Scenes, symbols and social roles: raising the curtain on OSCE performances.

INTRODUCTION: Objective structured clinical examinations (OSCEs) are a complex form of assessment, where candidates can interact with 'patients' in a constructed socio-clinical encounter. Conceptualizing OSCEs as a complex socially and culturally situated activity offers important research affordances. There are concerns that OSCEs may encourage more strategic 'tick-box' candidate behaviours and have a potential negative impact on learner identity formation. This study explored, at a micro-level, the social roles and behaviours occurring within the OSCE triad of simulated patients, candidates and examiners. We used a theoretical framework drawn from Goffman's dramaturgy metaphor. METHODS: OSCE candidates, examiners and simulated patients were invited, consented and recruited using maximal variation sampling. Participants were allocated to a summative OSCE circuit that had unobtrusive video cameras. Video footage of 18 stations was transcribed. Analysis was interpretative and iterative until a rich and thick description was achieved. RESULTS: Focusing on elements of Goffman's dramaturgy metaphor, we foregrounded our analysis by considering the performers, costumes, props and the theatre of the OSCE. A combination of symbols, both physical and semiotic, was used to construct and maintain layered roles and identities within this tightly defined socio-clinical setting. Informed by this foregrounding, we then considered the social interactions and behaviours within the OSCE: 'Creating the right impression?', 'A performance of contradictions?' and 'Simulated patients: patients or props?' DISCUSSION: In the pursuit of standardization, OSCEs have potential to mediate less desirable test-taking behaviours that are not entirely patient-centric, and beyond this may have an impact on professional identity. Whilst OSCE checklists provide objectivity, they have potential to promote a presentation of self that is in tension with good medical practice. The certainty of checklists needs to be looked at afresh in order to better reflect the many uncertainties that doctors face in real clinical practice. This research opens up new ways of thinking and enhancing future assessment practices.