The OSCE Exam – a new model for assessing clinical skills

Why is OSCE implemented?

This is due to the applicable regulations and educational standards for medical programs. Pursuant to the Regulation of the Minister of Science and Higher Education of 2023, medical universities are obliged to implement the final OSCE examinations in medical and dental faculties. In accordance with other provisions of law, WUM also plans to use this formula more widely – also in selected programs of the Faculty of Health Sciences, such as nursing, midwifery and emergency medicine. As regards these programs, certain forms of the OSCE are already in use at our university, and they will soon become the standard.

How innovative is this form of assessment?

Although it may sound like something entirely new to some people, the exam format itself is not an experimental solution. The OSCE has been in use for many years in countries such as the United Kingdom and the United States, and it has also been implemented at Polish medical universities for several years. Its aim is to assess, as objectively as possible, whether the student is able to apply the knowledge gained during their studies in clinical practice.

What will the OSCE exam look like at WUM?

We will conduct it in specially prepared rooms at our Center for Medical Simulation (CMS). This applies to both final exams and earlier stages of instruction in the pre-OSCE format. In the case of the Dental Faculty, students will take the OSCE at the University Dental Center, which also houses appropriate exam rooms. 
Exam spaces must accurately reproduce clinical working conditions, and in dedicated rooms, they can be flexibly arranged depending on the scenario. One station may resemble a doctor's office and be used to assess communication with patients, another – resembling a treatment room, will be equipped with manikins, patient simulators and equipment needed to practice emergency procedures, such as resuscitation, defibrillation, intubation, blood collection or venous cannulation. At each station, students receive instructions to perform appropriate tasks, procedures or conduct an interview or physical examination. Our CSM houses a room where examiners may use cameras to observe the implementation of station scenarios. All activity around stations must be unidirectional and smooth, because if someone stays in one place for too long, they will disrupt the course of the exam for other people, and they will lose time at the next station. 

And what competences will be checked?

At the Faculty of Medicine, the final OSCE exam should be at least 90 minutes long and consist of 12 stations. Each station usually takes 10 to 15 minutes, and students move through the stations according to a strictly set schedule. The subject matter covers knowledge and skills primarily in the following areas: internal medicine, pediatrics, emergency medicine, gynecology and obstetrics, surgery, psychiatry, family medicine. 
For fifth-year dental students, the final OSCE should consist of 9 stations, including: conservative dentistry with endodontics, pediatric dentistry, dental surgery, maxillofacial oncology, dental prosthetics, geriatric dentistry, periodontal and oral mucosa diseases, orthodontics and patient communication. 

Some scenarios also include situations requiring cooperation with the medical team, which allows for an assessment of work organization and communication skills. Another important component of the exam is the presence of standardized patients, i.e., specially trained individuals who act out specific clinical scenarios. Such patients allow us to assess how the student conducts a conversation with the patient, conveys difficult information, prepares the patient for an examination and handles situations requiring a high degree of attention and empathy. It is also possible to use virtual reality and artificial intelligence technologies at stations, as well as create automated stations.

It is important – the tasks won't be limited to medical procedures, will they?

The OSCE is used to assess not only the correctness of performing specific procedures, but also clinical thinking, communication with the patient and decision-making skills. The student must demonstrate the ability to recognize the situation, plan further management and apply the knowledge in practice. That is why this exam is considered one of the most complete tools for verifying the competence of future doctors and other representatives of medical professions.

So the point is to evaluate not only what the students know, but also how they think and analyze?

Exactly! Its aim is to verify decision-making thinking, knowledge about medical conditions, the ability to interpret tests, critical thinking in differential diagnosis and strategic planning for further diagnosis and treatment.

Will it be a difficult exam from the students' perspective?

It will definitely be a demanding exam. Our observations of the implementation of the OSCE examinations at various universities show that it is a considerable challenge and stress for students, but also a source of satisfaction. The student goes from room to room and faces a completely different task in each place – interpreting results, interacting with a simulated patient, having a difficult conversation or performing a procedure on a simulator. This may remind students of the concept of "escape rooms", where real clinical and practical skills are verified in each successive room. This is actually the entire kaleidoscope of medicine condensed in one exam. This is the culmination of studies – the most important assessment of what the student has learned and whether they are practically prepared to work in the medical profession.

It sounds like an exam that's more demanding than the current LEK (Medical Final Examination).

Compared to the current formula of the LEK exam – it seems that it is. With the OSCE, there is time pressure and a lot of diversity. This exam cannot be planned in the same way as a multiple-choice exam, where you can learn strategies for answering questions. Here, there is a time limit for each station, each task is a separate unit and you cannot go back to it. The station scenarios will be changed daily so that students taking the exam in the next session will not have exactly the same scenarios as those who took it in the previous session. This means that the entire system needs to be based on the preparation of a large number of scenarios and checklists. I would also like to reassure you that the exam largely verifies basic practical skills, e.g., chest auscultation, sterile field preparation, urinary catheter insertion, and blood pressure measurement.  

What are checklists?

These are, in other words, tick sheets in which the examiner checks whether the student has completed specific parts of the task in the correct steps, order, or according to the plan. Thanks to the checklists, each student is assessed according to the same criteria. One of the most important features of the OSCE exam is its standardization and objectivity.

What does it look like during the exam?

Each station is assessed by an examiner using a uniform checklist – the assessment is based on the same criteria regardless of the examiner. This is particularly important in the case of tasks that require not only theoretical knowledge, but also manual dexterity, coordination and the ability to work under time pressure. Basic resuscitation activities may be the topic of a station. At such a station, the student receives a scenario of a situation, e.g., a passenger fainted on a train or a person was found unconscious in another public space – and the student must take the appropriate action. The assessment focuses not only on the technical correctness of the procedures, but also on the ability to respond to stress, organize assistance and communicate with others. We plan to provide examiners with appropriate training for each station so that the evaluation is truly consistent rather than subjective. Another station may require the performance of typical procedures, such as, for example, collecting blood, taking a swab, inserting a catheter, as well as immobilizing a fractured limb. 

When will the first exam of this kind be held in the medical program at WUM?

As for the Faculty of Medicine, the final OSCE exam will be held during the 2029/2030 academic year, meaning that current second-year students will take it when they reach their sixth year of study. As for the Faculty of Dental Medicine, this will happen a year earlier, in 2028/2029, because the degree program lasts five years there. During the 2027/2028 academic year, the pre-OSCE is planned at the Faculty of Medicine, when current students will be in their fourth year – as the final exam based on the competences that students have acquired up to that stage of their studies. 

We want to use the upcoming vacation for a pilot project that will allow us to assess our logistical capabilities. It will be more of a trial run for the exam – an opportunity to review the procedures, processes and logistics. Our goal is to identify difficult moments as well as coordination, organizational and technical challenges.

As part of preparation for the final OSCE exam, we plan to introduce the mini-OSCE concept, i.e., an assessment based on 2-4 stations, as a practical component of the assessments for individual clinical courses in the higher years of study. This will allow for the gradual development of scenarios, gaining experience in conducting this form of examination by the university teacher, as well as identifying logistical challenges.  

The first three years of the medical program do not include practical clinical classes – what will the pre-OSCE exam include then?

That's true, but the third year already includes propedeutics and the pre-OSCE will verify this particular area, that is medical communication, first aid, propedeutics of internal diseases, interpretation of the results of additional tests, including laboratory findings. Therefore, these will primarily be preliminary skills, including soft skills, related to areas such as communication.

You mentioned that WUM already has some experience with the OSCE format. What exams and faculties do you mean?

Yes, we already have a lot of experience in this area at individual faculties, although OSCE elements are implemented to varying degrees. These are practical exams, during which we verify competences based on 2-4 stations in one or two subjects. Such exams are administered in emergency medicine, midwifery and nursing, but also at the Faculty of Medicine. The OSCE exam pilot was also carried out at the Faculty of Dental Medicine. Starting in the the first year, the first aid course assessment takes the form of a practical verification of the student's skills within the framework of a comprehensive scenario. This year, the mini-OSCEs in dermatology also look very interesting, because they evaluate algorithmic clinical thinking – from skin lesion assessment, through preliminary and differential diagnosis, all the way to the treatment. Very good experiences are also gained by students in the mini-OSCEs in gynecology. They have to perform medical procedures that enable the verification of their practical skills in obstetrics and gynecology, e.g., CTG interpretation, taking swabs, etc. Students have been familiar with an idea similar to the OSCE exams since the first year of study at WUM as part of the practical exam in normal anatomy – the so-called "pins".

In which programs is this type of exam already used as a final assessment? 

Emergency medicine and nursing may serve as examples – diploma examinations in this format have already begun, so we have already implemented the requirements. In accordance with legal requirements, current students of emergency medicine, nursing and midwifery programs should take the final OSCE exams in their third year, which means for the first time in the 2027/2028 academic year.

How big of an organizational challenge is to prepare and administer the OSCE exam at our university?

The implementation of the OSCE at such a large medical university as ours means the need to involve many people and a lot of resources. Staff from the Center for Medical Simulation, university teachers, standardized patients, as well as technical and administrative staff are all involved in organizing the exam.  

The scale of the project is also huge due to the number of students – we are the largest medical university and we have a lot of students. We educate almost 800 students at the Faculty of Medicine alone. With such a number of people, the entire process of exam administration spans several weeks of intensive work. We plan to conduct the OSCE examinations over a period of about 6 weeks in the sixth year at the Faculty of Medicine. At other faculties, these periods will be shorter, but in the university-wide approach it will be a significant use of space, technical facilities and CMS employees for a large part of the academic year.

I cannot fail to mention the obvious costs generated by the equipment and supplies, disposable items and all the materials used in the course of such an examination. These are specific considerable expenses related to simulator use, but also to parts that wear out or are damaged during the exam. Disposable materials such as syringes, needles, catheters, gloves for the OSCE exam already generate huge costs. It is a small piece of equipment that individually seems inconspicuous, but with such a number of students and with the daily consumption of several dozen or even hundred of pieces, it becomes a very serious financial burden.

What about the examiners and the rest of the staff? 

Involvement of the staff is the biggest challenge. I will present basic calculations of the use of personal resources – if each station requires the presence of 1 examiner, it means the need to assign 1 academic teacher to this station for several hours, which means 12 teachers for 1-2 turns of the OSCE exam at the Faculty of Medicine. Assuming that 4 turns of the OSCE exam can be conducted per day for a group of about 40-44 students, 25 university teachers should be assigned to the CMS on a given day. In practice, this means diverting teachers from their other standard teaching or clinical duties, which will likely not be easy and will be a subject of discussion very soon. That's where I see a significant risk of organizational difficulties.

If we take account of the fact that the exams will last several weeks, it becomes clear that the scale of staff involvement is truly enormous. Additionally, the involvement of an analogous group of technical and administrative personnel should be taken into account, as they will supervise the logistics and schedule of individual examination turns. 

Therefore, discussions with other universities have highlighted the need to secure additional financial support from the Ministry of Science and Higher Education. We count on this support, particularly for the administration of the OSCE examinations, because the costs of conducting them are enormous and were not included in the subsidies for medical universities.  

How will the OSCE results be technically assessed and communicated?

The OSCE requires IT tools that would allow real-time checking checklists and scoring from individual stations. In addition to the score, it is also necessary to check whether the so-called critical points have occurred, i.e., failure to perform a necessary procedure or lack of ability to complete the entire station. It is technically impossible for the student to obtain full information about the score immediately after the exam. This is primarily due to the fact that each station is assessed by a different examiner, so each student will be assessed by at least ten examiners. Therefore, the coordinator will be responsible for the entire process and for the final compilation of the results from all stations. 

Will the standardization of teaching methods be also required?

Definitely, yes. We do not need to standardize every detail, but a common program framework needs to be established. For example, surgery instruction is based on the same set of seminars, as is the practical internal medicine program – there is also a shared set of seminars. If a given subject is implemented in one unit, it is easier to maintain the standard. The second issue, equally important, is the development of scenarios and checklists. In fact, the entire academic community should be involved in exam preparation. A large bank of various scenarios in the field of oncology, internal diseases, pediatrics, cardiology, pulmonology, gastroenterology is needed, as well as scenarios verifying surgical competences, such as wound suturing or drainage placement.

And what is the importance of the OSCE exam in the entire system of medical education? It seems that the very introduction of such an exam at the end of studies is a clear signal that it is becoming increasingly important to test practical skills – not only how much the student knows, but whether he can apply this knowledge in practice.

Practical knowledge is verified in more and more study subjects. The OSCE exam tests knowledge and skills from the entire study program. We may again compare it with the LEK exam – it is a practical equivalent of LEK.
The difference is that while the LEK is a test-based exam which does not determine the possibility of graduation, the final OSCE will be a prerequisite for receiving a passing grade for the completion of studies. 

Will it be possible to repeat it?

Yes, and this is another huge challenge. The resit session places an additional burden on both university teachers and the Center for Medical Simulation. The final year of study is already stressful enough, because everyone just wants to wrap up this chapter of their lives, and then, there's this difficult exam covering the entire syllabus.

Feedback after the OSCE exams raises many questions – is it necessary and to what extent?

There is no single common philosophy of approaching feedback after the OSCE exam. The practice varies across universities in Poland – starting from the information whether the student "passed" or "failed" to indicating which stations have been passed and which have not. From my knowledge, it also looks similar at universities abroad. Usually, the student receives incomplete feedback – information about which stations they did poorly and which ones they passed. It is different in the case of the mini-OSCE exams during studies, as there is more space to discuss individual elements of the procedure or competences requiring further work. However, when it comes to the final OSCE, i.e., the exam administered  after the completion of the educational process – the prevailing view is that its purpose is to assess the outcome of that process, which is why feedback is not necessary.

However, I think such issues will need to be standardized across the country. This is one of the reasons why the OSCE committee at the KRAUM was established this year, the aim of which is to develop certain standards for the examinations. I think that the topic of feedback will also be discussed there as part of a uniform formula applicable across Poland.

It is very important that the student – regardless of which medical university he studies at – is sure that the exam will be conducted according to the same standards and rules. 

What challenges does WUM currently face in connection with the introduction of the OSCE exam?

Currently, mini-OSCE ideas are being implemented as part of the assessment of individual subjects, such as the aforementioned assessment of the gynecology course. University teachers are currently participating in study visits to obeserve the OSCE exam at other medical universities. 

At this point, training in developing scenarios and checklists, preparing a bank of the scenarios and checklists will be necessary. We hope to use artificial intelligence as part of the didactic platform for this purpose. Teachers need to be trained in the principles of examining and evaluating individual scenarios.

The digitization of the exam is of key importance – we cannot afford to use paper checklists. If the student is to be informed within a reasonable time whether he passed or not, the entire process must be conducted electronically and integrated with the virtual dean's office. It is a massive logistical and digital undertaking. It means the need to plan schedules, calculate all points, issue grades and harmonize rules.

Each WUM faculty has its own OSCE exam team, but the OSCE exams will require the involvement of all university teachers, both at the preparation and administration stages.

I would like to emphasize that the implementation of the OSCE at WUM is not only a response to formal requirements, but also an important step in the development of modern, practical medical education.

Interview by Agnieszka Wlazłowska-Pietrzak
Photo by Michał Teperek
WUM Communication and Promotion Office