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Objective structured clinical examination

The Objective Structured Clinical Examination (OSCE) is a performance-based assessment method used in health professions education to evaluate clinical skills and competence through a series of timed, structured stations where examinees interact with standardized patients or simulators to perform tasks such as history-taking, physical examination, communication, procedural skills, and diagnostic interpretation.^[1]^[2] Developed in 1975 by Ronald M. Harden and colleagues at the University of Dundee as a response to the subjectivity and limited scope of traditional long-case clinical examinations, the OSCE has become a globally adopted standard for assessing practical abilities in medical, nursing, and allied health training programs.^[3]^[2] At its core, an OSCE typically consists of 10 to 25 stations, each lasting 5 to 20 minutes, through which candidates rotate in a circuitous format, encountering diverse clinical scenarios designed to sample a broad range of competencies including problem-solving, ethical decision-making, and teamwork.^[2] Standardized patients—trained individuals simulating specific conditions—or mannequins are employed to ensure consistency and realism, while examiners use detailed checklists and rating scales to score performance objectively, minimizing bias and enhancing reliability.^[1]^[2] This structure allows for the assessment of both cognitive and psychomotor skills in a controlled yet authentic environment, distinguishing it from written exams or unstructured observations.^[1] The OSCE's advantages include high validity in reflecting real-world clinical practice, reproducibility across administrations, and the ability to test large cohorts efficiently, though it demands substantial resources for station development, actor training, and logistics.^[1]^[2] Widely implemented in undergraduate and postgraduate education, as well as licensure exams in regions like North America, Europe, and increasingly in Africa and Asia, it supports curriculum evaluation and continuous professional development by identifying gaps in trainee performance.^[1] Studies affirm its superior reliability over conventional methods, with inter-station consistency often exceeding Cronbach's alpha of 0.7, making it a cornerstone of competency-based medical education.^[2]^[4]

History

Origins

The Objective Structured Clinical Examination (OSCE) was invented by Ronald M. Harden and colleagues at the University of Dundee in 1975 as a novel tool for evaluating clinical skills in medical education. This approach emerged from efforts at the Centre for Medical Education in Dundee to create a more reliable assessment method beyond conventional evaluations.^[5] The initial motivation stemmed from the recognized shortcomings of traditional bedside assessments, including high levels of subjectivity, inconsistency arising from examiner bias and patient variability, and limited ability to comprehensively sample a student's competencies across multiple domains. Harden's team sought to address these issues by designing an examination that incorporated structured stations with predefined checklists and observable tasks, thereby enhancing objectivity and standardization while allowing for broader coverage of practical abilities. The OSCE was first detailed in a seminal publication in the British Medical Journal in 1975, titled "Assessment of clinical competence using an objective structured clinical examination," which outlined its framework and rationale. Early pilot testing at Dundee Medical School involved final-year students progressing through 20 stations in a circuit, where they performed tasks such as history-taking, physical examinations, and data interpretation under timed conditions to simulate real-world clinical scenarios.^[3]

Development and adoption

Following its initial description in 1975 by Ronald Harden as a means to standardize clinical skills assessment, the Objective Structured Clinical Examination (OSCE) saw significant expansion during the 1980s, particularly in the United Kingdom, where it was increasingly adopted by medical schools for undergraduate evaluations.^[5] The General Medical Council (GMC) encouraged performance-based assessments in its 1993 "Tomorrow's Doctors" report, with explicit integration of OSCEs into recommendations for undergraduate medical education in the 2002 edition, emphasizing their role in ensuring reliable and objective assessment of clinical competencies.^[6] This adoption marked a shift toward performance-based evaluations in UK medical training, influencing licensing processes and promoting OSCEs as a core component of summative assessments.^[7] In the United States, OSCE formats gained traction in licensing examinations, notably with the introduction of the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) in 2004, which utilized a standardized patient-based OSCE to evaluate clinical and communication skills for medical licensure.^[8] Although the Step 2 CS was discontinued in 2021 due to evolving medical education needs and pandemic-related challenges, its implementation represented a key milestone in integrating OSCEs into high-stakes national assessments.^[9] Paralleling this, the Educational Commission for Foreign Medical Graduates (ECFMG) introduced the Clinical Skills Assessment (CSA) in 1993 specifically for international medical graduates, employing an OSCE-style format to verify clinical proficiency before U.S. residency entry; the CSA's success led to its evolution into the Step 2 CS requirement.^[10] The 1990s and 2000s witnessed broader incorporation of OSCEs across healthcare disciplines beyond medicine. In nursing education, OSCEs were progressively embedded in pre-registration curricula starting in the late 1980s and gaining prominence through the 1990s as a reliable tool for evaluating practical skills like patient assessment and care delivery.^[11] Pharmacy programs followed suit in the early 2000s, adopting OSCEs to assess competencies in patient counseling, medication management, and clinical decision-making, often as part of licensure preparation in regions like North America and Europe.^[12] Similarly, veterinary medicine saw rapid OSCE uptake during this period, with implementations in the late 1990s and 2000s to standardize evaluations of animal handling, diagnostic procedures, and communication, enhancing the objectivity of clinical training assessments.^[13] Into the 21st century, international bodies advanced OSCE standardization to support global medical education quality. The World Federation for Medical Education (WFME) incorporated OSCE-aligned standards into its global framework for basic medical education, emphasizing performance-based assessments of clinical skills as essential for accreditation and competency verification.^[14] This push facilitated widespread adoption in diverse educational contexts. Amid the COVID-19 pandemic, OSCEs were adapted for remote delivery, such as through teleconferencing platforms for virtual stations, enabling continued assessment of clinical skills while minimizing infection risks; these "teleOSCEs" maintained reliability in evaluating history-taking and communication remotely.^[15] Key figures contributed to refining the OSCE format during its growth. Ian Hart, collaborating with Harden in the 1980s, played a pivotal role in disseminating OSCEs internationally, particularly in Canada, by introducing them at conferences and co-founding the Ottawa Conferences on medical education to promote best practices in performance assessment.^[16] Pat Lilley advanced OSCE implementation through her work with the Association for Medical Education in Europe (AMEE), co-authoring influential guides on practical design and operations that supported its refinement for diverse healthcare training programs.^[17]

Purpose

Assessment objectives

The Objective Structured Clinical Examination (OSCE) primarily aims to evaluate practical clinical skills, communication abilities, clinical reasoning, and professionalism in a standardized, performance-based format that minimizes subjectivity in assessment.^[18] By rotating candidates through multiple stations with simulated patients or clinical scenarios, the OSCE targets observable behaviors rather than theoretical knowledge alone, ensuring a comprehensive appraisal of how competencies are applied in context.^[5] This approach aligns closely with the "shows how" level of Miller's pyramid of clinical competence, demonstrating skills in a controlled, simulated environment.^[19] Unlike lower pyramid levels focused on "knows" (factual recall) or "knows how" (application in theory), the OSCE emphasizes direct observation to verify proficiency in integrating knowledge with action, thereby bridging the gap between education and practice.^[20] Educationally, the OSCE serves dual purposes: as a formative tool to deliver immediate, detailed feedback that supports skill refinement and self-directed learning during training,^[21] and as a summative evaluation to determine readiness for certification or progression, providing stakeholders with reliable evidence of competence.^[5] These objectives promote iterative improvement while maintaining high standards in clinical education. The intended outcomes of OSCE implementation center on enhancing patient safety by rigorously verifying hands-on abilities, such as history-taking, physical examinations, and procedural skills, which are critical for safe, effective patient care.^[22] Through standardized checklists and multiple encounters, it identifies gaps in performance that could otherwise lead to errors in clinical practice, ultimately contributing to better-prepared healthcare professionals.^[23]

Comparison to traditional methods

Traditional clinical assessments, such as the long case examination—where students observe and manage a single patient interaction over an extended period—and the viva voce oral exam, have long been staples in evaluating medical competencies but are plagued by inherent limitations.^[24] These methods often suffer from observer bias, as examiners' subjective judgments can vary widely without standardized criteria, and limited sampling, where performance on one case may not represent broader skills.^[5] Additionally, they lack structure, leading to poor inter-rater reliability and vulnerability to the halo effect, in which a strong performance in one area unduly influences overall evaluation. In contrast, the OSCE addresses these issues by employing multiple short stations, each focusing on specific skills, thereby providing a broader and more representative sampling of clinical abilities than the narrow scope of traditional bedside teaching or single-case evaluations.^[24] Studies have demonstrated OSCE's superiority in mitigating biases inherent in traditional formats. For instance, research comparing long cases to OSCEs found that the latter reduces the halo effect through diverse station designs and structured checklists, allowing for more granular assessment without one skill overshadowing others, unlike apprenticeship-based evaluations.^[5] While reliability coefficients may vary—for example, a 2001 study of final-year students reported a long case reliability of 0.84 compared to 0.72 for OSCE under equal testing time—OSCE's multi-station approach enhances content validity and generalizability, compensating for any marginal differences in internal consistency.^[24] This objectivity is further bolstered by trained, multi-observer scoring across stations, minimizing individual examiner variability seen in viva voce or long case assessments. The introduction of OSCE marked a paradigm shift in clinical evaluation, moving away from subjective, trainer-dependent assessments toward a standardized, blueprint-driven format that emphasizes fairness and comprehensiveness.^[5] OSCE's design promotes a more equitable testing environment, influencing global adoption in medical education by prioritizing observable behaviors over holistic impressions.^[24]

Design

Core elements

The Objective Structured Clinical Examination (OSCE) is fundamentally designed as a circuit-based assessment that evaluates clinical skills through a series of timed, standardized stations, aiming to provide an objective measure of competence in simulated clinical scenarios.^[5] This structure ensures that candidates demonstrate practical abilities in a controlled environment, minimizing subjective influences common in traditional evaluations.^[1] The circuit structure forms the backbone of an OSCE, typically consisting of 10 to 20 stations arranged in a sequential loop through which candidates rotate. Each station lasts 5 to 15 minutes, allowing sufficient time for task completion, followed by brief 2-minute transition periods to the next station; this format promotes efficiency and equal opportunity for all participants.^[5] In the original conceptualization, the circuit included 18 testing stations and rest areas, with each active station timed at approximately 4.5 minutes and 30-second intervals, setting a precedent for the balanced pacing seen in modern implementations.^[5] Standardized patients (SPs) are integral to maintaining consistency across stations, comprising trained actors or lay individuals who portray specific patient roles based on scripted scenarios. These SPs follow detailed checklists to standardize their responses and behaviors, ensuring that every candidate encounters identical clinical presentations and reducing inter-station variability.^[1] This approach, pioneered in early OSCE designs, enhances the reliability of skill assessment by simulating realistic interactions without the unpredictability of actual patients.^[5] Examiners play a critical role in observing and evaluating performance, with typically one or two observers stationed at each site to score candidates using predefined criteria. To mitigate bias, examiners often rotate alongside candidates or remain fixed while candidates move, promoting impartiality and workload distribution; training for examiners emphasizes uniform application of assessment tools to uphold objectivity.^[1] Task categories within OSCE stations encompass essential clinical competencies, including history-taking to gather patient information, physical examination to assess signs and symptoms, diagnostic interpretation to analyze findings or test results, and counseling to communicate advice or management plans. These categories target a range of skills from data collection to patient interaction, ensuring comprehensive evaluation of clinical proficiency.^[1]

Station types

OSCE stations are designed to assess specific clinical competencies through a variety of task formats, arranged in a circuit where candidates rotate sequentially to ensure comprehensive evaluation.^[25] These stations typically last 5 to 10 minutes each and are categorized based on the nature of the interaction and skills required, allowing for targeted assessment of knowledge, skills, and attitudes in a standardized manner.^[26] Interactive stations emphasize candidate interactions with simulated patients, often portrayed by standardized or simulated patients (SPs), to evaluate communication and interpersonal skills. Examples include obtaining informed consent from a patient prior to a procedure or delivering difficult news, such as a cancer diagnosis, where candidates must demonstrate empathy, clarity, and active listening while gathering relevant history.^[26] These stations assess the ability to build rapport and elicit information effectively, with examiners observing and scoring based on predefined behavioral checklists.^[25] Procedural stations focus on hands-on technical skills, typically using manikins, models, or simulated equipment to replicate clinical procedures without involving live patients. Common tasks include inserting an intravenous line, performing suturing, or conducting basic life support maneuvers like cardiopulmonary resuscitation.^[26] Candidates are evaluated on precision, safety, and adherence to protocols, ensuring competence in psychomotor abilities essential for clinical practice.^[25] Static stations, also known as interpreter or analysis stations, require candidates to independently interpret data or materials without direct interaction, often in an unmanned setup to test analytical and decision-making skills. Typical examples involve reviewing X-rays to identify fractures, analyzing electrocardiograms (ECGs) for arrhythmias, or prioritizing patient cases based on provided charts.^[26] These stations promote objective assessment of cognitive integration, with responses typically recorded via written answers or computer-based inputs.^[25] Hybrid stations combine elements from multiple categories to simulate more complex, real-world scenarios, integrating interaction with procedural or analytical tasks. For instance, candidates may communicate with a simulated colleague, such as a nurse, to discuss a multidisciplinary management plan for a deteriorating patient, or perform a brief physical examination followed by explaining findings to an SP.^[26] These formats assess integrated competencies like teamwork and situational judgment, commonly used in advanced OSCEs to mirror interprofessional clinical environments.^[2]

Variations

Traditional adaptations

Traditional adaptations of the Objective Structured Clinical Examination (OSCE) emerged in the late 20th century to address specific limitations in assessing non-clinical or specialized skills within medical education, modifying the core circuit-based format to better suit laboratory, procedural, or collaborative contexts.^[5] The Objective Structured Practical Examination (OSPE), introduced in 1986, adapts the OSCE for preclinical laboratory sciences such as physiology and biochemistry, emphasizing objective evaluation of practical knowledge through static stations that require written responses rather than interactive patient encounters.^[27] In OSPE, examinees rotate through "response stations" where they answer questions based on observations from preceding "observation stations" featuring lab equipment or specimens, allowing assessment of data interpretation, procedural understanding, and application without the need for live demonstrations.^[27] This format enhances reliability in scoring cognitive and interpretive skills in lab-based disciplines, where traditional viva voce or long practical exams often suffered from subjectivity.^[27] The Objective Structured Assessment of Technical Skill (OSATS), developed in 1997, tailors the OSCE specifically for evaluating surgical and procedural proficiency in postgraduate training, focusing on hands-on tasks like suturing or knot-tying at dedicated skill stations.^[28] OSATS incorporates global rating scales alongside checklists to measure technical execution, economy of motion, and instrument handling, providing a validated tool for discriminating between novice and expert performance in operative settings.^[28] Unlike standard OSCEs, which prioritize history-taking and communication, OSATS stations simulate real procedural environments with bench models or simulators, ensuring direct observation of dexterity and decision-making under time constraints.^[28] The Team OSCE (TOSCE), first evaluated in 1999, modifies the individual rotation model into a group-based format to foster interprofessional collaboration, where teams of students (typically 4-5 members) collectively manage stations involving shared tasks like patient assessment or care planning.^[29] In TOSCE, team members divide roles—such as one conducting history while another performs examination—rotating responsibilities across stations, with one member resting per circuit to observe and debrief.^[29] This adaptation promotes teamwork competencies essential for multidisciplinary healthcare, demonstrating high acceptability among students for its realistic simulation of clinical environments while maintaining OSCE's objectivity through structured checklists.^[29] Early adaptations also differentiated OSCE circuits by learner level, with undergraduate programs employing shorter formats (e.g., 4-8 stations lasting 5-10 minutes each) for formative feedback on basic clinical skills like vital signs measurement.^[30] In contrast, postgraduate versions featured extended circuits (10-20 stations) for summative evaluation of advanced competencies, such as differential diagnosis in complex cases, to align with higher training demands.^[5] These modifications, common by the 1990s, used fewer stations in formative undergraduate assessments to reduce anxiety and emphasize learning over high-stakes testing.^[31]

Modern and global adaptations

In the 21st century, the Objective Structured Clinical Examination (OSCE) has expanded beyond traditional medical education into various global and interdisciplinary contexts, adapting to diverse healthcare systems and resource constraints. In dentistry, OSCEs have been integrated into training programs across Europe, such as in France where they assess clinical competencies in dental preliminary exams using standardized patients to evaluate practical skills like diagnosis and treatment planning.^[32] Similarly, in Ireland, dental hygiene curricula at institutions like Trinity College Dublin incorporate OSCEs to evaluate hands-on abilities in oral health education and clinical procedures alongside written assessments.^[33] In pharmacy education in the United States, OSCEs are employed to test clinical skills in simulated patient interactions, though national licensing through the National Association of Boards of Pharmacy (NABP) primarily relies on knowledge-based exams like the NAPLEX, with OSCE formats more common in academic settings for competency assessment.^[34]^[12] Adaptations for low-resource settings have simplified OSCE designs, such as using fewer stations and locally available materials, as demonstrated in implementations in resource-limited environments where traditional setups are infeasible, ensuring feasibility without compromising core evaluative principles.^[35] Disciplinary expansions have further broadened OSCE applications into veterinary medicine and allied health professions. In veterinary education, OSCEs are used to assess clinical skills in areas like small animal internal medicine and surgery, aligning with competencies required for AVMA accreditation, with examples including multi-station exams at institutions like the University of Illinois that test competencies in client communication and technical procedures.^[36] For allied health, physiotherapy programs worldwide utilize OSCEs to assess psychomotor and cognitive skills, such as in Canadian licensure where they measure clinical performance in joint assessments and patient management, showing high reliability in evaluating entry-level competencies.^[37] These adaptations maintain the OSCE's structured format while tailoring stations to profession-specific tasks, like therapeutic exercises in physiotherapy.^[38] Recent research in the 2020s has emphasized equity in OSCEs, particularly through cultural adaptations to support diverse populations. Studies highlight the integration of language-inclusive standardized patients (SPs) to reduce biases and improve accessibility for multilingual examinees, with innovations like diversity, equity, and inclusion (DEI)-focused OSCEs/OSTEs training faculty to address cultural competence in assessments.^[39] These efforts aim to enhance fairness by incorporating intersectional perspectives, ensuring OSCEs better reflect global patient demographics without altering core validity. The COVID-19 pandemic accelerated shifts to hybrid OSCE formats post-2020, combining in-person and virtual elements to maintain safety and continuity in assessments. This approach, involving online proctoring for some stations and physical setups for others, proved reliable for high-stakes evaluations, as seen in medical schools transitioning to "COVID-safe" hybrids that preserved skill assessment integrity.^[40] Building on hybrid formats, as of 2025, OSCE training has increasingly incorporated artificial intelligence (AI) simulations to provide scalable, personalized practice opportunities.^[41] Such formats have become ongoing fixtures in licensing exams, including Australia's Australian Medical Council (AMC) clinical examination, an OSCE-style test with 16 stations assessing communication, history-taking, and physical examination skills for international medical graduates seeking registration.^[42]

Advantages and Disadvantages

Strengths

The Objective Structured Clinical Examination (OSCE) enhances objectivity in clinical assessment through the use of standardized checklists and multiple trained observers across stations, which significantly reduces inter-rater variability and subjective bias compared to traditional methods.^[5] Studies have demonstrated high inter-rater reliability, with Cohen's kappa coefficients often exceeding 0.8, indicating substantial agreement among examiners.^[37] This structured approach ensures that evaluations are consistent and focused on observable behaviors, making OSCE a reliable tool for measuring clinical competence.^[1] OSCE allows for comprehensive sampling of a broad range of clinical skills within a constrained timeframe, enabling the assessment of cognitive, psychomotor, and affective domains through diverse, focused stations that simulate real-world scenarios.^[5] Unlike single-patient encounters, this multi-station format provides a more holistic evaluation of examinee performance across various competencies, such as communication, history-taking, and procedural skills.^[1] Empirical evidence supports its effectiveness in capturing a wide spectrum of abilities without the limitations of prolonged traditional assessments.^[5] A key strength of OSCE is its capacity to deliver immediate, constructive feedback through post-station debriefs with examiners or standardized patients, which promotes reflective learning and skill improvement among examinees.^[1] This formative aspect has been shown to enhance educational outcomes, with studies reporting improved interpersonal and technical skills following OSCE participation.^[5] Such timely insights help identify strengths and areas for development in real time, fostering professional growth.^[1] OSCE is feasible for large-scale implementation, particularly in high-volume educational settings, due to its modular design that accommodates numerous examinees efficiently through parallel stations.^[5] This scalability supports its widespread adoption in medical and health professions training programs.^[1]

Limitations and criticisms

The Objective Structured Clinical Examination (OSCE) faces significant criticism for its high resource demands, including the substantial costs associated with training standardized patients (SPs), examiners, and securing appropriate facilities. These expenses encompass recruitment, rehearsal sessions for SPs to ensure consistent portrayal of scenarios, calibration training for examiners to minimize subjectivity, and logistical needs such as multiple examination rooms equipped for simulation. For instance, a financial analysis of an OSCE for 145 medical students reported total personnel costs of 12,468 €, highlighting the economic burden on institutions, particularly in resource-limited settings.^[43] Another key limitation is the potential for sampling issues, where the brief duration of individual stations—typically 5 to 10 minutes—fails to replicate the multifaceted nature of real-world clinical encounters, resulting in construct underrepresentation. Faculty and researchers have noted that OSCEs often fragment patient interactions into isolated tasks, such as a single physical examination skill, without allowing for the integrated approach involving history-taking, diagnosis, and management that characterizes actual practice; this can portray patients as mere collections of symptoms rather than holistic cases.^[44] OSCEs can also induce considerable stress, exacerbated by strict time pressures that may hinder examinee performance, especially among non-native English speakers who face additional linguistic barriers under timed conditions. Students frequently report anxiety from rushed transitions between stations and the high-stakes environment, potentially skewing scores unrelated to clinical skill.^[44] Equity concerns further undermine OSCE fairness, as scenarios may embed cultural biases that disadvantage diverse examinee groups, a issue increasingly highlighted in diversity studies from the 2020s. For example, critical reviews have identified potential ethnic and gender biases in examiner scoring, where implicit prejudices influence evaluations despite the format's intent for objectivity, and scenarios rooted in Western clinical norms may not resonate with or fairly assess candidates from varied cultural backgrounds.^[45]

Marking and Assessment

Scoring systems

Scoring systems in the Objective Structured Clinical Examination (OSCE) evaluate examinee performance across stations using structured methods to ensure objectivity and fairness. These systems typically combine task-specific assessments with holistic evaluations, allowing for both detailed feedback and overall competence judgments. The original OSCE design by Harden et al. emphasized checklists for scoring to minimize subjectivity, setting a foundation for modern approaches.^[25]^[5] Checklist scoring involves a predefined list of observable tasks or behaviors, where each item is marked as completed (e.g., yes/no for binary) or assigned points based on quality (e.g., weighted scales). For instance, in a handwashing station, items might include "Did the candidate wash hands? (1 point if yes)" or "Did the candidate use soap correctly? (0-2 points)". This method promotes reliability by standardizing criteria across examiners and stations, as demonstrated in Harden's seminal 1975 OSCE where checklists were used for tasks like history-taking and physical examinations.^[25]^[5] Checklists are particularly effective for procedural stations, providing granular feedback but potentially overlooking integrated skills. Global rating scales offer a holistic assessment of overall performance at a station, using ordinal scales such as a 1-5 Likert-type rating (e.g., 1 = fail, 5 = excellent) to judge competence in dimensions like communication or clinical reasoning. Unlike checklists, these scales capture nuanced judgments beyond discrete tasks, often complementing itemized scores for a more comprehensive view. In practice, examiners apply global ratings after observing the entire station interaction, which helps identify strengths in complex skills like patient empathy.^[5] The borderline regression method integrates checklist and global scores to set station-specific pass marks, using linear regression to predict a cutoff from borderline global ratings. Examiners assign both checklist percentages (0-100%) and global scores (e.g., 1-5); regression is then performed per station, with the pass mark calculated by substituting a borderline global score (typically 2 or 3) into the equation:

\text{Checklist Cut-off} = a + b \times \text{Global Score (Borderline)}

where a is the intercept and b is the slope derived from examinee data. This approach, widely adopted since the early 2000s, enhances decision-making by leveraging both analytic and impressionistic data, with studies showing high reliability (e.g., root mean square error of 0.55).^[46] Aggregate approaches determine overall OSCE outcomes by combining station scores, either through compensatory thresholds (e.g., achieving a 60% average across all stations) or conjunctive standards (e.g., passing a minimum number of stations plus an overall score). For example, some programs require examinees to pass at least 80% of stations individually while meeting a circuit-wide threshold to prevent compensation for weaknesses. These methods balance station-specific rigor with holistic evaluation, commonly used in high-stakes assessments like medical licensing exams.^[5]^[47]

Validity and reliability

Content validity in OSCE is primarily ensured through blueprinting, a systematic process that maps examination stations to specific curriculum objectives and competencies, thereby providing a representative sample of the required clinical skills and knowledge domains.^[26] This approach aligns the assessment content with educational blueprints, such as two-dimensional matrices linking clinical tasks (e.g., history-taking) to patient conditions, to minimize construct underrepresentation and enhance the relevance of the evaluation.^[48] Reliability of OSCE scores is assessed using metrics like internal consistency, often measured by Cronbach's alpha, where values exceeding 0.7 are typically considered acceptable for high-stakes assessments, indicating consistent performance across items within stations.^[26] Generalizability theory further evaluates the stability of scores across facets such as stations and raters, aiming for coefficients of 0.7–0.8; this framework accounts for sources of variance like station sampling to support broader inferences about examinee competence.^[48] Studies have shown moderate predictive validity for OSCE, with correlations between OSCE scores and subsequent workplace clinical performance typically ranging from r=0.2 to 0.5.^[37] However, critiques regarding consequential validity have emerged in post-COVID adaptations, particularly with virtual OSCE formats, where limitations in assessing hands-on procedures and technical barriers may undermine the intended educational impact and equity of outcomes.^[49] Key factors influencing OSCE validity and reliability include the number of stations, with a minimum of 12 recommended to achieve score stability and reduce sampling error, as fewer than 10 stations often yield reliabilities below 0.6.^[50] Rater calibration through standardized training is also essential, as it mitigates inter-rater variability influenced by examiner biases, ensuring consistent application of scoring criteria across diverse cultural and professional contexts.^[48]

Preparation

For examinees

Examinees preparing for an Objective Structured Clinical Examination (OSCE) should focus on deliberate practice to build essential clinical skills, including history-taking, physical examinations, communication, and time management within the constrained station durations. Simulation labs provide an ideal environment for this, allowing students to rehearse structured approaches such as mnemonics like WIPERS for patient encounters (Wash hands, Introduce yourself, Patient details, Explain the procedure, Right-sided approach, Stethoscope placement) and nonverbal cues via the SOFTEN technique (Smile, Open posture, Forward leaning, Touch, Eye contact, Nodding).^[51] Effective communication is emphasized, with practice in using layperson language to avoid jargon and signposting transitions, such as stating "Next, I would like to discuss your risk factors," to maintain clarity and patient engagement.^[51] Participating in mock OSCEs, whether peer-led or faculty-supervised, is crucial for familiarizing examinees with the format and reducing anxiety. Peer-led simulations, such as those involving rotation through roles of student, examiner, and patient across multiple stations, have been shown to significantly boost confidence (mean score 7.9/10) and perceived performance (mean 7.5/10) while providing a safe space for feedback.^[52] These formative sessions help simulate real exam conditions, including adhering to door instructions and managing transitions between stations, thereby improving overall readiness.^[51] Useful resources for preparation include instructional videos demonstrating procedures, non-binary checklists to self-assess performance, and reflective portfolios to document learning experiences. Videos and checklists enable examinees to verbalize steps during practice, aligning with how standardized patients score interactions, while portfolios promote critical reflection on skills development, leading to enhanced OSCE scores through self-directed learning.^[51] Station types, such as history-taking or procedural skills, can be targeted using these tools for comprehensive coverage.^[51] Strategies should prioritize common clinical scenarios encountered in OSCEs, such as emergency assessments using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) for acutely unwell patients. Practicing this systematic method ensures efficient evaluation and initial management, as recommended for resuscitation scenarios, helping examinees maintain composure under time pressure.^[53] Focus on high-yield elements like chronological history structuring with ICE (Ideas, Concerns, Expectations) further refines responses to typical patient presentations.^[51]

For organizers and standardized patients

Organizers of Objective Structured Clinical Examinations (OSCEs) must ensure examiners undergo structured training to standardize assessments and minimize biases. Calibration sessions, often conducted in pre-examination workshops, align examiners on rating scales and rubrics through activities such as case reviews, video-based marking exercises, and discussions to establish consistent performance standards for pass, borderline, and fail criteria.^[54] These sessions emphasize objective observation to avoid common biases, including leniency, severity, halo effects, and influences from fatigue or personal impressions, thereby enhancing interrater reliability.^[54]^[55] Standardized patients (SPs) are recruited from diverse pools, such as local theater groups, retired healthcare professionals, or the general public via institutional websites, with selection prioritizing individuals demonstrating strong acting ability, empathy, and physical suitability through interviews and health assessments.^[56]^[57] Training involves multiple sessions, typically 2-6 hours total, focused on scripting portrayals for consistency, including rehearsal of emotional states, must-use phrases, physical findings, and scenario responses using video feedback and peer assessments.^[56]^[57] This preparation ensures reliable, standardized interactions across stations, often tested in formative OSCEs before high-stakes events.^[57] Logistics planning requires securing adequate space for multiple stations, equipped with relevant clinical materials and infection control measures such as hand sanitizers and disposable items to maintain hygiene between examinees.^[58] Equipment must be managed per medical standards, including cleaning and sterilization protocols for reusable tools to prevent cross-contamination, often conducted in dedicated simulation centers.^[58] Contingency plans address potential disruptions, such as participant no-shows, by incorporating backup SPs, simulators, or makeup examinations, alongside staggered scheduling and reassurance through safety protocols.^[58] Ethical considerations for SPs include obtaining informed consent or assent, particularly for younger participants, and providing comprehensive debriefing to process emotional residues from intense portrayals, such as anxiety or withdrawal following scenarios involving distress.^[59] Organizers must prioritize psychological safety by offering orientation, supervision, and support resources to mitigate potential long-term emotional impacts, aligning with standards from bodies like the Association of Standardized Patient Educators (ASPE).^[59]^[56]

Implementation

Practical considerations

Organizing an OSCE requires careful attention to venue selection to ensure smooth operation and confidentiality. Venues typically consist of multiple small rooms or a large hall partitioned with soundproof screens to create 10–20 individual stations, each accommodating specific tasks such as physical examinations or simulations.^[26] Adjacent spaces are essential for candidate briefing, examiner debriefing, rest areas, and storage of equipment like manikins or examination tools.^[60] Timing mechanisms, such as audible bells or buzzers synchronized across the circuit, facilitate precise 5–10 minute station rotations, with venues booked well in advance to avoid conflicts.^[61] Security measures, including "No Entry" signage and controlled access, prevent unauthorized entry and maintain the integrity of the assessment.^[60] Effective cohort management involves dividing candidates into manageable groups to optimize flow and equity. Circuits are commonly designed for 20–30 candidates, matching the number of stations to allow simultaneous rotations, though larger cohorts may require multiple parallel circuits or multi-day scheduling.^[26] Pre-examination briefings on logistics and content reduce anxiety and ensure fairness, while sequestration protocols—using holding rooms and staff marshals—prevent communication between groups if knowledge-based elements are included.^[60] Accommodations for disabilities, such as extended time or modified stations, must be integrated into grouping plans through advance coordination with candidates and venue adjustments to comply with accessibility standards.^[62] Rest stations, positioned every 4–5 active stations, provide brief recovery periods, particularly important for extended circuits lasting 1–2 hours.^[61] Resource allocation demands meticulous budgeting to balance quality and efficiency. Costs encompass human resources (e.g., examiners and standardized patients), equipment (e.g., stethoscopes, manikins), and consumables (e.g., gowns, disposables), with total expenses for a 14-station OSCE for 100 candidates estimated at around $3,750, or $37.50 per participant, dominated by personnel at approximately 44%.^[63] Equipment lists per station, including spares for malfunctions, are prepared via risk assessments, with reusable manikins and domestically produced supplies recommended to minimize expenses.^[60] Training for support staff, such as animal handlers or technical aides, and provision of catering (e.g., water at rest stations) further allocate resources, while leveraging existing clinical skills centers avoids infrastructure costs.^[63] For large-scale events, electronic mark sheets or scanners streamline administration, reducing clerical demands.^[61] Post-event activities focus on data analysis to enhance future iterations. Psychometric evaluation of scores, including station difficulty (e.g., pass rates of 50–100%) and discrimination indices (e.g., 8.95–16.45), identifies underperforming stations for revision, such as adjusting content to reduce high failure rates.^[64] Debriefings with examiners and organizers capture operational issues, like timing delays, informing quality improvements.^[60] Prompt feedback to candidates and appeals processes are managed through examination boards, with aggregated data used to refine station blueprints and budgeting.^[26] This iterative analysis ensures progressive enhancements in feasibility and credibility.^[64]

Technological advancements

Technological advancements in Objective Structured Clinical Examinations (OSCEs) have significantly enhanced accessibility, efficiency, and realism, particularly through virtual formats and simulation tools developed in response to the COVID-19 pandemic. Virtual OSCEs (vOSCEs), implemented using video conferencing platforms like Zoom since 2020, allow for remote assessment of clinical skills via breakout rooms and screen-sharing for performance stations. These adaptations enable standardized evaluations without physical presence, reducing travel costs and anxiety for participants while maintaining high satisfaction rates (mean 4.7/5). For instance, a 2024 study at King Khaled University Hospital demonstrated that vOSCEs were perceived as comparable or superior to in-person formats by 69.5% of candidates, though challenges like internet connectivity and limited physical exam assessment persist.^[65] Integration of artificial intelligence (AI) into vOSCEs further automates feedback and grading, revolutionizing preparation and evaluation. Tools like ChatGPT generate case scenarios, checklists, and real-time performance analyses from transcripts, outperforming human learners in some OSCE scoring tasks (77.2% vs. 73.7%). A 2024 exploration highlighted AI's role in reducing educator workload and enhancing trainee readiness by simulating standardized patients and providing instant, personalized feedback. Simulation technologies complement these virtual approaches with high-fidelity manikins equipped with sensors to measure procedural accuracy, such as vital sign responses during emergency scenarios. Virtual reality (VR) and augmented reality (AR) offer immersive environments for skills like history-taking; a 2023 study on VR in pediatric settings showed improved competency in complex interactions, while 2025 trials integrated VR stations into OSCEs with comparable difficulty and better discrimination of performance levels to traditional methods.^[66]^[67]^[68] Digital scoring systems streamline assessment by enabling real-time checklist entry via mobile apps, minimizing paperwork and errors. Platforms like the Online Smart Communicative Education System allow Wi-Fi-enabled devices for instant scoring and extended online feedback, achieving high reliability (G coefficient 0.88) and facilitating post-OSCE discussions. Emerging blockchain applications in medical education provide secure, tamper-proof storage for assessment results, particularly in global contexts, ensuring verifiable credentialing and data integrity across institutions. Recent 2024-2025 multicenter trials confirm vOSCEs' validity, assessing 92% of required competencies under national guidelines with moderate-to-good agreement (kappa 0.4-0.72) to in-person OSCEs, alongside benefits like enhanced remote accessibility for rural learners and telehealth alignment.^[69]^[70]^[71]

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