Assessing clinical competence of graduating medical students at the Warren Alpert Medical School of Brown University.

mediciNe & HealtH/RHode islaNd An Objective structured clinicAl Examination (OSCE) is a performance assessment that enables medical educators to evaluate the clinical skills and professionalism of future physicians. At the Warren Alpert Medical School of Brown University (AMS), there are multiple OSCEs in the first two years of the Doctoring course, in the Clinical Skills Clerkship and in three specialty-specific clerkships: Internal Medicine, Obstetrics and Gynecology and Pediatrics. In this paper, we focus on the fourth-year OSCE, a summative clinical examination which is administered at the start of our students’ final year of medical school. Harden and colleagues first described an OSCE in 1975 as students rotating “round a series of stations... At one station they are asked to carry out a procedure, such as take a history, undertake one aspect of physical examination, or interpret laboratory investigations... Students may be observed and scored at some stations by examiners using a check list.” OSCEs are now commonplace in undergraduate medical education. Approximately 80% of US allopathic medical schools currently require students to pass a summative fourth-year OSCE prior to graduating from medical school. In addition to medical students, other types of health professional students, including pharmacy and nursing, are now evaluated using OSCEs. An OSCE is best used to evaluate a learner’s competence in clinical skills such as taking a patient history, performing a physical examination and professionalism. There is evidence that OSCEs also effectively evaluate a student’s ability to use information technology in patient encounters, to understand patient interactions within a large health care system and to advocate for patients within the health care system. An OSCE can be used as a teaching tool, specifically to give students feedback on their patient care skills. 8 OSCEs have also been shown to predict future real life performance of students. In one study, over 90% of individuals who passed a medical school-based OSCE also passed subsequent licensing examinations. Fewer than 70% of those who did not pass the same school-based OSCE passed a subsequent licensing exam. Perhaps most importantly, OSCEs can predict residency performance. A major driving force behind requiring the passing of the fourth-year OSCE as a graduation requirement is to ensure that AMS students are ready to enter residency with proficiency in data gathering including taking a history and performing a physical examination, patient counseling and clinical decision making. The secondary force behind the OSCE as a graduation requirement is that students need to pass a national board examination, USMLE Step 2 Clinical Skills (CS) as part of a threestep, four test sequence in order to become fully licensed in the United States. To create a summative OSCE for a medical school, medical education experts such as clerkship directors usually write cases, often based in part on real life patient care experiences. OSCEs typically use standardized patients (actors hired to portray real patients) in place of actual patients. At AMS, over the years, several clerkship directors have contributed to writing cases. The Office of Medical Education staff train approximately 40 standardized patients (SPs) per year to participate in the fourthyear OSCE. This training encompasses both portraying a specific case and giving written feedback to students. AMS students take the fourth-year OSCE in June immediately following the completion of third-year clerkships. Students are graded on their performance on individual stations. The overall OSCE is graded on a pass/fail basis. Students receive their grade and detailed written feedback within two weeks of taking the examination. Students who do not pass the fourth-year OSCE are required to remediate. Successful performance on the exam is a graduation requirement. Results of the fourth-year OSCE are reported in the Medical Student Performance Evaluation (or Dean’s letter), the summative narrative every allopathic medical school in the US sends out as part of a medical student’s application to residency programs. assessing clinical competence of graduating medical students at the Warren alpert medical school of Brown university