The impact of video-based versus in-person osces on medical student clinical reasoning

OBJECTIVE: To determine if video-based patient interactions provide assessment of clinical reasoning comparable to standardized patient (SPs) in Objective Structured Clinical Exams (OSCEs). BACKGROUND: Medical schools customarily develop clinical skills curricula using SPs as the interactive medium, however their use are often constrained by financial and operational limitations. While video-based scenarios may appear comparable to face-to-face patient interactions for instruction in clinical neurology, assessment of clinical reasoning may benefit from the nuanced interaction afforded by a hands-on encounter. DESIGN/METHODS: The present study employed clinical scenarios presented as part of end-of-rotation neurology clerkship OSCEs. Third-year medical students (N=100) were randomly assigned two of six scenarios, one each of video and live SP formats. Post encounter notes, completed after each encounter, included history, physical, investigations, differential diagnosis, and management. Notes were independently scored using pre-determined scoring rubrics. Overall and sub-scores were compared for video versus SP presentation modalities using Welch’s t-test. RESULTS: Video-based encounters returned statistically significant improvements in lab/imaging interpretation (p< .05), primary diagnosis (p< .01), and management (p< .05). However, results were suggestive of the opposite effect when investigations ordered (p< .01) and the expanded set of differential diagnoses (n/s) were compared. CONCLUSIONS: Video-based encounters may appear comparable to SP-based when assessing student performance in post clerkship OSCEs. However, our findings suggest premature diagnostic closure may be occurring in the more passive video-based modality. Students agreed video-based scenarios allowed them to better focus on in-room documentation while face-to-face interactions enabled them to tailor their history and physical to the individual patient. We believe video-based presentations may be an effective supplement to live patient-based encounters, but face-to-face interactions may offer a level of fidelity useful for adequately assessing subtleties in students’ neurological examinations and, by extension, their diagnostic and clinical reasoning skills.