Conducting Integrated Objective Structured Clinical Examination: Experiences at KIST Medical College, Nepal

Rano Mal Piryani; Ravi P Shankar; Suneel Piryani; Trilok Pati Thapa; Balmansingh Karki; Mahesh Prasad Khakurel; Shital Bhandary

doi:10.4103/2321-4848.123042

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MEDICAL EDUCATION

Year : 2013 | Volume : 1 | Issue : 2 | Page : 166-170

Conducting Integrated Objective Structured Clinical Examination: Experiences at KIST Medical College, Nepal

Rano Mal Piryani¹, Ravi P Shankar², Suneel Piryani³, Trilok Pati Thapa⁴, Balmansingh Karki⁵, Mahesh Prasad Khakurel⁶, Shital Bhandary⁷
¹ Internal Medicine and Medical Education, KIST Medical College, Lalitpur, Kathmandu Valley, Nepal
² Clinical Pharmacology and Medical Education, KIST Medical College, Lalitpur, Kathmandu Valley, Nepal
³ Clinical Anatomy, KIST Medical College, Lalitpur, Kathmandu Valley, Nepal
⁴ Clinical Anatomy and Medical Education, KIST Medical College, Lalitpur, Kathmandu Valley, Nepal
⁵ Clinical Microbiology, KIST Medical College, Lalitpur, Kathmandu, Valley, Nepal
⁶ General Surgery, KIST Medical College, Lalitpur, Kathmandu Valley, Nepal
⁷ Community Medicine and Medical Education, Patan Academy of Health Sciences, Patan, Nepal

Date of Web Publication

13-Dec-2013

Correspondence Address:
Rano Mal Piryani
Department of Internal Medicine and Medical Education, KIST Medical College, Lalitpur, Kathmandu Valley
Nepal

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2321-4848.123042

Abstract

Background: Objective structured clinical examination (OSCE), an important tool for assessment of clinical skills, introduced more than 4 decades ago. KIST Medical College, a new medical school of Nepal, affiliated to Tribhuvan University Institute of Medicine, has made learning of physical examination skills structured and integrated with greater involvement of different clinical science departments. Students learn physical examination skills in second year MBBS as a part of early clinical exposure. Objective: To share the experiences regarding implementation of integrated OSCE. Materials and Methods: At the end of clinical posting of learning of physical examination skills, assessment was done with OSCE. Fifteen OSCE stations including each of 5 minutes were developed and arranged. Standardized patients and validated checklist were used. OSCE was conducted in novel way. Prior to the OSCE session: Suitable venue was selected, assessors were identified, standardized patients were selected, running order of the stations in circuit was developed, list of equipments/instruments required was prepared, and tasks, checklists, feedback questionnaires were printed. The day before the OSCE session: OSCE stations were inspected and clearly labeled, condition of required equipments/instruments was checked, a pack of the documents for each OSCE station were made available, and signs were displayed at proper places. On the day of the OSCE session: Reliable stop watch and loud manual bell were used, support staffs were placed to direct the candidates, examiners, and standardized patients (SPs), assessors explained SPs, students were briefed, supervisors observed the session, and feedback were taken from students, assessors, and SPs. At the end of the OSCE session: Checklists and feedback questionnaires were collected, token money was paid to SPs, and a contribution of everyone was appreciated. After the OSCE session: Score was compiled and result declared, and feedback questionnaires data compiled and shared with academic team. Results: Ninety eight percent of the students attended the OSCE session. All agreed that standardized patient were co-operative, 93% found the faculty's presentation as non-threatening where as 99% found the overall OSCE environment conducive. Most (92%) of the faculties found the selection of simulated patients appropriate, and all were satisfied with student's approach towards SP. All expressed satisfaction with the overall management. Only 250 US dollars expended for conducting session. Conclusion: Integrated OSCE session was organized in novel way and cost effectively. Both students and faculty members were satisfied with OSCE process and management.

Keywords: Clinical skills assessment, early clinical exposure, integrated objective structured clinical examination, physical examination skills, standardized patients

How to cite this article:
Piryani RM, Shankar RP, Piryani S, Thapa TP, Karki B, Khakurel MP, Bhandary S. Conducting Integrated Objective Structured Clinical Examination: Experiences at KIST Medical College, Nepal. Arch Med Health Sci 2013;1:166-70

How to cite this URL:
Piryani RM, Shankar RP, Piryani S, Thapa TP, Karki B, Khakurel MP, Bhandary S. Conducting Integrated Objective Structured Clinical Examination: Experiences at KIST Medical College, Nepal. Arch Med Health Sci [serial online] 2013 [cited 2023 Mar 29];1:166-70. Available from: https://www.amhsjournal.org/text.asp?2013/1/2/166/123042

Introduction

About 40 years ago, the objective structured clinical examination (OSCE) was introduced as a method for assessment of clinical skills. ^[1] This test format is based on a circuit of patient-based "stations." At each station, students or trainees interact with a "real patient" or a "standardized patient" to demonstrate specified skills. OSCE stations may be as few as 8 stations or more than 20 and may be short as 3-5 minutes or as long as 15-30 minutes. Scoring is done with a task specific checklist or a combination of checklist and rating scale. The scoring of the students or trainees may be done by observers such as faculty members and/or patients. ^{[2],[3],[4],[5],[6],[7],[8],[9]}

KIST (Kathmandu Institute of Sciences and Technology) Medical College (KISTMC) is a new medical school located in the Lalitpur district of Kathmandu Valley, Nepal. The teaching hospital started functioning in January 2008. The first batch of students for undergraduate medical course (MBBS) was admitted in November 2008 and the fifth batch in November 2012. Students are exposed to patients from the first year for learning communication and history-taking skills and in second year for learning physical examination skills as a part of early clinical exposure. KISTMC has made learning of physical examination structured and integrated with greater involvement of different clinical science departments-Internal Medicine, General Surgery, Pediatrics, Obstetrics and Gynecology, Orthopedics, Otorhinolaryngology, Ophthalmology, and Family Medicine.

At the end of the clinical postings for learning physical examination skills, assessment is done using OSCE. Standardized patients are used for testing physical examination skills. Fifteen OSCE stations including a rest station are arranged, and each station is of short duration i.e. 4 or 5 minutes. The clinical tasks for the OSCE are chosen as per the learning objectives of the program. Scoring is done by faculty members using a task-specific checklist. Fourteen OSCE stations, each representing a different system, were developed. The systems were: 1. Cardiovascular System, 2. Respiratory System, 3. Peripheral Nervous System, 4. Central Nervous System, 5. Abdomen I, 6. Abdomen II, 7. Obstetrics, 8. Gynecology, 9. Pediatrics I, 10. Pediatrics II, 11. Musculoskeletal System 12. General Physical Examination, 13. Eye, and 14. ENT. ^[10],[11]

Developing the OSCE Stations

Stations are the backbone of an OSCE. Critical planning and sufficient time is required to develop stations. ^[2]

First, we share "how OSCE stations were developed and used in 2010 by OSCE academic team" and subsequently, use of validated OSCE stations in 2011 and 2012. OSCE academic team comprised of faculty of various clinical sciences departments involved in teaching physical examination skills, experienced senior faculty members, clinical coordinator acting as OSCE coordinator (Principal Author), and program coordinator. Development of OSCE stations was done according to the steps mentioned below:

Step I: OSCE academic team was formed in March 2010. Preliminary workshop on OSCE was arranged in May 2010 for 3 hours for developing OSCE stations (development of all three components of OSCE station - tasks, checklists, and instruction/direction to simulated patients) utilizing standard book of clinical methods and evidence-based literature. For drafting of tasks and checklists, Hutchison's Clinical Methods 22 ^nd edition published in 2007 was chosen as a standard book. ^[12] Faculty members involved in teaching physical examination skills were instructed to prepare two OSCE stations for each system within 8 weeks time and share the same during the second workshop.

Step II: Second workshop of OSCE for two half days was organized in July 2010 to assess and finalize all three components of OSCE stations, develop instructions for examiner/assessor, and scoring (marking) criteria. Editing of all three components of OSCE stations was done by experienced senior faculty members during the workshop.

Step III: All the documents developed in second workshop were used for conducting OSCE at the end of August 2010 for first batch of undergraduate students.

Step IV: OSCE session was conducted successfully in the last week of August 2010. Written feedback was obtained from the examiners/assessors, faculty involved in teaching physical examination skills and students. This session was considered as a pilot for OSCE to be conducted for batch II in 2011 and subsequently in 2012.

Step V: Feedback from the examiners/assessors, faculty involved in teaching physical examination skills and students were compiled, analyzed, and shared with OSCE academic team in a meeting arranged in September 2010. Also, score obtained in each station and total score by students were shared in the same meeting. The team was fully satisfied with the entire process, analyzed critically, and made some recommendations for conducting session for batch II in 2011 for the proposed project "Introduction of structured physical examination skills to second year undergraduate medical students."

Step VI: Faculty members involved in teaching were assigned to review all three components of OSCE stations i.e. Tasks (stem), checklists, and instruction/direction (training information) to simulated patients used in 2010 for assessment of first batch technically and as well as in the light of recommendation of OSCE academic team for conducting next session. OSCE academic team reviewed in depth all three components of OSCE stations in July 2011 in a meeting cum workshop conducted for two half days. OSCE was held on September 27, 2011 for second batch.

Step VII: OSCE session was conducted successfully in September 2011 for second batch of students. Written feedback was obtained from the examiners/assessors, faculty involved in teaching physical examination skills, and students. Verbal feedback was also obtained from standardized patients.

Step VIII: Feedback from the examiners/assessors, faculty involved in teaching physical examination skills, and students were compiled, analyzed, and shared with OSCE academic team in a meeting arranged in November 2011. Also, scores obtained in each station and total score by students were shared in the same meeting. The team was fully satisfied with the entire process, analyzed the process critically, and made one recommendation for reducing time from 5 to 4 minutes for conducting session for batch III in 2012.

Setting Up and Running OSCE

OSCE is regarded as a costly, time-consuming, and labor-intensive method of assessment. The key to running a successful OSCE is careful planning. ^[1],[2] The academic, technical, and administrative staff responsible for conducting OSCE session are to be well briefed, organized, and prepared for all possible events. In the following section, we focus on how OSCE was conducted in 2011.

Preparation for an OSCE session

An OSCE session normally runs smoothly if an OSCE coordinator is selected and assigned to take full responsibility for the organization of OSCE. This role is demanding and requires the coordinator to be well prepared. Preparation for an OSCE should ideally start approximately three months before the OSCE. Clinical coordinator (acting as OSCE coordinator) took full responsibility for smooth organization of the OSCE in KISTMC.

Preparation for OSCE started four months (in May 2011) ahead for the OSCE . The co-coordinator decided to arrange 15 stations (including one rest station) and worked out the type of stations required in liaison with other members of the OSCE academic team. The date of OSCE session was decided during planning of schedule for teaching physical examination skills in December, 2010. OSCE academic team agreed on time, format, and content of the OSCE in May 2011.

The smooth running of OSCEs is very dependent on the appropriate practical arrangements.

Practical arrangements

The details of practical arrangements done at KISTMC are discussed under following headings:

Prior to the OSCE session
The day before the OSCE session
On the day of the OSCE session
At the end of the OSCE session
After the OSCE session

Prior to the OSCE

Advance preparation and arrangement is crucial for success of OSCE. Following arrangements were made at KISTMC:

Selection of suitable venue: Multipurpose auditorium on the top floor of teaching hospital was divided into small cubicles using movable partitions (screens). Fifteen OSCE stations including one rest station were created in the auditorium. For seating of the candidates prior to the OSCE, two rooms adjacent to the auditorium were used where they registered and were briefed about the way OSCE will be conducted.

Adjacent to the auditorium, one room was used for simulated patients to take rest in between the examination.

Recruitment of examiners : The identified examiners/assessors (faculty involved in teaching physical examination skills) were informed in advance through circular and sms about the venue, date, and time of OSCE by OSCE coordinator and his office staff.
Recruitment of Standardized Patients (SPs) : The SPs required were listed and contacted for their consent to participate in the OSCE. Identified SPs were informed about the date of OSCE and date and time of briefing by the identified examiners/assessors about their role.
Numbering of the stations : Stations were numbered from 1 to 15 including one rest station-number 8.
A list of all the equipments required : A list of the equipments required at each station was prepared. Staff members were assigned to arrange the same. It was checked a week before OSCE session.
Printing of tasks, checklists, feedback questionnaires etc. and marking of score : After finalizing tasks and checklists including marking of score, required number of tasks and checklists printed, packed, and sealed in envelope. These were opened just before the start of OSCE session in presence of OSCE academic team.

The day before the OSCE

It is important to review the arrangement made by OSCE support staff the day before the OSCE takes place. The OSCE coordinator reviewed the arrangements made.

Inspection of stations : Enough space for the student to examine the SPs was present in each station. Required furniture like bed covered with clean linen, side table, and chairs as per list was found in each station. Screens were used as partitions, and each station was separated from adjacent ones using screens to maintain privacy.
Labeling of stations : The stations were clearly labeled with the station number and the type of station.
Condition of diagnostic equipments : Required diagnostic equipments like BP apparatus, torch etc. were in good working order, and spare batteries were also arranged.
A pack for the OSCE examiners, students, and patient : Following documents were made available as a pack

The schedule for the day

The post-session feedback questionnaires

The lists of participating students

The station tasks with all instructions

Enough checklists, with few in spare

The instructions for the students

The instructions for the assessors

Signs: Signs indicating the rooms for the students, the patients, and the examination were pasted at proper places.

On the day of the OSCE

The OSCE co-coordinator and support staff arrived at 7.00 am at the OSCE venue. They greeted the assessors, once again explained the set up, their role, and process of conducting the OSCE.

The following were ensured on the day of OSCE.

Timing : A reliable stopwatch and loud manual bell were used.
Support staff : Support staff were placed to direct the candidates, examiners, and SPs to ensure that everyone is in the right place at the right time.
Food: The arrangement for refreshments for all participants, water for the candidates at rest stations, drinks for all other staff, and lunch for those who spend the whole day - assessors, SPs, and support staff were made.
Briefing: Students gathered in a room, registered, and were briefed about the practical arrangements for the day. The examiners were reminded to switch off mobile phones, explained how to score the mark on checklist and conduct the stations appropriately.
Assessors and SPs : Assessors explained SPs about their role once again.
Feedback from Students: Students immediately after completing the OSCE filled a feedback questionnaire.
Photography: Snaps of OSCE were taken.
Visit of Senior Team Members: Principal, Director Academics, Advisers, Program Coordinator, and senior faculty members visited the venue to observe the conduct of the OSCE.

At the end of OSCE

The OSCE co-coordinator convened a meeting of OSCE team-assessors, SPs, and staff. He appreciated their contribution.

Feedback session: At the end of the OSCE session, written feedback were taken from the assessors and verbal feedback from SPs and support staff.
Collection of checklists: Checklists along with completed score sheet were collected from assessors before they left.
Payment to SPs: The token money paid to SPs.

After the OSCE session

Compilation of score: On the next day, OSCE coordinator with the help of support staff verified checklists and score sheets. Staff entered the score in excel data sheet and compiled.
Declaration of result: Compiled score was sent to examination section on third day; examination section published the result on fourth day.
Feedback from students and assessors: Feedback was entered into excel data sheets and compiled in next week.

Expenses

The session was organized cost-effectively. Only 250 US dollars (equivalent twenty thousand Nepalese rupees) were expended for conducting OSCE session.

Feedback from Students, Faculty, and Standardized Patients

Feedback from students

Out of hundred, students attended OSCE, 75 returned filled feedback forms. The form has two parts: 1) OSCE Environment and 2) OSCE Management.

Frequency of each item feedback scores was calculated. Most (91%) of the students found the OSCE contents from the (Structured Physical Examination Skills Training) S-PEST module, all agreed that patient were co-operative, 93% found the faculty's presentation as non-threatening where 99% found the overall OSCE environment conducive. On OSCE setting, nearly 79% were found to be satisfied with the setting and 69% with the logistics where 71% expressed satisfaction with the overall management.

Feedback from faculty (assessors)

Out of 14 faculties who evaluated OSCE, 12 returned filled feedback forms. The form has two parts: 1) OSCE Environment and 2) OSCE Management.

Frequency of each item feedback scores was calculated, which shows that majority of faculty satisfied from proceedings of OSCE. Most (92%) of the faculties found the selection of simulated patients was appropriate, and all were satisfied with student's approach towards SP. Most (92%) of the faculties found stations setting was good to excellent, and 75% were satisfied with logistic arrangement while all expressed satisfaction with the overall management.

Feedback from standardized patients

Verbal feedback was taken from the standardized patients. Most of SPs consented to be the part of process in future. Majority were satisfied with the environment. Most suggested to have 2 SPs for each station so as to avoid exhaustion.

Conclusion

KIST Medical College organized Integrated OSCE in novel way using validated checklists, standardized patients. Both students and faculty members were satisfied with OSCE process and management. Standardized patients consented to be part of the process in future. The OSCE session was organized cost-effectively.

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