Objective Structured Clinical Examination Exam Research Articles

The Relationship between Anxiety Level and Cognitive Function of Students Class of 2022 Medical Faculty of Universitas Palangka Raya in Dealing with OSCE

Anxiety is a feeling that is often felt in dealing with various life situations that occur to a person. This can also happen to new students taking the Objective Structured Clinical Examination (OSCE). Anxiety that is continuously experienced by students will disrupt their sleep patterns, and lack of sleep results in poor sleep quality which can affect the cognitive and psychomotor aspects of medical students. This study aims to determine the relationship between anxiety levels and students' cognitive function in dealing with OSCE. This research is a cross-sectional study, where the research subjects are students from the class of 2022 who meet the exclusion and inclusion criteria. The research was conducted in June 2023 at the Faculty of Medicine, University of Palangka Raya. This research was conducted on 135 subjects consisting of 41 men and 94 women with an average age of 19(17-21) years. The highest anxiety level before the OSCE exam in the study was a moderate anxiety level of 75.5%. There is no significant relationship between anxiety level (ZSAS score) and cognitive function (Moca-Ina) with p=0.680. In conclusion, there is no relationship between anxiety level and students' cognitive function in dealing with OSCE.

The use of objective structured clinical examination in dental education- a narrative review.

The Objective Structured Clinical Examination (OSCE) is a performance-based assessment intended to assess medical students' clinical competency in a simulated, standardized environment. Because it measures the student's ability to use clinical knowledge, diagnostic skill, and decision-making, the OSCE is thought to be more objective than traditional tests. OSCE exams have been increasingly employed in dentistry schools, particularly in the last decade, and it is crucial to investigate instructors' and dental students' experiences with this evaluation approach.

Inter-observer variance of examiner scoring in urology Objective Structured Clinical Examinations.

The Objective Structured Clinical Examination (OSCE) is an attractive tool of competency assessment in a high-stakes summative exam. An advantage of the OSCE is the ability to assess more realistic context, content, and procedures. Each year, the Queen's Urology Exam Skills Training (QUEST) is attended by graduating Canadian urology residents to simulate their upcoming board exams. The exam consists of a written component and an OSCE. The aim of this study was to determine the inter-observer consistency of scoring between two examiners of an OSCE for a given candidate. Thirty-nine participants in 2020 and 37 participants in 2021 completed four stations of OSCEs virtually over the Zoom platform. Each candidate was examined and scored independently by two different faculty urologists in a blinded fashion at each station. The OSCE scoring consisted of a checklist rating scale for each question. An intra-class correlation (ICC) analysis was conducted to determine the inter-rater reliability of the two examiners for each of the four OSCE stations in both the 2020 and 2021 OSCEs. For the 2020 data, the prostate cancer station scores were most strongly correlated (ICC 0.746, 95% confidence interval [CI] 0.556-0.862, p<0.001). This was followed by the general urology station (ICC 0.688, 95% CI 0.464-0.829, p<0.001), the urinary incontinence station (ICC 0.638, 95% CI 0.403-0.794, p<0.001), and finally the nephrolithiasis station (ICC 0.472, 95% CI 0.183-0.686, p<0.001). For the 2021 data, the renal cancer station had the highest ICC at 0.866 (95% CI 0.754-0.930, p<0.001). This was followed by the nephrolithiasis station (ICC 0.817, 95% CI 0.673-0.901, p<0.001), the pediatric station (ICC 0.809, 95% CI 0.660-0.897, p<0.001), and finally the andrology station (ICC 0.804, 95% CI 0.649-0.895, p<0.001). A Pearson correlation coefficient was calculated for all stations, and all show a positive correlation with global exam scores. It is noteworthy that some stations were more predictive of overall performance, but this did not necessarily mean better ICC scores for these stations. Given a specific clinical scenario in an OSCE exam, inter-rater reliability of scoring can be compromised on occasion. Care should be taken when high-stakes decisions about promotion are made based on OSCEs with limited standardization.

A Comparison of Checklist and Domain-Based Ratings in the Assessment of Objective Structured Clinical Examination (OSCE) Performance.

The Objective Structured Clinical Examination (OSCE) is the mainstay of clinical assessment in the final-year undergraduate Family Medicine clerkship at King Faisal Specialist Hospital and Research Centre (KFSHRC). The gold standard for OSCE assessment is the checklist rating, completed by physician examiners. Numerous studies have suggested that global or domain-based OSCE ratings may be a better indicator of competence than checklist ratings. The aim of this study was to examine the utility of domain-based OSCE ratings in the context of final-year, undergraduate, Family Medicine OSCE examinations in Riyadh, Saudi Arabia. This is akin to an exercise in quality improvement, as we continuously look for ways to improve our OSCE assessment processes. This study utilised a quantitative methodology. Three final year OSCE exams were chosen. Physicians rated each student using a checklist score and using a more holistic domain-based score. Physician checklist scores and physician domain-based scores were then compared, and correlation was assessed. We also looked at the internal consistency of the scoring methods. A significant correlation was found between checklist and domain-based scores by physicians for all exams (r=0.858, p<0.01), with a good internal consistency for these methodologies for all exams. The results demonstrate that both checklist and domain-based scores offer some benefit to the assessment, with a similar internal consistency and strong correlation. Domain-based ratings should be utilised for softer skills that are not easily assessed by checklists. There is clearly a need to rethink our OSCE assessment. The assessment should combine checklist and domain-based physician scores. As trainees become more experienced, checklist OSCE may penalise directness and efficiency, while domain-based ratings would offer a better appraisal of competence, and have been shown to be more sensitive to the level of training and expertise. Changing the assessment methods will lead to necessary changes in the student approach to the OSCE and improve authenticity and validity.

MP66-19 INTER-OBSERVER RELIABILITY OF EXAMINER SCORING ON HIGH STAKES UROLOGY OBJECTIVE STRUCTURED CLINICAL EXAMINATION

You have accessJournal of UrologyCME1 Apr 2023MP66-19 INTER-OBSERVER RELIABILITY OF EXAMINER SCORING ON HIGH STAKES UROLOGY OBJECTIVE STRUCTURED CLINICAL EXAMINATION Charles Paco, Iain Macintyre, and Naji Touma Charles PacoCharles Paco More articles by this author , Iain MacintyreIain Macintyre More articles by this author , and Naji ToumaNaji Touma More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003329.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Objective Structured Clinical Examination (OSCE) is an attractive tool of competency assessment in a high stakes summative exam. An advantage of the OSCE is the ability to assess more realistic context, content and procedures. Each year, the Queen’s Urology Exam Skills Training (QUEST) is attended by graduating Canadian urology residents to simulate their upcoming board exams. The exam consists of a written component and an OSCE. The aim of this study was to determine the inter-observer consistency of scoring between two examiners of an OSCE for a given candidate. METHODS: 39 participants in 2020 and 37 participants in 2021 completed four stations OSCEs virtually over the Zoom platform. Each candidate was examined and scored independently by 2 different faculty urologists in a blinded fashion at each station. The OSCE scoring consisted of a checklist rating scale for each question. An intra class correlation (ICC) analysis was conducted to determine the inter-rater reliability of the two examiners for each of the four OSCE stations in both the 2020 and 2021 OSCEs. RESULTS: For the 2020 data, the prostate cancer station scores were most strongly correlated (ICC 0.746, 95% CI (0.556-0.862) p<0.001). This was followed by the general urology station (ICC 0.688, 95% CI (0.464-0.829) p<0.001, the urinary incontinence station (ICC 0.638 95% CI (0.403- 0.794) p<0.001) and finally the nephrolithiasis station 0.472 95% CI (0.183-0.686) p<0.001). For the 2021 data, the renal cancer station had the highest ICC at 0.866 (95% CI (0.754-0.930) p<0.001). This was followed by the nephrolithiasis station (ICC 0.817 95% CI (0.673-0.901) p<0.001), the pediatric station (ICC 0.809, 95% CI (0.660-0.897) p<0.001) and finally the andrology station (ICC 0.804, 95% CI (649-0.895) p<0.001). Values less than 0.5 are indicative of poor reliability, values between 0.5 and 0.75 indicate moderate reliability, values between 0.75 and 0.9 indicate good reliability, and values greater than 0.90 indicate excellent reliability. CONCLUSIONS: Given a specific clinical scenario in an OSCE exam, inter-rater reliability of scoring can be compromised on occasion. The factors determining this divergence in examiner agreement will need further research to help elucidate, especially if OSCEs are continued as the gold standard in high stakes examinations. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e941 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Charles Paco More articles by this author Iain Macintyre More articles by this author Naji Touma More articles by this author Expand All Advertisement PDF downloadLoading ...

THE STUDENT VOICE TO IMPROVE OSCE

Background: Nursing education is not only about cognitive field but also include the affective and psychomotor domains. Nursing involves “hands-on” psychomotor skills and clinical decisions in the affective and psychomotor domains which needs to be evaluate in a method that cover both domains. The most important goal of student’s assessment is promoting learning process and improvement of educational programs quality. through different methods of assessment OSCE(An objective structured clinical examination) could be mentioned as an appropriate way for evaluating the medical students specially nursing students.it is undeniable that the student’s attitude toward evaluation methods, as a main client of education programs, could be highly effective and valuable for educational systems objective: present study is conducted to investigate the student’s views toward OSCE, to find out the present problems in this evaluation method. Design: A qualitative, exploratory study. Methods: For this qualitative study, twenty-five students who experienced OSCEin their university were selected purposively. The data were collected by using semi structured interviews. The interviews were verbatim transcribed and analyzed according to the qualitative content analysis based on Graneheim and Lundman method. Findings: Two main themes emerging during data analysis were: 1- Management aspects problem, that includes 3 categories: 1) supervisor’s behavior, 2) time management,3) Facilities, and 2- Educational aspects problem including three categories of 1) Simulation, 2) Educational background, 3) Question design which are key factors in conducting a more rational and helpful OSCE exam. Conclusion: the result of the present study could be highly effective in promoting both clinical skills evaluation and educational programs. Using this kind of methods requires revision on education method, using more student-center methods in teaching and providing facilities to bring students to the real world of profession helping them to improve their ability in clinical decision making for their career prospect.

Students' perception and scores in Paediatrics end-of-clerkship and final professional Objective Structured Clinical Examination (OSCE): A comparative study.

Objectives:This study aims to understand students’ perception of the usefulness of end-of-clerkship (EOC) as compared to professional exam Objective Structured Clinical Examinations (OSCE) and to compare student performance in both examinations.Methods:We conducted a cross-sectional study of medical students who were studying in the final year at Shifa College of Medicine, Shifa Tameer-e-Millat University, and appeared in both end-of-clerkship and final professional exams. The study was conducted in October 2019. The data was collected through a self-constructed questionnaire. The scores of all participants were also recorded. The data obtained was analyzed on IBM’s statistical package for the social sciences (SPSS) version 23 (IBM, Armonk, NY). Descriptive statistics were used for qualitative variables. Mean and standard deviation was calculated for quantitative variables. Chi-square test was also applied to assess for significant differences.Results:Out of 115 participants, 57 (49.6%) were males and 58 (50.4%) were females. Most of the participants (75.7%) agreed that both OSCEs were well-structured. Participants found that both the exams give a good cross-section of paediatrics and allowed them to learn something new (p=0.00). 45% of participants perceived that the end-of-clerkship OSCE exam helped in orienting them for the final professional exam by identifying their weaknesses.Conclusion:Although the EOC OSCE served as a good preparatory exercise, it did not alleviate the stress levels. However, the results in both OSCEs were comparable and students were satisfied with the current weightage of marks distribution.

Dental students' perception of the Objective Structured Clinical Examination (OSCE): The Taibah University experience, Almadinah Almunawwarah, KSA.

ObjectiveThe Objective Structured Clinical Examination (OSCE) is an assessment tool used to objectively evaluate clinical competence in medical schools and, more recently, in the nursing profession as well. However, few studies have been conducted to elicit the views of dental students in KSA regarding the OSCE. The present study was designed to explore, evaluate, and analyse students' perceptions of the OSCE and to explore the strengths and weaknesses of this assessment tool as perceived by dental students.MethodsThis was a cross-sectional analytical observational study using a survey design. It took place in the College of Dentistry, Taibah University, KSA. The study sample consisted of third, fourth, and fifth-year students who took the OSCE assessment during their studies.ResultsOf 138 invited students, 119 responded (response rate of 86.2%). Almost half the students (47.1%) agreed that the OSCE exam was fair, while 19.3% agreed that a broad range of clinical skills were included in the OSCE exam. A low percentage of students believed to a great extent that the scores were standardised; however, the practicality and usefulness of the OSCE was questioned. Students perceived that issues pertaining to personality, ethnicity, and gender would not impact the scores.ConclusionThe findings of this study indicated that the OSCE is a meaningful and fair assessment tool for clinical skills.

Perception and acceptance of senior medical students at King Abdulaziz University of the use of Objective Structured Clinical Examination as a tool of assessment

This article was migrated. The article was not marked as recommended. Introduction: The faculty of Medicine at King Abdulaziz University (KAU) introduced the Objective Structured Clinical Examination (OSCE) as a tool of assessing medical students in the last decade. In our study, we aimed to assess the perception and acceptance of OSCE among students and to interpret rating of OSCE in relation to other assessment methods.Methodology : A cross-sectional survey using electronic validated questionnaire, was distributed through different methods which included Short Message Service, social media website, and posters. The questionnaire contained various domains about students' perception of OSCE validity and reliability, and rating of OSCE in relation to other assessment methods.Results : Among 246 students who responded to the survey, 52% of them denied that OSCE provided opportunity to learn real life scenarios. Interestingly, more than 80% of students showed concern about inter-evaluator and inter-patient variability as bias factors that could affect their scores. Passing or failing the OSCE was not a true measure of clinical skills as 77% of students admitted.Conclusion : Although OSCE exam is supposed to be standardized and fair to students, our survey raised concerns regarding the conduction of OSCE especially regarding inter-evaluator and inter-patient variability.

Brief Analysis of Application of Objective Structured Clinical Examination (OSCE) in Graduation Exams of Clinical Medical Students

This article gives a brief introduction to the Objective Structured Clinical Examination (OSCE) and analyzesdevelopmental progress of OSCE at both home and abroad and standardized patients’ application in OSCE. Also,this article expounds application of OSCE in graduation exam of clinical medical students. Finally, this articlesummarizes pre-exam preparation work and flow of OSCE exam in Affiliated Hospital of Clinical Medical School,analyzes OSCE and puts forward suggestions to improve OSCE.

Neurology assessment by objective structured video examination.

The ability to carry out a neurological examination and make an appropriate differential diagnosis is one of the mainstays of our final Bachelor of Medicine (MB) exam; however, with the introduction of objective structured clinical examinations (OSCEs) it has become impossible to arrange for adequate numbers of suitable real patients to participate in the exam. It is vital that newly qualified doctors can perform a basic neurological examination, interpret the physical signs and formulate a differential diagnosis. It is vital that newly qualified doctors can perform a basic neurological examination Since 2010 we have introduced an objective structured video examination (OSVE) of a neurological examination of a real patient as part of our final MB OSCE exam. The students view clips of parts of the examination process. They answer questions on the signs that are demonstrated and formulate a differential diagnosis. This type of station is logistically a lot easier to organise than a large number of real patients at different examination sites. The featured patients have clearly demonstrated signs and, as every student sees the same patient, are perfectly standardised. It is highly acceptable to examiners and performed well as an assessment tool. There are, however, certain drawbacks in that we are not examining the student's examination technique or their interaction with the patient. Also, certain signs, in particular the assessment of muscle tone and power, are more difficult for a student to estimate in this situation.

Experience of OSCE in faculty of medicine, Alzaeim Alazhari University, Sudan

Background: The traditional classical clinical exam (CCE) has limitations in terms of validity and reliability. Nowadays the Objective Structured Clinical Examination (OSCE) is widely used to assess the clinical pe rformance of medical students. Objective : To reflect and share the experience of OSCE exams in clinical departments in the Faculty of Medicine, Alzaeim Alazhari University (AAU) and to encourage more modifications to improve its quality. Material and Methodology: Data regarding clinical assessment; OSCEs versus cl assical clinical examinations was collected from faculty records. Th e collected data was entered computer and managed statistically using SPSS version 21. Results: Overall in the group of students examined by OSCE 67.7% rewarded grade B and above, whereas in the contrary 60.5% of students in CCE rewarded grade C+ and below, this difference was statistically significant (p=0.002). Conclusion: OSCE is an excellent tool, and fair to the students , as all examiners use the same check lists provided by the department . Students tend to do better in the clinical part of the examination when this type of assessment is used.

Assessment of current undergraduate anesthesia course in a Saudi University

Background:The assessment of the anesthesia course in our university comprises Objective Structured Clinical Examinations (OSCEs), in conjunction with portfolio and multiple-choice questions (MCQ). The objective of this study was to evaluate the outcome of different forms of anesthesia course assessment among 5th year medical students in our university, as well as study the influence of gender on student performance in anesthesia.Methods:We examined the performance of 154, 5th year medical students through OSCE, portfolios, and MCQ.Results:The score ranges in the portfolio, OSCE, and MCQs were 16-24, 4.2-28.9, and 15.5-44.5, respectively. There was highly significant difference in scores in relation to gender in all assessments other than the written one (P=0.000 for Portfolio, OSCE, and Total exam, whereas P=0.164 for written exam). In the generated linear regression model, OSCE alone could predict 86.4% of the total mark if used alone. In addition, if the score of the written examination is added, OSCE will drop to 57.2% and the written exam will be 56.8% of the total mark.Conclusions:This study demonstrates that different clinical methods used to assess medical students during their anesthesia course were consistent and integrated. The performance of female was superior to male in OSCE and portfolio. This information is the basis for improving educational and assessment standards in anesthesiology and for introducing a platform for developing modern learning media in countries with dearth of anesthesia personnel.

Objective Structured Clinical Examination (OSCE) as an Assessment Tool for Clinical Skills in Sohag University: Nursing students' perspective

The aim of this study was to investigate the students′ perception of the OSCE as part of an evaluation of clinical skills in Med-Surgical Nursing students′. A self-administered questionnaire was completed by 1st year Med-Surgical Nursing students immediately after the OSCE exam using Pierre et al., (2004) questionnaire, in addition to 7 questions about the organization of OSCE evaluation. The results of this study indicate that OSCE has been fair assessment tool (75.9%) and comprehensive (72.4%) and with clear instruction (50.0%), minimized the chance of failing (68.9%), and highlighted areas of student's weakness (46.6%). However, some students felt that OSCE was very stressful (24.1%), twenty nine (50.0%) of student expressed concerns about inadequacy of time. As well, the OSCE provided opportunities to learning, reflected those which were taught (36.2%), and (48.3%) reported that the stations were organized and of logical sequence and appropriate. Thirty two (55.2%) of the student felt that, the exam score provide true measure clinical skill, (56.9%) believed that the score was standardized, and the personality and social relations did not affect OSCE scores. Student feedback confirmed their acceptance of OSCE as an evaluation tool for their clinical skills, so as to fairness and unbiased, cover a wide range of knowledge and comprehensive, provide opportunities to leaning. Also the majority of examinees was satisfied with organization and administration of the OSCE; as well prefer using the OSCE exam more in the clinical exams than other assessment. Further studies are required involving larger number of students and staff member to establish the effectiveness of OSCE within nursing education programs, in addition use of Watched Structured Clinical Examination (WSCE) to overcome the limited equipment and manpower.

Introducing the Objective Structured Clinical Examination (OSCE) in the Undergraduate Psychiatric Curriculum: Evaluation After One Year

The Objective Structured Clinical Examination (OSCE) was introduced in undergraduate psychiatry clerkship in 2008. The authors studied the effect of OSCE on the students' performance. The ″short case″ (SC) and ″oral examination″ (OE), two of the five components of the previous assessment format, were replaced with the OSCE. Results were compared with those of the 2007 students. The introduction of the OSCE had little impact on the overall scores, but the 2007 students had significantly higher scores on the essay examination and long case, whereas the 2008 group had significantly higher scores on the OSCE (versus the OE for the 2007 group). In comparing the top 10 scoring students from the two classes, the 2007-year students had significantly higher overall scores, both on end-of-course tests and the annual examinations. In particular, the scores for the OSCE exams for the 2008 class were significantly lower than the scores for the OE in the 2007 class. The higher scores on OSCE in Year 2008 suggest that students performed better on clinical skills and professional development than recall on the factual-knowledge domains. Since the changes were introduced in the year 2008, the comparison can best be regarded as qualitative, and it is probably too early to judge the impact of the OSCE. Further studies to determine validity of the OSCE are needed.

Applied basic surgical sciences for the IMRCS OSCE course

The Intercollegiate Basic Surgical Examinations Committee (representing the three royal colleges of surgeons in the United Kingdom) has recently made a very significant change to the format of the intercollegiate membership of the Royal College of Surgeons (IMRCS) examination. Parts 1 and 2 (applied basic sciences and clinical problem solving), which comprised the written component of the old format, have now been replaced by part A, which is made up of two papers—applied basic sciences and clinical surgery—to be done at the same sitting. The candidate is required to pass both papers individually and at the same sitting. Part 3 of the old format (comprising three separate components: oral examination followed by the clinicals and communication skills) has been replaced by the new part B objective structured clinical examination (OSCE). Although part 3 of the old MRCS examination is still available for those who have passed their written components under the old system, it is being phased out and will cease altogether in the autumn of 2010. In conforming to the altered format of the new examination, candidates will need to adopt a different approach when studying and preparing for the part B OSCE exams from that which might have been appropriate to the old part …

“You can do it late at night or in the morning. You can do it at home, I did it with my flatmate.” The educational impact of an OSCE

Background: The use of an objective structured clinical examination (OSCE) has been a powerful influence on doctor training but assessments do not always drive study behaviour in predictable ways.Aims: To investigate the impact an OSCE has on study behaviours by exploring how 5th year medical students identify what to learn for a summative OSCE and the role of the clinical environment in their preparation.Methods: A semi-structured questionnaire survey asked about strategies used by students to prepare for the OSCE. Focus group interviews explored successful methods of preparation for the OSCE. Themes were identified and classified.Results: The questionnaire response rate was 84%. Topic identification was usually from the list of examinable problems, past OSCE papers and a booklet prepared by a previous student containing a series of OSCE checklists. The study behaviours of students preparing for the OSCE exam were predominantly to practise on each other, and to rehearse routines. Strategic and efficient study habits were favoured over conscious utilization of the clinical environment.Conclusion: The expectation that an OSCE drives learning into the clinical workplace was not supported by this study. This suggests the role of clinical experience in helping students prepare for the exam may be more subliminal, or that an OSCE is more as a test of psychomotor skills than a marker of clinical experience. An unexpected benefit may be to drive more collaborative learning.

The Objective Structured Clinical Exam - practical aspects

Assessment of clinical skills in addition to factual knowledge has become part of the examination system in both undergraduate and postgraduate examinations. There is an increasing interest in the concept of competence and how it can be measured, particularly for the process of revalidation of practitioners. The Objective Structured Clinical Examination (OSCE) has been introduced for the assessment of clinical skills into postgraduate anaesthetic examinations in the United Kingdom. As with any examination, the issues regarding setting a standard are under continual review. The application of this exam format to the measurement of competency as well as skills has been the subject of scrutiny during the period reviewed. The literature suggests that competence is a much more complex construct than skill and that OSCE exams will be a contributory part but more work is required to establish assessment methods which will produce a global rating of competence. The role of the OSCE format in education as well as assessment has been examined and it is suggested that formative assessment can be made, and peer review learning brought about using an OSCE performed in teams.

Assessment of an objective structured clinical examination (OSCE) for undergraduate students in accident and emergency medicine.

Conventional techniques for assessing the knowledge and clinical competence of undergraduate medical students are widely acknowledged as being unsatisfactory. We introduced an objective structured clinical examination (OSCE) for our fourth year medical students at the end of their accident and emergency (A&E) medicine attachment. This paper outlines the organisation of the examination and the results of a comparison of marks obtained from the OSCE, from a multiple choice type examination and from a subjective rating of the students performance by their teachers. We found the OSCE to be an acceptable form of examination to both medical students and examiners. Our results show significant correlation between marks obtained on the OSCE exam and subjective rating of the students ability. There was no statistically significant relationship to marks obtained on a multiple choice questionnaire exam. The OSCE format is particularly appropriate to A&E medicine where the participation of patients in traditional clinical examinations is impractical.