Clinical Examination: the students' experience

The Objective Structured Clinical Examination (OSCE) of the USI Faculty of Biomedical Sciences was held in the past few weeks. Simulated patients took part in the practical examinations of Master of Medicine students to test the skills of future doctors. During the practical examinations, students questioned and examined patient-actors who, after careful training, simulated an actual patient, reproducing the history, personality and emotions of a sick patient, showing clinical signs and adopting the corresponding body expression. The Federal exam in medicine is held once a year, and passing it allows students to pursue postgraduate training or specialisation. The Federal exam in medicine is held identically and simultaneously in Swiss medical faculties at the end of basic training (three years of bachelor's and three years of master's degrees). Starting from the educational objectives defined by the Profiles (Principal Relevant Objectives and Framework for Integrated Learning and Education in Switzerland), it includes two types of examinations: a written examination in the form of multiple-choice questions (QCM) and a structured practical clinical examination, referred to as the Objective Structured Clinical Examination or OSCE examination. 

To mark the occasion, we interviewed some USI Faculty of Biomedical Sciences students to get their take on the experience and what they learned. 

"This year, I took an OSCE exam for the first time," Stefania Huber tells us. "The exam aims to test medical students on theoretical and practical communication skills. For the first time, students are alone in front of a patient (simulated extremely well). To be honest, I only became aware of the real task that awaits me in the future because of this exam. I enjoyed putting myself out there and trying to apply what I learned from the frontal lectures. The clinical practice experienced twice a week during the first two semesters of the master's programme in different hospitals in Ticino helped a lot. I was surprised how some notions and manners I observed from my medical mentors remained in my subconscious and appeared spontaneously during the exam. The road ahead is still long. I have learned where my shortcomings are, particularly trying to think broadly throughout the simulation. Plus, explaining the most likely diagnosis to a patient is not always obvious and trivial, and word choice is not a given." 

"The exam with simulated patients was an interesting experience," says Carlotta Cimiotti. "Like all practical exams, it puts students in an uneasy situation to demonstrate theoretical knowledge, interactive skills, and empathy. This experience showed me what it means to take charge of patients in their entirety: to understand which health problem they have, to perceive their needs and what they expect from me. Moreover, only in this examination modality do students have the opportunity to train their ability to make a differential diagnosis from the symptom. It is, therefore, a fundamental exercise to prepare us for the medical profession."  

For Mathias Baumberger, "the exam with simulated patients is an excellent experience to test oneself and apply the theoretical knowledge acquired during the semester and practising the skills acquired during clinical days in hospitals. In addition, it is a great way to improve communication skills, observation and in general the conduct of the entire course from the moment the patient walks in the door to the diagnosis, treatment and discharge of the patient." 

How do you evaluate this examination modality? Is it useful? How will it help you in the future? 

"Clearly, this mode of examination," explains Stefania Huber "where you only have 13 minutes per patient to put together a correct anamnesis, an appropriate physical examination, as well as the analysis and next steps leading to the communication of the probable diagnosis and subsequent treatment is a way to put the medical student under pressure and focus as objectively as possible." 

"I find this examination modality very useful, but with some limitations," continues Carlotta Cimiotti. "On the one hand, it allows to project oneself into the role of the doctor and take on responsibilities; on the other hand, it remains a situation that is not completely authentic, and the knowledge that these are simulated patients is a major brake on the student's spontaneity. Nevertheless, I believe that these are the conditions that most allow for the simulation of a real situation and represent for the student the step before the full responsibilities that await us as future doctors." 

"I find this mode of examination extremely important; it is a great way to prepare for the practical part of the state exam and gain familiarity with its structure." tells us Mathias Baumberger tells us. "It's not just about preparing for the state exam because this exam mode tests all of the student's theoretical knowledge and practical skills needed to perform the activities that a doctor needs to master to operate properly." 

For a more in-depth look at the federal medical examinations, we interviewed Dr Fabrizio Barazzoni, Head of the Faculty and Federal OSCE Clinical Practical Examinations, at USI Faculty of Biomedical Sciences. Dr Barazzoni, how is the Federal exam in medicine carried out? 

The Federal exam in medicine is held once a year, and passing it allows students to continue in postgraduate training or specialisation. The examination is held identically and simultaneously in Swiss medical faculties at the end of basic training (3 years of bachelor's and 3 years of master's degrees). Starting with the educational objectives defined by the Profiles (Principal Relevant Objectives and Framework for Integrated Learning and Education in Switzerland), it includes two types of examinations: a written examination in the form of multiple-choice questions (QCM) and a structured practical clinical examination, referred to as the Objective Structured Clinical Examination or OSCE examination. 

What are OSCE examinations, and what is their starting point? 

The OSCE exam consists of a series of test stations, which students must take one after the other. Each station relates to a specific clinical case, the same for all students, to be completed within 13 minutes. In each station, the student has to face a predetermined task identical to all students in terms of duration, content, sequence, mode and evaluation criteria. 

The drafting of clinical cases is ensured by the vital contribution of individual physicians in charge of modules or their collaborators. This editorial work, which we might call the scripting of the examination case, takes place based on a predefined grid, substantially similar to that used in Federal examinations. Following this work, the part to be played by the simulated patient is drafted. 

Who is the simulated patient? 

A simulated patient means a person carefully trained to act as a "real" patient. It is a person trained to reproduce an actual patient's history, personality and emotions at a given time of illness by simulating the clinical signs from which he or she suffers and adopting the corresponding body expression. 

What does the simulated patient do? 

An interdisciplinary team accompanies the volunteer. Doctors and teachers from the Dimitri Theater Academy ensure their expertise to help the person step into the shoes of the simulated patient, who - at the exam- will be questioned and examined by the student. During the OSCE exam day, the simulated patient must play his or her role many times, meeting up to 10 students consecutively and up to 20 candidates altogether. This kind of activity requires concentration and endurance to fatigue. If the student intends to perform clinical examinations in the intimate or delicate parts of the simulated patient, dummies are employed. 

How are students evaluated? 

In addition to the simulated patient and the student, there is an examiner within each station, who - based on predefined criteria that apply equally to all students and with the support of a tablet - evaluates the performance at the individual exam station. 

How are the OSCE exam stations structured? 

Logistics is an essential aspect in the setup of OSCE exams. Based on the requirements and guidance provided for Federal examinations, there is a need for a standardised and similar layout of each station (couch, table for the simulated patient, the student and the examiner), the content and arrangement of the material the student will need, as well as the placement of the clock at the student's disposal always to be able to orient themselves in the course of the examination. 

Does IT play a role in this context? 

The support of USI's IT Department is a fundamental and indispensable pillar in ensuring the proper and timely conduct of the OSCE exams. Thanks to a computerised gong system, the student's transition every 13 minutes from one station to another is paced and guaranteed to be accurate and reliable. Moreover, the fact that we have created a proper centralised control room with individual PCs, from which the OSCE examination of each station can be viewed, has proven to be a great and indisputable added value. 

How often are optional OSCE exams held? 

The Examinations Committee of our Faculty decided from the very beginning to hold optional OSCE exams annually alongside the written ones. This is to better prepare our students for this type of examination and thus be ready to face the federal ones confidently. 

To date, we have held the following optional OSCE exams: 

• July 2021: 1st year master's students: formative exams over two separate days (8 stations); 
• July 2022: 1st year master's students: same as 2021; 2nd year master's students: summative exams over the course of a single day (8 stations); 

and for the first time also bilingual (in Italian and German). 

When will the Federal exam in medicine be held at USI?

In September 2023, the Federal exam, consisting of as many as 12 stations that can be conducted in Italian or German, will also be held for the first time at our Faculty.

Is it possible to draw a brief balance of what has been done so far?

From the general standpoint, the balance sheet of the first two years of experience with the OSCE exams indicates that what has been undertaken and accomplished so far seems adequate and correct to face the challenge of the Federal OSCE exam next year. However, we would like to improve further by putting special efforts into training simulated patients and developing the skills and knowledge of examiners.