WPBA or CASC/OSCE: where is it going wrong?

I have been involved in all aspects of training and workplace-based assessment (WPBA) as a consultant, chair of annual review of competence progression panels and a Royal College of Psychiatrists' examiner for the past 6 years, and experience the problems discussed by Menon et al ¹ and commentators ^2,3 regularly. The inherent weaknesses of WPBAs have been well documented in these studies, but one also needs to seriously consider why trainees who are proclaimed as competent in clinical skills (as evidenced by successful WBPAs) are performing so poorly at the College's Clinical Assessment of Skills and Competences (CASC) exam, where the success rate has dropped to less than a third?

As an examiner, I sometimes have been exasperated at the poor standards of performance in the recent CASCs where problems have been evident in all aspects of clinical and communication skills (knowing, knowing how, showing how and doing). Is that a reflection of failure of training systems and assessments (WBPA) or should the obvious conclusion be that there is no correlation between demonstrating competence in clinical practice and performing in an exam (something many may argue has been present all the time)? Should we then do away with the final exam altogether (as run-through training under Modernising Medical Careers may allow in some specialties) or return to the old-fashioned part II clinical exam which some (examiners and trainees alike) may argue was a better test of clinical competence and, more importantly, excellence? These are very important questions that the College and the Postgraduate Medical Education and Training Board need to consider, as one should not lose sight of the ultimate goal (becoming a specialist/consultant) of being in a postgraduate medical training programme in any specialty.

Following Lord Darzi's recent review of the National Health Service (NHS), ⁴ it has become ever so important for consultants to be at the forefront of driving quality in the modern-day NHS, something that will be difficult to achieve if we do not produce adequate numbers of quality-trained consultants. This may paradoxically suit many strategic health authorities, primary care trusts and NHS trusts! Many medical managers like me are constantly put under pressure to reduce medical costs (there is anecdotal evidence that consultant posts are not being advertised or retiring consultants are not being replaced throughout the country). As consultants remain relatively expensive units, it would suit the NHS ultimately to have fewer. New Ways of Working ⁵ is another tool of reducing consultant workload and perhaps ultimately numbers. Thus, if we continue with the current framework of training and assessment, we may inadvertently be facilitating that process.