Study results were organised around two overarching themes, with both themes being viewed through the perspective of the student and the examiner:
- Impact of the long case process
- Impact of the long case score
A further six themes were inductively identified from the dataset, with three sub-themes for each overarching theme.
Theme 1: Impact of the long case process
Exploration of the educational impact of the long case process generated three common themes: the development and refinement of core skills in clinical medicine (‘Fundamentals’); the authenticity of the long case (‘The genuine article’); and the travails of students as they strove to achieve mastery of the task (‘Reaching the pinnacle’).
Fundamentals
Students frequently commented that the long case provided them with an organisational structure for approaching and interacting with patients. They spoke of the ways in which they relied on this structure, such as on return to the ward after a research semester; the long case framework had been so ingrained that students could still call it to mind:
[Student 15] “Even just going into the ward, though – I remember when I first went back, how long ago, and I was like, oh! What do I need to do? Just totally blanked. And then the structure of the long case came back…and that helped.”
Students also noticed significant improvements in their ability to manage time when talking to patients, as demonstrated by Student 4’s observation that “…[the long case] was helpful to try and refine that kind of time management skill.”
Though examiners certainly recognised that the long case process was helpful in providing students with a means of “approaching medical clerking in a practical way” [Examiner 1], they also reflected that the long case was the only clinical assessment to test a holistic approach to patients. This made full advantage of the case specificity inherent within the long case, as each patient needed to be treated as a distinct individual.
[Examiner 3] “…it is a KPI [key performance indicator] of a doctor, really, you know, your ability to do a thorough assessment of the whole of a person and sort out all of their problems and how each problem interacts with the other, and the psychosocial impact of the person’s circumstances and how that impacts on their illness and their ability to comply with the treatment strategy and all that kind of stuff, is only to be got through a long case.”
Where students typically provided concrete examples of skills aided by the long case, examiners tended to make expansive statements about the benefits of the long case, with descriptions such as “it is fundamental in what we all do” [Examiner 4], “exactly the skills that you need as an intern” [Examiner 1] and “teaching them the skills that they need to practise” [Examiner 5]. This implied that the completion of a long case may have demanded so many foundational competencies that it was easier or more natural for examiners to describe the benefits of the long case in broad terms rather than targeting specific domains.
The genuine article
Students viewed the long case as an authentic task and contributed many specific examples of the ways in which long cases would assist them during internship, including at patient handover, during preadmission clinic, and when admitting new patients from the Emergency Department, which was described as “just doing a mini long case” [Student 18].
Although a minority of students felt that the long case was somewhat artificial, in that “doctors never go and see patients without knowing anything about them” [Student 9] and that “in real life you probably wouldn’t be that comprehensive” [Student 16], students generally agreed that “it felt legit [sic]” [Student 6] with statements such as “it feels real, cause you come up with an issues list, and management” [Student 10] and “the long case was the only time I felt like I was actually learning to do medicine” [Student 6].
[Student 1] “It’s like all of medicine – there’s two types of study. There’s study for the exams, and there’s study for being a good doctor and a competent doctor. And the two don’t necessarily seem to match up…I do think it falls into that ‘how to be a good doctor’, as opposed to ‘how to do the exams well’.”
In contrast to students’ beliefs that long cases were an authentic representation of medical practice, several students held fairly cynical opinions about the authenticity of the OSCE, which was described pejoratively as a “dance” [Student 8], “very artificial” [Student 12], and “terrible because I feel like you just go in there and you’ve rehearsed a little thing you’re going to do and you just regurgitate it” [Student 11].
One student contrasted the two forms of clinical assessment as follows:
[Student 4] “I really can’t imagine having gone through medical school without having to, I guess, learn skills that I got from trying to practise the long case. I mean, the OSCE’s an entirely academic exercise, and at the bare minimum you don’t really have to think about what you’re doing, you just go through the motions – but the long case you’re forced to process what it is you’re doing, why you’re listening to the heart, or if you’re hearing anything, and then formulate it and discuss it and present it…I think those skills are important. I’m glad that I’ve had the time to work on them in a safe kind of environment.”
Examiners were universal in their opinion that the long case mirrored what doctors do in their everyday work:
[Examiner 1] “I think it directly relates more than most of what you do in the medical course to your job as an intern.”
[Examiner 4] “…essentially that’s what we do day in day out, is do long cases, or medium-long cases, with almost every patient we meet.”
[Examiner 5] “…all we’re really testing is what you do every day in your practice.”
[Examiner 6] “it mimics real life”
Reaching the pinnacle
This subtheme reflected the conceptualisation of the long case as a summit of sorts, which was challenging to scale and required great perseverance to conquer. Students described the long case as a “stretch goal” [Student 11] and “the pinnacle of what we were trying to do” [Student 8].
[Student 7] “I think there’s no substitute for it. You can’t really assess it any other way as comprehensively as you do in the long case, cause…it’s the culmination of everything, it’s your knowledge and your skills and your ability to relate to a patient and talk to them but also manage time, yeah.”
Students found the long case to be highly complex and challenging, and a minority were deterred from seeing patients if they had insufficient time or energy to undertake such a comprehensive patient assessment:
[Student 9] “…it was almost like, if I saw a patient and I didn’t do a whole long case, like I’d failed in that interaction? …and so then the follow-on effect of that was like, if I didn’t feel like I had it in me within an afternoon to spend a whole hour, hour and a half with a patient, then I might just stay in the library.”
Examiners also acknowledged the challenging nature of the long case assessment, with Examiner 5 describing it as “the apex of all those other tasks”. Examiners were united in their view that the high educational value of the long case meant it should be retained despite its challenges:
[Examiner 2] “I’ve always told the students: the students that do the best are the students that talk to the most patients, examine the most patients, see the most patients, spend the most time in the wards…patients teach you medicine, not textbooks. And I think the long case in some ways exemplifies that learning and that teaching.”
Theme 2: Impact of the long case score
Challenges associated with standardisation and scoring (‘Comparing apples and oranges’), the emotional impact of their graded long case assessments (‘Emotional roller-coaster’) and the meaning which students and examiners attached to long case scores (‘On/off the mark’) were recurring themes with implications for student learning.
Comparing apples and oranges
Students and examiners were aware that the long case could not be fully standardised. Students were preoccupied with the equivalence of assessments at different sites or with different patients, whereas examiners were mostly concerned about what they could do to make it fairer for the students.
[Student 2] “I think because all of that variability exists, it’s a really good assessment in making us do it, but it would seem unfair if it was – it had a large weight.”
[Examiner 4] “…you obviously bring in the very subjective aspects of patient cases, where some cases will be deemed to be seen as easy and some will be deemed to be more difficult, and is that fair? But I think examiners often take that into account as well, when they’re seeing how they do it.”
[Examiner 5] “…you’ve got an hour and you get one patient and if that’s not your particular thing or the thing you didn’t study as well as something else, then you could be somewhat, perhaps, at a disadvantage, by almost random circumstance. Of course, that depends on the way that you assess it too. I mean if you – the assessment’s not just about that particular case but on the generalities of the process, you can get around that to a degree.”
Emotional roller-coaster
When reflecting on their long case assessments, students typically experienced strong emotions that ran the gamut of high stress, anxiety, apprehension, confidence, enjoyment and accomplishment:
[Student 6] “I found it a really enjoyable assessment in the end. Even though I was obviously stressed by it.”
[Student 11] “…I found the whole thing really stressful but I also think it’s probably our best assessment, even though I hated it a lot.”
The strongly negative reactions which long cases triggered in some students were mostly related to a fear of the assessment, or of failing it. Students described long cases as “daunting” [Student 13], “intimidating” [Student 11] and “stressful” [Student 12], and spoke of the pressure that they felt from their clinical schools and peers to practise long cases so that they would be prepared for their assessments. Though such profound feelings of fear may be an unintended consequence of assigning scores to clinical assessments, student anxiety about the long case did motivate them to engage in a number of positive learning behaviours such as seeing patients on the wards and discussing cases with clinical supervisors.
The students’ emotional upheaval in undertaking summative long cases went largely unrecognised by examiners, who on the whole did not mention the affective sequelae for students.
On/off the mark
The meaning ascribed to the long case score by students and examiners was an important concept which became apparent across the focus groups and interviews. There was general agreement that long cases had to be graded for students to “take it seriously” [Examiner 6]. Some students volunteered that if long cases were formative rather than summative, they would have “put much less effort in” [Student 3] and there would have been “decreased motivation” [Student 18]. Although a small number of students wished for long cases to be purely formative as it was “such a rich learning experience” [Student 7] in itself, they had great insight into the fact that their more results-focussed peers would be far less motivated to tackle the long case if it did not count towards their final marks:
[Student 10] “…some people would fully rise to the occasion, because at the end of the day you just want to be a good doctor and you want to impress the doctors that you work for. But other people would fall so far short of jumping that hurdle and would just be like, oh, I don’t care about that, I’ve got to get whatever they mark OSCEs out of, 40 out of 40 for my hypertension OSCE dance [laughter from group].”
As a point of differentiation from the earlier subtheme ‘The genuine article’, which was centred around the long case’s authenticity, the present subtheme focusses on perceptions of the long case’s validity in assessing clinical competence. Though students and examiners were wary of placing too much weight on a single long case assessment (see ‘Comparing apples and oranges’), both groups felt that student performance in long cases was a true reflection of their present and future clinical competence:
[Student 9] “…I did quite well in OSCEs and I do, I always do well in written exams, and out of all those things, my long case was the worst…I think that was more reflective of the level I was at clinically, than the exam marks which were great but probably really unreflective of how I was going as a whole doctor.”
[Student 11] “…it’s just so in depth that you can’t really, you can’t accidentally do really badly or really well”
[Examiner 3] “I think it is the best yardstick against which to measure a student’s performance as a practising doctor”
Examiners in particular regarded competence in the long case as a marker of future clinical competence, asserting that a student proficient in long cases would become a capable intern:
[Examiner 2] “Well I think it certainly reflects their practice as interns. I think there’s no doubt about that – if someone can do a long case, whatever that means, as a student, they’re going to be a good intern, most likely, because they’re going to know the questions to ask, they’re going to know how to follow the leads, they’re going to empathise with the patient, and once you develop empathy and rapport with the patient, you’re much more likely to get a deeper understanding of what this illness or this group of illnesses means to that patient. And I think that once you understand all of that, your treatment plan is going to be persuaded by what you learn about the patient, not just what you know about the disease, but what you learn about that person.”
Observations such as these afforded the long case a certain gravitas and elevated it from the daily grind of student assessment, as it shaped into a means to predict the intangible: whether someone would become a good doctor.