Celebrating 50 volumes

Revisiting ‘Assessment of clinical competence using an

objective structured clinical examination (OSCE)’
Ronald M Harden

Editor’s note: As part of our 50th volume celebrations, Medical Education is looking back at its most impactful articles, as
defined by citation count. The most cited articles from each 5-year interval were identified and the original authors of one of
them (or other knowledgeable scholars if the original authors could not be found) were asked to comment on the state of the
field at the time of publication, the impact of the article, and what we have learned since then. The article illustrated in
Figure 1 was one of the most cited articles in our journal in the 1977–1981 period. To see the other top-cited articles from
Volumes 1–50, please view the interactive PDF by visiting www.mededuc.com.

The Association for the Study of Medical Education cow of British medicine’ and as a ‘half-hour disas-
(ASME) publication ‘Assessment of clinical compe- ter session’.3 Thirdly, it seemed to me that it
tence using an objective structured clinical examina- should be possible to construct an examination
tion (OSCE)’1 provided the first complete that reliably assessed the range of competencies
description of the use of the OSCE to assess a stu- expected of the student, in which what was to be
dent’s clinical competence (Fig. 1). This current assessed at each station would be defined clearly in
paper describes the background to the introduction advance and reflected in a checklist and rating
of the OSCE and how it became the reference stan- scale to be completed by the examiner. I was aware
dard for performance assessment. of the work of Barrows and Abrahamson4 and
others on the use of simulated patients and felt
In the late 1960s and early 1970s, as a senior lec- that in some areas, such as the assessment of com-
turer in medicine in Glasgow and later in Dundee, munication skills, a simulated patient could replace
I was responsible for student assessment. Three a real patient in the examination. In other situa-
things struck me. The first was that the assessment tions, such as those concerning a patient with a
of a student’s clinical skills was regarded as impor- hernia or goitre, the student should be assessed
tant and a student could not graduate without pass- with a real patient.
ing the clinical examination. Secondly, there were
major deficiencies in the clinical examination rep-
resented by the impact of the luck of the draw on In the traditional clinical examination, marks awarded
both the type of patient seen by the student in the by one examiner often varied considerably from those
long case and the two examiners assigned to assess awarded by another observing the same performance
the student’s competence. In the traditional clinical
examination, the marks awarded by one examiner
often varied considerably from those awarded by In Dundee I found a culture that encouraged
another examiner observing the same perfor- innovation in medical education. I recall a conver-
mance.2 John Stokes, an experienced examiner, sation in the hospital car park with Alfred
described the clinical examination as the ‘sacred Cuschieri, who had been appointed professor of

Medical Education 2016: 50: 376–379,

doi: 10.1111/medu.12801

Dundee, UK Correspondence: Ronald M Harden, Association for Medical

Education in Europe, 12 Airlie Place, Dundee DD1 4HJ,
UK. Tel: 00 44 1382 381953; E-mail: [email protected]

376 ª 2016 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 376–379
 Celebrating 50 volumes

Figure 1 Title page from ‘Assessment of clinical competence using an objective structured clinical examination (OSCE)’1

ª 2016 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 376–379 377
Celebrating 50 volumes

surgery. He made clear his determination to Why has the OSCE been widely adopted as the
change the format of the final examination in recommended approach for the assessment of
surgery. Working with his two senior lecturers, Paul clinical competence and become the reference
Priece and Robert Wood, and with Fergus Gleeson, standard for performance assessment?11 Schnei-
who had come across from Ireland to work with der12 identified four characteristics that lead to
me in the field of medical education, we planned the adoption of an innovation. The first character-
to introduce the OSCE as the final examination in istic is perceived significance. Ideas that are
surgery at Dundee. The faculty board agreed that adopted, Schneider argues,12 stand out not neces-
we could run a pilot final surgery OSCE alongside sarily because they are but, rather, because they
the traditional final surgical clinical examination. seem to be significant. The OSCE was perceived by
The result was a success and the following year the teachers as addressing an important problem: the
board agreed to replace the traditional surgery assessment of a learner’s clinical competence. The
final clinical examination with an OSCE.5 This was second characteristic is philosophical compatibility:
possible because, in the UK, final examinations are teachers must view the innovation as appropriate
the responsibility not of a national body, but of for use. Clinical teachers and examiners easily
each school independently. identified the OSCE with their own thinking.
Schneider’s12 third characteristic refers to occupa-
tional realism: ideas must be practical and easy to
It should be possible to construct an examination put into immediate use. This is certainly true of
that reliably assessed the range of competencies the OSCE. The fourth characteristic is transporta-
expected of the student bility: the approach must be easily explainable to
a busy colleague and adaptable for use in differ-
ent situations. The OSCE has proved to be user-
This early development of the OSCE has been friendly and can be adapted for use in different
described in more detail.6–9 A preliminary report contexts.8 Its characteristics of perceived
that described the OSCE concept was published in significance, philosophical compatibility, occupa-
the British Medical Journal10 and a more complete tional realism and transportability have facilitated
description was published in Medical Education as an the wide adoption of the OSCE as a tool to assess
ASME medical education booklet.1 clinical competence.

The OSCE became widely adopted as an examina-

tion tool with which to assess students’ clinical com- The OSCE is now used in countries around the world to
petence. Teachers became aware of the approach assess clinical competence in a range of disciplines
through the published papers, and external examin-
ers from other schools who participated in the Dun-
dee OSCE spread the initiative to their schools, as Reflecting on my experience with the OSCE over
did Dundee staff when they transferred to other the last 35 years, I find I have learned eight lessons.
schools. Ian Hart, a senior physician in Ottawa,
Ontario, Canada, with whom I had previously collab- Firstly, as demonstrated with our initial implementa-
orated in the area of thyroid research, spent a sab- tion of the OSCE, obtaining agreement for a pilot
batical in Dundee and rapidly became a convert to test is a quick way of introducing a new assessment
the OSCE. Together we organised the first Ottawa approach.
Conference in 1985, which aimed to share across
the Atlantic approaches to the assessment of clinical Secondly, having powerful champions is vital. The
competence, including the OSCE. support of senior professors within the school of
medicine was important and facilitated the introduc-
The OSCE is now used in countries around the tion of the OSCE.
world to assess clinical competence in a range of
disciplines, in different health care professions Thirdly, there are major advantages if a medical
and in the different phases of education. It has school has the freedom to innovate in assessment.
also been used outside medicine, for example in The medical school in Dundee had the authority to
the police force.8 More than 1600 papers on the design its own assessment procedures and was not
OSCE have been published, including about 400 dependent on the agreement of a national examina-
since 2011 (almost one new paper every 3 days!). tion body.

378 ª 2016 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 376–379
 Celebrating 50 volumes

Fourthly, flexibility and the ability to adapt a ing schemes using, for example, iPads. Further,
method to local contexts are key to the success of more serious attention is now paid to standard set-
an innovation. ting and to the assessment of competencies, such as
teamwork skills and error management, and to
Fifthly, scarce resources and the presence of large patient safety, none of which featured much on the
numbers of students need not stand in the way of agenda in 1979.
innovation. I have yet to see an example of a situa-
tion in which the cost or the number of students to
be assessed prevents the adoption of the approach.
The only limitation is the imagination of the REFERENCES
developer.
1 Harden RM, Gleeson FA. Assessment of clinical
My sixth lesson refers to the discovery that here competence using an objective structured clinical
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Reliability and validity are related to how the 2 Wilson GM, Lever R, Harden RM, Robertson JIS,
OSCE is implemented. The OSCE is really a MacRitchie J. Examination of clinical examiners.
Lancet 1969;293:37–40.
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Although there is a place in medical education for Professor Ronald Harden about the OSCE. https://
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