Given the current circumstances resulting from the pandemic, the implementation of a V-OSCE was proposed as an alternative to the evaluation of clinical skills that were carried out in person in faculty facilities. Understanding the students' perspective on this new methodology is particularly important to ensure a quality examination that allows them to measure their abilities while meeting their expectations.
The perspective of the students on the V-OSCE was encouraging, receiving an average rating of 4.28/5 on the Likert scale, well above the results presented by Novack, where the virtual exam received an average rating of 3.88/5, and the study carried out at the Autonomous University of Madrid, where the student satisfaction survey offered an average value of 3.9/5 5,10.
A high proportion of students (85%) recognized that the V-OSCE allowed them to put their knowledge into practice, which is consistent with previous studies. In a study conducted at the University of Arizona, Prettyman reported that 81% of the students strongly agreed that the V-OSCE allowed them to demonstrate their clinical skills 8. In the study by Majumder, it was observed that more than half of the students considered that the evaluated scenarios reflected ‘in some way’ the knowledge acquired during their clinical rotations 13. Similarly, other studies conducted in Nigeria and Ireland found that a large percentage of their medical students believed that OSCE measured their knowledge accurately 14,15. It is positive and motivating to find that, although the organization of this exam modality was more tedious (requiring more hours of rehearsals and training to ensure a good adaptation to the virtual platform), 82.5% of the students considered that the V-OSCE fulfilled their learning expectations.
Regarding the negative aspects of this virtual modality, the vast majority of students agreed that the greatest limitation was not being able to perform the physical examination, with comments such as: ‘being unable to perform the physical exam […] disadvantaged us’, ‘the main problem is that we cannot develop our skills in taking vital signs and performing a physical examination’. It was algo suggested that the V-OSCE is only feasible in scenarios where the physical examination is not essential, but that "nothing beats being able to do the physical exam by ourselves". This opinion was shared by the medical students from Weill Cornell Medicine-Qatar surveyed in the Stella Major and Novack studies, where it was stated that the physical examination proficiency score did not reflect previously acquired skills 4,10. In our study, the scenario with the lowest rating was rheumatology, which required a more detailed and exhaustive physical examination, difficult to perform verbally; while the best-rated scenarios were those of diabetes and anemia, where anamnesis played a more important role.
Virtual medical consultation constitutes an artificial barrier to effective communication, the possibility of performing an adequate physical examination is limited and, thus, weakens the relationship with the patient (rapport). This limitation was detailed in the studies by Novack and Danforth, where the student-patient relationship was diminished by a difficulty in responding to nonverbal language in a virtual interface 10,16. Similarly, our students commented: ‘I felt that I had less interaction with the patient, which makes it difficult for me to see how he really feels or to clearly see his expressions' and ‘I am concerned about eye contact with the patient [...] many times I had to look at the screen and not at him, I felt disconnected’.
In addition, there were technological limitations during the evaluation. Students emphasized the need to ‘improve the training of the actors with the virtual environment’. This contrasts with what was stated in the Stella Major study, where simulated patients were surveyed to assess their technological skills on the virtual platform and, subsequently, staff members ensured that they were eligible to participate 4. On the other hand, some students did not have a suitable device to access the exam; therefore, it is recommended that the organizing institution ensures equitable access to adequate technology and offers suitable devices to those who do not have one.
Furthermore, 54.2% of the students considered that the time allocated to complete the stations was insufficient, generating stress and anxiety. For decades, the duration of medical consultation has been a highly debated and disparate issue depending on the health systems of the different countries. Although the World Health Organization (WHO) states that for an effective medical consultation, an average of 20 to 30 minutes must be granted for each patient, a systematic review published by Irvin in the British Medical Journal found that 18 countries, representing 50% of the global population, spend on average 15 minutes in the consultation with their primary care doctor 17,18. In Peru, the general practitioner spends 12 minutes on average in an outpatient consultation 19.
It is essential to have the appropriate digital resources to achieve an immersive experience with students. To improve the V-OSCE, it would be recommended to incorporate the use of virtual simulators, such as PCS Spark® (PCS North America LLC, Florida, USA) or the Oxford Medical Simulation® (Oxford University, London, UK) to make virtual consultations more dynamic and similar to a real physical exam. One of the students suggested ‘improving the physical examination by recording the patient's heart sounds or the vesicular murmur’. In the V-OSCE proposed by Novack, students could access heart and lung sounds, and images related to the pathology of the simulated patient were projected 10.
When comparing the V-OSCE and face-to-face OSCE, the students reported feeling more comfortable being at home, without having to physically move from station to station, and with the V-OSCE being a formative evaluation without real impact on their final grades. On the other hand, the inability to perform the physical examination, connectivity issues and the diminished patient relationship caused by the digital interface turned out to be considerable limitations. It is worth noting that the vast majority of Peruvian medical students are used to the traditional paper-based health record system 11; thus, students agree that they must also be trained to properly fill the virtual medical records. Nevertheless, the virtual modality does not replace, much less exceeds, the face-to-face examination. However, it is important to emphasize that this new modality allows us to continue with the training of medical students, especially in a health emergency situation, where face-to-face lessons and evaluations have been limited by social distancing during the COVID-19 pandemic. Additionally, the V-OSCE is suitable for evaluating scenarios that do not involve performing a physical examination or procedure, which can be useful for simulating teleconsultations for the control and monitoring of patients 20.
Among the limitations of the study is the use of indirect data collected from a database of the UPCH. Likewise, the data is from a single group of fifth-year-grade students, without including V-OSCEs from other years. Finally, comments and perceptions of the examiners, designers, and simulated patients were not included in our analysis, which could enrich the experience of future V-OSCEs.
We consider that, when returning to face-to-face activities, the V-OSCE can be useful as a formative evaluation of interview-like scenarios. This way, the optimization of resources from the Simulation Center for other activities is guaranteed, allowing for a more flexible schedule. Lastly, the V-OSCE constitutes an important individualized feedback tool for the learner.
In conclusion, the OSCE in its virtual form constitutes a good evaluation and learning tool for medical students, providing a safe and efficient alternative in the context of the COVID-19 pandemic and an option that can be extrapolated to other medical schools.