Lam Hing-Chung M.D., F.A.C.E.林興中 醫師

高雄榮總教學研究部醫學研究科

OSCE 介紹

• Functioning (fully integrated)

• Conditional (“know when”)

• Procedural (skills = “know how”)

• Declarative(theoretical knowledge base = “know

that”)

D e c la ra tive P ro ced u ra l

C o n d it io n a l

F u nc tion ing

Types of Knowledge

Performance and Competence

Performance -based assessment measures what doctors do in their professional practice

Competence-based assessment measures what doctors can do in controlled representations of professional practice最成熟者以 Outcome-based assessment 為之

Knows

Knows How

Shows How

Does

MCQs (Factual test)

MCQ, MEQ (Clinical)

OSCE, SP, VR

Reality (Behaviors,attitudes)

(BETTER)

Miller’s Pyramid of Competence

Performance assessment in vivo

Performance assessment in vitro

Cognitive

Competence

Performance

Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990; 65:563-67

A performance-based test in a multiple-station format

Assess Clinical SkillsOSCE = Objective Structured Clinical Examination

OSCE

OObjectivebjective SStructuretructuredd CClinicallinical EExaminatixaminationon

Ronald M. Harden

BMJ 1975;1:447-51

Prof. Ronald M. Harden ： Postgraduate Dean, Director, Centre for Medical Education, University of Dundee, SCOTLAND

OSCEDefinition: Task oriented, multi-station

exam; stations can be 5-30 minutes and require written answers or observation (ex. Take orthostatic VS; perform a cardiac exam; smoking cessation counseling; read and interpret CXR or EKG results; communicate lab results and advise a patient)

Measures: Knows, Knows how, Shows how and Does. But: Cost (time, $ resources)

OSCE:Multiple StationsStation

4Station

2Station

3

Station 5

Station 13

Station 1

Station 12

Station 9

Station 11

Station 8

Station 7

Station 10

Station 14

Station 6

1 min

5~10 min

Objective

Each Each station is station is markedmarked in in a standard a standard wayway

Structured

15 stations

5~10 minutes each (USA 30 min)

rotate around stations

75 minutes totallyEach station consists of a task to do

Explain, recognise, examine, demonstrate….

Diagnostic Skills (History taking, P.E., data interpretation)

Procedural SkillsMedical Management SkillsCommunication and Counseling

SkillsHumanistic & Professional SkillsOthers

Clinical Competence Components

OSCE = Objective Structured Clinical Examination

OSPE = Objective Structured Practical Examination

1 2 3 4 5

Student has to fulfill different tasks, e.g. simulated patient contact, stitching, iv injection, CPR…

OSCE:Multiple Stations

Clinical Station

Static Station

Practical Station

Procedure Station Response Station

Communication Skills Station

Assessing whether student: Introduce self (shake hands with patient) Put the patient at ease Elicit the simulated patient’s story in an

effective and efficient manner Retain a friendly but professional relationship

with the patient Convey sensitivity to the needs of the patient Students are not expected to make a diagnosis

Communication Skills Station

10 minutes

Simulated patient (SP) SP also assessor

(fully trained)

Mr XYZ (Date of Birth 23/3/44), a gentleman with known depression and atrial fibrillation presents to you with a fever secondary to an uncomplicated community acquired pneumonia. He has brought his usual medication with him. Take a drug history and write up his prescription sheets appropriately.

Example of a Simulated Communication Question

Left: Student taking detailed drug history from ‘simulated’ actor patient demonstrating the need for knowledge of drug names as well as the skill of history- taking and communication

Right: Example of drugs used

Take a Drug History

Standardized Patients Programmed Patients

Simulated PatientsPatient Instructors

Practical InstructorsTeaching Associates

Standardized Patients

Definition: Simulated patient/actor trained to present history in reliable, consistent manner and to use a checklist to assess students skills

and behaviors

Standardized Patients in USA

SP’s, first introduced in the 1960’s, are now used in most USA medical schools for clinical skills teaching and assessment

Medical schools and testing organizations can best use SP’s to test clinical, communication, and interpersonal skills. Limitations of SP use (e.g., no physical findings, reliability, expense) must be considered.

The USMLE Step 2 CS exam is a practical, reliable, and expensive method to test clinical skills for licensure

Passing the Step 2 CS exam requires examinees to demonstrate clinical skills that they should use routinely in clinical practice

Static or Response Station

Static or Response Station

National University of Singapore

Department of Surgery

OSCE

24 January 2005

Warning!Begin only when told to do so

Begin

a. Give 2 differential diagnoses of this lesions. (4 marks)

b. Name a simple test to confirm the diagnosis. (3 marks)

c. What treatment would you recommend. (3 marks)

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24 Jan 2005OSCE QuestionOSCE Question

This patient presented with right sided abdominal pain and fever. This investigation was done.

a. What is this investigation called? (3 marks)

b. What does it show? (3 marks)

c. In the context of the diagnosis you are considering, name 4 other findings that the investigator should look for. (4 marks)

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24 Jan 2005OSCE QuestionOSCE Question

A 50 year old man was found unconscious on the floor. An urgent CT scan was done.

a. What are the likely neurological signs of this patient? (4 marks)

b. What is the treatment for this condition? (3 marks)

c. What is the long term prognosis and likely neurological deficit? (3 marks)

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24 Jan 2005OSCE QuestionOSCE Question

a. What is your diagnosis? (2 marks)

b. What is the most useful staging investigation at the time this picture was taken? (2 marks)

c. What are the common complications of this lesion? (3 marks)

d. List the modes/routes of spread of this disease. (3 marks)

A 70 year old lady presented to hospital with vomiting and epigastric discomfort for 1 month. Examination revealed that she was mildly dehydrated.A vague swelling was palpable at epigastrium. Blood investigation showed that she had microcytic anemia. A gastroscopy was performed and revealed an ulcerating lesion at atrium.

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24 Jan 2005OSCE QuestionOSCE Question

How to do an OSCE ?1. Assure support (A small responsible team)

2. Select Clinical Skills appropriate for level of training (Constructing a Blueprint)

3. Set up Objectives for each station in an OSCE (Designing the Stations)

4. Choose Real Clinical material to develop cases

5. Prepare student instructions for each station with a clear presenting situation. Include specifics of expected task to be completed by student ( 不可模稜兩可 )

6. Recruit standardized patients to fit clinical scenario( 演員、志工、總醫師 )

7. Write patient instructions in lay terms, as used by real patients and train selected standardized patients (especially if they are also the markers)

8. Create Examiner’s checklist for assessing student’s responses (also written instructions for examiner)

9. Include Teaching Outline with supporting literature for distribution

10. Note special equipment / materials if needed for the station (X 光片、安妮 )

How to do an OSCE ?

How to do an OSCE ?

11. Rehearse the prepared station prior to the actual exercise (Pilot testing) ( 找出缺失：時間？ )

12. Correct any presentation flaws & print multiple copies of checklist

13. Schedule sufficient office staff to help coordinate the examination

14. Instruct all concerned of their respective tasks, before the start of the examination

15. Debrief students, patients and teachers at the completion of the examination

16. Use feedback to revise stations, as necessary

How to do an OSCE ?

How to do an OSCE ?

Competence Categories

CVS RS Neuro GI GU/Renal MSS Endo/Metab Hema/ Oncology

Other

History Taking

Physical Exam

Tests and Procedures

Data Interpretation

Management

Communication and Patient Education

Blueprint Structure

Competence Categories

CVS RS Neuro GI GU/Renal MSS Endo/Metab Hema/ Oncology

Other

History Taking x x

Physical Exam x xTests and Procedures x xData Interpretation xManagement xCommunication and Patient Education

x

Sampling Process

Competence Categories

CVS RS Neuro GI GU/ Renal

MSS

Endo/ Metab

Hema/ Oncology

Other

History Taking Chest Pain

Raised Blood Sugar

Physical Exam Shortness of Breath

Weight Loss

Tests and Procedures

Headache Visual Loss

Data Interpretation

Jaundice

Management Acute Retention

Communication and Patient Education

Joint Pain

Sampling Process

Creating an OSCE Station Marksheet/Checklist

e.g. ： Giving an

intramuscular injection

Im InjectionPreparation (2 marks) needle & syringe

Drug (3 marks) check drug chart check drug (name & date) double check

Im Injection

Patient (3 marks) introduce self

confirm name, date of birth

explain procedure, obtain permission, provide a screen

Im Injection

Injection (5 marks) identify deltoid muscle

hold skin

insert needle

check for blood

give injection

Needle and syringe disposal (1 mark)

Im Injection

Questions (2 marks)What is the surface anatomy of the

deltoid muscle?

What is one potential complication of attempted intramuscular injection?

Im InjectionTotal mark ： 16

Pass mark ： 9

Actually giving the injection is only one mark

Department: Grade:

Student name: Number:

A. General assessment Score（ Full: 1 point ）

1. Greets patient and introduces self

2. Identifies activity

3. Appropriate posture/positioning of patient

4. Identifies and responds to verbal and non verbal cues

5. Close interaction with patient and explain

TOTAL SCORE

Scoring:

1=perform the task correctly and in appropriate order

0=did not perform/attempt the activity

Examiner:

中國醫藥大學：以 OSCE 測試 Mid Taiwan J Med 2005;10:32-7

Department: Grade:

Student name: Number:

B. Assessment for abdominal examination Score（ Full:1 point ）

1. Did student ask you to point out the pain area first with one finger before the examination?

2. Did student begin palpation from your left lower abdomen and finally to right upper abdomen?

3. Did student perform Murphy sign?

4.Did student ask whether the pain refer to right scapular area or right shoulder?

5.Did student auscultate chest?

TOTAL SCORE

Scoring:

1=perform the task correctly and in an appropriate order

0=did not perform/attempt the activity

Examiner: 中國醫藥大學：以 OSCE 測試 Mid Taiwan J Med 2005;10:32-7

Station (7min each) Skill

1 History-taking [Examiner (E), Standardized Patient (SP)]

2 Laboratory Data

3 Radiograph interpretation

4 Rest

5 Clinical [E, Patient (P)]

6 Clinical (E, P)

7 Rest

8 Clinical (E, P)

9 Clinical (E, P)

10 Rest

11 Procedure (E, SP)

12 Communication (E, SP)

13 Patient Data

14 Picture or slide

15 Laboratory Data

16 Laboratory Data

17 Rest

牙買加西印度大學小兒科五年前實行

Total: 2 hours7 min/station except station 1 (14min)

1 min for change

BMC Med Edu 2004;4:22

參加醫學院基本技能會議 93 年 11 月 20~21 日赴臺北醫學大學出席會議 94 年起醫學院主要教學醫院改由 TMAC 來評鑑，徹底並完整評核醫學院學生所受教學是否完善

95 年起醫學系唸 6年，先考國考 (大幅減少次專科考題 )，再做一年「畢業 前一般醫學訓練」

畢業後再做一年「畢業 後一般醫學訓練」 (95年起訓練改為一年 )

以 OSCE 方式考核學生 (包括 PGY1) 臨床基本技能

醫師考試方式之一 (加拿大 10 年，美國剛採用 )

本院圖書館醫學生該具備之基本臨床技能：以 OSCE 測試

醫北

本院圖書館

測試病史詢問及 Vital Signs 之檢查技巧

標

準

病

人

醫學生該具備之基本臨床技能：以 OSCE 測試

本院圖書館

測試學員對心肺方面之理學檢查技巧

標

準

病

人

醫學生該具備之基本臨床技能：以 OSCE 測試

本院圖書館

測試學員對腹部方面之理學檢查技巧

標準病人

醫學生該具備之基本臨床技能：以 OSCE 測試

本院圖書館

考評者以標準表格評分並立即回饋學員

標準病人

醫學生該具備之基本臨床技能：以 OSCE 測試

Checklist

OSCE

not only a not only a tool for tool for assessment of assessment of student, but student, but also of also of residentresident

PARTICIPANTSMedical Students

Physical Diagnosis OSCE -2nd yr. medical studentsClerkship OSCE (in all disciplines) -3rd yr. medical studentsSummary Formative OSCE -3rd yr. medical studentsSummative OSCE -4th yr. medical students

IM ResidentsBasic Skills -1st yr. medical residentsAdvanced Skills -2nd yr. medical residentsSpecial Skills -3rd yr. medical residents

PG Trainees from Other SpecialtiesPG Trainees from Other InstitutesHospital Employees

OSCE

OSCEnot only a not only a tool for tool for assessment but assessment but also a also a methodmethod for for teachingteaching

Task:To examine for clubbingChecklist

Feedback to student and teacher

Does he see the nail profile ? (93% yes)

Does he palpate for fluctuation ? (45%)

Does he compare both hands ? (50%)

Does he examine the toes ? (25%)

Does he interpret correctly ? (93%)

Summative

Objective Structured Clinical Examination

Principle purpose is evaluation of performance

Provides a final, cumulative, uncued objective assessment of clinical competence and readiness for promotion

High Validity and reliability index

Can not be used as a teaching method

Formative

Objective Structured Clinical Exercise

Principle purpose is feedback on performance and remedial teaching

Can not be used for final grade and promotion decisions

Potential for decrease in reliability

Can be used as a teaching method to improve student’s clinical skills

Use of OSCE as Summative vs Formative Tool

Clinical Skills Training - Standardized Patient Program

Summative

OSC Exam (continued)Valuable resources used just for assessment rather than education of students

Students perceive this new

evaluation method as a threat

Intense preparation needed to produce fool proof objective and standardized stations

Piecemeal biopsy of knowledge

regarding clinical skills

Test security issues are of concern

Formative

OSC Exercise (continued)Resources used to improve educationalexperiences of students and sensitize teachers to specific areas of teaching that need improvement

Students view the exercise in a more positive manner

Less stress on faculty and on assessment to be objective and standardized

Uniform and structured exposure of students to a variety of clinical material important to cover curricular objectives

Test security issues are not a major concern

Clinical Skills Training - Standardized Patient Program

Design Curriculum

Must be Objective-BasedNOT just a list of topicsBe specific! What are the

specific objectives that relate to what you want the resident to learn ?

Design CurriculumExample:

Objective—”The resident must be able to recognize and treat an acute MI”

Curricular components:The resident shall be trained in EKG

interpretationThe resident shall have ACLS training and

become certifiedThe resident must log “X” number of acute MI

cases in which they were the one “in charge” of the case

Design CurriculumMust be “outcomes-based”

– Why are we asking the resident to learn this piece of information and how can we evaluate to see if he/she achieved the goal ?• What outcome do we expect to see from this tr

aining ?

– MUST be measurable– Consider Objective Structured Clinical Eval

uations (OSCEs) or Computer Simulations• MI objective example

Design Curriculum

Objective—”The resident must be able to recognize and treat an acute MI”

Use OSCE or computer simulation modules to show resident can meet this objective

Design CurriculumMust show progression fro

m one training level to the next“A first year 內科 resident should

be able to…”“A Second year 內科 resident sho

uld be able to…” etc.

Design CurriculumTransition from one year to the next sh

ould not just mean more of the same!There should be measurable differences

between each year. ( 例如 by OSCE)There must be more than just additiona

l time in clinic or in the ERAdditional responsibilities, new proced

ures, more integrative knowledge base, etc.

Inventory Basic Skills 150 Stations Advanced Skills 50 Stations Other Specialty Skills 5 modules

Design / Schedule Post Graduate Level I Basic Skills 3 exercise / year

15-20 station / OSCE Post Graduate Level II Advanced Skills

3 exercises / year10-15 station / OSCE

Post Graduate Level III Other specialty skills3 special modules /

year

Internal Medicine Residency

FORMATIVE SUMMATIVE

Written ObservedObserved

MCQ

MEQ

Application

Essay

PracticalPractical

Note/Chart Review

SP

OSCEOSCE

OralOral

Longitudinal Clinical Longitudinal Clinical ObservationObservation

KNOWS

KNOWS HOW

SHOWS HOW

DOES

提供迴饋（主厨試菜 )

及格與否（顧客試菜 )

觀察 Behavior 最真實

報紙沒拿反

會讀簡體字

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