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Experienced medical teachers were interviewed regarding creation and use of objectives for instruction. This paper summarizes reported advantages and disadvantages of objectives, describes reported changes in strategy with experience, and provides advice on the creation and use of objectives. Medical teachers agree that the process of writing objectives leads to clarification of intuitively held teaching goals and thus leads to better teaching and testing decisions. To achieve this benefit, an instructor must invest considerable time, effort and creativity in the process. The path of least resistance in writing objectives often leads to goals which serve no useful function and may be harmful to the teaching-learning process.

Doctor ratings of clerkship performance are often discounted as not accurately reflecting clinical competence. Such ratings are influenced by the following uncontrolled variables: case difficulty; differing rater focus and standards; lack of agreement on what constitutes acceptable performance; and collective patient care responsibility masks individual contributions. Standardized direct measures of clinical competence were developed to control these factors and allow direct comparisons of student performance. Students saw 18 patients representing frequently occurring and important patient problems. Student actions and decisions were recorded and subsequent responses to questions revealed knowledge of pathophysiology, basis for actions, use and interpretation of laboratory investigations, and management. Actions and responses were graded using a pre-set key. The examination covered 73% of designated clinical competencies. Examinations scores corresponded with independent measures of clinical competence. Reliability studies indicated that new cases can be substituted in subsequent years with confidence that scores will maintain similar meaning. Costs are +6.95 per student per case, which is modest considering the quality and quantity of information acquired. Methods described are practical for evaluation of clerks and residents and for licensing and specialty certification examinations.

Written examinations are widely used for assessment in clinical clerkships and for licensure and specialty board certification, as opposed to assessment based on actual performance with patients. This reliance on written examinations is due to their ease of use and perceived objectivity and occurs despite the fact that the examinations assess few components of clinical competence. Simulated patients can standardize the presentation of a patient problem; and, if the patients are employed in an assessment in a manner parallel to the design of written test items, the assessment can have an objectivity similar to that enjoyed by written tests. Such an assessment allows the major components of clinical competence to be tested. The results and feasibility of using simulated patients in a multiple-station assessment of an entire senior class in January 1986 are described. A second assessment was administered to a different senior class in December 1986. This latter assessment was designed in collaboration with another medical school that administered the same assessment to its senior students in March 1987.

The Southern Illinois University School of Medicine has completed a five-year experience applying an objectives-based approach to an entire curriculum in a medical school setting. Approximately 250 students have worked and studied within the system, and three classes have been graduated. This paper describes the instructional system and the procedures for monitoring, maintaining, and improving it and provides available outcome data.