Re: ACEM OSCE 2019:1 ‘Refugee‘ Station
Back of Bourke Base Hospital
April the 1st 2019
(not in jest)
Dear Dr Jeff Cott,
Cultural competence is a central part of Emergency Medicine practice, especially in 2019 in an Australasian setting. I was glad to hear that ACEM are considering increasing their summative assessments of cultural competency. Further, I note this now applies to both for trainees and FACEMs. The ACEM college should be congratulated on addressing this important issue in-line with RACS and ANZCA.
Early this week (on the 1st of April; but not in jest) we were informed (having not been present at the 2019:1 OSCE examination) that one of the stations aimed to test cultural competencies and communcation skills in an extraordinary way. Paraphrasing, it’s apparent that one of the OSCE stations used the case of a ‘refugee‘; ‘muslim‘; ‘female‘; ‘quiet‘; ‘refusing to speak‘; ‘distressed‘ patient who had multiple somatoform complaints. Clichéd? appropriate? offensive? necessary? – are all words I have heard to describe the station from various quarters…
Needless to say, this particular OSCE station has caused a wee bit of a stir. Was it based on a real case? Was it in an exam blueprint or was it just made up? I am sure it has been included with best of intentions and it is important to test the topic of cultural competence.
As a perpetual ACEM trainee what is my opinion? Well, while clichéd grey cases in medical exams are less than ideal, they always have been common place… These types of questions have been an integral part of the assessment process for many years especially in MCQ exams….
These grey cases with a ‘touch of stereotype‘ are a classic form of question, but should these pattern recognition cases be kept of the OSCE exam? The rationale would be that the professional ‘live actor’ may play their OSCE role neither safely nor consistently. Additionally, who can really judge objectively what ‘cultural competency’ looks like from a particular minority’s perspective in a stressful OSCE setting? What if the observers (examiners) are not in fact from the minority group concerned?
On the other hand, in a written exam the wording can be precisely workshopped leaving no doubt to either the reader or examiner of what exactly is being tested. Furthermore general rules can be tested and specific documents recommended for reading in the curriculum list.
For example, describing ‘a 22-year-old middle eastern patient with recurrent acute abdominal pain and peritonism‘ would make me think (the exam answer) of Familial Mediterranean Fever. This would be a classic case that I think you need to ‘classic descriptions for’ to make the ‘spot diagnosis’. This kind of thing should be tested – but in a written format. Likewise you could test the “refugee patient” case in a written exam somewhat effectively, albeit at a lower level of application on Miller’s Pyramid (Fig. 1):
I think what caused such a stir in this case wasn’t the idea of testing Cultural Competency per se, but rather the issue was putting this, otherwise appropriate case in a high-stakes OSCE setting.
This has upset many in minority groups who feel that the case is perpetuating stereotypes. They are especially concerned because of the perception that the exam has been stacked against individuals from minority groups and non-english speaking backgrounds.
Dr Ed Reje
ACEM Trainee (Perpetual Maintenance Pathway)