Clinical case reports and the viva voce: a valuable assessment tool, but not without anxiety

The clinical case report is often used in health education contexts as part of a “viva voce” (“viva”) or oral examination, to scrutinize the knowledge and understanding of the novice practitioner 1–3. The viva most often complements a written examination, and requires the novice to present a clinical case report to a panel of experts, which then questions the novice in detail about the case report. Use of the viva is an important part of the assessment of learning in medical and allied health education programs 1,4, nurse practitioner programs 5, as well as doctoral programs 6,7. The rigor and validity of this form of examination has been well established, with the viva known to provide unique insights into the capacity of the novice to think critically 8,9,3. The viva format varies across countries. For example, in Australia and the United Kingdom, vivas are generally undertaken in private, and include an independent chair and a number of examiners, one or more of whom are external to the associated higher educational institution; as well as the novice's supervisor, who plays a supportive role 10,11. In contrast, in doctoral programs in some Scandinavian countries, the viva is undertaken in public, with candidates required to defend their thesis through verbal debate and discussion that involves an audience, which is invited to ask questions 7. While there is no fixed structure to the viva, in general the role of the independent chair is to ensure that the viva proceeds smoothly, all policies and procedures are followed, questioning of the novice is appropriate and productive, the judgments made by the panel members are consistent and reliable, and all criteria of the assessment are addressed 12,13. The task of the examiners is to professionally and productively question the novice about the details of the case report 7. The role of the supervisor, in addition to providing support to the novice, is to ensure the processes involved are consistent, transparent, accountable, and fair 12. Despite the long history of use in health education contexts, the viva is not without its critics as an assessment tool. For example, the viva has been referred to in the literature as a “rite of passage” 1 that is inherently unreliable 10 and anxiety inducing for many novices 8. Reasons for this anxiety are debatable, with some suggesting that the viva has “end-point uncertainty” 1, p. 169], which includes ambiguity around how much the novice is questioned, and the nature of these questions. Also challenging are the diverse agendas, ideologies and practices that can be evident within the process itself 2 – for example, difficulties may arise if the chair is unable to manage the process effectively or ensure that the examiners are in agreement about what is an acceptable response from the novice; how often the questions can be re-framed; how much the novice can be prompted when formulating his or her responses; and/or the most appropriate focus of the questioning. Some chairs may also lack the skills required to engage with the novice; or the capacity to reassure them that the aim of the viva is to assess their knowledge and understanding of the case in question, rather than disempower or embarrass them in any way. Finally, a related problem can be the implicit influences at play, in the conduct of the viva itself, around power. For example, if the chair or one of the examiners is in a position of authority in their professional roles, other members of the panel and the novice may be loath to question or challenge that panel member's approach or judgment. When anxiety levels are high, assessment of knowledge, understanding, or capacity to think critically can be limited 8. There is a need, then, to consider how the viva can be used effectively as a tool of assessment. Perhaps what is most important for those involved in the conduct of the viva, or examination by viva, is preparation 13. Indeed, many commentators suggest that raised anxiety levels related to vivas can be reduced by preparing novices through careful preparation, including involvement in mock vivas and role plays 14,15. Others note the importance of increasing the novice's knowledge of the viva by providing the details of the processes involved through, for example, the use of audio-visual recordings of vivas that have occurred in the past 8. It is also important to prepare the panel for the viva, with mandatory pre-viva meetings to discuss requirements and expectations, as well as approaches to questioning, and to ensure that all panel members have reviewed and discussed the case report, including the major area requiring additional information or further evidence of critical thinking. Case-based vivas remain an important means of assessing the knowledge and understanding of novice health professionals. Like all types of examination, however, examination by viva can generate anxiety. Familiarity with the processes involved in the conduct of a viva can support the novice, panel members, and supervisors alike to participate with less anxiety, and thereby achieving the best possible outcomes.