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THE DEFINITIVE GUIDE
TO THE OSCE
For Elsevier
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THE DEFINITIVE GUIDE
TO THE OSCE
The Objective Structured Clinical Examination
as a performance assessment

Ronald M. Harden OBE MD FRCP (Glas) FRCPC FRSCEd

Professor Emeritus Medical Education, University of Dundee, UK;
General Secretary, Association for Medical Education in Europe (AMEE)

Pat Lilley BA (Hons)

Operations Director, Association for Medical Education in Europe (AMEE)

Madalena Patrício PhD

Professor of Education, Faculty of Medicine, University of Lisbon, Portugal

Foreword by

Geoff Norman PhD

Professor Emeritus, Department of Clinical Epidemiology and Biostatistics,
McMaster University, Hamilton, Ontario, Canada

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto

2016
SECTION A Atrophies and Disorders of Dermal Connective Tissues

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Notices
Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
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 Contents

Foreword vii
Preface xi
About the Authors xiv
Contributors to Case Studies xvi
Acknowledgements xix

SECTION A
An introduction to the OSCE 1

1 What is an OSCE? 1
An introduction to the OSCE for readers unfamiliar with the concept and, for those already familiar with
the OSCE, a more in-depth insight into the characteristics that define the OSCE as an assessment tool.

2 The inside story of the development of the OSCE 13

An account of how the OSCE was conceived and developed in the 1970s in response to the assessment
challenges facing educators in the healthcare professions.

3 The OSCE as the gold standard for performance assessment 23

The OSCE with its multiple samples of performance has come to dominate performance assessment
and merits a place in every assessor’s toolkit.

4 How the OSCE can contribute to the education programme 35

The OSCE can be adopted as an assessment tool in any situation or phase of education where an
assessment of the learner’s clinical or practical skills is important.

5 What is assessed in an OSCE? 49

The OSCE can be used to assess a range of learning outcomes, including communication skills, physical
examination, practical procedures, problem solving, clinical reasoning, decision making, attitudes and
ethics and other competencies or abilities.

SECTION B
Implementation of an OSCE 65

6 Choosing a format for an OSCE 65

Flexibility is a major advantage of the OSCE. Many factors influence the choice of format. These include
the number of examinees, the purpose of the examination, the learning outcomes to be assessed, the
resources available and the context of the local situation.

7 The setting for an OSCE 83

The OSCE can be located in a range of settings. The selection of a venue will depend on the nature of
the examination and the local circumstances.

v
 8 The patient 91
Patients in an OSCE may be represented by real or simulated patients, computer representations, video
recordings, medical records and investigation results or a combination of all these. Each has a specific
role to play.

9 The examiner 105

Health professionals, simulated patients and students can serve as examiners in an OSCE. Their roles
and responsibilities should be defined and training provided.
Contents

10 Implementing an OSCE 115

There are ‘good’ and ‘bad’ OSCEs. Advance planning and effective organisation on the day are neces-
sary to deliver a ‘good’ OSCE.

11 Evaluating the examinee’s performance 127

Different approaches can be adopted for assessing performance in an OSCE, making pass/fail decisions
and setting standards.

12 Providing feedback to the learner 149

The OSCE can be a powerful learning experience, and a variety of approaches can be adopted for the
provision of feedback to the learner.

13 The examinee’s perspective 161

Communicating with learners about the OSCE is important. Examinees can prepare for and maximise
their performance during an OSCE.

14 Evaluating an OSCE 169

Evaluation and quality control of an OSCE is important, and constant monitoring and improvement are
necessary.

15 Costs and implementing an OSCE with limited resources 181

The resources required and the costs incurred can be tailored to the local situation. The OSCE can, but
need not, be expensive to administer. Many OSCEs are run at little or no additional cost.

SECTION C
Some final thoughts 193

16 Limitations of the OSCE 193

The OSCE has an important role to play in the examiner’s toolkit alongside other assessment approaches.
If recognised, the limitations of the OSCE can be addressed.

17 Conclusions and looking to the future 203

The OSCE will continue to evolve and have a major role to play in response to changes in medical
education.

SECTION D
Case studies 213

SECTION E
References 323

SECTION F
Bibliography 345

Index 353

vi
 Foreword

When Ron Harden approached me to write the foreword, I viewed it as a distinct

honour. It was also a bit of a watershed. There was a time, now two decades ago,
when I would have been the last person Ron would have asked (and, yes, it’s Ron
to me, not Professor Harden – entirely as a result of the incident I am about to
relate). And if he had asked me to write the foreword, to paraphrase Lyndon Johnson,
“If asked, I would not write”. But something happened twenty years ago that has a
bearing on both the book itself and my authoring of the foreword.

Prior to 1995, Ron and I were at opposite poles. With my PhD in physics, I was a
purist ivory-tower researcher whose goal was to advance the science of education.
Consequences of my actions were of no consequence. Ron’s goals were almost dia-
metrically opposed. He genuinely wanted to improve the education of medical stu-
dents and physicians, and the more people he could influence, the more impact he
could have. I was the elitist; Ron the populist. To me, no standards could be rigorous
enough; to Ron, engagement was the issue, and so he would bring in the novices
and nurture them to higher standards.

Then, in 1995, we met at a small conference in Islamabad, and ended up in my

hotel room – just me, Ronald and a third participant named Johnnie Walker. And
we have become good friends and confidants ever since. In hindsight, I began to
understand better where he was coming from, and moreover, I began to realize that
the inclusiveness of meetings like AMEE and the Ottawa Conference, both of which
had a large Harden imprimatur (along with Ian Hart, rest in peace, one of the loveli-
est men ever to grace this planet), served an ulterior motive. By making a conference
presentation accessible to almost all, he created a venue where even novices could
come and fall under the influence of some of the masters. Moreover, the large
number of participants enabled the conference to “buy” top class people as plenary
speakers. So my arrogance was misplaced and arguably Ron, with his inclusiveness,
has done more to improve the quality of medical education than all of us
academics.

At another level, perhaps we were both right. Both of us went on to be awarded the
Karolinska Prize, the highest award in medical education research. We have both
been widely recognized for our contributions – far more than I (and my wife) could

vii
 ever have dreamed possible. And despite the fact that our world views remain dis-
tinct, each has come to appreciate the contribution of the other.

Back to Ron, and the underlying rationale for this book. Nowhere is his genuine
concern more evident than in the development and success of the OSCE. Ron
describes the concerns he had about assessment in Chapter 2. Recognizing the fail-
Foreword

ings of the traditional clinical examination, which bore more resemblance to the
Spanish Inquisition than anything in education, he devised the OSCE strategy to
provide a more equitable test of clinical skills.

However, left unstated in his narrative is just why the OSCE became so popular.
(And it is popular. I do a workshop on assessment around the world. I used to ask
people if they know what an OSCE is. I don’t anymore. Everyone, in every land,
knows what OSCE is.) To understand its popularity requires an expanded history
lesson.

Back in the early 1970s when I was first hired into medical education, we were all
preoccupied with “skills” – problem-solving skills, critical thinking skills, commu-
nication skills, physical examination skills, evidence-based medicine skills, etc. I
was hired (Why me, Lord? Goodness knows.) to investigate clinical problem-solving
skills. We put doctors and students into rooms with simulated patients, videoed
them, reviewed their tapes, and pored over the transcripts seeking the mysterious
elixir of problem-solving skill. We never found it. Instead what we found, looming
large, was “content specificity”, as identified by the group at Michigan State (Elstein
et al. 1978). In brief, successful problem-solving was dictated as much by the specific
knowledge required to solve the problem as by any general intellectual skill. And
when we looked at other measures of “problem-solving” we found the same issue.
Patient Management Problems or PMPs (McGuire and Babbott 1967) were a written
objective case-based test, requiring about 45 minutes per case. For them as well, the
correlation of performance measures across problems was 0.1 to 0.3. Since each
PMP took about 45 minutes, it was not long before PMPs were dropped from licens-
ing and specialty examinations.

The solution to the psychometric problem was simply one of sampling. To get good
measurement required multiple samples rated by multiple observers (and, inciden-
tally, sampling across cases was more important than sampling across raters). The
larger issue, as noted by Ron in Chapter 2, was that removing the PMP meant that
most examinations were now multiple choice only. While that may be acceptable
for a specialty examination where the goal is just precise and valid measurement, it
is not acceptable for educational programs because of the potential steering effect
(Newble and Jaeger 1983). What was required was something that, on the one hand,
efficiently sampled over cases and raters, and on the other, measured actual perform-
ance. Enter OSCE! And as they say, the rest is history.

Not surprisingly, though, as an innovation gets disseminated, it also gets diluted

and mutated. Strategies like problem-based learning, small group learning,

viii
multiple-choice tests – just about everything we do in education – eventually get
reborn in so many variations as to be almost unrecognizable. It’s not like a drug – 
there is no equivalent of 300 mg t.i.d. As a result, it is critical to develop standards
of best practice, based on evidence. To some degree this is achieved by approaches
like Best Evidence Medical Education (another Harden innovation), although the
constraints of systematic review methodology limit the usefulness of these reviews

Foreword
as guidelines for educational practice. And that is where this book is an invaluable
addition. It pulls together in one place pretty well everything that is known about
the OSCE; what works and what doesn’t. It is a welcome addition to the bookshelf
of any educational leader. Please enjoy!

Geoff Norman
Professor Emeritus, Department of Clinical Epidemiology and
Biostatistics, McMaster University, Hamilton, Ontario, Canada

References
Elstein, A.S., Shulman, L.S., Sprafka, S.A., 1978. Medical Problem Solving: An Analysis of
Clinical Reasoning. Harvard University Press, Cambridge MA.
McGuire, C.H., Babbott, D., 1967. Simulation technique in the measurement of clinical
problem-solving skills. J. Educ. Meas. 4, 1–10.
Newble, D.I., Jaeger, K., 1983. The effect of assessments and examinations on the learning
of medical students. Med. Educ. 17, 165–171.

ix
This page intentionally left blank
 Preface

The assessment of the competence of a student, trainee or healthcare professional,

it can be argued, is the most challenging task facing the teacher or educator today.
There are many reasons why it is an important task. The public needs to be reas-
sured that the doctor certified by the medical school as competent to practise has
the necessary knowledge, skills and attitudes. In the undergraduate curriculum, the
student has to show that he/she has achieved the competencies necessary to move
on to the next stage of the curriculum. The junior doctor or trainee has to demon-
strate that he/she is qualified to work as a specialist in medicine, surgery, general
practice or some other field. Assessment of the learner is a key element in the move
to outcome-based or competency-based education, with an answer to the question
– has the learner achieved the necessary learning outcomes?

There are other reasons why assessment is important. What we choose to assess
is perceived by the learner as an indication of what we value in a training pro-
gramme, and this impacts directly on the learner’s behaviour and study pattern.
There is also a new understanding of the relationship between learning and
assessment that embraces more than ‘assessment of learning’. In ‘assessment for
learning’, or ‘assessment as learning’, assessment is an integral part of the overall
educational programme. So, although this book is about assessment and, indeed,
one approach to assessment, it is relevant to everyone who is engaged with cur-
riculum planning, teaching and learning, instructional design, quality assurance
and student selection.

Over the years there has been an increasing interest in both the theoretical principles
underpinning assessment and the tools used to implement assessment in practice
(McGaghie 2013). Whilst much has changed, much has remained the same. Reliabil-
ity (consistency), validity (measuring what we need to measure) and feasibility or
practicality remain key criteria on which an assessment tool can be judged, with the
acceptability and impact that the assessment method has on the learner also attract-
ing attention. In the past, much emphasis had been placed on reliability as an
assessment matrix and on the assessment of knowledge acquisition. The importance
of the validity of an assessment and the need to assess clinical skills and competen-
cies rather than simply knowledge acquisition, however, is now recognised. It was
with this in mind that the OSCE was developed as a reliable and valid tool to assess

xi
 the clinical skills of the learner (Harden et al. 1975). The OSCE has come to domi-
nate performance assessment (Norman 2002) and is recognised as the best method
of formally assessing clinical skills (Reznick et al. 1997). The OSCE has proved to
be a useful tool for both summative assessment with judgements as to the exami-
nee’s competence to practise or move on to the next step of training and for formative
assessment with feedback to the examinee. The OSCE has also been used extensively
Preface

in the evaluation of curricula, courses or teaching methods and is now used also as
a tool to select students for admission to medical studies.

A key factor in the acceptance and increasing use made of the OSCE has been its
flexibility, with the process being readily adapted to meet local needs, simple or
complex, and to assess a range of learning outcomes in different phases of the cur-
riculum. Outcomes assessed include traditional competencies relating to communi-
cation and physical examination skills and also competencies attracting attention
more recently, including patient safety, professionalism and teamwork. There has
been increasing interest, too, in the selection of students for admission to medical
studies, and a version of the OSCE – the multiple mini-interview (MMI) approach
– has been used for this purpose. For all of these reasons the OSCE and this book
have a place in the assessor’s toolkit.

When administered well, the OSCE is a powerful and valuable tool to assess a
learner’s competence in the area tested. Examples can be found where the OSCE is
administered in an inappropriate manner and one that does not reflect best practice
(Gupta et al. 2010; Huang et al. 2010; Sturpe 2010). This can be a serious problem,
particularly when the OSCE is used as a summative assessment to certify that a
graduating doctor has the skills necessary to practise or that a trainee is competent
to practise as a specialist. The adoption of the approaches presented in the book
should ensure that problems are avoided in the implementation of an OSCE and
only high-quality OSCEs are used in the assessment of students and trainees.

We have written the book to provide the reader with an easily accessible account of
the basic concepts underpinning the OSCE and how an OSCE can be implemented
in practice. We thought that the reader might also be interested in the story of how
the OSCE was initially developed and introduced as an assessment tool in medicine.
The practical guidelines and tips provided are based on the extensive experience that
we and others have gained over the past 40 years. You will find in the text, as well
as in the case studies, information and ideas about how the OSCE can be used in
a wide range of settings and in different professions to assess the expected learning
outcomes. In the boxes, you will find personal accounts and anecdotes that illustrate
the points made in the text.

We look at the OSCE from the perspectives of the examiner, the student and the
patient and address issues, including advance planning, possible venues, the design
of stations, alternative approaches to scoring the examinee’s performance, the provi-
sion of feedback and the evaluation of the OSCE. We also look at how the OSCE
can be implemented when the available resources are constrained. The OSCE has

xii
not been without its critics, and in Section C of the book we address limitations on
the use of the OSCE and common misconceptions. Finally, we look at the continu- 
ing development of the OSCE and the changes we might see in the years ahead.

The book will be of interest to teachers or trainers in the healthcare professions

working in undergraduate, postgraduate or continuing education. Many teachers,

Preface
trainers or clinical supervisors will be engaged with an OSCE as an OSCE station
developer, an examiner, a curriculum or programme planner, a student/trainee
advisor or counsellor or an education researcher. The book should also have a
wider appeal outside the healthcare professions and be of value in any context
where there is an interest in performance assessment. As demonstrated by the
police force in England and Wales, the approach can be readily adapted for use
in different situations.

More than 1,800 papers have been published on the OSCE. This book is based on
our own personal experience with OSCEs and informed by the work of others from
around the world. The case studies included in Section D and referred to throughout
the book provide valuable examples of how the OSCE can be implemented in practice
in different situations.

It is not our intention to provide a complete systematic review of the published

literature on the OSCE. We have studied the publications on the OSCE, however,
and have referred to papers where we feel they add to an understanding of the OSCE
as it is presented in this book. We refer throughout the text to key papers in the area
and to examples that illustrate the different ways in which an OSCE can be employed
in practice, highlighting the use of the OSCE in different subjects and professions.
There are many more examples of its use that we could have included but have had
to omit them because of space constraints.

You may choose to read systematically through the book and address the themes as
we have presented them or to dip into the chapters and topics most relevant to your
needs. Whatever approach you adopt, we hope that you find the book an interesting
read and that it includes ideas that you can employ with advantage in your own
setting.

Ronald Harden
Pat Lilley
Madalena Patrício

xiii
 About the Authors

Ronald M. Harden
Professor Ronald Harden graduated from medical school in Glasgow, Scotland, UK.
He completed training and practised as an endocrinologist before moving full time
to medical education. He is Professor of Medical Education (Emeritus), University
of Dundee, Editor of Medical Teacher and General Secretary and Treasurer of the
Association for Medical Education in Europe (AMEE).

Professor Harden has pioneered ideas in medical education, including the Objective
Structured Clinical Examination (OSCE), which he first described in 1975; has
published more than 400 papers in leading journals; is co-editor of A Practical
Guide for Medical Teachers; and is co-author of Essential Skills for a Medical
Teacher: An introduction to learning and teaching in education. His contributions
to excellence in medical education have attracted numerous international awards,
including the Hubbard Award by the National Board of Medical Examiners, USA;
an OBE by Her Majesty the Queen for services to medical education, UK; the
Karolinska Institute Prize for Research in Medical Education, which recognises
high-quality research in medical education; and a Cura Personalis Honour, the
highest award given by Georgetown University, Washington, DC, USA.

Pat Lilley
Pat Lilley joined the University of Dundee in 1995 and worked on a range of projects
in the Centre for Medical Education. In 1998 she joined the Association for Medical
Education in Europe (AMEE) and has been part of its development into a leading
healthcare educational association with members in over 90 countries. Now AMEE
Operations Director, Pat is closely involved in all of AMEE’s projects and initiatives.
Since 2006 she has assisted in the development and execution of the AMEE Essential
Skills in Medical Education (ESME) face-to-face courses for teachers and is a course
tutor for the online ESME Course. Pat is also Managing Editor of AMEE’s journal
Medical Teacher.

Madalena Patrício
Madalena Folque Patrício is Past President of AMEE and an ex officio member of its
Executive Committee. She is Chair Elect of the Best Evidence Medical Education
(BEME) Collaboration, a member of the Editorial Board of the journal Medical

xiv
Teacher and external adviser to the World Federation for Medical Education. She is
Professor at the Institute of Introduction to Medicine at the Faculty of Medicine of 
the University of Lisbon and Head of the Lisbon BEME Group at the Center for
Evidence Based Medicine (CEMBE), where she coordinates a systematic review on
the reliability, validity and feasibility of the Objective Structured Clinical Examina-
tion (OSCE). Her special interests are evidence-based teaching, humanization of

About the Authors

medicine, community-based teaching, social accountability of medical schools and
the Objective Structured Clinical Examination (OSCE). She was awarded the 2013
AMEE Lifetime Achievement Award.

xv
 Contributors to
Case Studies

Case Study 1: Dundee Medical Mohi M.A. Magzoub, MBBS MSC

School – Year 2 OSCE PhD MFPHM
Professor of Medical Education, College of
Rob Jarvis, MA MB ChB MPH FHEA Medicine, King Saud bin Abdulaziz
Academic Mentor (Educational Guidance University for Health Sciences, Ministry of
and Support Tutor), Medical School, National Guard Health Affairs, Riyadh,
University of Dundee, UK Kingdom of Saudi Arabia

Case Study 2: King Saud bin Case Study 3: Manchester Medical

Abdulaziz University for Health School MBChB – Phase 2
Sciences Cardiovascular System Formative OSCE
Block Phase 2 OSCE
Alison Quinn, MBBS FRCA
Tarig Awad Mohamed, BSc (Hons)
FCARCSI PgC Med Edu
MSc MHPE
Honorary Lecturer, Medical School,
Lecturer, Department of Medical
University of Manchester, UK
Education, College of Medicine, King
Saud bin Abdulaziz University for Health
Clare McGovern, FRCA
Sciences, Ministry of National Guard
Consultant Anaesthetist, Medical School,
Health Affairs, Riyadh, Kingdom of Saudi
University of Manchester, UK
Arabia

Bashir Hamad, MB BS MD DTPH Emyr Wyn Benbow, BSc MB ChB

DCMT DET FRSTM FFSMSB FRCPath
Senior Lecturer in Pathology, Medical
Professor of Medical Education, College of
School, University of Manchester, UK
Medicine, King Saud bin Abdulaziz
University for Health Sciences, Ministry of
National Guard Health Affairs, Riyadh,
Kamran Khan, MBBS FRCA
Kingdom of Saudi Arabia
MMedEd FAcadMed
Consultant Anaesthesiologist, James Paton
Ali I AlHaqwi, MD MRCGP(UK) Memorial Hospital, Gander, NL, Canada
ABFM MHPE PhD (Med Edu)
Associate Professor, Chairman, Department
of Medical Education, College of Medicine,
King Saud bin Abdulaziz University for
Health Sciences, Ministry of National
Guard Health Affairs, Riyadh, Kingdom of
Saudi Arabia

xvi
Case Study 4: Monash Lisa Altshuler, PhD
University Malaysia Formative Associate Director of Evaluation and 
OSCE Assessment, Program for Medical Education
Innovations and Research (PrMeir), New
Wee Ming Lau, MD MMed AM Grad York University School of Medicine,
Dip FP Derm PG Dip Occ Health NY, USA
GCHE

Contributors to Case Studies

Senior Lecturer, Jeffrey Cheah School of Ingrid Walker-Descartes, MD MPH
Medicine and Health Sciences, Monash Program Director, Pediatrics Residency
University Malaysia, Malaysia Training Program, Maimonides Medical
Center, NY, USA
Case Study 5: UCL Medical School
Final Examinations – Short Station Lita Aeder, MD
OSCE Director, Board Review Course,
Brookdale University Hospital and
Kazuya Iwata, BSc(Hons) MBBS Medical Center, NY, USA
MRCPsych MSc FHEA Members of the Maimonides
Honorary Clinical Lecturer in Medical
Pediatrics OSCE Committee
Education, University College London
Medical School, UK
Case Study 7: Medical Council of
Canada’s Qualifying Examination
Daniel S. Furmedge, MBBS Part II
MRCP(UK) DRCOG MAcadMEd
FHEA AKC Sydney Smee, PhD
Honorary Clinical Lecturer in Medical
Assessment Advisor, Medical Council of
Education, University College London
Canada (MCC), ON, Canada
Medical School, UK
Members and Consultants of MCC OSCE
Alison Sturrock, BSc(Hons) MRCP Test Committee who are Faculty members
PGCMedEd FHEA of Canadian Medical Schools
Clinical Senior Lecturer in Medical
Education, University College London Case Study 8: OSCE for
Medical School, UK Postgraduate Year-1 Resident
Physicians – Madigan Army
Deborah Gill, MBBS MRCGP MMEd Medical Center
FHEA EdD
Interim Director of University College Matthew W. Short, MD FAAFP
London Medical School, University College Madigan Army Medical Center, WA, USA
London Medical School, UK
Patricia A. Short, MD FACP
Case Study 6: Culture OSCE for Madigan Army Medical Center, WA, USA
Pediatric Residents

Elizabeth K. Kachur, PhD

Medical Education Consultant –
Maimonides Medical Center/Director,
Medical Education Development, National
& International Consulting, NY, USA

xvii
 Case Study 9: Dundee Mohamad Haniki Nik Mohamed,
Undergraduate BSc in Nursing PharmD BPharm
Programme – First-Year OSCE Associate Professor and Deputy Dean
(Academic Affairs), Faculty of Pharmacy,
Arlene Brown, MPhil BSc Nursing International Islamic University Malaysia,
PGCert(THE) RGN Kuantan, Malaysia
Lecturer in Nursing, School of Nursing and
Contributors to Case Studies

Midwifery, University of Dundee, UK Case Study 13: Postgraduate Year

1 – Patient Safety OSCE
Iain Burns, MSc Nursing BA
Business Organisation DipEd Dianne P. Wagner, MD
DipNurs RGN Professor of Medicine, Associate Dean for
Senior Lecturer in Nursing, School of College-wide Assessment, College of Human
Nursing and Midwifery, University of Medicine, Michigan State University, East
Dundee, UK Lansing, MI, USA

Case Study 10: OSCE in Ruth B. Hoppe, MD

Undergraduate Dentistry Professor of Medicine, Senior Associate
Dean for Academic Affairs Emeritus, College
Anthony Damien Walmsley, BDS of Human Medicine, Michigan State
MSc PhD FDSRCPS University, East Lansing, MI, USA
Professor of Restorative Dentistry, School of
Dentistry, University of Birmingham, UK Carol J. Parker, MPH
Executive Director of Academic Affairs,
Case Study 11: Diploma in College of Human Medicine, Michigan State
Veterinary Nursing University, East Lansing, MI, USA

Martin Barrow, BVM&S Case Study 14: Basic Abdominal

Chair of Governors, Central Qualifications Ultrasound Course
(CQ), Examination Board and Awarding
Organisation, UK Matthias Hofer, PD Dr med MPH
MME
Denise Burke Arzt für Diagnostische Radiologie, Leiter der
Quality Assurance Manager, Central AG Medizindidaktik, Studiendekanat,
Qualifications (CQ), Examination Board and Heinrich-Heine-Universitat Düsseldorf,
Awarding Organisation, UK Germany

Case Study 12: Summative OSCE Case Study 15: Dundee Medical
for a Clinical Pharmacy Course, School Multiple Mini-Interview
Malaysia (MMI)

Ahmed Awaisu, PhD MPharm Adrian Husbands, MSc

BPharm Lecturer in Medical Education, School of
Assistant Professor of Clinical Pharmacy Medicine, University of Dundee, UK
and Practice, College of Pharmacy, Qatar
University, Doha, Qatar Jon Dowell, MRCGP MD FHEA
Chair of UK Medical Schools Electives
Siti Halimah Bux Rahman Bux, Council, and Admissions Convener, School
BPharm of Medicine, University of Dundee, UK
Senior Academic Fellow and Deputy Dean
(Student Affairs), Faculty of Pharmacy,
International Islamic University Malaysia,
Kuantan, Malaysia

xviii
 Acknowledgements

Over the past 40 years we have benefitted from working with many colleagues in
different settings and have gained from them a wealth of experience on the OSCE.
We are indebted to those who made possible the early efforts to introduce the OSCE
into the medical school assessment programme in Dundee. In particular we would
like to thank Sir Alfred Cuschieri, Paul Preece, Robert Wood and James Crooks, who
played a leading role in the initial implementation of the OSCE in Dundee. As a
senior member of staff in the Dundee Centre for Medical Education, Fergus Gleeson
worked on the development of the OSCE and its implementation and co-authored
one of the two initial key publications on the topic. We would also like to acknowl-
edge the other members of staff of the Centre for Medical Education who have sup-
ported the ongoing work on the OSCE.

Special thanks should go to two medical educators who are, sadly, no longer
with us. Ian Hart spent several sabbaticals in Dundee working on the OSCE,
amongst other things. As described in the text, Ian made a significant contribu-
tion to the dissemination of the OSCE internationally through the Ottawa Con-
ferences, the first of which was held in 1985. Miriam Friedman Ben-David also
spent a sabbatical in Dundee, and her contributions to the OSCE and to assess-
ment more widely deserve special mention. We remember both Ian and Miriam
with great fondness, and the discipline of medical education is all the richer
for their contributions.

On our last count, more than 1,800 papers had been published on the OSCE. We
are grateful to everyone who took the time and effort to record their experiences on
paper, and we have learned a lot from these reports. In the same way, the OSCE has
featured prominently in medical education conferences, and this, too, has provided
a powerful learning opportunity for us. We are also grateful for the many invitations
we have received to visit other schools to see the OSCE in action in different loca-
tions throughout the world.

We are grateful to the students who have given us constructive feedback on the
OSCE over the years and hope that all examinees, whatever their stage of training,
believe the OSCE contributed to their development as learners, rather than remem-
bering it as a traumatic method of assessment.

xix
 The case studies described in Section D, we believe, represent an important part of
the book, and we would like specially to thank the contributors who have openly
shared their experiences with us.

Finally, we would like to thank everyone who supported us in the preparation of this
book, including Cary Dick from AMEE for help with typing and preparation of
Acknowledgements

graphics; Alex Haig and Valerie Harden, who undertook an initial review of the
papers published on the OSCE; Jim Glen, who drew the cartoons, which we hope
will entertain the reader; Geoff Norman who has written the Foreword; and Laurence
Hunter, Carole McMurray and Anne Collett from Elsevier.

Ronald Harden
Pat Lilley
Madalena Patrício

xx
 SECTION A AN INTRODUCTION TO THE OSCE

What is an OSCE?
1

An introduction to the OSCE for readers unfamiliar with the concept

and, for those already familiar with the OSCE, a more in-depth
insight into the characteristics that define the OSCE as an assess-
ment tool.

A definition
This book is about the Objective Structured Clinical Examination, or the ‘OSCE’,
the acronym by which the approach has become widely known. The concept is well
established in health professions education and the approach is familiar to many
teachers. We start, however, by defining an OSCE and outlining the features that set
it aside from other assessment tools. It is as Hodges (2003) suggested, ‘An examina-
tion like no other.’ In short, the OSCE is a performance-based examination in which
examinees are observed and scored as they rotate around a series of stations accord-
ing to a set plan (Figure 1.1). Each station focuses on an element of clinical compe-
tence, and the learner’s performance with a real patient, a simulated patient (SP),
a manikin or patient investigations is assessed by an examiner. An example of a
20-station OSCE is given in Table 1.1.

To understand better what an OSCE is and the features that characterise the
approach, it is helpful to look more closely at the elements in the name (Table 1.2).

Objective
The OSCE was introduced, as described in Chapter 2, to replace the traditional
clinical examination, which had been demonstrated to be an unreliable form of
assessment. Problems with the traditional clinical examination included the small
sample of skills assessed and the subjectivity or bias associated with the examiner’s
rating of the candidate. The OSCE was designed to avoid these problems. It has
attracted attention as the ‘gold standard’ in performance assessment at least in part
because of its perceived objectivity. The notion of objectivity is, however, a relative
one. Even multiple-choice questions and other so-called objective tests are not as
truly objective as their designers may claim. The issues of objectivity and reliability
in an OSCE are discussed in more depth in Chapter 3.

1
SECTION A

Figure 1.1 In an OSCE students rotate around a series of stations. At each

station an element of competence is assessed.

Figure 1.2 In any clinical

examination there are three variables:
Student
the patient, the examiner and the
candidate.

OSCE

Patient Examiner

In any clinical examination there are three variables: the patient, the examiner and
the candidate (Figure 1.2). In the OSCE, any bias as a result of the patients seen
and the examiners is reduced so that the result is a truer assessment of the exami-
nee’s clinical competence.

A number of stations
The first key feature of the OSCE is that examinees are assessed over a number of
stations. The OSCE has sometimes been referred to as a multistation clinical exami-
nation. This is very different from the traditional clinical examination with a single
long case. In a typical OSCE, there may be 20 or more such stations. The number

2
 Table 1.1 Example of a 20-station OSCE
1
Station Description Patient Examiner
1 History from a patient with pain in the hip SP Yes
2 Questions relating to Station 1 – –
3 Auscultation of chest in a patient with a Harvey manikin Yes

What is an OSCE?
murmur
4 Explain insulin administration to a diabetic SP Yes
patient
5 Examination of neck in a patient with goitre Real patient Yes
6 Questions relating to Station 5 – –
7 Examination of hands in a patient with Real patient Yes
rheumatoid arthritis
8 Preparation of case notes relating to – –
Station 7
9 History from a patient with dysuria SP Yes
10 Referral letter to hospital for a patient in – –
Station 9
11 Catheterisation of a patient Cystoscopy manikin Yes
12 Interpretation of chest X-ray X-rays –
13 Interview with a psychiatric patient Video recording –
14 Discuss interview with examiner – Yes
15 Questions relating to ward prescription Patient’s drug chart –
chart
16 Questions relating to drug advertisement Drug advertisement –
17 Examination of leg for a patient with Real patient Yes
hemiplegia
18 Questions relating to Station 17 – –
19 Measurement of blood pressure in a patient Real patient Yes
with hypertension
20 Questions relating to Station 19 – –
SP, simulated patient.

Table 1.2 The OSCE

Objective A number of stations
Examinees assessed on the same stations
Clear specification of what is assessed
A number of examiners
Specification of standards required
Structured OSCE blueprint
Clinical Students watched performing a clinical task on real and standardised
patients

3
 of stations may vary, as described in Chapter 6; this may be as low as 6 or as high
as 40. What is known, however, is that the reliability of the examination increases
as the number of stations increases. Each domain to be assessed, such as commu-
nication skills or physical examination skills, is usually tested at several stations.

To allow a smooth rotation of examinees around the OSCE stations, the time allo-
SECTION A

cated to each station is uniform. In some examinations this may be 5 minutes and
in other examinations it may be 15 to 20 minutes. Each examinee starts at a dif-
ferent station and on a given signal at the end of the set time period they move
forward to the next station. The exception to this is a double station where exami-
nees spend double the amount of time at a station. How this works in practice is
described in Chapter 6. Stations can also be arranged as linked stations where the
examinee’s competence in relation to a patient is assessed over two stations.

Uniform examination
A key feature of an OSCE is that all examinees are assessed on the same set of
stations. In one circuit of 20 stations, 20 candidates can be assessed in an examina-
tion. Where more than 20 candidates have to be assessed, two or more circuits with
matched stations can be run in parallel. Alternatively, the same circuit can be
repeated sequentially with a further set of candidates examined after the first circuit
has been completed (Box 1.1).

Specification of what is assessed

Another key feature of an OSCE is that what is to be assessed at each station is
agreed upon in advance of the examination. The examinee may be assessed carrying
out a practical procedure, such as the measurement of a patient’s blood pressure.
Decisions need to be taken in advance of the examination as to what is to be assessed
at the station (Box 1.2). Should the examinee’s attitude and communication with
the patient be taken into account or is the assessment to be based only on the
examiner’s observation of the technical aspect of how the candidate undertakes
the procedure? Is the accuracy of the blood pressure measurement arrived at by the
examinee and his/her interpretation of the results also to be taken into considera-
tion? What is to be assessed will be reflected in the checklist and rating scale to be
used by the examiner at the station, and this is described in Chapter 11.

Box 1.1

When the OSCE was introduced as the final medical examination in Dundee, more than
120 students were examined in one morning. Three circuits, each with 20 stations, were
used simultaneously. Stations were identical in terms of the tasks expected of the student
and the scoring sheets. Patients or simulated patients (SPs) were carefully matched
across different circuits. Following a short break, another group of 60 students was
assessed later in the morning on the same three circuits. To ensure that the matched
stations were comparable, an analysis of students’ performance at each of the matched
stations in different circuits was undertaken.

4
 Box 1.2
1
In a study carried out by RMH and co-workers at Glasgow University, a significant variation
was found between the marks awarded by different examiners to students in a traditional
clinical examination (Wilson et al. 1969). One of the reasons for the variations was that
there had been no decision in advance as to what was to be assessed in the examination.
Some examiners took into account the student’s dress, how the students presented them-

What is an OSCE?
selves and their attitudes towards the patient whilst others restricted their assessment of
the student to the technique demonstrated by the student.

A number of examiners
During the examination each candidate sees a number of examiners. This is a key
feature of an OSCE. With a 20-station OSCE there may be 10 examiners or more
at one circuit. Each examiner is carefully briefed as to what is expected of them at
the station and training is given in advance of the OSCE with regard to what the
examiner should be looking for and how the checklist and rating scale should be
interpreted. This is discussed further in Chapter 9.

Specification of standards required

The standard expected of the examinee in the overall examination and in individual
stations is specified. This can be determined by using an established approach to
standard setting, as described in Chapter 11. The minimum requirements for a pass
can be set and excellence can also be recognised.

Structured
What was assessed in a traditional clinical examination was often opportunistic and
depended on the patients available in the hospital or as outpatients. In contrast, a
key feature of the OSCE is that what is to be assessed during the examination is
carefully planned and agreed upon before the examination is implemented.

OSCE blueprint
A blueprint or a grid for the OSCE is prepared in advance. This outlines the learning
outcomes and core tasks to be assessed at each station in the OSCE, for example in
the domains of communication skills, physical examination, practical procedures
and analysis and reflection. This important feature of an OSCE is discussed further
in Chapter 6.

The grid maps on one axis the key learning outcome domains and on the other axis
the elements of the course, e.g. the body systems or context in which the learning
outcomes are to be assessed. For example, patient education skills may be assessed
in the endocrine system with a diabetic patient, history taking in the cardiovascular
system in a patient with chest pain, and physical examination in the respiratory
system in a patient with asthma (Table 1.3).

5
 Table 1.3 Section of a blueprint showing content of an OSCE as tested at
Stations 1, 2, 3, 4, 6, 8, 10 and 12
Learning Body system
outcome CVS RS NS AS ENDO
History (2) Chest pain (10) Diarrhoea
SECTION A

taking
Patient (1) Diabetes
education
Physical (4) Asthma (6) Hemiplegia
examination
Practical (8) BP (12) FEV
procedures
Problem (3) Headache
solving
.
.
.
AS, Alimentary system; BP, Blood pressure; CVS, Cardiovascular system; ENDO, Endocrine
system; FEV, Forced expiratory volume; NS, Nervous system; RS, Respiratory system.

Box 1.3

A common and important comment from students following an OSCE is that the examina-
tion is perceived as ‘fair’. One reason for this is that students in general see that the OSCE
reflects the teaching and learning programme and the stations overall address the learning
outcomes of the course.

What is assessed in the OSCE should reflect the content covered in the teaching
and learning programme (Box 1.3). The learning outcomes assessed can be related
on a curriculum map to the relevant learning opportunities for the examinee, for
example a session in the clinical skills unit, a simulator, a ward-based experience,
a video available online or even a lecture.

Clinical
The OSCE is a clinical or performance-based examination. It tests not only what
examinees know, but also their clinical skills and how they put their knowledge into
practice. Think outside medicine for a moment. If we were to design a test to assess
students’ ability to tie their shoelaces, it would not be sensible to assess their knowl-
edge relating to the task as shown in Table 1.4, rather than their technical skill. To
assess students’ competence what we need is to observe their skill as they tie their
shoelaces.

Whilst this may seem obvious, all too often in medicine we fall into the trap and
rely on testing the students’ knowledge with written assessments when what we are
interested in is their clinical competence. This represents the bottom of Miller’s
Pyramid (Miller 1990) at the ‘knows’ and ‘knows how’ levels rather than the ‘shows

6
 Table 1.4 The assessment of a student’s competence in tying shoelaces
1
Objective: The student should be able to tie his/her shoelaces
Assessment options
• Write short notes on the origin of shoelaces.
• Describe the materials from which shoelaces are made.

What is an OSCE?
• Write an essay to explain how shoelaces are tied.
• Answer an MCQ relating to tying a shoelace.
• Observe an individual tying his/her shoelaces.

how’ level, as described in Chapter 5. The OSCE is a performance measure of what

the individual would do in a clinical context. Examples of the range of clinical skills
that can be assessed in an OSCE are given in Table 1.5.

In an OSCE, it is the examinee’s clinical skills and what he/she does when faced
with a patient or clinical situation and the competence demonstrated that are
assessed – not simply what he/she knows as tested by a written or theoretical ques-
tion on the subject. It is the application of the knowledge to practice that is assessed
in an OSCE.

In ‘procedure’ stations, examinees are watched and assessed by the examiner as they
take a history, examine a patient, or carry out a practical procedure. In a history
taking station, for example, the history taking techniques used by the examinees
and the questions they ask as well as their approach to the patient are taken into
consideration. A ‘procedure’ station may be followed by a ‘question’ station, where
the examinee is asked about their findings at the previous station and the conclu-
sions they have reached based on their findings. The examinee’s response may be
in the form of:

• a multiple-choice question (MCQ).

• a short constructed response to a question.

• a note about the patient they have seen – sometimes called a ‘post-encounter
note’.

• a letter referring the patient for further investigation or treatment; or

• an oral report to an examiner.

In addition to the use of real patients, simulated or standardised patients may be

used to provide examinees with a standardised experience. This is discussed further
in Chapter 8. The emphasis placed on the use of standardised patients varies. In
the USA the OSCE is often equated with a standardised patient examination.

7
 Table 1.5 Examples of clinical skills assessed in an OSCE (Harden 1988)
Skill Action Example
History taking History taking from a patient Abdominal pain
who presents a problem
History taking to elucidate a Hypothyroidism
SECTION A

diagnosis
Patient Provision of patient advice Discharge from hospital following a
education myocardial infarction
Educating a patient about Use of an inhaler for asthma
management
Provision of patient advice Endoscopy
about tests and procedures
Communication Communication with other Brief to nurse with regard to a
members of healthcare teams terminally ill patient
Communication with relatives Informing a wife that her husband
has bronchial carcinoma
Writing a letter Referral or discharge letter
Physical Physical examination of a Hands of a patient with rheumatoid
examination system or part of the body arthritis
Physical examination to follow Congestive cardiac failure
up a problem
Physical examination to help Thyrotoxicosis
confirm or to help confirm or
refute a diagnosis
Diagnostic Diagnostic procedure Ophthalmoscopy
procedure
Interpretation Interpretation of findings Charts, laboratory reports or findings
documented in patient’s records
Patient Patient management Writing a prescription
management
Critical Critical appraisal Review of a published article or
appraisal pharmaceutical advertisement
Problem Problem solving Approach adopted in a case where
solving a patient complains that her weight
as recorded in the hospital was not
her correct weight

A flexible format
The OSCE is not a rigid prescription for how a candidate is examined. One is
unlikely to see two OSCEs which are identical in the skills tested and the ways in
which they are assessed. Within the principles set out above, there is the opportunity
to adapt the process to a particular context and to suit the needs associated with:

• a particular discipline or specialty whether this is general practice, surgery or

psychiatry.

8
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