract too many greenfly and was roundly admonished for my flippancy. Still not sure why (answers all welcome, dear readers) this lack of knowledge has yet to impact on my practice. There was also the matter of preparing answers likely to be relevant to a particular examiner as it was well known that most had their own pet subject and to show some confidence in that would guarantee a good pass. I got through, and was lucky enough to have an excellent pre-reg year experience. The two were not necessarily connected, however.
Continuous monitoring
This month sees the first crop of pre-reg optometrists starting the new pre-registration qualification process and it is fair to say it bears little resemblance to the old system. Furthermore, contrary to the oft-levelled accusation that it is a 'dumbed-down' process, the new scheme, if properly implemented, is not only a challenging process but also reflects a better continual appraisal of performance throughout the year as well as offering an opportunity to sample the competency at the end of the year in a process far more standardised than the old exam system.
The key component of the scheme is ongoing assessments throughout the year. The new process has two stages of assessment visit. Stage 1 comprises three (or more if needed) visits by a College assessor and the candidate is assessed against the GOC competencies and has to support their competence in a variety of ways. The initial visit takes place early on in the year and requires assessment of soft lens insertion and removal, keratometry, pupil assessment, verification of spectacles and colour vision screening. These are best assessed by direct observation of the candidate, while the remaining competencies (10 in all are assessed at this initial visit) may be assessed by looking at record cards, the candidates log book of their refractions and dispenses along with an enquiring discussion. Importantly, the outcome is not 'pass/fail' but a discussion with the candidate and their supervisor about how to move forward and what plan to implement to help address any areas of weakness.
Two further visits are used to assess the remaining competencies (31 for visit 2 and 34 for visit 3) and these include watching a full routine examination, contact lens fitting, practical assessment of techniques such as tonometry, direct and indirect ophthalmoscopy, interpretation of fields, discussion of binocular vision cases and so on. Early concerns about differences in expectations among assessors (some were perceived as tougher than others) have been largely addressed by a continual feedback process and the monitoring by lead assessors who ensure consistency between assessors in their region.
Where not all competencies are signed off a fourth visit may be necessary, but at each stage a management plan is agreed with both candidate and supervisor, so ensuring a continual learning and development process. The days of cruising until two weeks before exams are over (I wonder how I would have coped under this system, being a serial last minute crammer!). Once stage 1 competencies are signed off, a new stage 2 process begins.
Stage 2
A second assessor undertakes the stage 2 visit which involves a full routine eye examination on a presbyope, a soft lens fitting and an aftercare. Patients will be provided on the day from the College. The assessor will also have to sign off the so-called over-arching competencies. These are the ones designed to reflect a range of continuing experience over the year such as 'The ability to make appropriate prescribing and management decisions based on the refractive and oculomotor status' or 'The ability to manage patients presenting with sight- threatening eye disease.' It is expected that stage 2 assessors will be more experienced assessors or examiners (or both). Once all competencies have been signed off, time for the OSCEs.
OSCEs
Objective structured clinical examinations (OSCEs) are used in most clinical professions as a means of assessing by a standardised and non-biased or subjectively weighted method. A good example of standardisation might be in the ocular disease subject. Historically, exams were notoriously erratic some candidates were lucky to get a well-dilated patient with obvious pathology, others difficult patients with obscure diseases. Does any reader remember the patient with Stickler's that usually featured in Bradford exams? Far better then to use a model to check examination technique than an image or video sequence to assess knowledge of disease. Remember, to get to this stage they have already had to prove to two independent assessors that they have had adequate experience with real patients. This way everyone has the same challenge. Patient interaction may be assessed in a standardised manner using actors. This approach has been used already in the Welsh WEHE/PEARS accreditation process and we have also tried the technique with final year students at City. The actor based stations are surprisingly demanding and you forget you are taking a history or explaining a disease to an actor instantly. It is proposed there will be 16 OSCE stations of five minutes each (including one rest station), each run sampling a different but equally broad spread of competencies. Those examiners who recently undertook a trial in London will vouch that this is in no way a dumbed-down process.
So is this aimed at changing pass rates? Making life easier? No. But I can state that we now have a much fairer and objective system. A few egos may have been rattled but, providing that assessor standards are monitored and maintained, I believe we have a rigorous and constructive interaction process making the pre-reg year a much better structured development phase. Good luck to all those just beginning! ?
? Bill Harvey is a College assessor and examiner