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COMMENTARYOSCE: The subjective experience of an objective examAlim Nagji, BHScMedical Student (2012), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, CanadaCorrespondence to Alim Nagji, Email: anagji@ualberta.caAbstractThe Objective Structured Clinical Examination (OSCE) is theprimary modality for testing clinical skills throughout medicalschool and in residency training. This article explores the difficultiesof the exam via the subjective perspective of a student in thesystem, commenting on reticent standardized patients, the lackof consensus on what makes an ideal medical student and theabsence of feedback. As the exam celebrates nearly four decades inuse, it is important that we continue to evaluate its usefulness andbrainstorm innovative approaches to advancing the state of clinicalexaminations.The Objective Structure Clinical Examination (OSCE) has rapidlybecome the leading clinical examination in North American MedicalSchools. The unassailable champion of repetitive and reproducibleevaluation, it has become the envy of all other tests. While multiplechoice still holds a prominent position in most medical curricula,that is usually for the convenience of administering the test and thesheer volume of information one can sift through. As a learner, onehas had ample time to exploit the system, mastering the nuances ofthe “all of the following EXCEPT” and “which answer is the BEST”questions. In reality, we have been asked this type of question sincekindergarten and the PBS specials we grew up on sang “one of thesethings is not like the other one.” 1The OSCE is succinctly explained in the abstract of a 1975 BMJ article:“the examination is more objective and a marking strategy can bedecided in advance.” 2 The veracity of the latter half of this requirementis evidenced by the rubric style approach of many modern OSCEs.However, the first part is where the interesting dilemma lies. Is theexamination more objective? From the subjective experience ofstudents, it would hardly seem so.The variability lies in the innate qualities of both the “standardizedpatient” and the examiner. Having worked as a standardized patient,the instructions one often receives is to be as guarded as possibleabout information, refraining from volunteering details unlessspecifically probed. This is in direct contrast to the guidance offeredin basic history taking skills, where students are counselled to allowthe patient to convey the narrative of their illness uninterrupted. Forthose that have participated in OSCEs, it is easy to recall those actorsfrom whom information had to be stolen as if it were precious gems.From many a station I have walked out and, in conversation withmy peers in different tracks, realized that another “standardized”patient had been much more forthcoming with a pivotal piece of thediagnostic puzzle.In Rowntree’s 17 proposals for better assessment, he notes that“there is an assumption rampant in talk of academic standards,that all qualified assessors feel, understand and judge in much thesame way when confronted with the work of a particular student.It is presumed that they would notice and value the same skills andqualities and would broadly agree in their assessments. Abundantevidence attests to the falsity of such assumptions.” 3 In the sameway, examiners vary widely in their preferences of what they believemakes the ideal learner. One need only glance at the complicatedmedical admission system or the behemoth that is the CanadianResident Matching Service (CaRMS) to realize that we cannot agreeon the perfect model student, yet we continue to cling to antiquatedstandards so as to maintain a united front. Despite the broadaccusations suggesting poor inter-rater reliability across a varietyof domains, 4 OSCE examinations remain a mainstay of evaluationdespite their artificial construction and potentially variableenvironment.In the same seminal article, the authors proclaim that the“examination results in improved feed-back to students and staff.” 2This may hold true for the teaching OSCEs, where 2 minutes ofpersonalized commentary follows each station, but for the majorityof exams in medicine, the results are protected and not released. Sowhile occasionally one may receive a grade or score sheet, one isleft waiting for the commentary that can enhance clinical skills orrefine an approach. The majority of instructors emphasize the needto train physicians, not test takers, yet the very nature of receiving apass or a fail undermines the learning process. Research has shownthat overall, detailed, descriptive feedback was found to be mosteffective when given alone, unaccompanied by grades or praise, thedirect opposite of what students usually receive. 5 The OSCE hassignificant advantages over multiple choice questions, providing arich opportunity for students to simulate patient encounters andmaintain some degree of standardization. However, it’s limitationsand shortcomings should be discussed, rather than disputed. Themodern OSCE, nearly 40 years after its rise to prominence, seemsstagnant in the face of the rapid change in the medical community.Perhaps as we enter a new decade of medical education we cancritique our instruments, as well as our students, and developinnovative models to evaluate competence in clinical skills.1. Cooney, J.G. (creator). Seasame Street [Television Series]. New York:PBS 1969.2. Harden, R. McG. Stevenson, M., Downie, W.W. & Wilson, G.M.Assessment of clinical competence using objective structuredexaminations. British Medical Journal 1975;I: 447.3. Rowntree, D. Assessing students: how shall we know them?London: Kogan Page 1977. As cited in: Harden, R., Gleeson, F.A.Assessment of clinical competence using an objective structuredclinical examination (OSCE). Medical Education 1979;13(1):39-54.4. Thistlethwaite, JE. Developing an OSCE station to assess theability of medical students to share information and decisionswith patients: issues relating to interrater reliability and the use ofsimulated patients. Educ Health (Abingdon) 2002;15(2):170-9.5. Lipnevich, A.A., Smith, J.K. Response to assessment feedback: Theeffects of grades, praise and sources of information. Retrieved fromProQuest Digital Dissertations 2008; 3319438.2University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1