Use of case-based exams as an instructional teaching tool to teach clinical reasoning

Background: It is a very well-known fact that examinations drive learning to a great extent. The examination program is actually the 'hidden curriculum' for the students. In order to improve teaching and learning one option is to strategically use of exams. Aims: This report of the strategic use of an innovative assessment tool in clinical problem solving domain, presents the design, format, content, students' results and evaluation of one year test results of instructive case-based exams for 6th year medical students. Method: Using a hybrid form of the OSCE, PMP and KFE formats, we developed a case-based stationary exam. Students were treated as advanced beginners in medical career and forced to an inquiry to use their clinical knowledge in the cases. Case discussions and question-answer sessions followed the exams. Six exams were held in 2000-2001 and 382 students participated in the study. One or two problems were used for each exam and the mean duration was 27 minutes for 7-11 stations. 17-19 observers contributed to each exam. Exams were evaluated by questionnaire based feedbacks of the students and oral feedbacks of the staff members. Results: The exams were well received and rated 'fair' by the students and the format was found highly 'relevant for learning' while the content was 'instructive' and 'not difficult'. The total non-satisfactory performance rate was 2.36%. Students asked to take a similar test weekly. Although it was labor intensive, staff members appreciated the collaborative working process. Conclusions: Instructive case-based exams and the following case discussions seemed a high potential and motivating teaching tool in the clinical problem solving domain for 6th year students.