A Handbook for Teaching and Learning in Higher Education Enhancing academic and Practice

Medicine and dentistry
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In the 1960s and 1970s, the assessment of medical undergraduates was similar worldwide
and had remained largely unchanged since Sir George Paget introduced clinical
graduating examinations in the 1840s. Written assessments consisted of free response
essay questions, and clinical assessments were traditional ‘long’ and ‘short’ cases, with
most schools using viva voce. The principal problems with these forms of assessments
were that the written assessments had both weak validity and reliability and the short and
long cases, despite their relatively strong validity, had poor reliability. In addition,
students were able to compensate for poor performance in one domain or assessment
with better performance in another. Methods for combining marks were often inadequate.
The viva voce, perhaps the least reliable of all these assessments, was often used to make
critical decisions around the pass/fail borderline, and for the awarding of ‘excellence’.
Cynics may point to the emergence of examination litigation, notably within the USA,
as a reason for change in assessment methods, but there are other, more cogent reasons,
especially needing surety that we assess the main things we want students to know, do
and understand and that qualifying doctors and dentists have all attained certain
minimum standards. Maastricht psychometricians (notably Van der Vleuten and
Schuwirth) have been prominent, along with the American National Board of Medical
Education (Case, Swanson and Norcini) and the Medical Council of Canada, in introducing
greater reliability into assessment in medicine, and by osmosis into dentistry.
From the early 1990s there was greater ‘objectification’ of medical assessment (Van der
Vleuten et al., 1991) and with it, an increase in reliability. Since about 2004 the pendulum
has swung to put more emphasis on validity and on more difficult to assess qualities such
as reflective practice, ethical behaviour and decision-making. Van der Vleuten and
Schuwirth (2004, 2005) and Schuwirth and Van der Vleuten (2006) now counsel assessors
that over-reliance on any one property pushes others out of the picture, which is also
detrimental. These changes are reflected in new forms of postgraduate assessment, such
as the work-based assessments (see later), all of which are having an influence at
undergraduate level. In undergraduate curricula there has been a major shift away from
a ‘big bang’ graduating examination towards continuous assessment, led by Liverpool
and Dundee medical schools. This has shifted the emphasis of final examinations to
‘fitness to practise’. Keys to good assessment include making it compatible with what is
expected from learners (i.e. with learning outcomes) and realising that few types of test
are perfect; a range is often needed both to adequately sample and to assess the different
domains of knowledge, behaviours and attitudes and also to allow for variability in
candidates’ performance in any single assessment format.
The future of written assessment
The next ten years may signal the death of ‘written’/paper-based examinations.
Computer-assisted assessment can and is being used for multiple choice questions
(MCQ) and extended matching questions (EMQs), and lends itself more easily to the
testing of complex data, radiology, histology and anatomy. Virtual reality will also add