The OSCEs appear as a new cornerstone of medical studies in France. Results of the national OSCEs will be integrated to determine students’ disciplinary orientations. Identification of factors associated with success to the OSCEs is aimed at developing pedagogical avenues to improve the students’ preparation. Our study demonstrated that clinical training during internships was the main OSCE success factor. Indeed, the students had better results in the OSCEs and perceived lower difficulty in the station if they had gone on an internship in the discipline. This relationship has been described for psychiatry with higher OSCE scores in the event of a specialized internship [12]. Indeed, the mental status examination, phenomenology, and differential diagnosis are probably more easily apprehended by the student and better mastered if they attend these diagnoses during internships rather than by learning during lessons or in textbooks [12]. In our study, this observation was corroborated for all the clinical domains evaluated, except for OSCE scores in clinical examination stations. The two disciplines evaluated in the latter were neurology and rheumatology. The correlation was significant in rheumatology, but not in neurology. This latter discipline is taught at an earlier age and is favored by students as an important [13] but difficult discipline [14]. Completion of an internship in this discipline therefore may carry less weight. In France, medical students carry out several periods of full-time 3-month internships in a given discipline, during which they receive clinical training and carry out, independently and under direct supervision, clinical examinations every day. This daily training with real patients concretely prepares students for clinical practice, and their learning and practice of fundamental skills can help to explain its status as a major success factor in completed specialized internships. Surprisingly, OSCE success was not linked to completion of the formative and summative OSCE sessions organized during the various internships, even though OSCEs have been systematized in most hospital internships. This may be explained by differences and lack of homogeneity in the conduct in internships of OSCEs, which are quite new in France and in our university, explaining that the training of teachers as well as students is yet heterogeneous.
In a study assessing the predictive factors for OSCEs success among 5th -year medical students in another French university, factors significantly associated with higher OSCE success were female gender, absence of health problems during the clerkship, high number of clerkships in a medical specialty (≥ 6) and low number of clerkships in a surgical specialty (< 3) [15]. In contrast, one of the factors of success to the OSCEs in our cohort was success in theoretical faculty exams. More precisely, students with good grades in faculty exams tended to have better OSCE results. For example, a correlation between theoretical knowledge and OSCE performance has been clearly demonstrated in the musculoskeletal domain, as shown in a study by the Mexican Board of Rheumatology on postgraduate certification procedures [16]. This correlation can be easily explained by the presumably greater work capacities of these students and by the fact that the OSCEs still involve theoretical knowledge. However, this correlation is not perfect and reflects the fact that theoretical faculty exams and OSCEs do not assess the same skills.
The scores obtained in the clinical examination and therapeutic education stations were lower than the scores obtained in the procedure stations. Therapeutic education requires communication skills, which have been shown to be correlated with OSCE performance evaluating clinical examination, problem solution prescription, and medical records [17]. In one hand, carrying out of some procedures such as an electrocardiogram are part of the daily life of medical students. On the other hand, communication with the patient, therapeutic education and performance of specialized clinical examinations, one example being examination of the knee in rheumatology are skills acquired by only a minority of students. This is in line with a study showing that among the different skills evaluated by OSCEs, medical students are less effective at clinical reasoning skills, while better results are found in procedural skills [18]. It is therefore appropriate to increase this form of skill acquisition so as to upgrade our students’ OSCE results. The particularity of the musculoskeletal examination was previously described in the literature. In this domain, the addition of an interactive workshop with a focus on clinical examination of the knee in the rheumatology rotation of medicine residents led to a significant improvement of OSCE performances [19].
Although the stress level perceived by the students was high (4.4 ± 0.5/5), it was not correlated with a lower overall OSCE score. A literature review confirmed this observation with no negative impact of students' anxiety level on OSCE performance [20]. This high stress level, generated by the OSCE, does not seem to impact students’ performance, a finding that may serve as an illustration of increased test-induced stress tolerance and/or effective stress-coping mechanisms acquired during medical studies. This statement should be weighted by the fact that more than 60% of 4th -year medical students in New Zealand frequently feel stressed during their studies [21], and that, as shown in a Saudi Arabian study, medical students frequently struggle to adhere to healthy stress-coping strategies [22]. Since these evaluation methods are being implemented during the 2nd part of French medical studies, students may be more resilient to OSCE-related anxiety than their less advanced counterparts. To conclude, regardless of its impact on exam performance, OSCE-related anxiety should still be considered in the context of student wellness.
Homogenization of internships during medical training courses and relevant activities in the different disciplines help to improve skills acquired by medical students and are likely to improve grades obtained during the OSCEs. If our study did not show a significant result between conduct of formative and summative OSCEs during internships and throughout medical training, the benefit of this continuous training has been underlined in the literature and should be encouraged [5–7].
Our study has several limitations. First, it was conducted with a relatively small number of students recruited at a single institution. Despite a high response rate (83.1%), due to the small sample size, the issue of non-respondent bias can be raised. Moreover, a survey is associated with potential declarative biases and a certain number of missing data, and result should be considered with caution. Measurement of level of stress was obtained using numeric scale. A validated scale (GAD-7) has been shown to improve understanding of the various stress sub-factors [23].