An objective structured clinical examination: From examination room to Zoom breakout room

Objective structured clinical examinations (OSCEs) in the United States medical schools traditionally involve students interviewing and examining standardised patients (SPs) in clinical skills laboratories. Our medical students complete two-station OSCEs at the end of each clerkship. We suspended in-person curricular activities during the coronavirus disease 2019 (COVID-19) pandemic. Our dilemma referred to whether we should administer OSCEs upon the return to an in-person curriculum, or release final grades without conducting OSCEs, or convert to the use of remote OSCEs. To ensure clerkship objectives were met, we converted in-person OSCEs to remote OSCEs. We used task analysis to break down each in-person OSCE element and develop remote solutions with necessary resources. Because physical examinations could not be completed remotely, we implemented a narrative physical examination whereby students verbalised manoeuvres they would perform and SPs reported findings. An online survey platform Qualtrics (Qualtrics LLC, Provo, UT, USA) was used for door notes, student encounter note entry and SP checklists. A video teleconference platform Zoom™ (Zoom Video Communications Inc., San Jose, CA, USA) with breakout rooms was used for patient encounters. Students and SPs started the OSCE in the main Zoom room. Students then read the encounter note as the Zoom host placed student-SP dyads in breakout rooms. After the encounter, students completed encounter notes and SPs completed checklists. The process was repeated for the second case. We began with the surgery, internal medicine and neurology clerkships and ran one remote OSCE per day (11-19 students per clerkship) with four to six students per round for a total of 49 students. Students and SPs participated in a virtual examination training session 1 week earlier. Both students and SPs appreciated the training sessions, which helped them to become comfortable with the virtual format and allowed for the testing of student Internet capabilities. Another key factor was the incorporation of an extra 10 minutes for each round and between rounds to account for technology glitches, as we were concerned about the stability of the Zoom platform during periods of high use across the country. Technology issues had a minor impact on four students (8%). Finally, there was a cost saving for remote versus in-person OSCEs as we did not pay for clinical skills laboratory space or extra staff. The remote OSCE format allowed for the adequate assessment of history taking, clinical reasoning, clinical testing, documentation and communication skills; however, remote testing negatively impacted the assessment of physical examination skills as we were unable to assess students’ ability to accurately perform physical examination manoeuvres. Students felt the narrative physical examination flow was awkward and about half of the students (53%, n = 25) thought the remote OSCE was not as good as the in-person OSCE for assessing clinical skills. Based on feasibility, cost savings and the preserved utility of the two-station remote OSCE, we will proceed with our other four clerkships’ two-station OSCEs and scale up to deliver the six-station OSCE that is administered at the end-of-Year 3 during ongoing COVID-19 constraints on in-person examinations. However, because of the narrative physical examination fidelity and potential technology glitches, we will change the end-of-Year 3 OSCE from a must-pass to a must-complete requirement. Our next step is to explore alternative mechanisms to enhance remote physical examination assessment or to mimic a more traditional telehealth visit.