Integration of an Objective Structured Clinical Examination (OSCE) into the dental preliminary exams.

INTRODUCTION: In the pre-clinical phase of the study of dentistry at the University of Greifswald, the course "Early Patient Contact (EPC)" is conducted within the framework of Community Medicine/Dentistry. The course is based on three pillars: the patient visiting program, special problem-oriented seminars, and communication training for doctors. The essential goal consists of providing students with real patient contact right at the beginning of their study of dentistry, thus making the study of dentistry patient-based very early on. Students are trained in taking comprehensive anamneses and recording clinical findings.
METHODS: Within the framework of the dental preliminary exams, the course is evaluated using an OSCE on a standardized patient. Furthermore, the added value of an additional training unit (conducting anamnesis and clinical examination) in preparation for the OSCE was evaluated. The exam results of a group without training (control group) were compared with those of a group with training (intervention group).
RESULTS: The intervention group performed significantly better than the control on the following items: the total number of points achieved on the OSCE early patient contact, and in the most important points of the anamnesis and clinical examination. In addition, the intervention group tended to score higher in terms of the item "oral health status".
CONCLUSION: The present study showed a positive effect of an additional training unit on students' performance in the OSCE. Taking the limitations of the study and the results of a literature review into account, we recommend conducting such training as preparation for the OSCE.

RCT Entities:   Population Interventions Outcomes

Introduction

The course Early Patient Contact (EPC) is conducted in the preclinical section of the dentistry course at the University of Greifswald. The course is based on three basic principles: the patient visiting program, specific problem-oriented seminars and medical communication training. The main objective is to give students real patient contact right at the beginning of their dentistry studies and thus to introduce patient-based teaching early. The course consists of various modules and covers the first four preclinical semesters. The project has already been described in detail [1].

Based on clinical and practical examinations in the form of an OSCE (Objective Structured Clinical Examination), it is possible to examine practical and communicative skills [2]. This exam format was first published by Harden et al [3]. At an OSCE, the students are passed through an exam trail with a series of different test stations at which they must demonstrate defined clinical and practical skills. The assessment of their performance is based on an evaluation sheet with predefined content (checklist). The task is standardised. The aim is to make an objective and structured examination possible. The incorporation of OSCEs into the dental curriculum is mainly known from international publications [4], [5], [6], [7]. These publications describe the design and implementation of OSCEs and focus on possible changes in student learning behaviour.

As part of the Munich model of medical education, the added value of additional OSCE training regarding anamneses and clinical examination was evaluated [8]. To this purpose, the achievements of a group with no training (control group) were compared with the performance of group which had received training (intervention group). The intervention group performed better in the following tests: recognising important criteria in anamneses and examination, behaviour towards patients and identifying the correct diagnosis.

While to date little experiences has been gained at German universities in the field of dentistry with this form of testing, international publications on the implementation of OSCEs in dentistry have already been published [4], [5], [6], [7], [9], [10], [11], [12]. An American group of authors evaluated the communicative skills of students of the first (freshman) and second year (sophomores) in dentistry using an OSCE on informing smoking patients about oral cancer prevention [4]. In this context, the effect of additional communication training was evaluated. All students were trained in counselling patients about stopping smoking beforehand. Medical communication and anamnesis training were part of the pre-clinical training of the first and second year of study respectively. The students of the second year in addition took a course on behavioural sciences. At the beginning (pre-test) and end (post-test) of the study an OSCE using a standardised patient with a history of smoking was conducted for all students. Subsequently, the students were randomly split into two groups. The intervention group received an additional training session in which the instructors demonstrated doctor-patient communication, intra- and extra-oral examination and counselling patients about stopping smoking. The students then practiced clinical examinations on each other under the supervision of the instructors. A checklist specially developed by the Center for Clinical Medical Teaching of the University of North Carolina was used as an evaluation sheet. This included items on the behaviour of students in doctor-patient communication and important items about stopping smoking. The authors found no differences between the intervention and control groups at the start (pre-OSCE) and end (post-OSCE) examination for each year-group. Similar results were obtained for the counselling about stopping smoking. No group differences between pre-and post-test were found.

A further investigation on the influence of communication skills training on the students’ skills in counselling patients about stopping smoking was carried out by Koerber et al [13]. 22 students took part in the study, all of which were randomly assigned to an intervention group and control group. All participants trained in a special seminar about “stopping smoking” beforehand. They then gave counselling to standardised patients within the framework of an OSCE. The intervention group received 12 hours of motivational training in addition [14]. The OSCE was conducted again afterwards. The OSCE rated behaviour in front of the patient on the basis of the training given about motivational interviewing techniques, the doctor-patient interaction and the effects of the counselling on the smoking behaviour of the patient. The evaluation of the behaviour of students was carried out using special checklists [15], [16] and, using a Likert scale, it was established how effective the examinee carried out certain actions in the patient interview. Furthermore, an assessment of the doctor-patient relationship and an evaluation of the training from a student perspective was carried out. The intervention group used techniques from the motivational training significantly more often. In addition, they were better able to involve the patient in the counselling discussion. No significant effects were detected regarding the other investigated variables (doctor-patient relationship, the effectiveness of counselling).

The influence of communication training regarding the care exerted in the treatment of patients was studied with third year medical students [17]. Three medical schools in the United States developed special curricula focusing on doctor-patient communication. A total of 293 students participated in the study (intervention group, n=155; control group, n=138). The intervention group attended the special one-year curriculum. At the beginning and the end of the academic year, all participants took part in an OSCE to check their communication skills. The OSCE consisted of 10 stations. Standardised patients were used. To check the students’ results, a special evaluation sheet was developed containing 21 key items [18] regarding doctor-patient communication. Participants in the intervention group showed significantly better results in terms of their communication skills.

Aims

The influence of additional training on the performance in OSCEs of the dental Preliminary Medical Examination (Physikum) had not been studied previously. This study therefore investigated the influence of additional training (anamnesis and clinical decision making) on OSCE examinations in the context of the Preliminary Examination in Dentistry for the first time.

Hypothesis 1: In comparison with the control group, the intervention group will score higher in the OSCE overall in conducting an anamnesis, dental diagnostic findings and the oral hygiene status.

Hypothesis 2: There are no significant differences between the two groups studied regarding practical and oral knowledge of prosthodontics, anatomy, physiology and biochemistry.

It is furthermore possible in this study to test the overall sample for correlations between the examination forms: OSCE-achievements and traditional examinations are not related, i.e. the degree of correspondence between knowledge and examination skills is low. This question has so far not been studied.

Methods

Study Participants and Plan

In total 72 students of two examination cohorts took part in the study (winter semester 2007 and winter semester 2008). All Candidates had completed the EPC course. The study was therefore based on a non-randomised two-group experimental design. The control group (16 female, 17 male) consisted of the Physikum candidates of the winter semester 2007, all of whom took part in the OSCE without further preparation. The Physikum candidates of the winter semester 2008 formed the intervention group (22 female, 17 male), all of whom received OSCE training. The OSCE training consisted of two sessions and ran as follows: The students were split into teams of two. In rotation, each participant took an anamnesis and and a dental diagnosis.

Structure of the Dental Preliminary Examination (Physikum)

The dental Physikum consisted of several sub-tests: for achievements in anatomy, physiology and biochemistry a grade (1-6) was awarded. In addition, the OSCE Early Patient Contact was carried out, consisting of three stations (see Figure 1 (Fig. 1), 2 (Fig. 2) and 3 (Fig. 3)). A final result was calculated based on these individual results (total OSCE score). And finally, the practical and oral examination in prosthodontics was carried out. The practical test performance was evaluated using a points system, which resulted in a grade. The oral examination was graded according to the standard scoring system (grade 1-6). The overall grade in prosthodontics was calculated from the results of the OSCE and the oral and practical examination in prosthodontics.

Figure 1

Evaluation Form (Checklist) Anamnesis

Figure 2

Evaluation Form (Checklist) Clinical Examination

Figure 3

Evaluation Form (Checklist), Oral Hygiene Status

OSCE Examination

Each of these OSCE stations was assigned a special score sheet with predefined items. The individual testing stations were designed according to the learning objectives of the course Early Patient Contact on the basis of a blueprint [19]. The exam was conducted using two standardised patients (actors). These were professional actors from the Theatre Academy Western Pomerania. Both patients had a pre-determined, identical medical history, which was based on a detailed role script. This script was delivered to the actors in advance. The exam was then simulated at the dental treatment unit with the assistant scientific physician in charge of the OSCE. During this training, the actors were honed to the role script in detail to avoid differences between the examination sessions. In addition, it was ensured that the actors were similar in age, sex, height, weight and oral status.

During the OSCE exam, each examinee was in possession of the records relating to the clinical findings. Following the patient interview, the patient’s diagnosis was completed based on these documents.

The descriptive and inferential statistical analysis was performed using the statistical program SPSS. The examination of the normal distribution was performed using the Kolmogorov-Smirnov test. Using Mann Whitney U-tests, systematic differences between the groups regarding the effects of the OSCE training were evaluated; the significance of bivariate correlations were examined using Spearman’s rho [20].

Results

Table 1(Tab. 1) shows the descriptive statistics, which show that the performance of all study participants is in the upper range for all ten indicators. The distribution of the ten variables were tested for normal distribution. For the OSCE total score, overall grade, anamnesis, physiology and biochemistry exam the Kolmogorov-Smirnov test was significant (p<0.05) so we were able to reject the null hypothesis regarding normal distribution. For this reason, the inferential statistical tests were performed using nonparametric methods.

Table 1

Descriptive Statistical Data of the Study Variable

Table 2 (Tab. 2) shows the bivariate correlations for the total study population (Spearman’s rho); a separate evaluation of the inter-correlations for the control and intervention group showed no systematic differences. High correlations between the respective OSCE single discipline (anamnesis, diagnosis, oral hygiene status) and the OSCE overall grade and OSCE points total were shown. The three OSCE individual disciplines are not connected, except for anamnesis and oral hygiene status. Furthermore, significant correlations between the clinical diagnosis and the exam performance in anatomy were found.

Table 2

Inter-correlations (and Sample Sizes)

The results of the tests regarding group differences are listed in Table 3 (Tab. 3). The intervention group was significantly better in the following items compared to the control group: OSCE total point score and overall grade, anamnesis and diagnosis. The two groups did not differ regarding the oral hygiene status. With the exception of the latter variables, Hypothesis 1 was thus supported. Consistent with Hypothesis 2, there were no differences in the exam subjects anatomy, physiology and biochemistry and in the practical and oral examination in prosthodontics.

Table 3

Statistical Examination of Group Difference

Discussion

This study examined the impact of additional training on the OSCE examinations which are part of the Dental Preliminary Examinations. Our literature review showed that few studies had evaluated the effects of such training using OSCEs.

A study on the effects of OSCE training has been detailed for the Munich medical model degree course [8]. Similar to our study, an intervention group (trained group) and a control group were used. Both groups completed the same OSCE. The results show that the intervention group outperformed the control group in key areas of competence (recognizing important criteria in anamnesis and examination, behaviour toward patients and identifying the correct diagnosis). Our investigation showed expertise and knowledge to be independent of each other, i.e. performance in the OSCE could not be made predicted by the achievements in other subjects. In accordance with the findings of the Munich medical model degree course, we found significant group differences regarding the OSCE overall performance with the intervention group performing better, while the performance in the other subjects of the Physikum did not show differences. The latter data pattern indicates that the two year cohorts display similar general intellectual abilities. The better performance of the intervention group in our view might, in particular with regard to anamneses and clinical diagnosis, be attributed to the fact that they previously had the opportunity to familiarise themselves with OSCE procedures and to test their practical skills.

Our results are consistent with the results of Yedidia et al. [17]. Her findings underline the positive effect of communication training on communication skills tested in OSCEs. In contrast to our study, training did not primarily serve to prepare for the OSCE but to establish to what extent such a measure helps ensure that students gain a better competence in patient treatment later on.

Cannick et al. [4] on the other hand found no differences in performance between an OSCE training and control group. Their one-off training was not sufficient for a positive effect on communicative abilities. One possible cause could be the conduct of the training. While Cannick et al [4] primarily used observation, the participants in our study were actively involved in taking anamneses and establishing the diagnoses. Koerber et al. [13] also found no differences between the groups in their motivation study on stopping smoking using standard patients. However, the clinical diagnosis was not part of the OSCE performance but instead it aimed at systematically influencing a standard patient. It is therefore difficult to draw comparisons to our study.

In the studies listed, the communication skills of the students were checked before and after the intervention using an OSCE. All were randomly assigned to the respective study groups. This was not possible in our case because we compared two consecutive cohorts. There also was no baseline OSCE. Thus no conclusions can be drawn as to how the two academic years might have differed beforehand regarding their communication and clinical skills.

The correlation analyses revealed a correlation between the OSCE stations Anamnesis and Oral Hygiene but not regarding the clinical diagnosis. These results can be explained through the OSCE conduct. During the exam, each examinee had access to the records relating to the clinical findings. Following the patient interview, the diagnosis was completed based on these documents. Identifying the diagnosis in this case depended less on the communicative ability possibly more on learned knowledge. In contrast, taking an anamnesis and the oral hygiene status as part of the patient interviews relies on communicative skills. A systematic relationship between OSCE performance and the traditional subjects of anatomy and biochemistry was also found. While the performance in biochemistry is likely to be a chance finding, the link between anatomy and the clinical diagnosis could be explained through the content overlap. The anatomical structures of the oral cavity are discussed in detail in the microscopic and macroscopic anatomy course. Knowledge of the constituents and labels of oral structures from the anatomy course could facilitate the conducting an anamnesis and thus explain this relationship.

In our view, the OSCE constitutes an appropriate form of examination for medical skills, for example for taking an anamnesis.

It should be pointed out that the organisation and implementation of an OSCE entails a high time and labour cost in comparison to conventional forms of testing. Whether the motivation plays a role in the positive results of the OSCE participants as described in the literature cannot be answered from the results of this study. The collection of student feedback on our OSCE is the focus on ongoing student evaluation.

Conclusions

This study was able to show the positive effect of additional training on examination performance in the OSCE. Considering the limitation of the study and the results of our research of published literature, the implementation of such training in preparation for OSCE exams can be recommneded in our view.

Competing interests

The authors declare that they have no competing interests.