Navigating the boundaries of assessing diversity capabilities in OSCEs

Diversity encompasses more than visible differences like race, gender, or culture; it also includes socioeconomic status, disability, sexual orientation, religious background, language, and neurodiversity. Assessing students’ diversity capabilities is complex. Objective Structured Clinical Examinations (OSCEs) may offer a method to evaluate diversity capabilities. Whilst cultural competence has been explored in OSCEs, assessing other diversity capabilities remains limited. This study aimed to: (1) evaluate how diversity-related components are incorporated into OSCEs across four institutions in Australia, the United States, and the United Kingdom; (2) identify diversity-related changes prioritised by students and academics; and (3) explore barriers limiting meaningful assessment of diversity capabilities in classroom-based settings. A sequential explanatory mixed‑methods design was used. Two years of OSCE cases were quantitatively reviewed to identify diversity content, followed by semi‑structured interviews with academics and students across the three countries. Qualitative data were analysed using framework analysis guided by the Social Justice Framework. Across 40 OSCE cases, diversity considerations were largely absent. Most patient profiles were generic, with no references to any diversity trait except cultural identity which appeared in only two cases. Think aloud interviews with 9 students and 17 staff revealed religion, culture, and socioeconomic background as priority changes to OSCE cases. Disability and sexual orientation elicited greater hesitancy. However, participants questioned the suitability of OSCEs for assessing diversity due to time constraints, surface‑level interactions, fairness concerns, limited availability of diverse simulated patients, and the lack of debriefing. Rather, there were preferences for OSCE marking rubrics to include general interpersonal skills; openness, empathy, respectful communication. There was a reluctance to fail students on diversity capabilities in OSCEs, noting clinical competence should be the core criterion. This multi-institutional study found that diversity considerations are largely absent from OSCEs, despite the need to prepare students for diverse patient populations. Although students and educators support integrating diversity, they identified structural, pedagogical, and logistical barriers to meaningful assessment, including limited resources, risks of stereotyping, and challenges in authentic representation. Participants felt high-stakes OSCEs cannot adequately assess diversity capabilities and are better suited to fostering empathy, respectful communication, and openness.