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Journal of the West African College of Surgeons logoLink to Journal of the West African College of Surgeons
. 2017 Jul-Sep;7(3):59–72.

A COMPARISON OF THE OBJECTIVE STRUCTURED CLINICAL EXAMINATION AND THE TRADITIONAL ORAL CLINICAL EXAMINATION IN A NIGERIAN UNIVERSITY

KH, Tijani 1,✉, SO, Giwa 1, AO Abiola 2, AA, Adesanya 1, CC, Nwawolo 1, JO Hassan 3
PMCID: PMC6237407  PMID: 30525003

Abstract

Background

Assessment of clinical skills is essential in medical education. Ideally marks should be based on the student’s competence alone. The limitations of the traditional long case examinations such as the patient and examiner variability are well known. The objective structured clinical examination (OSCE) was designed to overcome these limitations. Studies comparing the OSCE and the traditional long case examination in the same group of students are very sparse.

Aim

To compare the objective structured clinical examination (OSCE) and the traditional long case examination by determining their correlations with other forms of assessment in undergraduate surgery.

Setting

This study was carried out at the College of Medicine, University of Lagos, Nigeria.

Methodology

The results of 612 undergraduate students in our medical school of the University of Lagos, Nigeria over a period of 4 years (2012-2015) were analysed. The scores in the long case examination , objective structured clinical examination (OSCE) , multiple choice questions and Essays were analysed and compared using the Pearson’s Correlation co-efficient. SPSS version 17 software was used and a P-value < 0.01 was regarded as statistically significant.

Results

Overall, there was a statistical significant positive correlation among most forms of assessment. The OSCE and the long case examination had a correlation of 0.374. Compared with the long case examination, the OSCE had a higher correlation with all other forms of assessment. The total clinical score (the sum of all long case examination and OSCE) however performed better than the OSCE or the long case examination alone as it had the highest correlation with all other forms of assessment.

Conclusion

The OSCE has been shown to be better than the long case examination as an indicator of the student overall knowledge of surgery as it had a superior correlation with other forms of assessments. The total clinical score was however the best indicator of the student overall knowledge in Surgery as it had the best correlation with other forms of assessment. We recommend and encourage institutions that presently combine the OSCE and the long case examination to carry out similar analysis such as ours to determine the desirability of combining LCE and OSCE rather than outright replacement of LCE with OSCE.

Keywords: Objective structured clinical examination, OSCE, Traditional oral clinical examination, Long case examination, Nigeria

Introduction

Most clinical teachers and educators agree that the assessment of clinical skills has a central role in medical education and the selection of suitable method of assessment has been of great concern. The traditional clinical examination has been shown to have serious limitations1. Ideally, marking should depend only on the students’ variability. However in the traditional oral clinical examination, also called the ‘long case examination’(LCE), patient and examiner variability significantly affect the scoring1,2. The marks awarded during a LCE do not reflect the global ability of the students and are most often not based on demonstration of specific or individual competences. Attitudes are not commonly assessed and in most cases the students are questioned only in relation to their findings. Similarly, the final scoring indicating the overall performance gives no systematic, feedback to the candidate and examiners3-4.

The objective structured clinical examination (OSCE) appears to provide answers to most of these limitations. It was introduced as a method of measuring clinical competence in a manner that allowed for control of biases of the traditional methods. Since its first description by Harden in Scotland in 19754, it has attained worldwide popularity by gradually replacing the LCE not only in the undergraduate and postgraduate medical education2,8 but also in nursing9 and medical social work10. In Nigeria, while there are no accurate methods to determine when it was first introduced into the medical education, available records at the College of Medicine of the University of Lagos have shown that the OSCE was first used by the school for the final year examinations in Medicine, Surgery, Obstetrics and Gynaecology and Paediatrics in 1979. Despite the initial reluctance by many medical schools in Nigeria, it appears to have gained popularity in the country.

In our medical school, the curriculum for surgery extends over the 3rd, 4th and 6th year. At the end of the 4th year posting the students are assessed using the LCE only, while at the end of the 6th year posting they are assessed using the LCE and the multiple-choice questions (MCQ) while at the final year (exit) examination they are assessed using the OSCE, MCQ and the essays.. The OSCE accounts for 44% of the overall marks (Fig. 1)

Fig. 1. Showing the contribution of the different marks to the final score.

Fig. 1

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Since socio-cultural factors are known to influence learning and students’ performance in examinations11, findings in western and Asian environments may not be applicable to the West African society. Adeyemi et al12 in Lagos had compared the pass rates in the OSCE and the LCE. However, in that study, the OSCE and the LCE marks were not from the same group of undergraduate students. While Famuyiwa et al13 had also studied the correlation between the OSCE and the MCQ in Psychiatry, most other studies in Nigeria had focused on the students’ attitude and perception about the OSCE with most reporting favourable outcomes14 -15. To the best of our knowledge, there has been no publication in the West African sub-region comparing the OSCE with the LCE in the same group of students in the undergraduate curriculum. In this study we aim to compare the students’ performance in the OSCE and LCE and relate this to their performance in other components of the exit examination in surgery.

Objective:

To determine if the OSCE is better than the long case examination as an indicator of the undergraduate medical students’ overall knowledge of surgery by determining their correlations with other forms of the students’ assessment in Surgery.

Methods

The results of all students for 5 consecutive years (2011-2015) were analysed. The same group of examiners were involved in both the long case examination (LCE) and the objective structured clinical examination (OSCE). The OSCE consisted of 20 stations with the candidates expected to spend 5 minutes at each station. There were 4 (or maximum 5) performance (manned by at least 2 examiners) stations where the student was either required to perform specific tasks such as taking a history taking or a conducting physical examination with each student being graded using a checklist. Each of these performance stations was then followed by another station where the candidates were required to spend 5 minutes to answer multiple choice questions (MCQ) related to the previous clinical activity. The remaining 10 or 12 stations consisted of various assignments like the examination of radiographs, clinical pictures, pathology pots, surgery related instruments or devices etc. At these stations the candidates were instructed to spend 2 minutes on the examination and spend the remaining 3 minutes to answer related MCQ. The total long case examination (tLCE) was the sum of the end of posting LCE in the 4th year and the end of posting LCE in the 6th year. The end of posting LCE in the 4th and 6th year carried equal weights. The Total Written Papers (TWP) was the total sum of the end of posting MCQ, the final year MCQ and the essays, while the total clinical examinations (TCE) represented the sum of the tLCE and the OSCE. The Final score (FS) was the total sum of tLCE, the OSCE and the TWP.

We compared the correlation between the different forms of assessments by calculating the Pearson’s correlation co-efficient. A P-value less than 0.01 was considered as statistically significant. These statistical analyses were performed using the SPSS version 17 software.

Results

Fig. 1 shows the different weights of the various marks with the OSCE and LCE accounting for 44% and 18% of the total marks respectively.

A total of 612 candidates were involved in the examination. Table 1 shows the Pearson correlation co-efficient for the different forms of assessments. There was a statistically significant positive correlation between most forms of assessments. In general the OSCE when compared with LCE had a stronger correlation with all the other forms of assessments. Overall, the OSCE and LCE had a positive correlation of 0.374. With the exception of the end of posting MCQ in 2012 and the final year essay in 2015, the OSCE (when compared with the LCE) had a higher correlation with all other forms of assessment. (Table 2

Table 1. Pearson’s correlation co-efficient for the different components of the examination in surgery.

EOPMCQ Essay FMCQ TWP tLCE OSCE TCS FS
EOPMCQ Pearson’s 1 .486* .298* .484* .178 .338* .342* .505*
P- value .000 .000 .000 .022 .002 .000 .000
N 612 612 612 612 612 612 612 612
Essay Pearson’s .486* 1 .345* 805* .495* 539* .472* .680*
P-value .000 .000 .000 .000 .000 .000 .000
N 612 612 612 612 612 612 612 612
FMCQ Pearson’s .298* .345* 1 .796* .168* .408* 546* .521*
P-value .000 .000 .000 .004 .000 .000 .000
N 612 612 612 612 612 612 612 612
TWP Pearson’s .484* .843* .796* 1 .346* .523* .672* .738*
P-value .000 .000 .000 .000 .000 .000 .000
N 612 612 612 612 612 612 612 612
OSCE Pearson’s .338* .539* .408* .523* .374 1 .975* .903*
P-value .002 .000 .000 .000 .000 .000 .000
N 612 612 612 612 612 612 612 612
tLCE Pearson’s .178 .495* .168* .346* 1 .374* 592* .520*
P-value .022 .000 .004 .000 .000 .000 .000
N 612 612 612 612 612 612 612 612
TCS Pearson’s .576 .562 .434 .673 .590 971 1 .941
P-value .000 .000 .000 .000 .000 .000 .000
N 612 612 612 612 612 612 612 612
FS Pearson’s 505* .680* .521* .738* .520* .903* .953* 1
P-value .000 .000 .000 .000 .000 .000 .000
N 612 612 612 612 612 612 612 612
EOPMCQ- End of posting MCQFMCQ- Final year MCQ*- statistically significantPearson’s- Pearson’s correlation co efficient
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Table 2. The Correlations between the clinical examinations and the written papers in each year.

tLCE/OSCE tLCE/EOPMCQ OSCE/EOPMCQ tLCE /Essay OSCE/Essay tLCE/FMCQ OSCE/FMCQ tLCE/TWP OSCE/TWP
Pearson’s .378* .099 .072* .354* .524 .323* .520* .342* .491*
P- value .000 .138 .000 .000 .022 .000 .000 .000 .000
2012 N 148 148 148 148 148 148 148 148 148
2013 Pearson’s .375* 381* .548* .427* .518* .250 .422* .457* .635*
P-value .000 .000 .000 .000 .003 .000 .002 .000 .000
N 146 146 146 146 146 146 146 146 146
2014 Pearson’s .501* .193* 244* .330* .440* .244 .343* .382* .462*
P-value .000 .000 .000 .001 .004 .020 .000 .000 .014
N 144 144 144 144 144 144 144 144 144
2015 Pearson’s .329* .090 .286* .423* .319* .494 .672* .273* .472*
P-value .000 .021 .000 .000 .000 .090 .000 .000 .000
N 174 174 174 174 174 174 174 174 174
TOTAL Pearson’s .374* .178 .338* .495* .539* .168* .408* .346* .523*
P-value .000 .022 .000 .000 .000 .004 .000 .000 .000
N 612 612 612 612 612 612 612 612 612
EOPMCQ- End of posting MCQFMCQ- Final year MCQ *- statistically significantPearson’s- Pearson’s correlation co efficient
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Discussion

There was a significant but weak positive correlation between the results of OSCE and the total long case examination (tLCE )in each of the 4 years in review. This was strongest in 2014 with a correlation of 0.501. Overall there was a correlation of 0.374 between the OSCE and the tLCE. This is similar to the report by Bakhsh et al 16 who reported a correlation of 0.40 in 904 under-graduate students in internal medicine. With the exception of the EOP in 2012 and the essay in 2015, the LCE when compared with the OSCE, had a higher correlation with all other forms of assessments in Surgery in each year under review. Indeed, overall (all the 612 candidates) the results of OSCE when compared with the tLCE had a higher correlation with all other forms of assessment in surgery including the EOP, MCQ, essay and the TWP. Our findings however contrast with the reports of Johnson17 who did not find a consistent relationship between the OSCE and other forms of assessment in their study involving 4th year undergraduates in Emergency Medicine. The correlations between the OSCE and the other forms of assessment in our study despite being generally statistically significant were however weak (less than 0.5). This is similar to the findings of Kirton [18] and Smith et al [19] who had reported weak but positive correlations (0.11-0.32) between the OSCE and other forms of assessment in undergraduate medical and pharmacy students respectively. The relatively higher correlation of the OSCE (compared with LCE) with all other forms of students’ assessment in our study appears to confirm the superiority of the OSCE over the LCE as a better reflection of the overall knowledge of the students in Surgery. Both the OSCE and LCE had their strongest correlation with the FS (0.93 and 0.52 respectively). This was however not unexpected as the marks for both the LCE and OSCE contribute to the FS with the OSCE contributing as much as 44% (Fig. 1). When all the different forms of examination were grouped into 3 i.e. the OSCE, tLCE and TWP (the sum of all other scores apart from the OSCE and tLCE) the OSCE had a higher correlation than tLCE with the TWP (0.52 versus 0.34). However the Total clinical score (TCS), a combination of the OSCE and tLCE marks, had a much higher correlation with the TWP (0.67) indicating that the TCS was superior to either the LCE or OSCE as a reliable predictor of the students performance in the other forms of assessments and as a result may be a better indicator of the overall knowledge of surgery by the students. While the gradual trend worldwide is the total replacement of the LCE by the OSCE [20-21] the findings from this study suggest otherwise as the two appear to be complementary.

This study had some limitations. It was retrospective and it did not take into consideration variables such as previous experience with LCE, OSCE or standardized patient which may affect students performance as some of the students were repeating.

Conclusions

In conclusion, amongst these students, despite the correlation between all forms of (non- mathematically related) assessments being weak, the OSCE appears to be better than the LCE as an indicator of the students’ overall knowledge of surgery as it had a superior correlation with other forms of assessments. However, the TCS appears to be superior to the OSCE alone as an indicator of the students’ overall knowledge as it had the best correlation with other forms of assessment in surgery. ‘We are aware that there are other institutions using a combination of LCE and OSCE in clinical assessment. We recommend and encourage these institutions to carry out similar analysis such as ours to determine the desirability of combining LCE and OSCE rather than outright replacement of LCE with OSCE.

Acknowledgment

The authors are grateful to the statistician Mr Idowu Saheed of Crescent Schools, Lagos State, for his assistance in the statistical analysis of the data.

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