What counts and who is accountable? An institutional ethnographic account of OSCEs

Abstract

In this thesis, I examine Objective Structured Clinical Examinations (OSCEs), a dominant form of assessment in medical education, using Institutional Ethnography (IE). My critical approach explores what counts and who is accountable in OSCEs, at a time where assessment is subject to increasing regulation.

I start in the everyday world of a medical student, who described drawing on her childhood drama coaching to write a script to perform in her OSCEs but explained how she felt unprepared and unable to vary her script when the OSCE unfolded unexpectedly. Drawing on student experiences, clinician examiner experiences and on my own experiences as both, I developed my ‘problematic’ for this study, where assessed methods of competence for final year medical students inadequately represent the messiness of clinical practice and non-standardised patients these students were soon to encounter.

I use the approach IE, as it aligns with both my ontological and personal position, guiding my data collection using observation, formal and informal interviews and textual analysis over an academic year.

In my analysis, I explicate the dominant discourse of the ‘work of standardisation’; the need to standardise organised and became the focus of the assessment, displacing clinical practice and patients. I traced this discourse back to the ruling relations of the regulatory body, within an accountability agenda. I map an ‘accountability circuit’ to demonstrate what counts institutionally – an objectively and quantitatively verified ‘quality assured’ assessment, promoting an ethos of accountability centred care. The work processes to deem these students ‘competent’ within the discourses of accountability and patient safety, brings students to the assessed world of scripted and standardised patients, removing them from real clinical practice and real patients. This happens at the brink of students gaining their licence to practice, adding to feelings of being unprepared for their work as doctors.

Coming back to the everyday world of the student, my research is an empirically based, alternative way of knowing OSCEs, based on the work and experiences of those on the ground. In line with the activist and emancipatory roots of IE, I offer a more generous approach to assessment with patients and practice at the focus; I endeavour to bring this new knowledge to where it can count for these students and their future patients.

Date of Award	Jul 2020
Original language	English
Awarding Institution	Queen's University Belfast
Sponsors	Northern Ireland Department for the Economy
Supervisor	Jenny Johnston (Supervisor), Nigel Hart (Supervisor) & Gerard Gormley (Supervisor)