The Objective Structured Clinical Examination (OSCE): AMEE Guide No. 81. Part I: An historical and theoretical perspective

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Practice points

Before the advent of OSCE, long case and short case examinations were used for the assessment of performance. The OSCE is an assessment tool based on the principles of objectivity and standardisation, which allows the assessment of candidates’ performance against standardised scoring schemes by trained assessors. The OSCE assesses performance in a simulated environment, at the ‘shows how' level of Miller's pyramid of assessment. The OSCE is most appropriately used, alongside other assessment methods, in a structured programme of assessment. A well-designed OSCE can drive learning, and therefore, can have a positive educational impact.

Table 1  Advantages and disadvantages of long cases

Advantages of long cases	Disadvantages of long cases
The use of real patients achieves the highest degree of realism	Inter-case variance or case specificity (Wass et al. 2001b)
Ability to assess on rare or complex problems with good clinical signs  and symptoms in patients (Smith et al. 1984)	Real patient variance or inconsistency in case presentation between candidates (Wass et al. 2001b)
Ability to choose from a variety of cases (Smith et al. 1984)	Single case limiting the ability to assess a broad spectrum of skills
Complete evaluation of the patient's problem–no compartmentalisation	Undue leniency or stringency of the examiners based on the candidate or patient characteristics (McManus et al. 2006)
	Low inter-rater and intra-rater reliability (Wilson 1969; Norcini 2002)
	High case-specificity (Norman 2002)
	Non-standardised scoring (McManus et al. 2006)
	No blueprinting resulting in random selection of cases for assessment

Table 2  Assessment domains in the OSLER (Gleeson 1997)

Assessment domains	Specific criteria in each domain
History	Pace and clarity of presentation
	Communication skills
	Systematic approach
	Establishment of case facts
Physical examination	Systematic approach
	Examination technique
	Establishment of correct physical findings
Construction of appropriate  investigations in a logical sequence
Appropriate management
Final clinical acumen  (ability to identify and solve problems)

Figure 1 Eighteen station OSCE as originally described by Harden (1979). Shaded stations had examiners present.

Figure 2 Scoring rubric used at station 3 as described by Harden (1979).

Table 3  Variations of the OSCE

OSCE variant	Brief description
Objective Structured Practical Examination (OSPE) (Harden & Cairncross 1980)	Assessment of practical skills, knowledge and/or interpretation of data in non clinical settings
Objective Structured Assessment of Technical Skills (OSATS) (Bodle et al. 2008; van Hove et al. 2010)	Designed for objective skills assessment, consisting of a global rating scale and a procedure specific checklist. It is primarily used for feedback or measuring progress of training in surgical specialities.
Objective Structured Video Examinations (OSVE) (Humphris & Kaney 2000; Vlantis et al. 2004)	Videotaped recordings of patient-doctor encounters are shown to students simultaneously and questions related to the video clip are asked. Written answers are marked in a standardised manner.
Team Objective Structured Clinical Examination (TOSCE) (Singleton et al. 1999)	Formative assessment covering common consultations in general practice. A team of students visits each station in a group, performing one task each in a sequence. The candidates are marked for their performance and feedback is provided. The team approach improves efficiency and encourages learning from peers.

Table 4  Affective, cognitive and psychomotor domains of learning from basic to advanced levels

Range of difficulty	Affective	Cognitive	Psychomotor
Basic	Receiving	Knowledge	Perceiving
	Responding	Comprehension	Patterning
	Valuing	Application	Accommodation
	Organisation	Analysis	Refining
	Characterisation	Synthesis	Improving
Advanced		Evaluation	Composing

Figure 3 Model for the competency based assessment of performance and examples of available assessment tools. Reproduced from Khan & Ramachandran (2012).

Figure 4 The OSCE in relation to the Miller's pyramid.

Figure 5 Factors influencing performance. Modified from Khan & Ramachandran (2012).

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