www.AJOG.

org Reviews

EDUCATION
To the point: reviews in medical education—the Objective
Structured Clinical Examination
Petra M. Casey, MD; Alice R. Goepfert, MD; Eve L. Espey, MD; Maya M. Hammoud, MD; Joseph M. Kaczmarczyk, DO, MPH;
Nadine T. Katz, MD; James J. Neutens, PhD; Francis S. Nuthalapaty, MD; Edward Peskin, MD; for the Association
of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee

A ppropriate assessment of medical

student performance throughout
the curriculum involves various meth-
This article, the eighth in the To the Point Series prepared by the Association of
Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee,
ods that target knowledge, skills, and be- discusses the effectiveness of the Objective Structured Clinical Examination (OSCE) for
havior evaluation.1 All methods listed in assessment of learners’ knowledge, skills, and behaviors. The OSCE has also been used
Table 1 have advantages and disadvan- for the appraisal of residents and physicians undergoing licensure examinations; herein
tages. The essay or oral examination is we focus on its application to undergraduate medical education. We review evidence for
difficult to standardize or evaluate objec- best practices and recommendations on effective use of the OSCE and requirements for
tively. The multiple-choice examination and challenges to its implementation, including creative ways to design an OSCE
greatly improves the reliability and con- program with a limited budget. We discuss its role in providing formative and summative
tent validity of tested material. However, feedback and describe learner performance on the OSCE as the OSCE relates to
because it tests the ability to memorize subsequent testing, including US Medical Licensing Examination step 1. A representative
and recognize facts, it falls short in mea- case with assessment used at the authors’ medical schools is included.
suring learners’ ability to gather appro-
Key words: assessment, Objective Structured Clinical Examination, simulation,
priate information, interpret that infor-
standardized patient
mation, and synthesize a management
plan necessary for patient care.2
In an effort to assess clinical skills con-
sistently and objectively, the Objective memorization. Unlike a real patient en- ing a debriefing after the examination.
Structured Clinical Examination (OSCE) counter, an OSCE occurred in a lower- The OSCE has since evolved into its cur-
model was described in 1975 by Harden risk setting and allowed students to be- rent structure, which includes the ele-
et al.3 The OSCE provided an innovative come comfortable with history taking, ments in Table 2.
method to assess learners’ clinical skills, examination, and interpersonal com- Most recently the role of the OSCE has
including effective communication and munication. The method also included a been expanded to assess professionalism,
examination skills in addition to factual performance review and feedback dur- quality improvement, and documenta-
tion. Certain variants of this versatile
tool concentrate on the individual
From the Department of Obstetrics and Gynecology (Dr Casey), Mayo Clinic, Rochester, learner, whereas others emphasize the
MN; the Department of Obstetrics and Gynecology (Dr Goepfert), University of Alabama at group/team dynamic in completing a
Birmingham, Birmingham, AL; the Department of Obstetrics and Gynecology (Dr Espey),
skill or communicating a task. Some test-
University of New Mexico Health Sciences Center, Albuquerque, NM; the Department of
Obstetrics and Gynecology (Dr Hammoud), Weill Cornell Medical College in Qatar, Doha,
ing scenarios focus on the application of
Qatar; the Department of Obstetrics and Gynecology (Dr Kaczmarczyk), Uniformed Services knowledge, whereas others highlight the
University of the Health Sciences, Bethesda, MD; the Department of Obstetrics and demonstration of a clinical skill.4 Analy-
Gynecology and Women’s Health (Dr Katz), Albert Einstein College of Medicine, Bronx, NY; sis of OSCE performance may reveal def-
the Department of Obstetrics and Gynecology (Dr Neutens), University of Tennessee icits in student exposure to particular
Knoxville, Knoxville, TN; the Department of Obstetrics and Gynecology (Dr Nuthalapaty), topics or the quality of teaching, thus
University of South Carolina School of Medicine, Greenville, SC; and the Department of promoting continuous quality improve-
Obstetrics and Gynecology (Dr Peskin), University of Massachusetts Medical School, ment in medical education.5 Although
Worcester, MA. the OSCE may not be optimal in all sit-
Received June 3, 2008; revised Sept. 19, 2008; accepted Sept. 30, 2008. uations, it provides a valuable comple-
Reprints: Petra M. Casey, MD, Department of Obstetrics and Gynecology, Mayo Clinic, 200 First ment to other assessment methods.6
St SW, Rochester, MN 55905. casey.petra@mayo.edu.
The views expressed in this article are those of the authors and do not reflect the official policy or
OSCE use in US medical schools
position of the US Department of Defense, the US Department of Health and Human Services, or
the US government. A recent Liaison Committee for Medical
0002-9378/$36.00 • © 2009 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2008.09.878 Education survey of 126 accredited US
medical schools found that 97 schools

JANUARY 2009 American Journal of Obstetrics & Gynecology 25

Reviews Education www.AJOG.org

TABLE 1
Evaluation methods for medical student clinical performancea
Formative vs summative
Method Evaluates evaluation
Direct observation History taking Both
Physical examination
Interpersonal interactions
................................................................................................................................................................................................................................................................................................................................................................................
Clinical evaluation exercises (ie, OSCE) History taking Both
Physical examination
Interpersonal interactions using simulated and standardized
patients
Synthesis of information with differential diagnosis and
management plan
................................................................................................................................................................................................................................................................................................................................................................................
Medical record reviews Information processing Both
Management plan development
................................................................................................................................................................................................................................................................................................................................................................................
Patient logs Breadth of experience Both
Procedures performed
................................................................................................................................................................................................................................................................................................................................................................................
Written (multiple-choice question) Knowledge base Summative
examinations (ie, NBME subject)
................................................................................................................................................................................................................................................................................................................................................................................
Structured oral examinations Knowledge base Summative
Information synthesis
Reasoning
Problem solving
................................................................................................................................................................................................................................................................................................................................................................................
Written (essay) examinations Knowledge base, information synthesis, reasoning, problem Summative
solving
................................................................................................................................................................................................................................................................................................................................................................................
NBME, National Board of Medical Examiners; OSCE, Objective Structured Clinical Examination.
a
The concepts in this table are derived from Fincher R-ME, editor. Guidebook for clerkship directors. Washington: Association of American Medical Colleges; 2000. 249 pages.
................................................................................................................................................................................................................................................................................................................................................................................

Casey. Objective Structured Clinical Examination. Am J Obstet Gynecol 2009.

used at least 1 OSCE in introductory physical examination skills, 80 examined a comprehensive summative evaluation
skills courses and 48 programs used the the ability to synthesize information, and in the preclinical and clinical phases of
method in the obstetrics and gynecology 76 evaluated communication skills.7 medical education. At several of the au-
clinical clerkship.7 In 82 schools, a com- Only 12% of schools did not include an thors’ institutions, the OSCE is combined
prehensive third- or fourth-year OSCE OSCE in either clerkship or comprehen- with the National Board of Medical Exam-
was given. The majority required a pass- sive evaluation. iners (NBME) subject examination and
ing grade for graduation. Eighty OSCEs The OSCE can be used for formative faculty/resident direct observation in the
evaluated history taking, 81 evaluated midrotation feedback as well as a part of final assessment of performance in ob-

TABLE 2
Modern OSCE elementsa
Element Purpose
Case-based scenario, interaction with a trained SP Demonstrates learner’s thought process in evaluation and management of a
clinical situation, skill, or behavior
................................................................................................................................................................................................................................................................................................................................................................................
Structured objective checklist Forms basis for evaluation, improves interrater reliability
................................................................................................................................................................................................................................................................................................................................................................................
Direct observation and/or recording of encounter Facilitates evaluation and feedback
................................................................................................................................................................................................................................................................................................................................................................................
Multiple clinical situations, termed stations Increases the number and range of competencies evaluated
................................................................................................................................................................................................................................................................................................................................................................................
Written summary of the history, physical examination findings, Demonstrates ability to formulate a differential diagnosis and management plan
assessment, and plan
................................................................................................................................................................................................................................................................................................................................................................................
NBME, National Board of Medical Examiners; SP, standardized patient.
a
The concepts in this table are derived from Newble6 and Tervo et al.15
................................................................................................................................................................................................................................................................................................................................................................................

Casey. Objective Structured Clinical Examination. Am J Obstet Gynecol 2009.

26 American Journal of Obstetrics & Gynecology JANUARY 2009

www.AJOG.org
stetrics and gynecology and other clerk-
ships. Multiple assessment strategies im-
prove the accuracy and consistency of
clinical skills assessments. Lower-stakes
OSCEs in medical school represent in-
valuable preparation for the high-stakes
US Medical Licensing Examination
(USMLE) Clinical Skills (CS) test. Since
2005, the USMLE CS test, essentially a
summative OSCE, has been required for
medical licensure.
What skills are best
assessed by the OSCE?
The OSCE is best for testing clinical,
technical, and practical skills as well as
demonstrating higher-order skills to ac-
complish knowledge or skill-based edu-
cational objectives.6 However, all com-
petencies recommended by the
Accreditation Council for Graduate
Medical Education for assessment dur-
ing clinical clerkships: patient care,
medical knowledge, interpersonal and
communication skills, professionalism,
practice-based learning and improve-
ment, and system-based practice—may
be assessed using the OSCE.8
Accordingly, specific communication
challenges such as obtaining informed
consent, breaking bad news, cross-cul-
tural interviewing, and behavioral mod-
ification or counseling can be easily tai-
lored into an OSCE case4 as can issues
involving documentation, quality im-
provement, and evidence-based medi-
cine.9 Furthermore, interpersonal com-
munication skills such as verbal and
nonverbal behaviors, acknowledging pa-
tients’ concerns or emotions, paralin-
guistic components, establishing rapport,
ethics assessment, cultural competence,
English proficiency, and flow of the inter-
view can be effectively assessed by the ex-
aminer or standardized patient (SP).10,11
Interestingly, in a recent study of more
than 3000 Canadian physicians, an in-
verse correlation was found between
physician communication and clinical
decision-making scores on the Medical
Council of Canada clinical skills exami-
nation and the number of meritorious
patient complaints during the ensuing
2-12 years of independent practice.12
Selection of OSCE case content
Among the first steps in establishing
content validity in an OSCE examina-
tion is development of specific goals and
corresponding tasks within simulated
clinical scenarios. For a valid test, the
teaching and testing goals must match
the learning level.3,13 Complexity of
OSCE cases should increase from junior
to more senior medical students.
Expert faculty in each specialty may
determine the learning objectives and
drive the focus of OSCE cases for any
given student training level.6 For exam-
ple, a third-year obstetrics and gynecol-
ogy learning objective may be to evaluate
possible ectopic pregnancy. A case of ab-
dominal/pelvic pain is designed with fea-
tures suggestive of ovarian cyst rupture,
pelvic inflammatory disease, and appen-
dicitis along with ectopic pregnancy so
that the learner has the opportunity to
develop a differential diagnosis and
management plan. Because student per-
formance in 1 scenario is a poor predic-
tor of performance in another, sampling
across a number of clinical conditions
ensures adequate content validity and
reliability.14 The number of stations is
generally related to the number of students
examined and the availability of faculty.13
Furthermore, an OSCE that focuses on
end-of-clerkship evaluation generally con-
sists of fewer cases than a comprehensive
OSCE encompassing multiple specialties.
The Appendix contains a representa-
tive OSCE used for evaluation of third-
year medical students after completion
of their required clinical clerkships. Doc-
uments include case goals and patient
description, case history and SP descrip-
tion, structured checklist history, exam-
ination and counseling, and student in-
structions for case summary. This
example illustrates the format and the
breadth and depth of content of a typical
OSCE.
The cost-effective OSCE
Setting up an OSCE program can be ex-
pensive, labor intensive, and administra-
tively cumbersome.15 Fortunately, these
challenges can be overcome by thought-
ful teamwork between the OSCE direc-
tor, SP coordinator, and a multispecialty
faculty group, with the support and use
JANUARY 2009 American Journal of Obstetrics & Gynecology
Education Reviews
of available resources at each medical
school, obstetrics and gynecology de-
partment, or both. Some medical
schools provide the resources for a cen-
tralized OSCE. Elsewhere, individual de-
partments develop their own OSCEs.
The OSCE director needs to have
strong leadership, organizational, and
communication skills coupled with en-
thusiasm for medical student education.
A current or former clerkship director or
any experienced, interested faculty
member can fulfill this role. The charac-
teristics of the SP coordinator are similar
and should also include some medical or
performing arts background. Table 3
contains a checklist of start-up compo-
nents for a new OSCE program. The col-
umns include suggestions for a typical
expert faculty-based model for an insti-
tution at which funding is abundant
alongside an adequate lower-cost model
in which resources are limited. Table 4
provides estimates of time commitments
to the program for various personnel
involved.
Case writing
Case authors play a key role in the suc-
cess of an OSCE program. The corner-
stone of the OSCE is a realistic and ap-
propriately challenging clinical case.
Some cases focus on communication
skills and others on factual knowledge,
but all require time and effort to write
and revise. Typically, interested faculty is
recruited by the OSCE director to write
and revise cases. A case-writing work-
shop, taught by the OSCE director or an
experienced OSCE faculty member, is
helpful to new OSCE faculty and case au-
thors (Bargsten DA, oral communica-
tion, 2008).
Three or 4 cases per specialty are kept
current in a case bank. Cases include the
clinical scenario; instructions for the stu-
dent, patient, and examiner; and the
structured checklist. Well-written cases
may be updated and reused during sub-
sequent examination sessions, thus min-
imizing the resource requirements of
writing new cases.
A core faculty from multiple special-
ties reviews each planned OSCE session.
The group identifies needed content ar-
eas, recruits case authors, and selects
27
Reviews Education www.AJOG.org

TABLE 3
OSCE program components: expert faculty-based vs lower-cost model
Program
component Expert faculty-based model Lower-cost model
Goals and objectives Experienced faculty Experienced faculty
................................................................................................................................................................................................................................................................................................................................................................................
Case writing Experienced faculty Senior medical students with faculty review
Midwives, nurse-practitioners with faculty review
................................................................................................................................................................................................................................................................................................................................................................................
OSCE cases Initial development of case bank Review and update of successful cases
................................................................................................................................................................................................................................................................................................................................................................................
Examiners Experienced faculty SPs
Senior medical students
Midwives, nurse-practitioners
................................................................................................................................................................................................................................................................................................................................................................................
Facility Simulation center with integrated recording equipment Office examination room
Recording equipment when possible
................................................................................................................................................................................................................................................................................................................................................................................
SP coordinator Experienced SP, nurse-educator with strong organization and Similar, perhaps less experienced person
communication skills and theater arts background Willing to train and learn on the job
................................................................................................................................................................................................................................................................................................................................................................................
SP training SP coordinator with faculty collaboration SP coordinator with limited faculty collaboration
Senior medical students
................................................................................................................................................................................................................................................................................................................................................................................
SPs Paid trained SPs Volunteer trained SPs
................................................................................................................................................................................................................................................................................................................................................................................
Medical, nursing students
................................................................................................................................................................................................................................................................................................................................................................................
Recording Digital or web-based imaging Videotape
................................................................................................................................................................................................................................................................................................................................................................................
Evaluations Web-based Paper
................................................................................................................................................................................................................................................................................................................................................................................
Debriefing Individual or group feedback with faculty Group feedback with SP
................................................................................................................................................................................................................................................................................................................................................................................
Self-assessment Senior medical students
................................................................................................................................................................................................................................................................................................................................................................................
Individual feedback with SP Midwives, nurse-practitioners
................................................................................................................................................................................................................................................................................................................................................................................
Combination of previously listed methods Individual feedback with SP or faculty to students with
poor performance only, self-assessment for all
students
................................................................................................................................................................................................................................................................................................................................................................................
OSCE, Objective Structured Clinical Examination; SP, standardized patient.
................................................................................................................................................................................................................................................................................................................................................................................

Casey. Objective Structured Clinical Examination. Am J Obstet Gynecol 2009.

cases for the OSCE given once during the intimately familiar with the case. By self-assessment, faculty debriefing for all
third year. Nonfaculty team members, using nonfaculty examiners, including students or only those with suboptimal
such as the SP coordinator, participate in SPs, MD/PhD students, nurse-practi- performance, or debriefing using trained
most aspects of case development. Each tioner students, and senior medical nonfaculty personnel may be done. De-
case is piloted with a mock examinee students, faculty time commitment briefing may also integrate feedback
who will not be taking the examination. and costs can be reduced. This was from students about the OSCE adminis-
A visiting medical student, a graduating found to be successful in a recent study tration, including discussion about sta-
fourth-year medical student, or a faculty of 214 third-year German students in tions to modify, retain, and replace for
member from an unrelated specialty acts which interrater reliability was not future examinations.
as the examinee for the case pilot. compromised by different examiner
backgrounds.16 Testing facility
Case examiners Testing facilities range from state-of-
Examiners participate in the adminis- Feedback and debriefing the-art simulation centers to readily
tration of the OSCE by observing the Following the completion of an individ- available office examination rooms.
learner and filling in a structured ual station or the entire OSCE, debrief- Handheld video equipment with a mi-
checklist. Depending on the availabil- ing provides opportunities for learner crophone and paper evaluation forms
ity of audiovisual equipment, they may feedback. Video recording allows de- can be used as alternatives to the high-
be in the examination room or view the briefing for individual students after the er-cost Web-based access to digital re-
examination from a separate room. completion of the OSCE by all examin- cording for documentation and feed-
Faculty briefing before the examina- ees. Student self-assessment may be ef- back.4 In a comparison study, a Web-
tion is helpful in situations in which fectively incorporated into the debrief- based OSCE resulted in similar class
the examiner is not the case author or ing session. Depending on resources, performance as a paper OSCE.4 Fur-

28 American Journal of Obstetrics & Gynecology JANUARY 2009

www.AJOG.org Education Reviews

TABLE 4
Representative time commitments for key OSCE personnel
Time per 8-case
Staff role Key training aspects examination, h Time used for specific tasks
Program director Faculty educator 70 Case review/selection, checklist preparation, on-site attendance for
examination, faculty debriefing, final scoring
................................................................................................................................................................................................................................................................................................................................................................................
75 Preparation and teaching case-writing workshop
................................................................................................................................................................................................................................................................................................................................................................................
Faculty Faculty educator 56 Case writing, pilot sessions, on-site attendance for examination
................................................................................................................................................................................................................................................................................................................................................................................
8 Case-writing workshop (once)
................................................................................................................................................................................................................................................................................................................................................................................
Program coordinator Administrative 165 Coordinating examination, case preparation, on-site attendance for
personnel examination
................................................................................................................................................................................................................................................................................................................................................................................
SP coordinator Allied health and/or 220 SP training, case review, pilot sessions, on-site attendance for
performing arts examination, props and makeup
background
................................................................................................................................................................................................................................................................................................................................................................................
15 Teaching IPS workshop
................................................................................................................................................................................................................................................................................................................................................................................
SP Various levels of 60 Case preparation, including examination
training
................................................................................................................................................................................................................................................................................................................................................................................
15 Attendance IPS workshop (once)
................................................................................................................................................................................................................................................................................................................................................................................
Administrative Administrative 3 Data entry score sheets, statistical analysis
support personnel
................................................................................................................................................................................................................................................................................................................................................................................
IPS, interpersonal skills; OSCE, Objective Structured Clinical Examination; SP, standardized patient.
................................................................................................................................................................................................................................................................................................................................................................................

Casey. Objective Structured Clinical Examination. Am J Obstet Gynecol 2009.

thermore, a correlation of student The role of the SP ings.18 Because SPs have first-hand expe-
achievement on the Web-based OSCE The SPs are individuals trained to por- rience with the examinee as a clinician,
to subsequent NBME subject examina- tray patient complaints dependably and they are uniquely qualified to rate exam-
tion supported the validity of either realistically and provide consistent ver- inees on interpersonal skills. Key charac-
documentation method. The use of al- bal and behavioral responses to stimuli teristics helpful in matching cases to ap-
ternative administration methods in- from examinees.4 The SPs may be propriate SPs are summarized in Table 5.
creases the feasibility of the OSCE in asymptomatic, have stable findings, or The Association of Standardized Pa-
which resources are limited.17 be trained to simulate physical find- tient Educators, founded in 2001 and

TABLE 5
Key SP characteristics before and after traininga
SP inherent characteristics SP characteristics after training
Age, language, sex, race/ethnicity, body ⬎ Promptness and preparedness during training
habitus
................................................................................................................................................................................................................................................................................................................................................................................
Physical examination findings: scars, body Ability to adapt to varying interviewer styles
art, stretch marks
................................................................................................................................................................................................................................................................................................................................................................................
Level of education and literacy Ability to sustain effective portrayal per case requirement
................................................................................................................................................................................................................................................................................................................................................................................
Experience with presenting illness Ability to adapt behavior as a result of coaching/feedback, active listening skills
................................................................................................................................................................................................................................................................................................................................................................................
Availability for training, examination schedule Ability to extrapolate from training experience a believable response to unrehearsed stimuli
................................................................................................................................................................................................................................................................................................................................................................................
Physical functionality, stability of physical Ability to accurately record and effectively deliver constructive feedback from the patient
findings perspective
................................................................................................................................................................................................................................................................................................................................................................................
SP, standardized patient.
a
The concepts in this table are derived from Adamo.4
................................................................................................................................................................................................................................................................................................................................................................................

Casey. Objective Structured Clinical Examination. Am J Obstet Gynecol 2009.

JANUARY 2009 American Journal of Obstetrics & Gynecology 29

Reviews Education www.AJOG.org

mance standards.6 These experts initially

TABLE 6 estimate the score that a minimally com-
Typical OSCE testing timeline petent student should achieve on each
Time allotted per tested OSCE element. The estimate is re-
OSCE component station, min vised in light of OSCE scores of actual stu-
Case scenario (history taking, physical examination) 15 dents and after structured discussion.
..............................................................................................................................................................................................................................................
Case write-up (history and physical, differential diagnosis, 10 Using the earlier example of the
evaluation plan)
..............................................................................................................................................................................................................................................
woman with abdominal pain, experts
Rest 5 may determine that a minimally compe-
..............................................................................................................................................................................................................................................
tent student should ask about the possi-
Feedback (when all stations completed) with examiner and SP 5 per student
.............................................................................................................................................................................................................................................. bility of pregnancy, history of appendec-
OSCE, Objective Structured Clinical Examination; SP, standardized patient.
..............................................................................................................................................................................................................................................
tomy, and sexual activity. The student
Casey. Objective Structured Clinical Examination. Am J Obstet Gynecol 2009.
would be expected to perform an ab-
dominal examination, review the vital
signs, and indicate the need for a pelvic
numbering more than 570 members, is Improving test performance examination. Following the case pilot, it
dedicated to professional growth and de- may become obvious that students
A common criticism of the OSCE is its low
velopment of its members, the advance- should also ask about bowel habits and
interrater reliability, with correlation coef-
ment of SP research, and setting stan- last menstrual period. These elements of
ficients reported to range from 0.2 to
the history would be added to the revised
dards of practice for SPs (Ferguson D, 0.95.18 Constructing checklist items im-
written communication, 2007).19 score. A noncrucial question about uri-
proves reliability to reported correlation
nary symptoms may be omitted from the
The SP coordinator, who may have a coefficients of 0.8 to 0.9.18 A checklist
background in performing arts or educa- initial minimal passing standard.
should include a manageable number of
tion, trains SPs and teaches a workshop By contrast, the borderline procedure
easily definable learning issues.6 Inclusion
wherein SPs learn to translate examiner for criterion-referenced standard setting
of more than 10-12 checklist items in any
behaviors into meaningful feedback and determines a global rating of pass/border-
of the case areas (history, physical exami-
an interpersonal skills score. Training, line pass/fail in addition to and irrespective
nation, and counseling, if included) is neg-
which varies on the basis of the complex- of the number of checklist items answered
atively associated with reliability and correctly.21 Each examiner makes a judg-
ity of the case and the experience of the validity.20 Conversely, close examiner
SP, includes an initial presentation of the ment based on the learner’s overall compe-
involvement with examination design tence in evaluating abdominal pain from
case by the SP to its author(s) and other and administration was positively as-
faculty; revisions of the case and check- gathering a history, formulating a differen-
sociated with interrater reliability.20 tial diagnosis, and planning an appropriate
list; and preparation of props, makeup,
and on-site fine-tuning on examination evaluation. A learner evaluating abdomi-
Standard setting nal pain may ask about bowel habits, his-
day. During training, the SP is briefed on The determination of an appropriate
the symptoms and physical findings of tory of appendectomy, and urinary symp-
standard for minimum examination toms but leave out a question about
the conditions on the case differential di- performance is a complex issue. Two
agnosis. The SPs learn how to adopt the pregnancy and sexual activity as well as a
major types of standards have been used. plan to perform a pelvic examination. It is
speech, demeanor, and appearance of With a criterion-referenced standard,
the case patient and respond in character not clear whether this learner is consider-
students are judged by the level of subject ing pelvic inflammatory disease and ec-
to unexpected questions. Pitfalls such as
mastery and should perceive the exami- topic pregnancy. Because both are poten-
inconsistency in responses and the so-
nation as easy if they know the material tially serious and life-threatening causes of
called prompting effect in which SPs
well. Criterion-based scoring may in- abdominal pain, this student would fail the
progress to a response without stimulus
clude 0 for omitted/incorrect, 1 for par- station.
should be addressed during training.4
tially correct, and 2 for correct items.18 A Both Angoff and borderline proce-
The SP coordinator solicits and provides
norm-referenced standard compares dures provide reasonable and defensi-
feedback to SPs regarding performance.
students against each other and compen- ble approaches to standard setting and
Examination administration sates for difficult material that fewer stu- are practical for use in medical
Time spent in each OSCE station de- dents master.15 Ratings may pertain to schools,22 although some report the
pends on the complexity of the history the examination as a whole, be station latter to provide a more consistent and
taking and the clinical skills of the person specific, or be a combination of both. reliable standard.21,23 The aforemen-
being tested.6 The time allotted per sta- The Angoff procedure is commonly tioned methods may also be combined.
tion may be longer in higher-stakes ex- used for criterion-referenced standard set- For example, the mean of checklist
aminations. A typical testing time line is ting and relies on the professional judg- items answered correctly in which a
listed as an example in Table 6. ment of expert faculty to establish perfor- borderline pass rating is assigned can

30 American Journal of Obstetrics & Gynecology JANUARY 2009

www.AJOG.org
be used as the minimum checklist item
total for passing the case. By combin-
ing the methods, the student’s overall
competence in evaluating abdominal
pain as well as the number of checklist
items queried is taken into account in
the final scoring and may resolve
equivocal examination results.
Regardless of the method used for
scoring each station, the sum of station
pass marks becomes the pass mark of the
total OSCE score6 and is reported to-
gether with statistical measures that as-
sure its reliability.24 A fully compensa-
tory model in which good performance
on 1 station compensates for poor per-
formance on another is commonly used.
Alternatively, a model with a require-
ment to pass a defined proportion of sta-
tions may also be used.6
Assessment factors influencing
performance: student and
examiner background
Studies have examined the influence of
student background, recent clinical ex-
perience, and learning style on OSCE
performance. In a prospective sample
of first-year students, a well-organized
deep learning style related favorably to
OSCE performance, but prior clinical
experience did not.25 Testing context
such as most recent rotation influ-
enced student approach to a case.
Students took a broader history after
completing more clinical rotations.26
Ethnicity was not associated with over-
all OSCE performance on checklist or
interpersonal skills scores.27 During
the OSCE, written communication
skills, as demonstrated in the case sum-
mary, correlated well with verbal com-
munication but not physical examina-
tion skills.28
Other studies have examined the effect
of examiner specialty background and
clinical experience on the perception of
student performance. Student ratings
and OSCE scores indicate that specialists
and generalists teach preclinical medical
students with equal effectiveness.29 The
SP examiners were acceptable to stu-
dents and tended to rate students higher
than physicians. However, unlike physi-
cian scores, SP scores did not correlate with
multiple-choice examination scores.30
Currently there is no single student or
examiner characteristic warranting
special consideration during OSCE
administration.
Can OSCE performance predict
a physician’s future success?
Performance on OSCEs was found to be
an excellent predictor of future perfor-
mance on standardized examinations
such as the USMLE step 1, which mea-
sures basic science knowledge and ability
to interpret data and identify pathologic
specimens and clinical problems
through the application of scientific
principles.31 In another study, 93% of
learners who passed the OSCE passed
subsequent Canadian medical licensing
examinations.10 Conversely, of those
who failed the OSCE, only 66% later
passed these examinations.10 Most im-
portantly, OSCE performance correlated
well with subsequent consultant evalua-
tion of house officers32 and peer-rated
competence of examinees as future doc-
tors.33 Thus, OSCE scores predict not
only future examination performance
but also the quality of patient interac-
tions once a physician’s training ends.
Why OSCE? A summary
During undergraduate medical training,
the OSCE provides both formative and
summative assessment of cognitive and
noncognitive skills domains. Formative
assessment identifies deficiencies and
motivates remediation. Summative as-
sessment pinpoints outstanding or sub-
optimal ability in particular areas. Glo-
bally, the OSCE provides immediate
feedback to detect weaknesses within a
curriculum, teaching methods, or both.
Therefore, it is useful both for assess-
ment and for the enhancement of educa-
tional effectiveness.5,15 Combining dif-
ferent testing modalities may give the
best assessment of competence20 for var-
ious domains of knowledge, skills, and
behavior. Despite the costs and logistical
challenges to the implementation and
maintenance of an OSCE program, com-
pelling evidence exists for supporting
and strengthening the modern OSCE as
an integral part of undergraduate medi-
cal training across the country. f BMJ 1995;310:1187-90.
JANUARY 2009 American Journal of Obstetrics & Gynecology
Education Reviews
ACKNOWLEDGMENT
The authors acknowledge Denise A. Bargsten,
the OSCE coordinator at the College of Medi-
cine, Mayo Clinic, for background information
about this program, especially the information
provided in Table 4.
REFERENCES
1. Kassebaum DG, Eaglen RH. Shortcomings
in the evaluation of students’ clinical skills and
behaviors in medical school. Acad Med
1999;74:842-9.
2. Wilkerson L, Lee M. Assessing physical ex-
amination skills of senior medical students:
knowing how versus knowing when. Acad Med
2003;78(Suppl 10):S30-2.
3. Harden RM, Stevenson M, Downie WW, Wil-
son GM. Assessment of clinical competence
using objective structured examination. Br
Med J 1975;1:447-51.
4. Adamo G. Simulated and standardized pa-
tients in OSCEs: achievements and challenges
1992-2003. Med Teach 2003;25:262-70.
5. McFaul PB, Taylor DJ, Howie PW. The as-
sessment of clinical competence in obstetrics
and gynaecology in two medical schools by an
objective structured clinical examination. Br J
Obstet Gynaecol 1993;100:842-6.
6. Newble D. Techniques for measuring clinical
competence: objective structured clinical ex-
aminations. Med Educ 2004;38:199-203.
7. Barzansky B, Etzel SI. Educational programs
in US medical schools, 2002-2003. JAMA
2003;290:1190-6.
8. Common Program Requirements: General
Competencies: Approved by the ACGME
Board Feb. 13, 2007 [Internet]. Chicago: Ac-
creditation Council for Graduate Medical Edu-
cation. c2000-2008 [cited May 13, 2008]. Avail-
able at: http://www.acgme.org/outcome/
comp/GeneralCompetenciesStandards21307.
pdf. Accessed June 1, 2008.
9. Frohna JG, Gruppen LD, Fliegel JE, Man-
grulkar RS. Development of an evaluation of
medical student competence in evidence-
based medicine using a computer-based
OSCE station. Teach Learn Med 2006;18:
267-72.
10. Mavis BE, Henry RC. Between a rock and a
hard place: finding a place for the OSCE in med-
ical education. Med Educ 2002;36:408-9.
11. Mazor KM, Zanetti ML, Alper EJ, et al. As-
sessing professionalism in the context of an ob-
jective structured clinical examination: an in-
depth study of the rating process. Med Educ
2007;41:331-40.
12. Tamblyn R, Abrahamowicz M, Dauphinee
D, et al. Physician scores on a national clinical
skills examination as predictors of complaints to
medical regulatory authorities. JAMA 2007;
298:993-1001.
13. Selby C, Osman L, Davis M, Lee M. Set up
and run an objective structured clinical exam.
31
Reviews Education
14. van der Vleuten C. Validity of final examina-
tions in undergraduate medical training. BMJ
2000;321:1217-9.
15. Tervo RC, Dimitrievich E, Trujillo AL, Whittle K,
Redinius P, Wellman L. The Objective Structured
Clinical Examination (OSCE) in the clinical clerk-
ship: an overview. S D J Med 1997;50:153-6.
16. Chenot JF, Simmenroth-Nayda A, Koch A,
et al. Can student tutors act as examiners in an
objective structured clinical examination? Med
Educ 2007;41:1032-8.
17. Nackman GB, Griggs M, Galt J. Implementa-
tion of a novel Web-based objective structured
clinical evaluation. Surgery 2006;140:206-11.
18. Doig CJ, Harasym PH, Fick GH, Baumber
JS. The effects of examiner background, station
organization, and time of exam on OSCE scores
assessing undergraduate medical students’
physical examination skills. Acad Med 2000;
75(Suppl 10):S96-8.
19. Association for Standardized Patient Edu-
cators [Internet]. New Orleans: Association of
Standardized Patient Educators; c2008 [cited
2008 August]. Available from: http://www.
aspeducators.org.
20. Wilkinson TJ, Frampton CM, Thompson-
Fawcett M, Egan T. Objectivity in objective
structured clinical examinations: checklists are
no substitute for examiner commitment. Acad
Med 2003;78:219-23.
21. Kramer A, Muijtjens A, Jansen K, Dusman
H, Tan L, van der Vleuten C. Comparison of a
rational and an empirical standard setting pro-
cedure for an OSCE: objective structured clini-
cal examinations. Med Educ 2003;37:132-9.
Erratum in: Med Educ 2003;37:574
22. Kaufman DM, Mann KV, Muijtjens AM, van
der Vleuten CP. A comparison of standard-setting
procedures for an OSCE in undergraduate med-
ical education. Acad Med 2000;75:267-71.
23. Boursicot KA, Roberts TE, Pell G. Using
borderline methods to compare passing stan-
dards for OSCEs at graduation across three
medical schools. Med Educ 2007;41:1024-31.
24. Morrison H, McNally H, Wylie C, McFaul P,
Thompson W. The passing score in the objec-
tive structured clinical examination. Med Educ
1996;30:345-8.
25. Martin IG, Stark P, Jolly B. Benefiting from
clinical experience: the influence of learning
style and clinical experience on performance in
an undergraduate objective structured clinical
examination. Med Educ 2000;34:530-4.
26. Blaskiewicz RJ, Park RS, Chibnall JT, Pow-
ell JK. The influence of testing context and clin-
ical rotation order on students’ OSCE perfor-
mance. Acad Med 2004;79:597-601.
27. Bienstock JL, Tzou WS, Martin SA, Fox HE.
Effect of student ethnicity on interpersonal skills
and objective standardized clinical examination
scores. Obstet Gynecol 2000;96:1011-3.
28. Keely E, Myers K, Dojeiji S. Can written
communication skills be tested in an objective
structured clinical examination format? Acad
Med 2002;77:82-6.
29. Zakowski LJ, Seibert C, VanEyck S, Skoch-
elak S, Dottl S, Albanese M. Can specialists and
32 American Journal of Obstetrics & Gynecology JANUARY 2009
generalists teach clinical skills to second-year
medical students with equal effectiveness?
Acad Med 2002;77:1030-3.
30. McLaughlin K, Gregor L, Jones A, Coderre S.
Can standardized patients replace physicians as
OSCE examiners? BMC Med Educ 2006;6:12.
31. Simon SR, Volkan K, Hamann C, Duffey
C, Fletcher SW. The relationship between
second-year medical students’ OSCE scores
and USMLE Step 1 scores. Med Teach
2002;24:535-9.
32. Probert CS, Cahill DJ, McCann GL, Ben-
Shlomo Y. Traditional finals and OSCEs in pre-
dicting consultant and self-reported clinical
skills of PRHOs: a pilot study. Med Educ
2003;37:597-602. Erratum in: Med Educ 2003;
37:1058
33. Dijcks R, Prince KJ, van der Vleuten CP,
Scherpbier AJ. Validity of objective tests to-
wards peer-rated competence by students.
Med Teach 2003;25:273-6.
Appendix
Typical clinical skills assessment case
This OB-GYN case has been used as part of
the end of third-year comprehensive OSCE
at College of Medicine, Mayo Clinic.
Case title: Contraceptive counseling
Date written: 1999; revised 2006
Dates used on examination: July
1999; March 2007
Physician’s name:
Case type
____ Chronic
____ Acute
__X__ Subacute/well
Physical examination findings
__X__ No
____ Yes. Describe:
Case goals and brief description
● Demonstration on counseling skills
and an understanding of the unique
issues surrounding adolescents
● Developmental assessment
● Consent to care
● Confidentiality
An 18 year old woman presents for a
prescription for the pill. The examinee
will need the necessary information to
decide whether such a prescription is ap-
propriate, counseling about safe sexual
practices, and discussion of the need for
a pelvic examination.
Standardized patient
Age/sex: 18-25 year old female, no
companion.
www.AJOG.org
Chief complaint
The patient is an 18 year old woman
who has come to the office for a prescrip-
tion for the pill.
Opening statement
(In response to question “What can I do for
you?” at the beginning of the encounter.)
“I want to go on the pill.”
Possible final diagnoses
1. Contraceptive counseling and pre-
scription
2. STD counseling
3. Acne
4. Family history breast cancer
5. Family history deep vein thrombosis
6. Dysmenorrhea
Summary of case
1. Chief complaint
“I want to go on the pill.”
2. History of present illness
Patient wants to go on the pill so she
does not get pregnant. She is sexu-
ally active with a steady boyfriend of
6 months and for 3 months had en-
gaged in vaginal intercourse. No
other sexual partners or sexual as-
sault or abuse. Boyfriend is 19 years
of age. She is unaware of his prior
sexual experience or history of sexu-
ally transmitted diseases. No known
history of drug use by boyfriend.
They have a healthy relationship.
She is currently using no contracep-
tion. Boyfriend says he does not
like condoms. She wants to have
the sexual relationship.
Menses are regular, every 28 days,
with menstrual flow for 4-5 days,
with cramping and heavy flow for
the first 2 days. Last menstrual pe-
riod 4 weeks ago (normal). She has
never had a pelvic examination.
She has a good relationship with her
parents but does not discuss issues
related to sex because premarital sex
is not consistent with her parents’
value system. She assumes her fam-
ily would be upset with her current
behavior. If they were to find out
about the pill use, then she would
say it is for the management of pe-
riod symptoms (cramps and flow).
www.AJOG.org
3. Past medical history
General health: Good. Patient does
have a history of acne.
Hospitalizations/surgeries
Tonsillectomy at age 6 years.
Appendectomy at age 12 years.
Gynecological history
Menarche at age 11 years. Menstrual
cycles are regular, every 28 days,
with menstrual flow for 4 days
with cramping and heavy flow for
the first 2 days. Last menstrual pe-
riod 4 weeks ago (normal).
Additional information
Development: normal intelligence.
Able to understand risks, benefits,
and alternatives. (This is necessary
to give consent.)
4. Medications, allergies, diet,
immunization
Medications (include vitamins and
any herbal supplements and doses)
a. Over-the-counter benzoyl perox-
ide topically
b. Ibuprofen for menstrual cramps (2
tablets 4 times a day for 2 days each
cycle)
Allergies
None
Diet (provide description)
Fast food 3-4 days/week. High in salt.
Immunizations
Up to date.
Measles, mumps, rubella ⫻ 2.
No hepatitis B vaccine.
5. Family history
Mother: 45 years old, good health
Father: 46 years old, good health
Siblings: 1 brother, 14 years old, who
had asthma as a young child
Spouse/partner: 19 year old boyfriend
Children: none
Other relatives of significance: Grand-
mother, 69 years old, diagnosed
with deep vein thrombosis and
breast cancer 5 years ago
6. Social history and habits
Lives at home with parents and
brother while attending commu-
nity college. She has a good rela-
tionship with parents.
Community college student, unde-
cided field of study
Smoking: denies tobacco products
Alcohol consumption: no alcohol
Illicit drug use: none
Hobbies: soccer and knitting
Regular exercise: soccer team
Sexual history: has been sexually active
for the last 3 months with boyfriend
of 6 months. Boyfriend is a fellow
student at the community college
who has own apartment. No undue
pressure on patient to have sex.
Dates are usually movies or hanging
out at his or a friend’s home.
Description of standardized patient
1. General appearance
Patient positioning on examination
table in hospital gown
Clean and well-groomed, minimal
makeup
Emotional state when appropriate:
appears anxious, fidgety, possible
nail biting
2. Responses to open-ended questions
General style
When asked questions in a straightfor-
ward manner, the answers are matter
of fact. Questions that use euphe-
misms are not understood. Questions
using technical terms are likewise not
understood. The patient is anxious
thatherparentswillfindoutabouther
being sexually active.
Specific response to initial open-
ended question (beyond opening
statement)
“I want to go on the pill.”
3. Findings on physical examination
None
JANUARY 2009 American Journal of Obstetrics & Gynecology
Education Reviews
4. Exclusionary physical findings in
SP (scars, body habitus, etc)
No body piercings, tattoos
5. Communication/counseling chal-
lenges
a. “I don’t need any exam, just the
prescription.”
b. Unaware of STD risks
Setting
Doctor’s office
Props needed for case
None
Doorway information
Setting: physician’s office
Opening scenario
The patient is an 18 year old woman
who has come to the office because she
wants a prescription for the pill.
Vital signs
BP: 110/72 mm Hg
Temp: 97.7°F (36.5°C)
Respiratory rate: 16
HR: 72
Examinee tasks
1. Obtain a history pertinent to the re-
quest for birth control pills. Do not
perform an examination.
2. Counsel the patient on the various
options of birth control and any re-
lated issues.
3. Discuss any test(s) that are necessary
prior to prescribing birth control pills.
4. After leaving the room, complete
your patient note on the given form.
Total: _____ (score of 22)
Global score for station (circle 1):
pass/borderline pass/fail
Student instructions for write-up
Please write a summary of your en-
counter with the patient that includes
your history, the content of the coun-
seling session, and the plan.
1. Include important positives and nega-
tives from the history of the present ill-
ness, past medical history, review of sys-
tems, social history, and family history.
2. Document the content of the coun-
seling session and plan for patient.
3. Initial diagnostic work-up: indicate
plans for no more than 5 further di-
agnostic studies if necessary.
33
Reviews Education www.AJOG.org

APPENDIX
Checklist for standardized history and counseling: contraception case
Patient’s response (historical information must also
Yes Question/inquiry appear in written case)
1. What concerns would you like to address today? or open-ended question I don’t want to get pregnant. I want to go on the pill.
................................................................................................................................................................................................................................................................................................................................................................................
2. Are you sexually active? or How many partners have you had? Current boyfriend only.
................................................................................................................................................................................................................................................................................................................................................................................
3. Have you ever had a sexually transmitted infection? No.
................................................................................................................................................................................................................................................................................................................................................................................
4. Has your boyfriend been sexually active in the past? or Has your I don’t know.
boyfriend ever had a sexually transmitted disease?
................................................................................................................................................................................................................................................................................................................................................................................
5. Are your periods regular? Yes, about every 4 weeks. They last 4 or 5 days.
................................................................................................................................................................................................................................................................................................................................................................................
6. When was your last period? About 4 weeks ago. I should start soon.
................................................................................................................................................................................................................................................................................................................................................................................
7. Have you ever been pregnant? No!!
................................................................................................................................................................................................................................................................................................................................................................................
8. What contraception are you using currently? Or What do you know about Nothing really. I saw an ad about condoms and the pill
contraceptives? in a magazine.
................................................................................................................................................................................................................................................................................................................................................................................
9. Are you taking any medicines? A cream for my acne, which I bought over the counter,
and ibuprofen for cramps.
................................................................................................................................................................................................................................................................................................................................................................................
10. Do you smoke cigarettes or use anything that has tobacco? No.
................................................................................................................................................................................................................................................................................................................................................................................
11. Do you use any illegal drugs? No.
................................................................................................................................................................................................................................................................................................................................................................................
12. Any family history of blood clots, breast cancer, migraines? (any of My grandma has breast cancer and when she had
these count) surgery for it, she had some sort of clot. No migraines.
................................................................................................................................................................................................................................................................................................................................................................................
Yes
................................................................................................................................................................................................................................................................................................................................................................................
1. Discusses condoms: effectiveness for prevention of pregnancy and STDs
................................................................................................................................................................................................................................................................................................................................................................................
2. Discusses patch and ring
................................................................................................................................................................................................................................................................................................................................................................................
3. Discusses diaphragm or foam
................................................................................................................................................................................................................................................................................................................................................................................
4. Discusses OCPs: effectiveness, missed pill procedure
................................................................................................................................................................................................................................................................................................................................................................................
5. Discusses OCPs: noncontraceptive benefits (acne, etc)
................................................................................................................................................................................................................................................................................................................................................................................
6. Discusses the birth control shot, IUD, implant
................................................................................................................................................................................................................................................................................................................................................................................
7. Discusses abstinence in a nonjudgmental way
................................................................................................................................................................................................................................................................................................................................................................................
8. Discusses need for pelvic examination (STD screen, Papanicolaou)
................................................................................................................................................................................................................................................................................................................................................................................
9. Requests that a pregnancy test be performed
................................................................................................................................................................................................................................................................................................................................................................................
10. Discusses relationship of hormonal contraception with breast cancer
and blood clots
................................................................................................................................................................................................................................................................................................................................................................................
BP, blood pressure; DVT, deep vein thrombosis; HR, heart rate; IUD, intrauterine device; OCP, oral contraceptive pill; STD, sexually transmitted disease.
(Courtesy B. Z. Morgenstern, MD, Mayo Clinic, Scottsdale, AZ; P. M. Casey, MD, and A. E. Good, MD, Mayo Clinic, Rochester, MN. Used with permission.)
................................................................................................................................................................................................................................................................................................................................................................................

Casey. Objective Structured Clinical Examination. Am J Obstet Gynecol 2009.

34 American Journal of Obstetrics & Gynecology JANUARY 2009