Pak J Ophthalmol. 2020, Vol. 36 (4): 312-314 312 

EDITORIAL 
 

 

Objective Structured Clinical Examination (OSCE); 
Strengths and Hurdles in Implementation 

 
Muhammad Moin

1
 

1
Director Medical Education, Head of the Ophthalmology Department 

Ameer-ud-Din Medical College, Postgraduate Medical Institute, Lahore 

 

Objective structured clinical examination (OSCE) was 

established by Harden in 1975 to assess performance 

in a simulated environment within a specified time.
1
 

There are many variations to this original technique. In 

Pakistan OSCE and later task oriented assessment of 

clinical skills (TOACS) was introduced by the College 

of Physicians and Surgeons (CPSP) in postgraduate 

examinations in 1990s and this was later implemented 

at the undergraduate level by Pakistan Medical and 

Dental Council as Objective Structured Practical 

Examination (OSPE).
2
 It has been used to assess wide 

range of topics including history, examination, 

radiological investigations, blood reports and 

counselling. Assessment methods in most of the 

postgraduate programs are designed to check the 

competence of students at the end of their training in 

the form of summative exit examinations. In the 

Miller’s pyramid ‘Knows’ is typically checked by 

using MCQs while ‘Knows how’ is checked by case 

presentations and essays. OSPE on the other hand 

assesses the performance of the student at the ‘shows 

how’ level of the Miller’s pyramid. ‘Does’ is checked 

by Work based assessments or Direct Observation of 

procedural skills. Most of the undergraduate and 

 

 
How to Cite this Article:  Moin M. Objective 
Structured Clinical Examination (OSCE); Strengths 
and Hurdles in Implementation. Pak J Ophthalmol. 
2020; 36 (4): 312-314. 
Doi: https://doi.org/10.36351/pjo.v36i4.1129 

 
 
 

Correspondence: Muhammad Moin 

Head of the Ophthalmology Department, Ameer-ud-Din 

Medical College, Postgraduate Medical Institute, Lahore 

Email: mmoin7@gmail.com 

 
 

Received: August 12, 2020 

Accepted: September 14, 2020 

postgraduate examinations assess their students up to 

the 3
rd

 level (shows how) as the feasibility to check the 

highest level (Does) is not good.
3
 

 Long and short case examination used to be the 

gold standard of assessment for a long time. The major 

drawback of this method was the subjectivity of the 

examination. Teachers had the power to pass or fail a 

student by assessing his performance on a few cases 

which did not cover majority of the topics in the 

specialty being examined. Students always felt that 

they were at the mercy of the bad examiners because 

of the poor inter rater reliability of this assessment 

method.
4
 OSCE was introduced to counter these 

weaknesses and now has become the new gold 

standard for assessing the clinical competence of 

students with a very high reliability of 0.91.
5
 It is now 

used as a method to assess all the 3 domains of 

learning in addition to the long case and short case. It 

has two major underlying principles which include 

objectivity and structure. The objectivity depends upon 

standardization of the answering rubrics and trained 

examiners. Each station has a standardized design 

which assesses a specific clinical task which is blue 

printed against the curriculum. More centers are using 

standardized cases to further improve the objectivity of 

this method. These characteristics have shown that 

OSCE has very high validity and reliability which can 

assess all three domains of learning including 

cognition, skill and affect.
6
 Feasibility of OSPE has 

shown that it is more resource intensive as compared 

to other techniques of assessment. Organization of an 

OSCE is time consuming and when conducted in the 

recommended manner it incurs huge costs for the 

medical institutions. Engaging multiple trained 

examiners for all the stations is a difficult task as 

well.
7
 Proper examination stations are required to 

maintain confidentiality of each station. Usually 8 – 16 

stations are included with a time duration of 5 minutes 

for each station. Usually 70 to 160 minutes are 

mailto:mmoin7@gmail.com


Muhammad Moin 

313 Pak J Ophthalmol. 2020, Vol. 36 (4): 312-314 

required for one round of OSPE with multiple 

examiners at all the stations.
8
 Multiple stations allow 

assessment of performance in different areas of the 

specialty in a short period of time. 

 Mujumdar et al in a study of 52 final year students 

and 22 examiners found that majority of the students 

gave positive feedback about the OSCE examination 

held in their university in Trinidad. The attributes 

(fairness, structure, administration, sequence, structure 

and coverage of knowledge/skills), reliability, validity, 

organization (time table, announcements, room 

quality) were all rated well by the students. However, 

they felt that the environment was stressful and the 

difficulty level of some stations was difficult. Majority 

of the examiners were satisfied with the process, 

administration and organization of the OSPE 

examination.
9
 Khan et al conducted a study of 250 

final year students at Khyber Medical College, 

Peshawar and found that the exam was found to be fair 

and comprehensive by 88% of the students, it was 

believed to be more stressful and tough mentally by 

94% students, it was felt to be reliable and valid by 

96% of the students and it was found to be an 

appropriate examination to assess clinical competency 

by 87% of the students.
2
 

 In Pakistan there are many challenges in assurance 

of quality in Medical education.
10

 This has led to a 

decline in the quality of assessment using OSCE over 

the years. The International Association of Medical 

Education (AMEE) has published guidelines for 

organization and administration of OSCE. The 

objectives have been developed to elaborate the 

essential steps to ensure quality of OSCE. According 

to the guidelines the reliability is compromised if the 

coaching of standardized patients is deficient, 

examiners are not trained adequately, quality of 

questions and answering rubric are poor. The validity 

is also affected if the questions are not according to the 

learning outcomes and are unrealistic.
11

 Unfortunately 

examples of lapses in such quality assurance steps are 

seen in our system of Medical Education. These 

include the introduction of many static stations instead 

of interactive stations during this exam. These stations 

do not assess the performance but just the knowledge 

which can be assessed by using other techniques. Time 

duration of the stations is manipulated by the 

examiners reducing the reliability of the examination. 

Some places lack proper stations for OSPE thereby 

encouraging the students to get help from their 

colleagues. This happens due to short distances 

between stations without any visual barriers thereby 

allowing the students to easily visualize the answer 

sheets of their colleagues. In some institutions even 

short cases are included as some OSPE stations. These 

stations with short cases do not include a rubric 

thereby leading to reduced objectivity in the 

examination and inadequate assessment of the students 

due to shortage of time at each station. Answering 

rubrics used for OSPE do not have a penalty for the 

incorrect sequence of response from the students. This 

allows the student to give multiple responses 

incoherently but as they are included in the key the 

examiners have the leverageto mark the responsesas 

correct. Training of examiners is deficient in 

undergraduate examination due to the large number of 

examiners required by the universities. Simulated 

patients are an asset to the exam because they improve 

objectivity by giving the same response to the students 

all the time. Unfortunately, many institutions do not 

have a large pool of simulated patients. Question 

banking with Item analysis of each station is required 

to improve the quality of OSPE in each examination.
12

 

Some institutions have this facility but it is lacking in 

other medical colleges. 

 OSCE is a valuable tool to assess performance of 

students in a simulated environment.
13

 We need to take 

necessary steps to improve the standards of OSCE in 

Pakistan by improving the validity, reliability, cost 

efficiency and acceptability of the test. The 

Universities conducting examination of multiple 

medical Colleges need to make sure that a central 

OSCE is developed rather than asking each institution 

to develop their own OSCE stations independently 

without any quality control. Training and certification 

of Assessors is an essential step in quality control. Use 

of trained simulated patients is becoming essential to 

check certain skills with high reliability. The validity 

can be improved by ensuring the blue printing of 

OSCE stations. All Institutions should develop 

dedicated examination halls to conduct OSCE for all 

specialties. This would reduce the burden on each 

specialty to develop stations in their department with 

compromised facilities. Feedback from students, 

examiners and patients’ needs to be taken to 

continuously improve the stations every year. It has 

been shown that students pass the examination even if 

they do not know certain essential skills asked at a 

station because of compensation from other stations. 

This reduces the assessment of competency of the 

students. Therefore, passing the stations having 



Objective Structured Clinical Examination (OSCE); Strengths and Hurdles in Implementation 

Pak J Ophthalmol. 2020, Vol. 36 (4): 312-314 314 

essential skill assessment should be made compulsory 

in all OSCE.Realization of these realities about OSCE 

in our country is essential and we should strive to 

bring it to international standards. 

 
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https://doi.org/10.1080/014215900409483
https://doi.org/10.1080/0142159X.2018.1487547
https://doi.org/10.12669/pjms.36.2.1319
https://doi.org/10.3109/0142159X.2013.818635
https://doi.org/10.3109/0142159X.2010.507716