Background

Setting up a clinical skills learning facility

P Bradley1 & K Postlethwaite2

Objective This paper outlines the considerations to be made when establishing a clinical skills learning facility. Considerations Establishing a clinical skills learning facility is a complex project with many possible options to be considered. A number of professional groups, undergraduate or postgraduate, may be users. Their collaboration can have benets for funding, uses and promotion of interprofessional education. Best evidence and educational theory should underpin teaching and learning. The physical environment should be exible to allow a range of clinical settings to be simulated and to facilitate a range of teaching and learning methods, supported by computing and audiovisual resources. Facilities should be available to encourage self-directed learning. The skills programme should be designed to support the intended learning outcomes and be integrated within the overall curriculum, including within the assessment strategy. Teaching staff may be congured in a number of ways

and may be drawn from a variety of backgrounds. Appropriate staff development will be required to ensure consistency and quality of teaching with monitoring and evaluation to assure appropriate standards. Patients can also play a role, not only as passive teaching material, but also as teachers and assessors. Clinical, diagnostic and therapeutic equipment will be required, as will models and manikins. The latter will vary from simple part task trainers to highly sophisticated human patient simulators. Care must be taken when choosing equipment to ensure it matches specied requirements for teaching and learning. Conclusion Detailed planning is required across a number of domains when setting up a clinical skills learning facility. Keywords education, medical *methods standards; clinical competence *standards; curriculum; interprofessional relations. Medical Education 2003;37(Suppl. 1):613

Introduction
The drive towards the development of clinical skills learning facilities is understandable in view of the changes in healthcare delivery and of changes in healthcare education. In the early 1990s the UKs General Medical Council (GMC) published its blueprint for medical education reform.1 This document, Tomorrows Doctors, called for a reduction in factual overload and a streamlining of the undergraduate medical curriculum along with the need for programmes of communication skills and clinical skills training.

Director of Clinical Skills, Peninsula Medical School, Universities of Plymouth and Exeter, UK 2 Head of Graduate Studies, School of Education and Life-long Learning, University of Exeter, UK Correspondence: Paul Bradley, Director of Clinical Skills, Peninsula Medical School, Universities of Plymouth and Exeter UK, 3rd Floor, Mary Newman Building, University of Plymouth, Drake Circus, Plymouth, PL4 8AA, UK. Tel.: 01752 238034; E-mail: Paul.bradley@pms.ac.uk

Deciencies in undergraduate programmes and a reliance on serendipity have been recognised as leading to inadequacy in the skills performance of students.2 These deciencies often then result in junior doctors being required to perform skills for which they have not been prepared and as a result they perform suboptimally,3,4 which can be a signicant source of stress for them5 and a potential source of risk for their patients. It was also of some concern is that the deciencies may not be recognised by either the junior doctors or their supervisors.6 It has also been noted that the clinical experience of students is changing and that opportunities for them to acquire skills is reducing.7,8 Furthermore, the changing nature of the relationship between patients and healthcare providers and educators means that patients acceptance of being a passive, uninformed participant in medical education, a situation which was common in the past, no longer exists. Todays patient is better informed, has greater expectations and is able to exercise the right not to be involved with students. At the same time, the drive of clinical governance is setting the standards expected of healthcare professionals,
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Setting up a clinical skills learning facility

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Key learning points

A number of healthcare professions at both the undergraduate and postgraduate levels are potential users of a clinical skills learning facility. A wide range of skills can be considered when developing a clinical skills programme, and sound educational methods and theory can be used to underpin learning. Integration within the curriculum and within assessment strategies highlights the importance of clinical skills learning. Teachers may be drawn from medical and other healthcare professional backgrounds providing fulltime, part-time or sessional input and may work alongside patients in teacher and assessor roles. Flexibility in the use of space and the wide range and sophistication of equipment, models and manikins allows the simulation of the simplest procedure through to the most complex clinical scenario. which inevitably impact upon education in both undergraduate and postgraduate arenas. Against this background therefore, the establishment of clinical skills laboratories, centres or resource centres has taken place. They have developed to provide an environment in which students can acquire skills required of them in order to be subsequently able to perform their functions as healthcare practitioners. The environment provides protected time during which the students can be introduced to the skills by experienced faculty staff.9,10 They can practise these skills under direct supervision and receive immediate feedback on their performance. Students can practise the skills at their own pace and they can practise iteratively. The faculty provides good educational support, ensuring that they use positive critiquing. Students can be condent that they can do no harm and are not embarrassed by their early failures and are positive in their evaluation of their learning.11 Inevitably, the way in which clinical skills learning takes place12 will evolve in relation to internal evaluation and as a result of external inuences.13 This paper sets out a pragmatic approach to setting up a clinical skills learning facility.

Often the original planning for such a facility may have arisen as part of a curriculum development in a single discipline. However, inevitably within the local higher education and National Health Service (NHS) communities there are other groups who may harbour ambitions to plan, or be in the process of planning, their own facility. Signicant gains stand to be made where the plans can be combined to realise benets of scale and to facilitate the breakdown of interprofessional and undergraduate postgraduate divides. The encouragement of collaborative working such as this is a potential starting point for a range of interprofessional learning opportunities to be exploited. The stakeholders who are identied and who commit to the development of a facility form the natural focus for the creation of a project management steering group who will oversee the planning and implementation of the facility and who will evolve into a management committee for overseeing the running and future development.9

Teaching and learning

In setting up a clinical skills learning facility the opportunity exists to incorporate the best possible practice utilising modern educational theory to support the development and delivery of the learning programme.14 A wide range of learning methods can be adopted, including small group work, role play, real patients, simulated and standardised patients and audio and video recordings, particularly in the domain of communication skills.15 In supporting the learning and teaching of psychomotor and technical skills, the widely used 4-stage process involving tutor demonstration, followed by explanation, practice under supervision with feedback and constructive, corrective critique can be utilised,16 which is based on a craft-orientated approach to knowledge use and application.17 Insights from constructivism and social constructivism can be explored (see the Editorial in this supplement). This environment is also an ideal one in which to encourage reection by the student; indeed Schon advocated a reective practicum as a means of developing professional skills;18 furthermore, the environment is ideal for providing observation and feedback, which may be decient in the clinical setting.19 The spiral curriculum is a model that is readily adapted to clinical skills learning.20 An iterative process of learning combined with repeated practice develops any individual skill and a programme can be designed that envisages the range and complexity of skills learning increasing as learners move along the continuum from novice towards expert.21

Identify the users

Essential to the development of clinical skills learning facilities is the identication of the key stakeholders.

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Setting up a clinical skills learning facility

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Teaching and learning space

Teaching spaces

Clinical skills learning facilities vary in size, shape and location. These depend very much on the local arrangements, funding and availability of space and buildings. Different models of use will develop depending on the physical location and conguration of available space or planned buildings. Where the luxury exists to be able to specify the nature of the building, e.g. as a result of major renovation or new build, the design team have an opportunity to develop a exible model that will facilitate and maximise opportunities for use in a range of different settings. Large open spaces provide a great deal of exibility in the ways in which the areas can be set up. However, these spaces are not conducive to say, an intense communication skills session focused on breaking bad news. Therefore, a set of smaller side rooms may be required. The exibility of space can be enhanced by using collapsible wall dividers (which nowadays can provide very good sound insulation) to break up large spaces. Areas which are exible can be used to create a variety of clinical settings, from the domestic bedroom through to a bay in an intensive therapy unit, from a general practice consulting room to an accident and emergency cubicle. Such versatility helps the simulation to aid the suspension of disbelief. Indeed the overall feel for the facility should be one which gives the sense of a clinical environment. This level of exibility, however, comes at a price. More labour is required to put up and take down resources for the different needs of users. This is balanced against dedicating a room to a particular skill or set of skills, e.g. ophthalmoscopy and otoscopy, which may only be used a limited number of times in a year for skills teaching and for self directed learning and revision (possibly just before the assessment). Other features of the facility should include a well positioned reception with clear signage to assist users to nd their venue. Some areas may be more appropriately dedicated to a particular clinical environment, such as a simulated operating theatre or a small simulated ward with associated facilities, including, treatment room, sluice and dirty utility areas.
Self directed learning

environment or over the internet. One advantage of the internet is that booking can be associated with access to an asynchronous on-line discussion forum which can enable staff to monitor and comment upon student issues raised as a result of the experience of self directed learning. Suitable support should be available and care must be taken to ensure that proper attention is paid to health and safety issues, such as the disposal of sharps.
Ofces

Ofces are needed for support and teaching staff, with hot-desking arrangements for teachers brought in for specic sessions.
Storage

A frequently overlooked requirement is for storage. Although space dedicated to storage might seem a poor investment, with inroads being made into teaching space, this is a mistake. The expenditure on equipment, models and manikins is likely to see a poor return if these expensive items are not stored appropriately: inconvenient access can mean that the equipment is not made available when it might be appropriate, and can pose health and safety issues for those who have to extract equipment from its storage location; equipment is itself placed at risk of damage or misuse through having to be placed inappropriately.

Integrate within the curriculum

Whatever the range of skills to be considered and included within a programme, it is important that these are seen within the context of the whole curriculum. Recent curriculum reforms have enabled schools in the UK to realign elements of the curriculum to seek synergy between components of learning, enabling theoretical learning (e.g. modules relating to the gastrointestinal issues) to be run alongside clinical skills learning (e.g. undertaking an interview with a patient with a gastrointestinal presentation, gastrointestinal examination, ano-rectal examination, etc.). This integration within the curriculum is a key element to the success of clinical skills learning. Embedding this learning in an integrated fashion avoids the view being taken that this is a peripheral add-on. Ideas from activity theory (see the Editorial to this supplement) may be helpful in informing the planning of effective integration of the overall curriculum, including simulation. The importance being placed on skills learning is of sufcient degree to require this to be a compulsory and also an assessed part of the curriculum.
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Self directed learning should be encouraged through the provision of access to material and equipment outside of the normal teaching time. This could be run via a booking system operated through a managed learning

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Setting up a clinical skills learning facility

P Bradley & K Postlethwaite

Identify the skills

The range of skills which are traditionally associated with the clinical environment varies depending on the individual perspective. The simplest list for an undergraduate medical curriculum would start with skills associated with obtaining a patients history including communication skills, physical examination and some technical and practical procedures, as outlined in Tomorrows Doctors.1 Communication skills can be learned during the undergraduate curriculum,22 and students can demonstrate both better communication skills and better attitudes in relation to the importance of communication skills.23 It makes sense to integrate communication skills within the overall clinical skills programme, as to divorce them is to produce an articial separation. The limited nature of this list was acknowledged by the GMC in the publication of a longer list in The New Doctor24 which has subsequently been introduced into a recent rewrite of Tomorrows Doctor.25 A more comprehensive overview of the range of skills expected in medicine and nursing demonstrates the scale of what might be considered.26 The increasing sophistication of facilities, and demands for a systematic approach to the delivery of skills learning opportunities in both undergraduate and postgraduate curricula have seen the possibility of a signicant expansion in the range of educational activities that could come under the umbrella of a clinical skills learning facility, as shown in the following list of potential skills:27 Administrative skills, e.g. paper work, sickness certication, death certication, referral procedures, admissions procedures, etc. Attitudinal awareness and professionalism, e.g. codes of conduct, professional behaviour, responsibilities of a doctor. Clinical reasoning skills. Communication skills, e.g. verbal non-verbal communication, breaking bad news, dealing with the difcult patient, written communications. Critical appraisal skills including evidence-based medicine (EBM). Documentation skills. Economic skills. Ethical legal considerations, e.g. obtaining valid informed consent, condentiality, statutory notications, etc. Health and safety and manual handling, including hand hygiene and universal precautions. History-taking skills, adult medical and surgical, paediatric, obstetric & gynaecological and psychiatric.

Information and communication technology including information retrieval, handling, generic information technology skills and internet use. Investigative skills including selection of tests and interpretation of results data. Learning skills. Organisational skills, e.g. time management. Patient management and prescribing skills. Physical examination skills. Practical procedures and techniques. Presentational skills including small and large audience presentations, bedside presentations, written materials. Resuscitation skills, both adult and paediatric basic life support and adult advanced life support. Teaching skills including basic educational principles and practical teaching sessions. Team working and leadership skills. The facility can also be seen to be a medium through which interprofessional learning can be promoted. Interprofessional skills learning can be facilitated in a general learning of generic skills28 or in specic and complex simulations.29,30 The nal list of skills that form a clinical skills programme will increasingly be driven by the focus on outcomes-based medical education31 and can be made explicit by inclusion in a curriculum map.32 Characteristics of an extensive clinical skills learning program are outlined in Table 1.

Stafng
Inevitably there are stafng needs that must be addressed. These relate to both teaching and support activities.
Support staff

The number of type of staff required will depend very much on the size of the facility and the range and number of projected users. Manager administrator Responsible for day to day operational control. Also involved in planning and development of the activities within the skills learning facility. Ensures smooth running of facility. Monitors use of and promotes facility as a learning resource. Patient simulated patient co-ordinator Responsible for maintaining a database of real patients and simulated patients (actors or volunteers) who will

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Table 1 Characteristics of clinical skills learning at the Peninsula Medical School, UK

Early From the very beginning of the course Runs throughout the course Innovative Uses a variety of new techniques and materials Range and sophistication of skills reect level of student Range and sophistication of skills increase with time

Table 2 Model of teacher support for clinical skills learning

Full or part time clinical skills teachers

Sessional clinical skills teacher

Peripatetic clinical skills

Continuous

Appropriate

Planned

Intensive

Developed from a skills matrix based on the learning outcome and linked to curriculum map Covering wide range of skills Runs in parallel with and complements other course themes

Progressive

Staff employed to Doctor, nurse or Specialist brought in provide teaching other healthcare for specic scheduled support to a specied professional learning activity, e.g. user group or, possibly, employed to provide resuscitation training as a generic teacher regular sessional ofcer for resuscitation for a range of users support usually for a training, cardiologist specied user group for ECG workshop, etc.

Evolutionary

Integrated

Educationally sound

Assessed

Throughout, formatively and summatively with feedback

Evidence & research based

Changes in response to evaluation Based on sound educational principles and theories and using proven methods Based on existing evidence and developing new

a regular or ad hoc basis, in which case the sense of ownership can be expanded across the wider clinical community, or on a combination of the two extremes. From whatever background that teachers are recruited there will be a need for a suitable staff development programme, including teaching skills, to assist in the enhancement of the characteristics of the good teacher.
Senior academic staff

be used in the learning and assessment of clinical skills. This post might also be combined with the role of training and standardisation of patients in order to ensure consistency of presentation.33 Receptionist secretaries Provides general ofce support for the activities and being the front of house interface with users, providing a rst stop contact for users and enquiries. Runs booking system and ensuring co-ordination between activities. Technician(s) Maintains and ensures availability of models, manikins and other clinical diagnostic and therapeutic equipment required for skills learning activity. Maintains and monitors use of clinical and other consumables. Puts up and takes down resources required for specied learning activities.
Teaching staff

As well as providing some of the teaching support, senior academic staff may also be involved as strategic leaders. Whether these appointments are full time or part time varies between facilities. In this role, senior academic staff are often responsible for overseeing a programme of skills learning and are charged with curriculum development roles in order to ensure congruence between clinical skills and other elements of the curriculum. As well as these teaching and administrative duties, senior academic staff have the opportunity to develop research programmes within this important area of healthcare education and to provide opportunities for developing links that can promote investigation into the interprofessional agenda.

Learning with patients

Although many centres will utilise the students themselves as patients in role play and as surrogate patients in clinical examination, and the students are largely willing to do so,34 there inevitably will be a need for more a complex presentation of patient problems. These patient representations may be undertaken by real patients, often trained to demonstrate a standardised portrayal of their illness. Alternatively, actors, both professional and amateur, can be used to simulate the history and, in some cases, the physical signs associated with particular presentations.35 The use of simulated patients in both teaching and learning and in the assessment of clinical skills is now commonplace.36,37 Outside of the UK there has been considerable

Teaching staff will be required to provide support for the learning activities. The models will depend on local needs and arrangements, and within different user groups there may well be different approaches (Table 2). Generally speaking the choices are whether to concentrate on a dedicated teaching staff, in which case the quality and consistency of teaching can be more readily assured, or on using teachers brought into the facility on

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experience of the use of teaching associates who enable the learning of intimate male and female examinations.3841 Incorporating real or simulated standardised patients requires recruitment to the programme; this may be facilitated through professional actor troupes or may be undertaken through local advertising seeking volunteers. Local clinician and self-help groups are ways in which the population of real patients can be approached. Whatever the means of recruitment, there follows a need to maintain a database of demographic and clinical details of patients, also including availability, transport needs, healthcare needs and so on. All patients, real or simulated, will require some degree of training, more so if they become involved in the teaching itself42,43 or as assessors.44,45

Resources
Models, manikins and clinical equipment

The range of models, manikins, diagnostic and therapeutic equipment that is available is increasing all the time. The equipment required will be partly determined by the user groups who are collaborating in setting up a facility, by the range of skills identied as forming the curriculum and by proposed teaching and learning methods. Some equipment will be fairly generic across groups and therefore a case can be made for sharing procurement costs and seeking economies of scale across the groups who use the facility. Other equipment, however, will be highly specic to a particular group and may be best sourced by the individual user who has the need. Whatever the procurement process, there is no substitute for clearly dening the specication of equipment and ensuring that these requirements are met. An example of this might be in purchasing ECG machines. If part of the requirement is to teach students how to measure parameters and read an ECG it would be inappropriate to purchase a top of the range model with automatic printout of ECG parameters and diagnostic interpretative algorithm software. At the same time, if students are to use ECG machines to learn how to make a recording, they are likely to work as pairs, one recording, one being recorded, if one is to use the teaching time most effectively then, with a group of 6 students, 3 machines would be needed. On this basis it is easy to see why so much storage might be required and why set up costs would be fairly signicant. Depending on the nature of the activity being undertaken and learning required, the models and manikins purchased will be judged on achieving a balance between realism and utility. For example, a model needed for

introducing students to the technique of female pelvic examination may compromise on external appearance in order to provide a more, realistic and robust feel permitting repeated examination by up to 100 students. However, a key principle must be that no matter how great the utility of a particular piece of equipment, this must never demote the importance of an accurate reproduction of the underlying human structure and function if this is essential to the subsequent successful application of a skill in clinical practice. An extreme, and entirely ctitious, example of this would be a model designed for demonstrating and practising liver biopsy with sites for biopsy provided on both sides! There is little comparative data about the attributes of different products for clinical skills learning. Inevitably, therefore, the potential user is charged with exploring the marketplace. Experience can obviously be tapped into and discussions with and visits to established clinical skills centres will provide much useful information about the pitfalls to be avoided and the essential background to be covered.
High delity simulation

The place of simulation in clinical skills learning is increasing, as illustrated in this supplement. High delity simulation in particular is establishing a place in both undergraduate and postgraduate arenas. Anaesthetic training has been at the forefront of these developments using computerhuman patient simulators that can be programmed to respond to a variety of physical and pharmacological interventions. Recently, slightly less sophisticated, but more affordable simulators, such as Laerdals SimMan have opened up the potential for complex clinical scenarios to be developed for use in undergraduate learning. Within the UK the British Heart Foundation has donated a Harvey, the cardiovascular patient simulator, to each medical school, which has the potential to greatly enhance the learning of cardiovascular skills provided it is properly integrated into the curriculum.46 More recently another cardiovascular simulator has been developed that is computer controlled and more portable.47
Information and communication technology (ICT)

The increasing importance of ICT cannot be underestimated. Access from the clinical skills facility to the institutions intranet and through that to internet-based resources will open up a world of support material. In addition, more and more material is available on CDROM and DVDs that can be used as support material, both in planned and self-directed learning. As

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mentioned above, ICT can provide asynchronous discussion facilities that can support learning (Seddon, personal communication, 2003). ICT may also provide a mechanism by which simulation centres could share data or collaborate in other ways in research to increase the sample size in studies that rely on quantitative data and statistical analysis.
Audio-visual facilities

Conclusion
The learning of clinical skills is a key component of the education of healthcare professionals. The recognition that serendipity has failed to deliver the required learning opportunities has led to the development of educational resources dedicated to ensuring a consistent and high quality learning experience that has been carefully planned and integrated within the curriculum. Clinical skills learning facilities provide an exceptional educational environment where protected time can be devoted to the development of a wide range of skills. Formal support for the learner through supervision and feedback can be combined with opportunities for self-directed learning and practice. These facilities are not intended to and never will replace the learning that is derived from real clinical experience. However, they do enable the learners to establish a foundation in a range of skills that can then be honed and be made more substantial through the experiential learning undertaken in clinical practice.

Alongside developments in IT are developments in audiovisual capabilities. The modern clinical skills facility provides high quality audio-visual facilities that can be used to promote analysis and feedback in a variety of settings. Individual consultations can be used to support communication skills learning. Team work in clinical scenarios can be recorded for later discussions. Interactions between students and patients can be recorded using a small unobtrusive digital camcorder and can be viewed simultaneously in a much larger room with an audience having uninterrupted views of the images using multimedia projectors. Simultaneous recording to a DVD recorder can allow almost instant replay and rapid fast forward or reverse, as well as providing individual students with a permanent record of their performances.

Acknowledgements
We wish to thank the students and staff involved in clinical skills learning at the Universities of Liverpool and Dundee and at Peninsula Medical School who have contributed so much to our knowledge and experience.

Evaluation
Evaluation of the activities taking place within a clinical skills setting is essential to ensure the quality and appropriateness of a learning programme. Feedback from and to students, users and teachers plays an important role in motivating and informing these constituents. Timely feedback can be used to address problems early and can demonstrate, powerfully, a commitment to meeting learners needs10 and to seek to improve the learning.48

References
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Assessment
A clinical skills learning facility is an ideal venue in which to assess the acquisition of clinical skills in an in-vitro environment at the shows how level of Millers hierarchy.49 Assessment can be both formative and summative. The use of the objective clinical skills examination (OSCE)50 or a variation thereof is becoming fairly standard across many healthcare professions at both undergraduate and postgraduate level. The logistics and skill required are very signicant and should not be under-estimated.51 Great care and attention is required in designing the assessment to ensure that it meets the standards required of modern educational practice.52,53

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34 ONeill P, Larcombe C, Duffy K, Dorman T. Medical students willingness and reactions to learning basic skills through examining fellow students. Med Teacher 1998;29:4337. 35 Collins J, Harden R. AMME Medical Education Guide, 13: real patients, simulated patients and simulators in clinical examinations. Med Teacher 1998;20:50821. 36 McGraw RC, OConnor HM. Standardized patients in the early acquisition of clinical skills. Med Educ 1999;33:5728. 37 Barrows HS. An overview of the uses of standardized patients for teaching and evaluating clinical skills. AAMC. Acad Med 1993;68:44351; Discussion 4513. 38 Hillard PJ, Fang WL. Medical students gynecologic examination skills. Evaluation by gynecology teaching associates. J Reprod Med 1986;31:4916. 39 Sachdeva AK, Wolfson J, Blair PG, Gillum DR, Gracely EJ, Friedman M. Impact of a standardised patient intervention to teach breast and abdominal examination skills to third year medical students at two institutions. Am J Surg 1997;173: 3205. 40 Rochelson B, Baker D, Mann W, Monheit A, Stone M. Use of male and female professional patient teams in teaching physical examination of the genitalia. J Reprod Med 1985;30:8646. 41 Behrens A, Barnes H, Gerber W, Albanese M, Matthes S, Cangelosi A. A model for teaching sophomore medical students the essentials of the male genital-rectal examination. J Med Educ 1979;54:5857. 42 Gruppen L, Branch V, Laing T. The use of trained patient educators with rheumatoid arthritis to teach medical students. Arthritis Care Res 1996;9:3028. 43 Hasle JL, Anderson DS, Szerlip HM. Analysis of the costs and benefits of using standardized patients to help teach physical diagnosis. Acad Med 1994;69:56770. 44 Gomez JM, Prieto L, Pujol R, Arbizu T, Vilar L, Pi F et al. Clinical skills assessment with standardized patients. Med Educ 1997;31:948. 45 Peitzman SJ. Clinical skills assessment using standardized patients: perspectives from the Educational Commission for Foreign Medical Graduates. Am J Phys Med Rehab 2000;79:4903. 46 Karnath B, Thornton W, Frye AW. Teaching and testing physical examination skills without the use of patients. Acad Med 2002;77:753. 47 Takashina T, Shimizu M, Katayama H. A new cardiology simulator. Cardiology 1997;88:40813. 48 Lam TP, Irwin M, Chow LWC, Chan P. Early introduction of clinical skills teaching in a medical curriculum factors affecting students learning. Med Educ 2002;36:23340. 49 Miller GE. The assessment of clinical skills competence performance. Acad Med 1990;65(9 Suppl.):S637. 50 Harden RM, Gleeson FA. Assessment of clinical competence using an objective structured clinical examination (OSCE). Med Educ 1979;13:4154. 51 Feather A, Kopelman P. A practical approach to running an objective structured clinical examination (OSCE) for medical undergraduates. Educ Health 1997;10:33350. 52 Wass V, Van der Vleuten C, Shatzer J, Jones R. Assessment of clinical competence. Lancet 2001;357:9459. 53 Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002;287(2):22635. Received 8 August 2003; editorial comments to authors 9 August 2003; accepted for publication 13 August 2003

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