|MEDICAL EDUCATION TECHNOLOGY
|Year : 2018 | Volume
| Issue : 4 | Page : 374-378
How to conduct medical viva
Vishnu Sharma Moleyar
Department of Respiratory Medicine, AJ Institute of Medical Sciences, Mangalore, Karnataka, India
|Date of Web Publication||2-Aug-2018|
Vishnu Sharma Moleyar
Department of Respiratory Medicine, AJ Institute of Medical Sciences, Mangalore - 575 004, Karnataka
Source of Support: None, Conflict of Interest: None
Medical viva is oral form of assessment of medical students. Viva helps to assess the competencies such as communication skills and professional attitudes which are essential to a medical graduate. Viva test delineates the limit of a candidate's knowledge and understanding of a particular subject/topic being tested. Viva should be conducted fairly, should be reliable, and free from any form of bias. Structured viva examination is better and more realistic to fulfill these criteria than traditional viva examination. Viva can be structured using viva cards. Trained and experienced examiners are a must for the proper conduct of viva.
Keywords: Candidate, examiner, medical viva, structured viva, viva cards
|How to cite this article:|
Moleyar VS. How to conduct medical viva. Med J DY Patil Vidyapeeth 2018;11:374-8
| Introduction|| |
Assessment of the students is central to the success of any educational program. Proper assessment and grading are very closely linked with student's learning. Assessment motivates students to learn and directs learning. Learning by the majority of students depends on the examination.
Viva examination is an integral part of assessment system during undergraduate and postgraduate medical practical examinations in India. Viva may be defined as “an examination process consisting of a dialog with the examiner, who asks questions to which the candidate must reply.”
During viva, emphasis should be to compare among the students so as to identify the best/poor student. Assessment should also focus on specific achievement level of students.
From students' perspective, an ideal assessment is one in which students should be satisfied, and it should increase their self-confidence. It should increase and improve their self-esteem.
| Why Medical Viva|| |
Viva mirrors the oral form of communication skill that dominates professional practice. Viva can test the limits of a candidate's knowledge and understanding. It helps to assess the competencies such as communication skill and professional attitude. Communication skill is essential for a medical graduate. This applies to even exceptionally capable candidates whose weakness in communication skill might not be otherwise exposed. Viva is useful to probe more deeply into a student's ability to think and to express.
| What is Assessed in Medical Viva?|| |
In medical viva, the following are assessed with appropriate questions:,
- Clinical decision-making skill or “the cognitive processes which constitute professional thinking”
- Interpersonal competence, focusing on communication skill in relation to clinical or problem-solving situations
- Personal qualities essential for a medical graduate such as confidence and self-awareness
- Subtle characteristics which are required to the specialty for which the person is being examined.
| Does and Don'ts in Viva|| |
A candidate's performance in viva should depend on what he knows, what he is able to do and on attitudes or values that are essential for the profession. Assessment should explicitly focus on and accurately measure those attributes such as knowledge, skills, and values that are requisite for professional practice-clinical-reasoning and decision-making. Unrelated qualities such as language skill should be excluded during assessment.
Context of the examination should always be priority while conducting the viva. Specific questions should be asked. Any aspects unrelated to the actual capabilities of the candidate should not be asked. Judgment of a candidate's performance should not be influenced by such factors as age, gender, race, or socioeconomic status. Assessment done by the viva should be valid, reliable, and fair.
This is capacity of the assessment process to prompt or allow candidates to demonstrate the extent to which they possess the requisite knowledge, skills, and values. It is about the relationship between an examination and the construct it purports to measure. It is also about the inferences to be made based on this assessment.
Viva should focus on the capabilities required for professional practice that is best assessed orally, namely clinical-reasoning and decision-making. The content of the examination should be determined by a panel of experts based on these capabilities. Examination should be within the scope of professional practice. Where language capabilities are examined, this should be done explicitly and at the level required of professional practice.
“Doctors do not perform consistently from task to task” (Wass et al., 2001). Candidates would not be expected to perform consistently across different tasks or cases. Hence, a broad sampling of cases/questions is essential.
Inter-item consistency, interexaminer reliability, interpanel reliability, and intracandidate consistency across items are essential in viva. An adequate number of questions should be asked to provide sufficient coverage of the depth and breadth of practice and to ensure inter-item variability at an acceptable level. Examiners should be formally trained in conducting oral examination. Interexaminer variations should be monitored and discrepancies if any should be addressed. Viva questions and viva implementation processes should be standardized.
Bias is recognized by administrators as an essential element of viva. Viva should be periodically scrutinized by an expert panel to detect item bias. Result patterns should be monitored to identify differential responses' levels from identifiable subgroups. When lower or higher scores for particular groups of examinees occur, the possibility of bias should be considered. If found, bias should be corrected.
| Conduct of Viva|| |
Ensure that the viva examination room is appropriately laid out. Questions should be asked in a constructive and positive way. Appropriate range of questions and proper questioning techniques should be used. Some candidates may need time to answer. Hence, proper time should be given to the candidate to answer. Candidate should be given a chance to recover from a poor answer. Rephrasing a question and asking it again may give the able candidate, the opportunity to answer properly or may confirm the inability to answer the question.
This should consist of at least two and no more than four examiners, of which two should be external examiners. At least two members of the panel must have previous experience of conducting a viva. All the panel members should not be of the same gender. This is to avoid gender bias. An additional staff member may attend as recorder wherever appropriate. Observers should not be permitted during the viva. Members of the panel should decide in advance who will chair the viva and be in overall control of the proceedings. The number of questions, nature of questions, expected responses, and mark allotment should be planned before the viva.
The chairperson should greet candidate, confirm the identity of the candidate, and should ensure that the candidate is comfortable. The chairperson should attempt to create a relaxed atmosphere, especially when a candidate appears nervous. Topics should be introduced, and questions should be asked without long preambles. Open questions should be used rather than closed questions. This gives the candidates the opportunity to demonstrate ideas, knowledge, and ability. Use simple questions rather than complex questions consisting of several parts. Avoid leading or hypothetical questions. Use questions covering a range of topics rather than those limited to a single topic. Questions should be strictly relevant to the purpose of the viva. Examiners should talk as little as possible. Examiners should listen to the answers carefully. While answering the candidate should not be interrupted without a proper reason. When the candidate deviates totally from the topic or gives irrelevant answers, he can be interrupted by the examiner.
Identical questions to each candidate may not be appropriate. However, each candidate should be asked questions of a similar nature. Hints can be given during viva to encourage the student to give correct answers. Panel members should maintain eye contact with the candidate while communicating.
Assumptions on matters of gender, age ethnicity, minorities, economic status, dress, personality, verbal style of the candidate race, etc., should be avoided when asking questions.
Do not persist with a question. Do not teach, contradict, or harass the student. Patronizing language or inappropriate body language by the examiner should be avoided.
Disagreements between members of the panel must not be discussed in the presence of the candidate. The chairperson should remain in control of the proceedings and deal promptly with any difficult or undesirable situation.
The candidate must not be given any indication, directly or indirectly, of the likely outcome of the viva. Value judgment words (e.g., excellent and good) after a candidate's response should be avoided, as these could be misinterpreted by the candidate to indicate a favorable outcome.
The candidate should be advised when the last question is being asked, and the viva should be ended formally. Viva for a candidate should not exceed 30 min. Concise written records of viva should be maintained, including the date, time, and length of the viva, the general line of questioning and answers, the recommendations of the viva panel to the examination board, and a summary of the reasons for the recommendations. Wherever feasible audio/video recording of the whole viva also can be done and kept as a record in safe custody. This will be useful in case of litigation by the students.
| Categorization of Viva Results|| |
Borderline viva – Candidate answers between 45% and 50% of questions properly.
Distinction viva – Candidate answers >75% of questions properly.
| Drawbacks of Traditional Viva|| |
Traditional viva voce is held usually toward the end of the practical examination. It is usually taken casually by the examiners and marred by high subjectivity of the examiners. Many of the examiners may be confounded with their whims, fancies, and their way of understanding of the subject, their preferred content area, and by numerous other momentary environmental factors. Traditional viva voce is oriented toward theory. Ego of the examiner, the difficulty level of the questions asked, and their sequencing in asking questions may be haphazard at times. The student may feel humiliated and dissatisfied after the viva. If not conducted properly, viva may be frightening, intimidating, and threatening to the students and may give way for confrontation rather than discussion. Even the examiners at times may feel tired, uninterested, or they may not have time to give adequate importance and at times may prompt or help some of the students. The examiners may discriminate on the basis of gender, ethnicity, minorities, economic status, or even influenced by dress, personality, and verbal style of the candidate in viva voce. In traditional oral examination, more emphasis is given on comparison between students rather than individual achievements.
Thus, the traditional viva voce results depend on the examiner, the student, and other situational factors during the assessment. The primary fault in traditional viva voce is unreliability due to confounding situational factors, anxiety of the examinee, and inconsistency of the examiners.
| How to Improve Viva|| |
Viva can be improved by organizing it in a structured manner. By structuring the viva, it is possible to elicit properly cognitive, problem-solving, interpretative, and decision-making skills of the students. This will ensure a higher degree of validity, reliability, and objectivity.
Examiners should be selected carefully. A new examiner should be paired with a more experience person. Examiners should be briefed before the viva. Topic can be shifted if some candidate fails to answer in one area.
| Structured Viva|| |
The viva questions can be constructed by a group of faculty with inputs from all those who have participated in the teaching process. Questions from each topic with varying difficultly among the learning objectives should be prepared. Make a large series of viva cards. On each card, write one carefully worded question. Check the wording by reading the question to colleagues make sure that they understand the question as intended. Divide the cards into groups. Each group should represent one section of the course.
During viva, the candidate randomly selects one card from each box. The examiner reads the question, repeats if necessary or the candidate reads the question if allowed. No cues or clues are provided. After the candidate answers the questions, the examiners place a tick in an appropriate box on a preprepared rating scale. The examiners should not indicate whether the student answers correctly or not. Each question should be marked individually and summing up should be done at the end. Each examiner should have equal time, each examiner should mark individually, and scores are averaged at the end. Questions, answers, and scores are noted concurrently by the examiners for each candidate. This will help in the feedback session while conducting internal assessment.
| Advantages of Viva Card|| |
Properly outlined scheme makes the viva more objective and structured, thus imparting a higher degree of validity and reliability.,, Using viva cards, viva becomes more objective because the candidate selects his or her questions, so examiners' whim or biases are obviated. Concurrent marking ensures that the examiner makes proper assessment. Using viva card, viva becomes structured because the questions are prepared in accordance with the educational objectives and clearly defined intellectual level to be assessed.
| Feed Back Session|| |
Student's feedback is always an important aspect of an assessment. Feedback is used following internal assessment viva. Here, students are individually appraised about their response to a particular question. Question, answers, and scores are noted by the examiners for each candidate so that they can be informed where they scored and where they did not score well. Students do come back to find out the lacunae in their knowledge or how to answer certain questions. Feedback gives the opportunity for students to improve their performance.
| Advantages of Viva|| |
Personal contact with the candidate allows in-depth discussion of topics. Viva allows flexibility of topics and questions to include all aspects of the syllabus. Depth of knowledge of the candidate can be assessed. Viva gives an opportunity for discussion which will help the examiner to assess the student's knowledge and understanding of the subject.
| Disadvantages of Viva|| |
Viva involves making judgments on the basis of limited evidence. In the case of appeals, it may involve justifying the marks without proper evidence. It is usually an unfamiliar and potentially difficult form of assessment for both, a new examiner and examinee. At times, it may be difficult to distinguish between what a candidate says, what he intends to say, and how he says it. It can induce performance inhibiting stress for students. If not conducted properly it may lack standardization, objectivity, and reliability of results. There is a possibility of abuse of personal contact. There may not be enough adequately trained examiners. It is expensive in terms of professional time and information yield. Language barrier may be a factor for poor performance by some students. Test questions and the student responses go unrecorded. It is a subjective test. Examiner may fail to properly assess the cognitive and problem-solving skills which are mainly aimed at in viva.
| Conclusions|| |
If conducted properly, viva is a useful component of assessment. Viva helps to assess the competencies such as communication skill and professional attitudes which are essential for a medical graduate.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
The Oral Examination, Singh T, Anshu. Principles of Assessment in Medical Education. Ch. 15. New Delhi: Jaypee Brothers; 2012. p. 167-79.
Iqbal IZ, Naqvi S, Abeysundara L, Narula AA. The value of oral assessments: A review. Bull R Coll Surg Engl 2010;92:1-6.
Muzzin LJ, Hart L. Oral examinations. In: Neufeld RV, editor. Assessing Clinical Competence. New York: Springer Publishing Co.; 1985.
Rahman G. Appropriateness of using oral examination as an assessment method in medical or dental education. J Educ Ethics Dent 2011;1:46-51. [Full text]
Vu NV, Johnson R, Mertz SA. Oral examination: A model for its use within a clinical clerkship. J Med Educ 1981;56:665-7.
Evans LR, Ingersoll RW, Smith EJ. The reliability, validity, and taxonomic structure of the oral examination. J Med Educ 1966;41:651-7.
Shenwai MR, B Patil K. Introduction of structured oral examination as a novel assessment tool to first year medical students in physiology. J Clin Diagn Res 2013;7:2544-7.
Thomas CS, Mellsop G, Callender K, Crawshaw J, Ellis PM, Hall A, et al.
The oral examination: A study of academic and non-academic factors. Med Educ 1993;27:433-9.
Daelmans HE, Scherpbier AJ, Van Der Vleuten CP, Donker AJ. Reliability of clinical oral examinations re-examined. Med Teach 2001;23:422-4.
Dhasmana DC, Bala S, Sharma R, Sharma T, Kohli S, Aggarwal N, et al.
Introducing structured viva voce examination in medical undergraduate pharmacology: A pilot study. Indian J Pharmacol 2016;48:S52-S56.
Verma A, Mahajan N, Jasani K, Patel J. Evaluation and comparison of result: Conventional viva vs. structured viva. Glob Res Anal 2013;2:188-9.
Kshirsagar SV, Fulari SP. Structured oral examination-student's perspective. Anat Karnataka 2011;5:28-31.
Schubert A, Tetzlaff JE, Tan M, Ryckman JV, Mascha E. Consistency, inter-rater reliability, and validity of 441 consecutive mock oral examinations in anesthesiology: Implications for use as a tool for assessment of residents. Anesthesiology 1999;91:288-98.
Puppalwar PV, Rawekar A, Chalak A, Dhok A, Khapre M. Introduction of objectively structured viva-voce in formative assessment of medical and dental undergraduates in biochemistry. J Res Med Educ Ethics 2014;4:321-5.
Ghosh A, Mandal A, Das N, Tripathi SK, Biswas A, Bera T, et al.
Students' performance in written and viva-voce components of final summative pharmacology examination in MBBS curriculum: A critical insight. Indian J Pharmacol 2012;44:274-5.
] [Full text]
Rangachari PK. The targeted oral. Adv Physiol Educ 2004;28:213-4.