Objective structured clinical/practical Objective structured clinical/practical examination (OSCE/OSPE)examination (OSCE/OSPE)

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ARAMBAM ARUNAARAMBAM ARUNA

An An Objective Structured Clinical ExaminationObjective Structured Clinical Examination ((OSCE) is a modern type of examination often used in health OSCE) is a modern type of examination often used in health sciences (e.g. medicine, chiropractic, physical therapy, sciences (e.g. medicine, chiropractic, physical therapy, radiography, nursing, pharmacy, dentistry) to test clinical skill radiography, nursing, pharmacy, dentistry) to test clinical skill performance and competence in skills such as performance and competence in skills such as communicationcommunication, , clinical examinationclinical examination, medical procedures / prescription, exercise , medical procedures / prescription, exercise prescription, joint mobilisation / manipulation techniques, and prescription, joint mobilisation / manipulation techniques, and

interpretation of resultsinterpretation of results

OSCE designOSCE design An OSCE usually comprises a circuit of short (usual is 5–10 An OSCE usually comprises a circuit of short (usual is 5–10

minutes although some use up to 15 minute) stations, in which minutes although some use up to 15 minute) stations, in which each candidate is examined on a one-to-one basis with one or each candidate is examined on a one-to-one basis with one or two impartial examiner(s) and either real or simulated two impartial examiner(s) and either real or simulated patientspatients (actors). (actors).

Each station has a different examiner, as opposed to the Each station has a different examiner, as opposed to the traditional methodtraditional method of clinical examinations where a candidate of clinical examinations where a candidate would be assigned to an examiner for the entire examination. would be assigned to an examiner for the entire examination.

Candidates rotate through the stations, completing all the Candidates rotate through the stations, completing all the stations on their circuit. In this way, all candidates take the stations on their circuit. In this way, all candidates take the same stations. It is considered to be an same stations. It is considered to be an improvement over improvement over traditional examination methods because the stations can be traditional examination methods because the stations can be standardisedstandardised enabling fairer peer comparison and complex enabling fairer peer comparison and complex procedures can be assessed without procedures can be assessed without endangering patients endangering patients health.health.

As the name suggests, an OSCE is designed to be:As the name suggests, an OSCE is designed to be: objectiveobjective - all candidates are assessed using exactly the same - all candidates are assessed using exactly the same

stations (although if real patients are used their signs may vary stations (although if real patients are used their signs may vary slightly) with the same marking scheme.slightly) with the same marking scheme.

-In an OSCE candidates get marks for each step on -In an OSCE candidates get marks for each step on the mark scheme that they perform correctly and one or two the mark scheme that they perform correctly and one or two examiners decide whether or not the candidate fails based on examiners decide whether or not the candidate fails based on their subjective assessment of their skills. their subjective assessment of their skills.

structuredstructured – –

stations in OSCEs have a very specific task. Where stations in OSCEs have a very specific task. Where simulated simulated patients are usedpatients are used ,detailed scripts are provided to ensure that ,detailed scripts are provided to ensure that the information that they give is the same to all the information that they give is the same to all candidates, candidates, including the emotions that the patientincluding the emotions that the patient should use during the should use during the consultation. Instructions are carefully written to ensure that the consultation. Instructions are carefully written to ensure that the candidate is given a very specific task to completecandidate is given a very specific task to complete

a clinical examinationa clinical examination – –

the OSCE is designed to applied the OSCE is designed to applied clinical and theoretical clinical and theoretical knowledgeknowledge. Where theoretical knowledge is required (for . Where theoretical knowledge is required (for example, answering questions from the examiner at the end of example, answering questions from the examiner at the end of the station) then the questions are standardised and the the station) then the questions are standardised and the candidate is only asked questions that are on the mark sheet.candidate is only asked questions that are on the mark sheet.

How is the OSCEs done? The exam day.How is the OSCEs done? The exam day.1. Registration: 1. Registration: The first step is the registration. You will :The first step is the registration. You will : Show your examination Show your examination invitation card and an identificationinvitation card and an identification. . Be reminded about the Be reminded about the exam rulesexam rules. . Be checked for things which are allowed and other not allowed Be checked for things which are allowed and other not allowed

things. things. Receive your exam envelope which contains your ID badge, Receive your exam envelope which contains your ID badge,

stickers, a pencil, a notebook o clipboard (both with numbered stickers, a pencil, a notebook o clipboard (both with numbered blank papers),.. etc. blank papers),.. etc.

2. Orientation:2. Orientation: The next step is orientation. An orientation video The next step is orientation. An orientation video may be shown. Here:may be shown. Here:

Exam format, procedures and polices will be reviewed. Exam format, procedures and polices will be reviewed. Introduced to your team and team leader. Introduced to your team and team leader. Instructed about your starting station and how to proceed. Instructed about your starting station and how to proceed. Your questions will be answered (and not allowed beyond this Your questions will be answered (and not allowed beyond this

step). step).

3. Escorting to exam position:3. Escorting to exam position: Now it is exam time. Now it is exam time. You will be escorted to your station. You will stop by the You will be escorted to your station. You will stop by the

assigned room door until a long bell / buzzer announces the assigned room door until a long bell / buzzer announces the start of the exam.start of the exam.

4. Station Instruction Time: 4. Station Instruction Time:  This is one or two minutes to read the instruction about this This is one or two minutes to read the instruction about this

station situation, patient, and required tasks. Read carefully. At station situation, patient, and required tasks. Read carefully. At the next bell / buzzer enter the room.the next bell / buzzer enter the room.

    5. The Encounter:5. The Encounter:   Start your encounter . This is a 5-20 minute encounter. Start your encounter . This is a 5-20 minute encounter.

Perform the required tasks. Stop at the next bell / buzzer.Perform the required tasks. Stop at the next bell / buzzer.

6. Post Encounter Period:6. Post Encounter Period: Next is a question period. There are Next is a question period. There are some differences here. Some OSCEs will have no post some differences here. Some OSCEs will have no post encounter periods. Some will have one or two minutes of the encounter periods. Some will have one or two minutes of the encounter period assigned to an oral questions asked by the encounter period assigned to an oral questions asked by the examiner inside the exam room. No more communication is examiner inside the exam room. No more communication is allowed. Others have written questions to be answered on allowed. Others have written questions to be answered on paper or computer outside the exam room for 5-10 minutes. At paper or computer outside the exam room for 5-10 minutes. At the next long bell / buzzer, the first station ended as well as the the next long bell / buzzer, the first station ended as well as the next station has started. You have to proceed to the next next station has started. You have to proceed to the next station quickly as it is the same long bell / buzzer at step 4.station quickly as it is the same long bell / buzzer at step 4.

77. Repeat Steps 4 to 6:. Repeat Steps 4 to 6: Steps 4 to 6 will be repeated until you have been in all the Steps 4 to 6 will be repeated until you have been in all the

stations. Some OSCEs will offer one or two short rest periods.   stations. Some OSCEs will offer one or two short rest periods.   

8. Exam ended / Escorting to dismissal area:8. Exam ended / Escorting to dismissal area: The exam is The exam is over.over.

You will be escorted back to the dismissal area for signing out. You will be escorted back to the dismissal area for signing out. You will be asked to handle back all what you had received on You will be asked to handle back all what you had received on signing in, the ID badge, remaining stickers, all the papers, and signing in, the ID badge, remaining stickers, all the papers, and the pencil. You may also be asked to stay without outside the pencil. You may also be asked to stay without outside contacts for some time (sometimes hours) for exam security contacts for some time (sometimes hours) for exam security reasons. reasons. 

OSCE markingOSCE marking::

- - Marking in OSCEs is done by the examiner. Occasionally written Marking in OSCEs is done by the examiner. Occasionally written stations (for example, writing a prescription chart) are used and stations (for example, writing a prescription chart) are used and these are marked like written examinations, again usually using these are marked like written examinations, again usually using a standardised mark sheet.a standardised mark sheet.

- One of the ways an OSCE is made objective is by having a One of the ways an OSCE is made objective is by having a detailed mark scheme and standard set of questions. For detailed mark scheme and standard set of questions. For example, a station concerning the demonstration to a simulated example, a station concerning the demonstration to a simulated patient on how to use a patient on how to use a Metered dose inhalerMetered dose inhaler [MDI] would [MDI] would award points for specific actions which are performed safely award points for specific actions which are performed safely and accuratelyand accurately..

- The examiner can often vary the marks depending on how well The examiner can often vary the marks depending on how well the candidate performed the step. At the end of the mark sheet the candidate performed the step. At the end of the mark sheet the examiner often has a small number of marks that they can the examiner often has a small number of marks that they can use to weight the station depending on performance and if a use to weight the station depending on performance and if a simulated patient is used then they are often asked to add simulated patient is used then they are often asked to add marks depending on the candidates approach.marks depending on the candidates approach.

- At the end, the examiner is often asked to give a "global At the end, the examiner is often asked to give a "global score". This is usually used as a subjective score based on the score". This is usually used as a subjective score based on the candidates overall performance and not taking into account candidates overall performance and not taking into account how many marks the candidate scored. The examiner is how many marks the candidate scored. The examiner is usually asked to rate the candidate as pass/borderline/fail (or usually asked to rate the candidate as pass/borderline/fail (or sometimes as excellent/good/pass/borderline/fail). This is sometimes as excellent/good/pass/borderline/fail). This is often then used to determine the individual pass mark for the often then used to determine the individual pass mark for the stationstation..

- Many centres allocate each station an individual pass mark. Many centres allocate each station an individual pass mark. The sum of the pass marks of all the stations determines the The sum of the pass marks of all the stations determines the overall pass mark for the OSCE. Many centres also impose a overall pass mark for the OSCE. Many centres also impose a minimum number of stations required to pass which ensures minimum number of stations required to pass which ensures that a consistently poor performance is not compensated by a that a consistently poor performance is not compensated by a

good performance on a small number of stationsgood performance on a small number of stations..

There are, however, criticisms that the OSCE stations can There are, however, criticisms that the OSCE stations can never be truly standardised and objective in the same way never be truly standardised and objective in the same way as a written exam. It has been known for different patients / as a written exam. It has been known for different patients / actors to afford more assistance, and for different marking actors to afford more assistance, and for different marking criteria to be applied. Finally, it is not uncommon at certain criteria to be applied. Finally, it is not uncommon at certain institutions for members of teaching staff be known to institutions for members of teaching staff be known to students (and vice versa) as the examiner. This familiarity students (and vice versa) as the examiner. This familiarity does not necessarily affect the integrity of the examination does not necessarily affect the integrity of the examination process, although there is a deviation from anonymous process, although there is a deviation from anonymous marking. However, in OSCEs that use several circuits of the marking. However, in OSCEs that use several circuits of the same stations the marking is repeatedly shown to be very same stations the marking is repeatedly shown to be very consistent which supports the validity that the OSCE is a fair consistent which supports the validity that the OSCE is a fair clinical examination.clinical examination.

Preparation:Preparation:- Preparing for OSCEs is very different from preparing for an examination Preparing for OSCEs is very different from preparing for an examination

on theory. In an OSCE, clinical skills are tested rather than pure on theory. In an OSCE, clinical skills are tested rather than pure theoretical knowledge. It is essential to learn correct clinical methods and theoretical knowledge. It is essential to learn correct clinical methods and then practice repeatedly until one perfects the methods. Marks are then practice repeatedly until one perfects the methods. Marks are awarded for each step in the method; hence, it is essential to dissect the awarded for each step in the method; hence, it is essential to dissect the method into its individual steps, learn the steps, and then learn to method into its individual steps, learn the steps, and then learn to perform the steps in a sequenceperform the steps in a sequence..

- Most universities have clinical skills labs where students have the Most universities have clinical skills labs where students have the opportunity to practice clinical skills, such as taking blood from or opportunity to practice clinical skills, such as taking blood from or mobilizing patients in a safe and controlled environment. It is often very mobilizing patients in a safe and controlled environment. It is often very helpful to practise in small groups with colleagues, setting a typical helpful to practise in small groups with colleagues, setting a typical OSCE scenario and timing it with one person role playing a patient, one OSCE scenario and timing it with one person role playing a patient, one person doing the task and (if possible) one person either observing and person doing the task and (if possible) one person either observing and commenting on technique or even role playing the examiner using a commenting on technique or even role playing the examiner using a sample mark sheet (many OSCE textbooks have sample OSCE stations sample mark sheet (many OSCE textbooks have sample OSCE stations and mark sheets). In doing this the candidate is able to get a feel of and mark sheets). In doing this the candidate is able to get a feel of running to time and working under pressure.running to time and working under pressure.

--In many OSCEs the stations are extended using data In many OSCEs the stations are extended using data interpretation. For example, the may have to take a brief history interpretation. For example, the may have to take a brief history of chest pain and then interpret an electrocardiogram. It is also of chest pain and then interpret an electrocardiogram. It is also common to be asked for a differential diagnosis, to suggest common to be asked for a differential diagnosis, to suggest which medical investigations the candidate would like to do or which medical investigations the candidate would like to do or to suggest a management plan for the patient.to suggest a management plan for the patient.

How is an OU-COM OSCE typically structured?How is an OU-COM OSCE typically structured? There are 4 standardized patient cases.  (Note:  NBOME There are 4 standardized patient cases.  (Note:  NBOME

COMLEX-PE consists of 12 encounters) COMLEX-PE consists of 12 encounters) You will have 23 minutes at each station.  You will have 23 minutes at each station.  14 minutes to read the scenario sheet on station door, then 14 minutes to read the scenario sheet on station door, then

evaluate and treat the patient as appropriate. evaluate and treat the patient as appropriate. At 12 minutes, there will be an announcement indicating two At 12 minutes, there will be an announcement indicating two

minute remaining. minute remaining. At 14 minutes, there will be an announcement to leave the At 14 minutes, there will be an announcement to leave the

room. You may leave the room early, but you will not be able room. You may leave the room early, but you will not be able to reenter. to reenter.

9 minutes to write a SOAP note outside the room. 9 minutes to write a SOAP note outside the room. At 7 minutes there will be an announcement indicating two At 7 minutes there will be an announcement indicating two

minutes remaining. minutes remaining. At 9 minutes you will be instructed to move to the next At 9 minutes you will be instructed to move to the next

station and repeat the process. station and repeat the process. The 4-station exam, orientation and debriefing is completed in The 4-station exam, orientation and debriefing is completed in

approximately 3 hours. approximately 3 hours.

What should I do during the OSCE?What should I do during the OSCE? DO ONLY WHAT IS REQUESTED. DO ONLY WHAT IS REQUESTED. No talking during the OSCE. This is an examination. No talking during the OSCE. This is an examination. Use your history to guide the scope of your examination, since Use your history to guide the scope of your examination, since

a complete exam is not required in all cases. a complete exam is not required in all cases. Elicit psychosocial, occupational, past medical/surgical history, Elicit psychosocial, occupational, past medical/surgical history,

medications and allergies as appropriate. medications and allergies as appropriate. Explain to the patient what you do before doing it, particularly Explain to the patient what you do before doing it, particularly

while setting up OMM. while setting up OMM. If you are not sure what is wrong, If you are not sure what is wrong, do notdo not say, “I will get back to say, “I will get back to

you after I have discussed this with the attending.”  This does you after I have discussed this with the attending.”  This does not evaluate your knowledge or skill. not evaluate your knowledge or skill.

See also:  Example SP Check Sheet. See also:  Example SP Check Sheet. 

What should I include in the SOAP note?What should I include in the SOAP note? SS= Subjective/patient input regarding the problems(s)= Subjective/patient input regarding the problems(s)

OO= Objective findings, physical exam, lab data, etc.= Objective findings, physical exam, lab data, etc.AA= Assessment—= Assessment—include 3 potential differential diagnoses include 3 potential differential diagnoses or etiologies. Rank in order of likelihoodor etiologies. Rank in order of likelihood.  For well visits, list .  For well visits, list at least 3 problems or risk factors.at least 3 problems or risk factors.PP= Plan for diagnostic investigations and/or treatment= Plan for diagnostic investigations and/or treatment

Bibliography:Bibliography:

1.http://vig.pearsoned.co.uk/catalog/uploads/Bloomfield%20-1.http://vig.pearsoned.co.uk/catalog/uploads/Bloomfield%20-%20Chapter%201.pdf.%20Chapter%201.pdf.

2.http://www.informaworld.com/smpp/2.http://www.informaworld.com/smpp/content~db=all~content=a784022189~frm=abslink.content~db=all~content=a784022189~frm=abslink.

3.http://en.wikipedia.org/wiki/3.http://en.wikipedia.org/wiki/Objective_structured_clinical_examination.Objective_structured_clinical_examination.

4. http://www.uams.edu/icm/osce/osce.asp.4. http://www.uams.edu/icm/osce/osce.asp.

5.http://meds.queensu.ca/courses/clinicalskills/5.http://meds.queensu.ca/courses/clinicalskills/student_resources/osce.student_resources/osce.

6. http://www.oscehome.com/What_is_Objective-Structured-6. http://www.oscehome.com/What_is_Objective-Structured-Clinical-Examination_OSCE.htmlClinical-Examination_OSCE.html