Competency-based assessment: The power of subjectivity


A paradigm shift in assessment tools and methods will be necessary with the introduction of competency-based undergraduate education in India. Complex combinations of multiple attributes make up competencies. Many of these are not easily assessed by objective methods. For lack of objective methods, assessment of communication and affective domains has been neglected. Only longitudinal assessment can be used to assess areas like professionalism, ethics, and communication, which are so important for Indian Medical Graduates. Although subjectivity is often criticized for being biased, it has been repeatedly proven that objective assessments in the hands of experts give comparable results to subjective ones. We may undermine the validity of the assessment by insisting on objectivity. This could also deprive students of enhanced subjective feedback and judgment. This review focuses on the importance of subjective assessments in competency-based assessment. It also discusses ways to improve the rigor and effectiveness of subjective assessment.

KEY WORDS - Competency-Based Medical Ed, objectivity and reliability, rubrics, validity

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Although it is widely acknowledged that assessment drives learning, there are unintended and intended consequences. [1] Students learn in a way that they perceive. Assessment should be a strategic tool to enhance teaching and learning in higher education. [2]

Competency-Based Medical education (CBME), which focuses on the acquisition of observable skills by students, is learner-centered and focuses on the outcomes relevant to daily practice of medicine. The much-awaited competency-based Indian undergraduate medical curriculum is now in effect. This paradigm shift has moved the emphasis to applying knowledge in real-life situations. CBME is a sign of a shift in medical education to assess general competencies. This reflects a wider, more inclusive view of physician competence through the eyes society. [3]

Medical educators have had to overcome this shift toward CBME in order to develop new methods for teaching and assessing professional and clinical competence. CBME was implemented in India during a time when Indian medical educators were just beginning to appreciate the value of objective assessment methods and objectivity. The pursuit of objectivity was also accompanied with the belief that all assessments should be objective in order to have any value. This tendency towards objectivity in medical education was supported in large part by the idea that professional roles could be broken down into distinct knowledge or skills. These can then be aggregated to assess overall professional competence. [5]

Learning is the key focus of CBME. A focused approach that includes reflection, exploration and feedback can improve performance. Competency-based assessments should aim to make summative judgments on learning competence and lack thereof. This will ensure that learners have the opportunity to develop their longitudinal and monitored skills.

This article attempts to critically and purposefully discuss the essential role of expert judgement and subjectivity in assessment, in the context the implementation of CBME in Indian undergraduate medicine education.

Is Objectivity Real?

It is not clear if standardised assessment methods can guarantee comparable performance in real-life situations, given the variability inherent in clinical practice. For optimal patient care, medical care requires that medical graduates are able to combine different competencies. [6] Is the whole competence a collection of individual tasks that are completed in the context of knowledge, skills and communication?

Although many clinical tasks can easily be broken down into steps, it's not always possible for complex skills like team-collaboration and professionalism to be broken down. This is why longitudinal development is necessary. These skills can best be assessed by direct observation under real-life conditions. Furthermore, once these skills have been mastered, the process can be automated and graduates are able to skip certain steps in diagnosis or treatment. This makes it unnecessary for objective, check-list-based assessments.

Assessments are not objective. All assessments are influenced by the values and attitudes of the assessor. Objectively-oriented assessments often use checklists that are heavily influenced by subjective opinions. If an assessor decides to be biased before marking a checklist for tasks completed or steps performed, it is not going to stop them from marking it incorrectly. Many steps in checklists require expert subjective opinions to be marked.

Blue-printing, though it was introduced to improve the validity and validity of an assessment. It again involves expert subjective judgments right from assigning clinical relevance or impact or frequency to the drafting of items and keys to distracters. Standard setting is an expert's subjective decision. If not enough candidates meet the cutoff, such as in post-graduate entrance exams, the standard setting is subjective and not based upon any objective methods. We make subjective decisions, but we try to measure them objectively. This process is called objectification by Vlueten. It doesn't give better results than expert subjective opinions. [10]

When assessing clinical competence, it is important to allow for variability and heterogeneity of performers. As such, an objective assessment will lose its value in competency-based assessments. Medical educators have rightly cautioned against objectifying competency based assessment. [9,10 and 11] We have the option to explore the possibility of using expert subjective judgment in competency-based curriculum. Let's briefly discuss the differences between objective and subjective assessment before we make our case for competency-based assessment.

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Objective Assessment versus Subjective

Objective assessment refers to information collected by measuring, observing, and examining facts. While subjective assessment is information primarily based upon personal views, opinions, or value judgments, it involves the use of information. Expert subjective opinions can be used to rate performance at higher simulation levels. They are often more flexible and require less effort and time. Expert subjective judgment can be a valuable addition to student assessment. It is essential for efficient assessment. Subjectivity offers students a lot of feedback. This is the most important thing. [12]

Objective assessments generally use "norm-referenced" approach without any specified criteria, while in subjective assessment the performance of students is generally assessed against a pre-determined criterion and thus follows "criterion-referenced" approach. Objective assessment allows for a wide selection of curriculum to be assessed in one assessment. This is possible within a short time frame. Expert subjective assessments, on the other hand, are based on assessing the overall performance of a simulation at a higher level over a longer period of observation. [12] Objective assessment can be compared to cross-sectional study, while subjective assessment can be considered "longitudinal".

Often, objective assessment is overvalued. Even though objectivity is sometimes incorrect, it's not always a perfect concept. It may work in some cases, but it is not always possible to divide the activity into smaller tasks and then assess objectively based on the task completed stepwise. You can de-assemble a cycle into different components, then assemble it again. But you can't disassemble a frog and then assemble it back into a frog. [13] Clinical competence is more than just a collection of skills and knowledge.

However, subjective assessments are often misunderstood as being subjective. It is false. Although subjective ratings might have a lower internal consistency for a given task than objective assessments, it is still consistent across all tasks. Its continuous, longitudinal nature provides immense feedback opportunities. It is not possible to ignore or challenge the utility of expert subjective judgment as part of competency-based assessment. a poker education is key to succes