Changing Student Perception of an Online Integrated Structured Clinical Examination During the COVID-19 Pandemic [Response to Letter]

Dear editor

We would like to thank the readership of the journal for their comments pertaining to our paper on “Changing Student Perception of an Online Integrated Structured Clinical Examination During the COVID-19 Pandemic”.¹ Collectively, they have highlighted the timeliness and relevance of our article during the current climate of medical education.

Hazell highlights that mock examinations themselves reduces exam stress among students beyond exam format (in-person or online).² In our majority online examination-naïve participants, it is possible that the experience which combines a mock examination and virtual platform use will improve overall exam anxiety. However, the change scores in Questions 5 and 6 in Table 2 specifically address the online nature of assessments and we had asked two versions of these questions – “If you do not do well” in Question 5 and “If you do well to” in Question 6 to parse the relevance of the examination outcome of students sitting these high stakes examinations if they were indeed conducted online. Since both results show statistical significance, we can confidently extrapolate that our results are beyond that observed from merely sitting a mock examination and the change in perception towards the exam format is key.¹

We thank Mellers et al for their suggestions to improve our mock experience, however they do not consider the difficulties implementing such suggestions for student societies.³ As also described by Mavis et al, choice of standardised patients depends on resource availability.⁴ Having no funding, we had to rely on volunteers among students as standardised patients (who are also likely to gain benefit from participation). We provided these student simulated patients with detailed information, scripts and advice on how to maintain the integrity of these examinations to mimic a real ISCE. Furthermore, nearly 5000 faculty-person hours would have been needed to run this mock and this was a constraint given that their efforts at the time was towards the real ISCEs due in 3 weeks following our student-led mock ISCE.

Mellers et al also suggest that telemedicine experience is an important unaccounted confounder, however we believe experience from formal high-stake examinations/interviews is significantly different from day-to-day patient communication.⁵ They also suggest the possibility that our mock was too easy, however our mock ISCE was tailored by students and clinicians who had previously sat these examinations at our institution and were reviewed by senior clinicians including those who have examined in the real examinations. Our excellent individual station feedback shown in Supplementary 2.1–2.4 depict this.¹

Akhtar et al suggest for open-ended questions on factors associated with worry in an online format,⁶ however we had executed this in our study and found no further themes (depicted in word cloud Supplementary 3.1 and 3.2) beyond our pre-set binary questions, which was created by individuals who have experience from high stakes online examinations/interviews.¹

Summative clinical examinations at our institution were eventually performed in-person, and this precludes further analysis suggested by Akhtar et al and by Mellers et al to isolate effects of ongoing improved perception change.^3,6

Nationwide studies of attitudes towards online clinical teaching have already been established.⁷ Given the potential logistical ease of online examinations as a supplement for in-person examinations, now is the right time to similarly address the role of the virtual platform to assess students and institutional collaboration is equally needed to improve the technical stressors (internet connectivity, communication barriers) associated with its implementation. This key stake-holder data will be needed before general implementation of this format for summative clinical assessments.