There are essentially four categories in which testing and assessment play a role:

(1) Teaching and Learning
(2) Program Evaluation and Research
(3) Guidance and Counselling
(4) Administration

While these are interrelated and test results can be used in several categories.

Teaching and Learning: All teaching has some goal or objective as its purpose

All teaching has some goal or objective as its purpose. The objective may be implicit or explicit. Teaching, then, is for the purpose of having students reach some intended learning outcome (objective). The only sound means by which a teacher can determine the extent to which students have achieved the objectives is to assess performance. The outcome of the testing, therefore, is an evaluation of not only student performance, but the effectiveness of the teaching itself as well. A main function of testing is to measure the extent to which the instructional objectives have been met.

Here are some examples of learning objectives that can be measured by testing, or assessment, including direct observation with a checklist:

1. The student will be able to describe in writing the interaction of tRNA and mRNA in protein synthesis.
2. At the conclusion of the neurology course, students can write a cost effective approach to the initial evaluation and management of patients with dementia.
3. At the conclusion of internal medicine clerkship, third-year medical students will be proficient in the diagnosis and management of hyperlipidemia, hypertension, diabetes, chronic obstructive pulmonary disease, angina, and asymptomatic HIV.
4. Student will demonstrate proper hand-washing technique prior to changing a dressing on a patient.

Tests also have a number of other functions in teaching and learning.

Enhance Learning: Testing promotes overlearning

Increasing student motivation to work and academic engagement will also increase their learning. When students anticipate a forthcoming test, they will attend to material more closely, increase their study time and work harder to learn the relevant material than they otherwise would. Also the anticipation of a test improves students’ learning set so that they increase their memory capacities for the material (through rehearsal, elaboration, organization). Students will make a conscious effort to improve their knowledge and understanding of material when they anticipate a test as opposed to when they do not.

Testing also promotes overlearning which occurs when you systematically study and prepare for a test. Of course some of the material learned for the test will be forgotten afterwards (hence the term overlearning) but more material will be retained in the long-run than if overlearning had not occurred. This “forgotten” material is much easier to recall or relearn even years later than if it had to be acquired without prior knowledge. Thus testing promotes not only learning in the immediate future but results in longer more stable learning as well.

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Test Theories

There are three major interrelated test theories today:

1) Classical test theory (CTT),
2) Generalizability theory (G-theory)
3) Item response theory (IRT).

All three theories are fundamental to the field of psychometrics – the theory and technique of psychological and educational measurement. This includes the objective measurement of attitudes, personality traits, skills and knowledge, abilities, and educational achievement. Psychometric researchers focus on the construction and validation of assessment instruments such as questionnaires, tests, raters’ judgments, and personality tests as well as with statistical research relevant to the measurement theories.

Classical test theory is so-called because it was developed first in psychometrics. The premise is simple: any observed score (e.g., a test score) is composed of the “real” score or true score plus error of measurement:

X (Observed score) = T (True score) + e (error of measurement).

The early foundational work of scholars like Karl Pearson, Charles Spearman, E.L. Thorndike, and Fredrick Kuder was based on this idea.

G-theory was developed by LJ Cronbach and colleagues (1963, 1972) [1] as an advance over CTT. In CTT each observed score has a single true score and has a single source of error of measurement. G-theory is a statistical framework for conceptualizing and investigating multiple sources of variability in measurement. An advantage of G-theory is that researchers can estimate what proportion of the variation in test scores is due to factors that often vary in assessment, such as raters, setting, time, and items. Anyone who has watched Olympic diving has observed the effect of different sources of variance: the divers’ scores vary based on particular differences in performance, by the different raters (judges), and the items (components of the dive). The variation in scores, therefore, comes from multiple sources. In health care assessment, the same situation obtains when the student performs skills, which are rated by two or more judges or raters. Both CTT and G-theory continue to play a role in testing and measurement.

The third major theory, IRT is also known as latent trait theory. Like CTT and G-theory, it can be used for the design, analysis, and scoring of tests, questionnaires, and assessments measuring abilities, attitudes, or other variables. IRT is based on mathematical modelling of candidates’ response to questions or test items in contrast to the test-level focus of CTT and G-theory. This model is widely used with multiple choice questions (that are scored right or wrong), but can also be used on a rating scales, patient symptoms (scored present or absent), or diagnostic information in disease.

In IRT it is assumed that the probability of a response to an item is a mathematical function of the person and item characteristics. The person is conceptualized as a latent trait such as aptitude, achievement, extraversion and sociability. The item characteristics consist of difficulty, discrimination (how they distinguish between people), and guessing (e.g., on multiple choice items). All three psychometric theories – CTT, G-theory, IRT – have their relative advantages and disadvantages.

1st Evolution: Mainframe Computers 

The advent of computers has played a large role in the expansion and evolution of testing in the last 60 or so years. Many of the complex statistical techniques that have been applied to testing, such as correlational and factor analysis and test theories such as IRT have only been possible with the use of computers. As large mainframe computers became commonplace in universities and some other institutions during the 1960s, large data bases from testing programs could be stored and the data analyzed with software programs. At the same time, software programs that could be installed into the computers also became available. Prior to this, users had to write their own software from scratch. Data could be entered into the computers (e.g., with punch cards, optical scanning sheets, bubble sheets, keyboards) and analyzed and reports generated for individual test takers.

By the 1980s, optical reading scanning machines (reading bubble sheets marked with pencils) had been more-or-less perfected and matched to desktop computers. Large numbers of bubble sheets (e.g., thousands) can be quickly and efficiently entered into a desktop computer where sophisticated software can quickly analyze the test results and produce individual reports, and psychometric results of the test.

2nd Evolution: Personal Computers 

The next evolutionary step that began in the 1990s was the elimination of pencil-and-paper (i.e., bubble sheets) so that students could take a test directly on a computer. This is called computer based testing (CBT).   The main advantage of CBT historically has been for report generation and quick feedback. With the advent of the personal computer, CBT functions primarily for the computer-administered versions of paper-and-pencil tests. These provided some advantages over paper-and- pencil in test administration, and item innovation. Some disadvantages include the need for latest hardware and software and large test centers to accommodate large group testing.

CBT can be innovative allowing flexible scoring of items. Test items can use sound or video to create multi-media items. An item may contain a 40 second video and audio sequence of a doctor performing a focused physical exam on the left lower quadrant of the abdomen for example. This can be followed by series of MCQ questions to the student.   Content innovation also relates to the use of dynamic item types such as drag-and-drop, point-and-click, or hovering over hotspots. Future developments in CBT are likely to focus on item innovation that measure complex cognitive outcomes such as clinical judgment and professionalism.

3rd Evolution: The Internet

Online testing refers to the delivery of tests via the Internet. This approach also provides a new medium for distribution of test materials, reports and practice manuals, and for the automated collection of data. Even traditional paper-and- pencil materials can be delivered online as PDF format files using e-book publishing technologies. Theoretically, anyone with an Internet connection could take a test at anytime from anywhere in the world. Such an approach provides much more flexibility in testing than has been possible in the past. Online testing highlights a whole set of issues: confidentiality, cheating, test taker identification, hacking, breaching the test bank, and so on.

Sources:

[1] Cronbach LJ, Nageswari R, Gleser GC (1963). Theory of generalizability: A liberation of reliability theory. The British Journal of Statistical Psychology, 16, 137-163.

Cronbach LJ, Gleser GC, Nanda H, Rajaratnam N. (1972). The dependability of behavioral measurements: Theory of generalizability for scores and profiles. New York: John Wiley.

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The Flexner Report

In 1910, Abraham Flexner produced the now famous Flexner Report, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of

Teaching that was commissioned by the Carnegie Foundation [1]. At that time there were approximately 157 medical schools that were loosely affiliated with educational institutions and the education of physicians was primarily a for-profit business. The knowledge and skills of the graduating physicians was highly variable, resulting in an over-production of poorly educated medical practitioners.

Flexner provided a review of medical education and medical institutions and reviewed the economic and social factors that had an impact on the delivery of medicine of that era. He concluded that the situation was untenable and that medical education needed to be radically transformed. Today, with a few rare exceptions, medical school organization in the United States and Canada consist of 4 years, the first two pre-clinical or laboratory sciences consisting of foundational knowledge in anatomy, physiology, pharmacology, and pathology, followed by two years of clinical sciences experiences. The Flexner Report also contained arguments for evidence-based and scientific-based medicine. It has had an impact on the medical school admissions process, the learning environment, the qualifications and expectations of medical teachers and the need for standardized licensure exams. The Flexner Report has been pivotal to most of modern medical education including the development of standardized testing and assessment in medicine.

Meanwhile developments in large scale standardized testing were taking place in Europe and the United States largely as a consequence of World War I. Large scale testing in Germany for army inductees had been in progress since 1905. Alfred Binet and Theodore Simon had discussed the application intelligence testing for the French army in 1910. In the United States Lewis Terman had completed the revision and standardization of the Binet scales in 1917 and these principles of mass testing were soon applied to the American military effort resulting in the Army Alpha and Beta Tests of intelligence . Nearly two million recruits were tested with these instruments before the end of WWI [2]. This testing was seen as so successful, that after the war large scale standardized testing swept the American school systems. The major types of test used throughout the 20^th century were pencil-and-paper multiple choice questions (MCQ).

Statistical and Mathematical Theories

Another important development that underlay this widespread testing was the development of modern statistics. The large databases that were generated from this prodigious testing required improvements in statistical methods. Beginning in the late 19^th century, there were a series of statistical and mathematical initiatives. Major contributors to the field have been Sir Francis Galton (polymath, correlation), Sir Ronald Fisher (analysis of variance), Karl Pearson (mathematical statistics, correlation), Charles Spearman (measurement of intelligence, factor analysis), E.L. Thorndike (educational measurement), Fredrick Kuder (reliability), Lee J Cronbach (reliability, generalizability theory), George Rasch (item response theory), Fredric M Lord (item response theory), Karl Joreskog (confirmatory factor analysis), and Peter Bentler (structural equation modelling) as well as many others.

Sources:

[1] Flexner, A (1910) Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching

[2] McArthur DL (1983). Educational Testing and Measurement: A Brief History, Center for the Study of Evaluation Report #216, University of California, Los Angeles.

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Assessment involves the assignment of numbers, quantities or characteristics to some dimension. Evaluation is the process of interpreting or judging the value of the assessment. Testing as used in the usual sense is a subset of assessment – in the classroom, in the clinic or on the ward it is assessment of educational outcomes. In recent years, the focus for classroom, clinic or ward based assessment has been on performance assessment (also called authentic, direct or alternative assessment). This sort of assessment involves “real life”, open-ended activities that are intended to measure aspects of higher-order thinking and professional conduct which together can be referred to as competence[1].

In psychology and medical education, assessment instruments include examples such as intelligence tests, achievement tests, personality inventories, biomedical tests, and any classroom tests that you have taken in school, college and medical school. All of these are measurement instruments because they attempt to quantify (assign a number) some dimension whether it is length (ruler), time (clock), intelligence (IQ test) or scholastic aptitude for medical school (Medical School Admission Test – MCAT). Each assigns a number to one of a physical (length), psychological (intelligence) or educational / achievement / aptitude dimension (MCAT).

In addition to the MCAT, another very important test in medicine is the Unites States Medical Licensing Examination (USMLE) which is given in steps, reflecting emerging competence over time in the physician’s development. Step 1 assesses understanding and application of important concepts of the sciences basic to the practice of medicine. Here the focus is on principles and mechanisms underlying health, disease, and modes of therapy. Step 2 assesses the application of medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision. Step 3, the final examination, assesses the application of medical knowledge and understanding of biomedical and clinical science essential for the unsupervised, independent practice of medicine, with emphasis on patient management in ambulatory settings. In all cases, scores or numbers are derived from these tests. Tests and assessment devices, therefore, are measurement instruments in education and psychology. Long before systematic or standardized testing in the United States and Europe, however, physician licensing has been rigorously practiced (see Blog Post 1 for historical examples).

Evaluation involves value judgments. To make an evaluation, you interpret a measurement according to some value system. A measurement may be a clinical teacher reporting Jason’s score on a procedural skills test, such as intubation, as 19. If the teacher interprets this score and concludes that Jason is excellent at intubation, then this is an evaluation.

• Assessment = assigning a number
• Measurement = assigning a number
• Testing = assigning a number
• Evaluation = assessment or measurement or testing + a value judgment

Test scores generally serve as measurements or attempts to quantify some aspect of student or clinician educational functioning. The letter grades (A,B,C,D,F) or adjective descriptions (Excellent, Fair, Poor) associated with these numbers are evaluations based on these test scores. In some medical schools, students are provided with a class ranking, which is a type of evaluation because the higher the rank, the better the standing. Evaluation, therefore, is measurement plus value judgments. The quality of the evaluation depends on both the quality of the measurement and the care with which this result is interpreted. A careless interpretation of good quality data is likely to lead to a poor evaluation just as a careful interpretation of shoddy data would. Evaluations by professors (or others) of student performance that are based on little or no data (that is, subjective evaluations) are likely to be of very poor quality. One of our main aims, therefore, is to help course professors, clinical teachers, assessment experts, licensing authorities and others to develop good quality assessments (measurement instruments) and to conduct careful interpretations of the results. Thus their evaluation of student and clinician performance will be enhanced.

Sources:

[1] Hodges B, & Lingard L (eds). (2013) The Question of Competence: Reconsidering Medical Education in the Twenty-First Century. Cornell University Press: Ithaca, NY

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The assessment of medical and healthcare competence continues to be one of the most challenging aspects of the education, training, licensing and regulation of health care professionals such as doctors, nurses, dentists, optometrists, and other allied health care workers. The report, To Err Is Human: Building a Safer Health System [1], of the Institute of Medicine of the National Academy of Sciences in the United States, made some staggering claims: nearly 100,000 people die annually in American hospitals as the result of medical mistakes. Subsequent commentators have suggested that this is an underestimate and the actual mortality rate is much higher. Some argue that the number of medical mistakes is much higher than is commonly accepted because most of the errors are buried with the patient.

A recent report on adults’ health care experiences in seven countries (New Zealand, the United Kingdom, the United States, Australia, Canada, Germany, and the Netherlands) indicated that 12-20% of adults experienced at least one medical error in the two years of the study [2]. These findings have triggered international discussion, concerns and controversies about patient injuries in health care. The major factors underlying medical errors are thought to be system-based factors (e.g., miscommunication on the ward) as well as person factors resulting in drug overdoses or interactions, misdiagnoses, surgical mistakes, incorrect medications, and simple carelessness. Patient safety, a topic that had been little understood and even less discussed in health care systems, has become a public concern in most Western countries.

Patient safety has now become a mantra of modern medical practice. Despite this, thousands of people are injured or die from medical errors and adverse events (incapacitation, serious injury or death) each year. Worldwide this figure may run into the millions. Leaders in the health care systems have emphasized the need to reduce medical errors as a high priority.   Doctors, as main participants, have been called upon to address the underlying systems causes of medical error and harm. Unfortunately, several studies [3] have shown that more than half of hospital doctors surveyed haven’t even heard of the report, To Err Is Human.

While both system-based factors as well as person factors are at the root of medical errors, it is now believed that the impact of some person factors have been underestimated: physician carelessness, lack of knowledge, lack of professionalism, physician exhaustion and sleeplessness, and poor self-assessment, particularly of personal limitations in medical skills [4] [5]. There is concern that the preferred tendency to put the emphasis on systems, but not holding individuals responsible for errors will weaken accountability for physician performance.   Failure to identify individual factors may contribute significantly to risk of adverse events and may lead to a focus of patient safety away from the clinician to a systems-based approach. The assessment of the competence of individual health care professionals looms larger than ever.

Assessment is also commonly known as testing. Testing has its roots in antiquity and has undergone rapid advances in the later part of the 20^th and the first part of the 21^st century. This is because some necessary developments in its emergence – statistical and mathematical theories, advances in test theory, and computer technology and optical readers, online testing, social and political policy – have come only in the last several decades. Currently, the field is undergoing rapid development and change bringing exciting possibilities and challenges. Before describing the current status of testing and its history, however, we must describe and distinguish testing, assessment and evaluation. See the next blog post on: “Assessment, Testing and Evaluation – Aren’t they all the same?”

Sources:

[1]  Kohn KT, Corrigan JM, & Donaldson MS (1999) To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press.
[2] Schoen C, Osborn R, Doty M, Bishop M, Peugh J, Murukutia N. (2007). Toward higher performance health systems: Adults’ healthcare experiences in seven countries. Health Affairs 26(6): 717–734.
[3] Brand C, Ibrahim J, Bain C, Jones C & King, B. (2007). Engineering a safe landing: Engaging medical practitioners in a systems approach to patient safety, Internal Medicine Journal, 37, 295-302.
[4] Newman-Toker DE, Pronovost PJ (2009). Diagnostic errors – the next frontier for patient safety. Journal of the American Medical Association, 301, 1060–1062.
[5] Sibinga, EM (2010). Clinician mindfulness and patient safety. Journal of the American Medical Association, 304, 2532-2533.

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Before The Renaissance

Prior to systematic testing as in modern times, the licensing of physicians has nevertheless been regulated. Control of the medical market place through licensing, prosecutions and penalties has a long history and is not unique to modern society. Several cases illustrate the practices in the past several hundred years.

Jacoba Felicie paced nervously in her room glancing through her notes a final time before she set out for the court house [1]. Powerful forces including the Dean and Faculty of Medicine at the University of Paris were allied against her. This was Paris in 1322 and the physician guilds and university faculty had increased in power and control of the medical marketplace. They were seeking to consolidate their regulation of medical practice. They decided that Jacoba was a particularly good case to prosecute as she was a woman practicing medicine. The Dean and Faculty of Medicine were determined to put a stop to the illegal practice of medicine.

For some time now the Parisian faculty wanted to gain stronger control over various practitioners of medicine such as surgeons, barbers and empirics whether male or female. The Dean and the Faculty of Medicine charged Jacoba with illegally visiting the sick, examining their limbs, bodies, urine and pulse, prescribing drugs and collecting fees. The Dean and Faculty were most outraged because she actually cured some patients, frequently after conventional physicians had failed to do so.

The Dean and Faculty of Medicine who prosecuted her did not deny her skill or even that she cured patients. They argued that Jacoba had not read the proper texts; medicine was a science to be acquired through proper reading of texts such as Galen and lectures and discourse based on the written word. Medicine was not a craft to be learned empirically.

Jacoba argued in court that the intent of the law was to forbid the practice of medicine by ignorant and dangerous quacks and charlatans but that this did not apply to her as she was both knowledgeable and skilful. She also argued that she was fulfilling a particular need with female diseases because conventional modesty precluded male practitioners from dealing with these. Many of Jacoba’s patients came to court that day to testify to her skill, knowledge and caring. Jacoba must have been crushed when the court ruled in favor of the Dean and Faculty of Medicine that she was not legally constituted to practice medicine in Paris. She was therefore prohibited from practicing medicine in the future on penalty of imprisonment. The court acknowledged her patients’ positive testimonies, but this was not deemed relevant to her legal status as a medical practitioner. Thus the case of Jacoba ended and we have no further historical record of her. Perhaps she left Paris to practice medicine.

The French medical establishment continued to do battle with illegal practitioners of medicine including the famous skirmishes with Louis Pasteur in the mid-19th century [2], some 500 years after the case of Jacoba. One incensed physician even challenged Pasteur to a duel. Louis Pasteur, primarily a chemist and microbiologist, is one of the main founders of the germ theory of disease. Although his discoveries reduced mortality from puerperal fever, created the first vaccine for rabies and anthrax, and eventually revolutionized medical practice, the medical establishment in France was hostile to him as an unlicensed interloper.

The Renaissance and the Case of Leonardo Fioravanti

The Milanese physicians had been plotting against him since his arrival from Venice in 1572. Fioravanti had been arrested and imprisoned by officers of the Public Health Board in Milan on the sketchy charge of not medicating in the accepted way [3]. After eight days in prison Fioravanti was becoming increasingly outraged by the indignity he was suffering. The Milan medical establishment considered him an outsider, an alien and an unwelcome intruder. They finally were able to have him incarcerated.

Fioravanti was not a conventional medical charlatan hawking his nostrums in the piazza and then moving on. Nor was he a run-of-the-mill barber-surgeon. He had practiced medicine for years in Bologna, Rome, Sicily, Venice and Spain. He had a MD from the University of Bologna, had published several medical texts, had developed many medicines, and was a severe critic of much of conventional medical practice. The Milan physicians were not welcoming and considered him a foreign doctor.

A prison guard provided pen-and-paper for Fioravanti, and in his most elegant and formal language, he addressed it to Milan’s public health minister from “Leonardo Fioravanti of Bologna, Doctor of Arts and Medicine, and Knight”. He asked to be released from prison and to “medicate freely as a legitimate doctor”. A paid messenger delivered the letter to the Health Office located in the Piazza del Duomo.

The health minister, Niccolo Boldoni, was responsible for overseeing every aspect of medical practice in Milan, from examining midwives, barber-surgeons, and physicians, to collecting fees, imposing fines, inspecting apothecaries, and ruling on appeals. The letter from the Doctor and Knight, Leonardo Fioravanti, claimed that the Milan physicians were in a plot to stop him from providing care and cures to the sick of Milan. Moreover, he claimed that the Milan physicians were a menace to their patients and did more harm than good with quack treatments, poisonous medicines, and careless and arrogant behaviors. Fioravanti challenged the minister to provide 25 of the sickest patients to him and an equal number to Milan doctors that the minister selected and that he – Fioravanti – would cure his patients quicker and better than the other doctors. It is unlikely that this early clinical trial ever occurred as there is no historical record of it, but Boldoni and the Milan court set Fioravanti free.

Sources:

[1] Magner, LN (2005). A History of Medicine (2nd edition). New York: Taylor & Francis, p. 154-155
[2] Debre P (2000). Louis Pasteur. Baltimore, MD: Johns Hopkins University Press.
[3] Eamon W (2010). The Professor of Secrets. Washington, DC: National Geographic Publishing.

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Modern testing of physicians and other healthcare professionals is well established and rely on scientific processes and procedures encompassed in the field of psychometrics. While the science of testing and assessment for the purpose of certification and licensure has developed in the past century or so, the regulation of medical and health care practice has its roots in antiquity (see other blog posts for its origins).

The first country in the world to implement standardized testing on a broad scale was Ancient China. Called the imperial examination, the main purpose of the test was to select candidates for specific jobs in the government[1]. The imperial examination was established during the Sui Dynasty in 605 AD. It lasted for 1300 years and was abolished in 1905 during the Qing Dynasty[2]. During the period of use the imperial examination system played a central role in the Chinese imperial government. It served as a tool for the political and ideological control, functioned as a proxy for education, produced an elite social class, and became a dominant culture in traditional Chinese society[3]. The examination system was an attempt to recruit candidates on the basis of merit rather than on the basis of family or political connection.

The texts studied for the examination were the Confucian classics. After a period of emphasis on memorization without practical application and a narrow scope, the exam underwent change (circa 960), stressing the understanding of underlying ideas and the ability to apply classical insights to contemporary problems. Students sometimes spent 20 to 30 years memorizing the classics in preparation for a series of up to eight examinations in philosophy, poetry, mathematics, and so on.

By the 20th century the imperial examination was considered outdated and inadequate. Meanwhile, an examination system modelled on the Chinese imperial exam was adopted in England in 1806. Its purpose was to select specific candidates for positions in Her Majesty’s Civil Service. This system was later applied to education and influenced testing in the United States as it became a model of standardized tests. These practices include using standard conditions for the test (e.g., quiet setting, proctors supervising) and standard scoring procedures (e.g. using exam scorers who were blinded to the candidates’ identity) and protocols (e.g., scoring rubrics).

Sources:

[1] Dubois, PH (1970). A History of Psychological Testing Boston: Allyn Bacon.
[2] Miyazaki I (1981) China’s Examination Hell: The Civil Service Examinations of Imperial China USA: Yale University Press.
[3] Wang R (2013). The Chinese Imperial Examination System. Plymouth, UK: Scarecrow Press.

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Dr. Claudio Violato is a leader in the industry with more than 200 academic publications and thousands of citations.  As a Professor, he has taught and mentored numerous psychometricians in the industry today. Dr. Violato is working on a new textbook on “Assessing Competence in Medicine and Other Health Professions”.

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