- Students on the degree course in medicine at UVic-UCC undergo a Structured Objective Clinical Assessment (SOCA) three times during the degree course: in the third, fourth and sixth year
- This June, around 130 bachelor’s degree course students will be taking the second assessment in a virtual format, which can be considered a medical challenge with a grade at the end
"Maria is a 58-year-old patient with no relevant clinical history. She has been feeling very tired for four weeks, she feels discomfort in her chest, and sometimes she feels short of breath." That could be the beginning of one of the tests in the Structured Objective Clinical Assessment (SOCA), the assessment method that the Faculty of Medicine at the University of Vic - Central University of Catalonia (UVic-UCC) used for third-year students for the first time last year.
Although most universities with a bachelor's degree course in Medicine only carry out the SOCA in the sixth year, UVic-UCC has chosen to use it at three points on the degree course: in the third, fourth and sixth years. It is not carried out in the fifth year, which is the internationalisation year, when many students are doing internships in other external centres, and many students from other countries come to study at the Faculty. According to the dean of the Faculty, Ramon Pujol, this decision is due to "the desire to make students used to this type of assessment, and our commitment to everything that the SOCA represents": it is Structured because the behaviour of the patients it includes is highly standardised; it is Objective because the contents are selected and it provides concrete results; it is Clinical because it is based on clinically based assumptions; and finally, it is an Assessment that observes, assesses and awards grades.
A medical challenge
But what is the SOCA really? It can be thought of in terms of a challenge event: a race in which the student must pass several tests. "The students encounter various challenges along the way, in which they have to demonstrate their ability to care for patients and some degree of practical skill," explains Carles Blay, vice-dean of teaching at the UVic-UCC Faculty of Medicine. As if it were a video game, as they do the tests the students accumulate points "that reflect how good the student is, or the extent which they have achieved what was expected of them" and which determine the final grade.
The SOCA is an extensively tested, reproducible, secure and reliable assessment system. "There is a very rigorous and validated method behind this appearance of a game, or tests that may even seem like fun," says the vice-dean. "You'll pass it if you've learned to be a doctor, because you need knowledge to pass the SOCA tests, but you also need to know how to apply it in the situations that arise, which are very similar to real life." Above all, it assesses skills in anamnesis, physical examination, interpersonal communication and diagnostic clinical judgement, "which are all broad-based competencies, and very important for engaging in high quality clinical practice."
An online SOCA
Although SOCAs are usually taken in person, in the last two academic years the pandemic situation has led the Faculty of Medicine to provisionally implement this test in an online format. Last year's third year students - a total of 63 students from the first year group of the bachelor's degree in Medicine - took the test virtually, and this year's third and fourth year students, totalling around 130 people, will do so this June.
In this online version of the SOCA, each student has to see six patients, who each have a different clinical profile, and who are played by actors who have learned their role and act according to guidelines provided by the teaching staff carrying out the assessment. Three tests or stages must be passed for each of these patients. Sitting in front of the computer, and with the assessment already under way, the student faces the first test - an online appointment with the first patient of the day, who they are only able to talk to.
The student then moves on to the second stage, in which they have to answer questions about the patient they have just seen, and more specifically, about the physical examination of them they would carry out; finally, in the third stage, the teaching staff ask the student for their diagnostic impressions, or in other words, "they have to say what the patient has, and how they propose to treat them based on their examination, the questions in the examination and the diagnostic tests provided, such as analyses and X-rays," explains Blay. After this first round, the second appointment begins, and so on until the day's six patients have been concluded, involving a total of 18 stages that last between four and five hours, and which each student copes with varying degrees of composure, just like in a real appointment.
The clinical cases presented to the students "have a high level of prevalence and are of paramount importance in the training of future physicians," says Blay. According to the vice-dean, "they are usually patients who come to the doctors due to general clinical problems such as fever, pain, fatigue, etc., based on which the student must obtain the relevant and pertinent details, and apply their clinical judgement to arrive at a diagnosis."
Improvements with simulated patients
If the aim is to reproduce medical reality as accurately as possible, many people may undoubtedly wonder why real patients instead of actors are not used during the students' examinations. According to Blay, "patients who are acting in order to simulate having a disease do so according to a very well-planned script and their behaviour is standardised, which is a great advantage because they provide a standard response to each student, which is always the same." For example, if the first simulated patient is asked if they have a fever, they will give every student an identical answer, "like in a film that is being shown over and over again," which means the students can also be graded more objectively. However, Blay adds, "a real patient may not give the same information to all the students who see them, or their response may be influenced by their mood at any given time." Another important reason for working with simulated patients is safety, i.e. it ensures that those involved do not unnecessarily expose each other to risk situations.
Face-to-face or virtual?
Both the face-to-face and the virtual SOCA model have advantages: "We have more years of experience with the face-to-face tests and how they are carried out in healthcare settings - in hospitals or health centres - that are more familiar to everyone who comes from a clinical environment. On the other hand, the virtual tests favour technological progress, facilitate the process and take us towards the future." On this issue, point Blay adds that as telemedicine becomes increasingly common, "carrying out the SOCA in a virtual format helps to train students in this new interaction model."
Last year's virtual SOCA was very highly rated by both the professionals involved and the students. For students, says Blay, "it means they are assessed in an environment that more closely resembles what they have learned during their clinical practice, and which they will come across in real life when they become doctors." The partnership between the Chair of Simulation and Patient Safety at UVic-UCC and the Centre for Innovation in Simulation (CISARC) in Manresa is crucial for carrying out these tests successfully.
"The SOCA is an original and effective way to evaluate a complex practice like anamnesis and physical examinations"
Ismael Gómez, fourth year medical student at UVic-UCC
What was your experience of your first SOCA last year?
Taking into account the six cases we had to see and the questions we had to answer about each one, the SOCA lasted between four and five hours. With the state of alert, all the classes went online and as the SOCA took place on 4 June and it was the last test of the year, I was able to do it at home on my computer. The truth is that I was a bit nervous because it was the first time I'd done this type of examination and particularly electronically, which mean that there was no physical examination. But because it was so long, in the end I shook off my nerves and I ended up doing it as if I was in a normal internship environment.
What do you think of this assessment system?
I think the SOCA is an original way (at least it was new to me) and it's quite effective at assessing a complex procedure like an anamnesis and a physical examination. It's usually a very subjective process, and having some established criteria like those in the SOCA and the same situations prepared so that all students can answer on the same basis means that the exam can be objective.
What practical cases did you have to deal with in the SOCA?
Last year we had to solve six very different cases: a case of fever and asthenia, which ended up being a paraneoplastic syndrome; a chest pain that eventually turned out to be an acute myocardial infarction; a patient with a supraclavicular nodule (in this case it was difficult to determine the diagnosis without any additional examinations because these nodules can occur for various reasons, ranging from a lymphoma to a respiratory infection, and if they are supraclavicular they are usually related to more malignant causes); a fourth case of abdominal distension, in which the patient said that she had diarrhoea, so as a result we knew it was gastroenteritis; fatigue in a cirrhotic patient (cirrhotic patients usually tire easily due to ascites, and may also end up developing anaemia); and finally a case of dysuria, which is the "typical" burning sensation that appears during urinary tract infections, although in this case it had evolved into pyelonephritis.
And how were the test results?
The grades took a couple of weeks to come out, and the truth is I was expecting a better grade than the one I got. But afterwards, talking to classmates, we found that everyone's grades were lower than we expected, and we came to the conclusion that we received these "low" grades because the assessment criteria will be the same for each year, from the third to the sixth year, and that is why they are demanding. In other words, I think we'll get better as the years go by, and that will be reflected in our grades.
What do you think are the advantages and disadvantages of the online format?
I think it's better to do the exam in person, but it was impossible with the pandemic, and the faculty managed to adapt the SOCA to the situation very effectively and very quickly. The major drawback for me was that we couldn't do the physical examination, which is a very important part of a medical appointment. But there were also some advantages, such as being able to do it in my room and not in a room set up as a consulting room. Being in a familiar environment gave me some peace of mind. What surprised me the most was the ability and speed with which they adapted it electronically and how well it was organised, as everyone started at a specific time and went through the various cases, we had enough time to solve them, and everything ran very smoothly.
Based on the experience of last year, are you planning to prepare for this year's SOCA in any particular way?
Last year, I basically prepared for it by reading through the anamnesis and physical examination classes we did during the Physical Examination 1 subject a couple of times. But what I really found useful was what I had learned during the internship. That’s why I think I won't prepare it any differently, because I don't even know if there would be a better way. Even if you prepare for the questions, you don't know how the conversation will develop or what situation you will find yourself in when the patients are in front of you. For me, the most important thing when doing this exam is to more or less have a mental outline of the essentials in each specialist field, and to be sure of the questions I need to ask, almost always to be able to focus the diagnosis afterwards and the tests I should ask for (if required) to confirm my suspicions.