Ricky Tsang1, Bailey Burrell1
1Faculty of Medicine, University of British Columbia, British Columbia, Canada
The emergence of COVID-19 has forced medical schools to adapt and re-imagine the delivery of curricular activities. Almost overnight, medical schools transitioned away from traditional, in-person instruction in favour of remote teaching to comply with public health orders. Digital technologies became paramount for the delivery of curricular activities and student assessment was no exception. Virtual Objective Structured Clinical Examinations (vOSCE) were developed and implemented at a rapid pace for the assessment of clinical skills.1,2 Thus far, they have been met with positive feedback from students and examiners.
Some studies posit that vOSCEs represent the future of clinical skills assessment. Proposed benefits include time and cost savings, adaptability and scalability, and comparability in scores between in-person and virtual examinations.2 Others maintain that in-person OSCEs remain the gold standard and should be reinstated once public health orders are lifted.1 We certainly agree that vOSCEs have merit in assessing history taking, counselling, and associated soft skills – the virtual platform lends itself well to their assessment. Our exposure to virtual care through primary care placements has reinforced the importance of developing these virtual care skills in an era where COVID-19 has catalyzed the growth of telemedicine. During the early stages of the pandemic, telemedicine represented between 38-77% of ambulatory visits in Australia, Canada, and the United States, and while reliance on this modality has declined with the relaxation of public health restrictions, use of telemedicine is projected to remain well above pre-COVID-19 levels.3 If it is the mandate of medical schools to train their students as well-rounded generalists, then developing and assessing their skills to conduct telemedicine-based, virtual patient encounters would appear indispensable as telemedicine is poised to remain integral to primary care in the post-pandemic world. This is also consistent with the eHealth-oriented CanMEDS competencies addendums proposed by the CanMEDS eHealth 2015 Expert Working Group, which suggest that the Medical Expert should be able to, “adopt a variety of information and communication technologies to deliver patient-centred care and provide expert consultation to diverse populations in a variety of settings.”4
Conversely, we believe the assessment of physical examination skills is ill-suited for the virtual format. Physical examination requires complex psychomotor skills and sensorimotor integration. Consider, for example, how impractical it would be to examine a baker’s capabilities through a virtual demonstration of their skill, without the opportunity to touch, smell, or taste their craft. Similarly, clinical skills are the “bread and butter” of a physician’s work and rely on aspects of the physical world that cannot currently be conveyed through a screen with any comparable degree of concision. Such an examination is neither practical nor feasible when assessed virtually, save for brief screening manoeuvres. That is why, when conducting telehealth appointments, physicians must recognize the limits of the appointment and arrange for in-person follow-up when necessary.5 Simply put, elements of a physical exam are lost when conducted virtually, and you cannot assess that which you have made impossible for students to perform. Likewise, students will be unable to receive feedback on important physical exam manoeuvres, many of which involve sensory feedback and nuance.
In an era where the physical examination is being eschewed in favour of medical technology that is increasingly relied upon for assessment and diagnosis, it becomes imperative to faithfully teach and assess physical examination skills to ensure future clinicians have robust competence in this dying art. The horse must remain in front of the cart – at least until the automobile that is medical technology becomes robust enough to replace it completely. Perhaps the solution in the meantime is one of compromise; the creation of hybrid OSCEs, one where in-person stations are utilized to assess the lion’s share of skills but are thoughtfully supplemented by virtual stations to assess the full spectrum of clinical skills required of the modern physician. It seems vital to us that physical exams remain physical, but that students are taught to incorporate the expanding number of options available to them for patient interaction.
Certainly, we do not mean to disparage the extraordinary efforts of medical schools that have adapted vOSCEs out of necessity and with great haste. The COVID-19 pandemic has affected life in a seemingly endless number of ways and forced the innovation of new paths forward. Perhaps too, it has catalyzed a new dawn in clinical skills assessment, one where physical and virtual skills are treated and examined as independent entities, but considered no less important than one another for the comprehensive education of a physician.
- Boyle JG, Colquhoun I, Noonan Z, McDowall S, Walters MR, Leach J. Viva la VOSCE? BMC Medical Educ, 2020; 20. https://doi.org/10.1186/s12909-020-02444-3
- Lara S, Foster CW, Hawks M, Montgomery M. Remote assessment of clinical skills during COVID-19: a virtual, high-stakes, summative pediatric objective structured clinical examination. Acad Pediatr, 2020; 20(6): 760–761. https://doi.org/10.1016/j.acap.2020.05.029
- Mehrotra A, Bhatia RS, Snoswell CL. Paying for telemedicine after the pandemic. JAMA, 2021: 325(5): 431-432. https://doi:10.1001/jama.2020.25706
- Royal College of Physicians and Surgeons of Canada. The CanMEDS 2015 eHealth expert working group report [Internet]. 2014. Available from: https://www.royalcollege.ca/rcsite/documents/canmeds/health-advocate-ewg-report-e.pdf [Accessed May 13, 2021].
- College of Physicians and Surgeons of British Columbia. Practice standard: telemedicine. 2020. Available from: https://www.cpsbc.ca/files/pdf/PSG-Telemedicine.pdf [Accessed May 13, 2021].