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Examination Formats


Key feature examination of clinical decision-making skills

Key features are defined as critical decisions that are decided on a case-by-case basis in order to solve a clinical problem.  This method and its use as a testing instrument was first developed in Canada in the 1990s and first described in the literature by Page and Bordage in 1995 [1].

 A case is developed from a specific clinical situation and is followed by several questions.  Each of these questions should be related to a critical action or decision, and not comment on the outcome.  Ideally, the questions relate only to this initial situation, not hinting towards the answer.  In the background are didactic considerations relating to medical problem solving as opposed to specific expertise, rather, a strong case-related context [1, 2].  The key feature approach assumes that the processing steps of a clinical case do not have the same weighting, but it is possible to reduce the clinically important aspects to a few key points.  Especially an exam situation, where only a limited amount of time is available, the key feature concept contributes to the examination of relevant practical issues.


The process defined in eight developmental steps such the key feature problem.  According to the definition of a clinical problem domain (e.g. emergency medicine), the second step is a selected clinical problem (e.g. myocardial infarction), and a typical clinical case situation (e.g. emergency care preclinical myocardial infarction), from which key elements are defined.  These include critical, decisive steps to resolve the problem presented, and among other things, steps, which are often erroneous or difficult, atypical and challenging aspects that can also occur (e.g. immediate therapeutic measures, drug delivery, or ECG interpretation). In the fifth step, the clinical scenario is concretely described (e.g. 60th patient be admitted to the emergency department with acute chest pain….). After the test questions (such as "What diagnostic steps do you authorize?” Or "What therapeutic measures do you believe are primarily indicated? ") are established, one answer per question is submitted (for example, free-text, text gaps, MC, long menu, short menu).  In the final and eighth step, a score report is presented to the test-taker (e.g. total points, score, pass-fail…).


Currently, the key-feature approach is being used at Heidelberg University in the areas of emergency medicine and internal medicine.


1. Page, G., Bordage, G., Allen, T. (1995): Developing key-feature problems and  examinations to assess clinical decision-making skills. Academic Medicine, 70; 194-201

2. Bordage, G. (1995): Content validation of key features on an national examination

of clinical decision-making skills. Academic Medicine, 70 (4); 276-281

3. Hatala, R. Norman, G. (2002): Adapting the key features examination for a clinical clerkship. Medical education, 36; 160-165


OSCE (Objective Structured Clinical Examination)

Abb. 1: Lernpyramide nach Miller
Abb. 2: OSCE-Parcours


Contrary to "traditional" examination forms, the OSCE (objective structured clinical examination) not only tests theoretical knowledge, but also directly assesses the implementation clinical skills in an exam setting (see Figure 1). Advantages of the OSCE include a standardized examination given directly at the hospital bed.  This means that the evaluation of the student is not influenced by subjective factors and that the OSCE can be regarded as a "fair" assessment tool.


How is an OSCE conducted?

In the OSCE, the exam candidates rotate through various testing stations.  The clinical capabilities of the students are then evaluated  (see Figure 2).  An OSCE should consist of at least 12 stations.  The exam time for the various testing stations must be equal for all stations, and determined accurately before the exam starts.  Usually the testing time at a particular station lasts 5 to 7 minutes.  On individual stations, the students read the tasks out loud, or it is provided in written form at the stations.  Each station is equipped with a trained examiner who assesses the students’ performance via a checklist.


Evaluation of Exam Performance in the OSCE:

The evaluation of the students’ performance is conducted at individual stations based on checklists or global ratings.  The points for the individual examination steps are added together at the end of the exam to obtain a comprehensive score. The assessment of the investigator is part of a global rating. The most effective strategy is a combination of both evaluation types within an OSCE exam or within a single OSCE-Station.

From our experience, it is most effective if the checklist in divided into 5 sub-tasks, with each sub-task giving the student the possibility to achieve 5 points, so that 25 points per station can be attained.  For example, a total 12 stations are part of the exam, thus a total score of more than 300 points can be attained.

Authors: Christoph Nikendei und Steffen Briem


Mini-CEX: Short Standardized Clinical Investigation

The basic idea of this widespread testing method, which was developed in the American medical education system, is a standardized examination with various evaluation criteria.  Thus, in addition to various aspects of a physical examination, additional aspects such as communication, organizational understanding, efficiency, and clinical decision-making are implemented.  The assessment based on predefined criteria remains in effect and applies to each examinee.  The difficulty remains, however, in evaluating different patients in these studies.  An examination of the exam pyramid developed by Miller (see figure) shows that despite these challenges, this method has a high degree of applicability. 


Ann Intern Med. 2003 Mar 18;138(6):476-81. The mini-CEX: a method for assessing clinical skills. Norcini JJ, Blank LL, Duffy FD, Fortna GS.