APPENDIX I

Objective Structured Clinical Examination (OSCE)

Explanation and Sample Clinical Station (scenario)
Description
The Objective Structured Clinical Examination, or OSCE (pronounced with a short “o”: oskey) is a
clinically oriented evaluation tool developed to assess communication and physical examination skills.
Objective Each student is graded by the same checklist comprised of behaviorally measurable criteria.
Structured Each student has the same tasks and the same time to complete those tasks. Each
patient is trained to role-play identical symptoms in a standard fashion.
Clinical Clinical skills are measured, reflecting a practitioner’s ability to take a relevant history,
conduct a focused physical examination, and provide appropriate counseling to a patient.
Examination It is a test.
OSCEs may vary in size, length and scope, and can be tailored to the educational level of the student. An
OSCE uses multiple stations, each with a specific time limit, that every student passes through. At the
stations basic clinical skills, including procedural, problem solving and counseling skills are evaluated.
Examples of the types of stations include:
• taking a history or doing a physical on a simulated patient
• interpreting microscopic slides, phonocardiographs and photographs
• analyzing diagnostic or management data
In ICM, you will experience only the first two types of stations; for the Senior OSCE, conducted after your
third year clinical clerkships and before your fourth year, you may be asked to accomplish tasks such as
analyzing diagnostic or management data or developing treatment plans. ICM OSCE stations use a trained
evaluator – real or Simulated Patients or physicians – to complete a standardized checklist immediately after
the student/patient encounter and provide feedback.
Each OSCE station is designed to test specific skills and to accomplish specific objectives (Example 1). These
skills and objectives are determined by the Program Director with the assistance of the ICM Steering
Committee (excepting student representatives) and the Program Coordinator.
The Logistics
Each ICM OSCE includes four clinical scenarios that all students encounter. For freshman OSCEs, the
tasks are limited to fundamental skills such as determining the patient’s Chief Complaint and taking a
History of Present Illness. Generally, freshman OSCE stations include seven or eight minutes to
accomplish a task, then a few minutes for the evaluator to complete the student performance checklist,
followed by a few minutes in which the evaluator provides individual feedback (at times general, at times
specific and at times both). A few minutes are provided for transition to the next station, and then the next
cycle of performance, evaluation, feedback and transition begins.
In order to test all students on the same day, ICM OSCEs run either four or five color-coded testing
circuits. For each OSCE, you will be assigned a color circuit and a starting number; you will stay within
that color circuit and rotate from station to station (#1#2#3#4, #2#3#4#1,
#3#4#1#2,or #4#1#2#3). The colors include red, blue, green, yellow and, if a five circuit
exam, purple. Each of these color circuits will include the same four clinical scenarios being offered
simultaneously, so that at any given time, several students will be provided the same task at all colors of
Station 1, several will be provided the same task at all colors of Station 2, and so on, through all four
stations. Depending on the number of circuits, 16 to 20 students will be testing concurrently.
Each testing station is marked by a color-coded number, usually clipped to the chart pocket at each clinic
room door. A chair is available outside of each testing station. After you are seated outside your first
station, you will listen to a number of tones used to signal when you may begin, when you have less than a
minute to complete your task, when the prescribed time is over, and when the evaluation/feedback period is
done. Monitors will check to ensure that you understand how you will move from station to station within
your color circuit. You will then hear a tone to indicate that you may begin.
 APPENDIX I

Behind the colored number sheet that marks each station’s location, you will find a task sheet (Example 2)
that provides a brief description of the patient you are about to see and a assignment to be accomplished
during the patient encounter. When you hear the tone, lift the colored number sheet, read the task sheet,
enter and accomplish. If you wish, you can take the task sheet into the patient encounter. You will hear a
warning tone less than a minute before your time is up, then a tone that indicates you are to stop. When
you hear the stop tone, you should give to the patient one of the labels you received when you signed in.
You will then be evaluated and provided feedback.
After the time allotted for each station, move to the next station and repeat the sequence. At the OSCEs
end, you will be dismissed from the clinical testing area.
The Patient
The patients with whom you interact during an OSCE are trained to simulate certain physical findings,
relate a consistent history of illness, or both, and to assess how well you accomplish the task outlined for
each station. The Simulated Patients (SPs) are provided instruction in basic anatomy so that they are
familiar with physical landmarks and, in the event that they are portraying illness (rather than portraying,
for example, an employment-mandated physical), they receive instruction, in lay terms, in the pathology of
the disease state – the physiological reasons they hurt where they hurt and why their pain is increased or
eased. SPs also receive instruction in the signs, symptoms, and etiology of their assigned ailments. They
are provided training to assess history-taking techniques, including the use of closed- or open-ended
questioning, facilitation, clarification, and other methods of physician/patient communication, as well as to
ascertain correct and incorrect physical examination maneuvers (Examples 3 and 5).
Patients encountered during an OSCE are likely to be qualitatively different from inpatients that you will
have interviewed. When you interview inpatients, you will often find that patients will not answer just the
question you asked, but will go beyond and volunteer information. For example, if you ask “Does anything
seem to make your pain worse?”, the patient may respond “(Xxxxxx) makes it worse and the only thing
that seems to make it better is (yyyyyyy)”. In contrast, patients that you interview in an OSCE will not
volunteer information, particularly information about the basic components of a History of Present Illness
(HPI). In an OSCE, you should be prepared to follow up “Does anything seem to make your pain worse?”
with “Does anything seem to lessen your pain?”. SPs do not volunteer information; to do so would
preclude your gain of credit for inquiries. To do well on the OSCE, you should be prepared, at minimum,
to inquire about each of the seven dimensions of an HPI and perform all appropriate exam maneuvers in the
correct order while keeping the patient’s comfort and modesty in mind.
The Assessment
After you have finished each encounter, the patient (in most cases) will complete a performance checklist
(Example 4). For most checklist items, the SP indicates that you either did or did not elicit certain
information or perform certain examination maneuvers; for some checklist items, the SP indicates that you
correctly and completely accomplished the task, that you attempted the task, but fell short, or that you did
not accomplish the task. The SP is provided space for narrative comments, which may include praise,
suggestions for improvement, or a note to exam administrators about your performance.
Each checklist item is reviewed by clinicians and educational specialists and deemed to be basic to the
proper elicitation of information, whether by history-taking or physical examination. Some OSCE stations
have more items than others, and not all checklist items are weighted equally. Some stations will include
extra credit items on the checklist for information that reflects a higher level of cognition or an exceptional
fund of knowledge.
It is important to remember that the patient’s perception – whether real or Simulated – affects the
information elicited. In real life or during an OSCE, the questions asked are less important than the
information gained. It is important to elicit information in a way the patient understands and then to allow
the patient to tell his or her story. A patient who does not understand a question cannot answer
appropriately. A patient who experiences the most painful, intrusive maneuver first cannot be faulted for
guarding against further pain.
 APPENDIX I

The Feedback
After the SP has completed your performance checklist, he or she will provide feedback on your
performance. Some of the feedback will be specific; for example, the SP might relate that the order in which
you performed certain maneuvers was incorrect and why, for that instance, the order of maneuvers is
important. The SP will also give you general feedback about the thoroughness of your inquiries or
examinations, as well as an idea of the level of interpersonal comfort they experienced during the interaction,
including whether or not they would feel confident in seeking treatment from you. The SPs are instructed to
provide personal feedback as necessary, such as noting professional demeanor and dress, excessive jewelry or
even the garlicky breath from last night’s lasagna. The SPs will provide you feedback that real patients will
not.
Scheduling
All students are scheduled on the same date for the OSCE and the written examination for reasons listed in
the syllabus; each student can expect to be involved in examinations for about two hours. Schedules of
assigned times will be provided approximately one month before each examination and will include
directions to the testing site and instructions for exchanging testing times with colleagues.
ICM OSCEs are scheduled for Saturdays in Kirklin Clinic because suitable clinic space is not available
Mondays through Fridays anywhere on the UAB campus.
Exam Date Orientation
You should arrive at the specified clinic a few minutes before your scheduled time. You will be asked to
read a statement of examination policies and sign to indicate your acceptance of and adherence to these
policies. An exam monitor will be available to answer questions you may have. You will then enter the
testing site, be directed to your first clinical station, and be seated.

Example 1: Station Objectives & Skills to be Measured

Standardized Patient Case Blueprint

Author(s): James R. Bonner, M.D.

Elizabeth B. Philp, M.D.
F. Stanford Massie, M.D.
Lisa L. Willett, M.D.
Lucy Yancey
Pseudonymous SP: Joan Doe

Tentative Case Title: Conductive Hearing Loss

Major Purpose of Case: To test student’s ability to examine

the ears and test hearing
Case-specific Essential Skills to be Tested: 1. Correct use of the otoscope to
examine the ear canal and tympanic
membrane
 APPENDIX I

2. Perform simple test for hearing

impairment
3. Use of tuning fork to diagnose
the site and nature of hearing loss

Example 2: Sample Task Sheet for Student

Joan Doe
Scenario

This patient complains of hearing loss. You are the first doctor the
patient has consulted.

Task
Using the available instruments, perform an examination adequate
to determine the nature of this patient’s hearing loss. You will not
be assessed on your diagnosis, but on the thoroughness of your
examination.
If any abnormality is detected, please notify the patient.

Example 3: Station Information & Training Tips for SPs

Patient Information Form

Task
Your task is to portray a patient with right-sided hearing loss. You will also evaluate the medical
student’s examination skills. During the student’s examination of your ears, you will exhibit:

1. Decreased ability to hear all sound on the right as might be tested by a whispered voice, a ticking
watch or fingers rubbed together. You are able to hear a loud voice.
2. When a vibrating tuning fork is held to your forehead or the top of your head, the sound is heard
best on the right. This is called the Weber test.
3.________________________________________________When a vibrating tuning fork is held to the
bone behind either ear, the sound-vibration can be heard and then slowly fades away. When the still-
vibrating fork is repositioned just beside your right ear, the sound cannot be heard (abnormal); beside
your left ear, the sound can be heard (normal). This is called the Rinné test.

Carefully practice your response to the above maneuvers so as to be consistent with all students.
Questions about symptoms for which you have not been provided a trained response should be answered as
though the symptom is not a problem.
 APPENDIX I

In this station, the student doctor is being assessed on his or her ability to perform a focused physical
examination on a patient with hearing loss. Your job is to respond appropriately to the hearing tests
described above and then to observe and assess the medical student’s physical examination techniques.
After the student doctor performs the examination, you will rate the student’s performance on the checklist
items as “Full Credit” or “No Credit”.

Example 4: Sample Performance Checklist(completed by SP)

Full Credit No Credit
Examines your ears with otoscope
1. Positions your external ear by pulling up and back O O
2. Inserts the otoscope gently O O
Tests your hearing
3. Tests both ears by whispering or a watch or rubbing fingers O O
4. Masks the opposite ear while testing hearing O O
Performs the Weber test
5. Places vibrating tuning fork mid-forehead or on top of head O O
6. Confirms better hearing on the right O O
Performs the Rinné test
7. Places a vibrating tuning fork on bone behind your ear until sound fades O O
8. Holds the still-vibrating tuning fork near your ear O O
9. Confirms reduced hearing on the right only O O

Example 5: Patient Demographic & Training Information

& Station Set-up/Preparation

Information Sheet for Recruiter/Trainer:

This is a case of unilateral conductive hearing loss, probably caused by fusion of the bones of the middle
ear. The student is expected to perform a technically correct ear examination and should be able to
determine the nature of the patient’s complaint as well as be able to ascertain from the patient increased or
decreased hearing. The patient can be an adult of either sex.
This station should be in an area with provision for quiet.
Equipment:
Seen Unseen
Charged otoscope with ear pieces
Tuning fork (512 cpm)
Training Tips:
SP should be instructed to:
 APPENDIX I

1. Feign moderately severe unilateral hearing loss in the right ear. The individual is able to hear a loud
voice but not a whisper, a ticking watch or rubbed fingers.
2. Lateralize away the affected side on the Weber test (i.e., the tuning fork is heard best on the affected
right side).
3. Indicate conductive hearing loss by being able to hear the tuning fork held close to the left ear, but not
in the right ear, after the sound disappears with the tuning fork on the mastoid process.