Why and how the long case became the OSLER-the sum of the parts

The Objective Structured Long Examination Record (OSLER) was introduced in 1987 in response to critcisims of the unstructured traditional Long Case. The previously designed Objective Structured Clinical Examination (OSCE) had replaced challenges relating to the short case exam. The Long Case was criticised in relation to its Objectivity, Validity and Reliability and calls for its abandonment were voiced. Others were concerned that without a Long Case, the skill standards involved in constructing a fully integrated Long Case Record for service and medico-legal requirements would regress. As a practicing clinician and medical educator, I studied the Long Case aims and objectives, regarding its shortcomings. A formal task analysis of the Long Case resulted in the development of the now termed acronym OSLER. The core principles of the Long Case were retained, but in the form of a structured innovation. The outcome resulted in a 10-item checklist Long Case exam. A criterion referenced assessment method was assembled, and a similar approach was developed for examiners to identify case difficulty. The outcome revealed that with 2 examiners, the number of their individual and agreed assessment decisions increased from 3 per candidate to a composite of 135 per candidate. With its development and with the support of colleagues, a one-week intensive MRCP clinical skills assessment pre-exam course was established and acted as a research instrument for the OSLER development The OSLER immediately revealed poor clinical skills of the course participants. However, with the benefit of immediate feedback alone, a second OSLER, within 48 h following the index exam, revealed an overall average gain ratio of 15% for the entire cohort. The OSLER has now been adopted by several healthcare institutions globally as an acceptable Long-Case solution for their needs. It has also been combined with the OSCE, which assesses the parts of the sum, with the OSLER assessing the sum of the parts.