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

Dear editor

We would like to thank Chu and Hale¹ for their comments regarding our recent paper published in the journal.² As an insight to how our summative ISCEs ran at our institution, we eventually executed these in-person. This consisted of two separate days to accommodate all our students. Each student only participated in one of these days which consisted of 8 stations assessing different competencies. The exact stations varied during each day and lasted 15-minutes each. Each of these stations consisted of an examiner and simulated (student actors/paid actors) patients. This was in place of previous ISCEs which consisted of four stations for three days for each student with real patients. The safety of these assessments was also given utmost priority. Students had to wear full personal protective equipment and change between each station. Collectively, these modifications also allowed our institution to run our summative examinations in a timely and safe manner.

We agree with Chu and Hale that cheating is an important issue to address with summative examinations especially online examinations, although this is not a new phenomenon. To circumvent this in multiple choice examinations, many universities have employed open book examinations.^3,4 However, for clinical examinations, due to the subjective nature and vast content that can be potentially tested, it is potentially not as easy to cheat. Furthermore, post graduate examinations such as the MRCP and MRCS have employed the need for candidates to disclose contents of their room and walls before sitting the examination.⁵ This could also be employed in these online clinical examinations. However, we appreciate that assessing ease/risk of cheating would have provided a useful assessment for our study. In terms of word cloud analysis (supplementary 3.1–3.2) for this concept of cheating or unfair practice (We employed the open-ended question pre and post ISCE questionnaire – is there anything else you are worried about if Medical School Finals were done on an ONLINE format?), concerns on cheating or unfair practice was mentioned by 2/84 (3.1%) participants in the pre questionnaire and 1/64 (1.6%) in the post-questionnaire.

With regards to polling students’ perceptions regarding online vs in-person OSCEs, these results are presented in the main paper showing that students were more worried and less confident performing ISCEs online vs in-person. However, we have no data on the change of this following our mock or considering alternatives for in-person assessments. We agree that it might be interesting to assess these results post-online mock ISCE.

In conclusion, we agree with Chu and Hale¹ that peer-led mock examinations help improve confidence in online ISCEs and provide valuable feedback for students. We have always believed that online assessments should not replace but rather supplement in-person alternatives given the current climate in medical education. An up-to-date nationwide assessment of students’ views with regards to these online assessments given recent exposure to in-person alternative could be warranted.