OSCE in Brazil: history, foundations, and perspectives for the assessment of clinical competencies

ABSTRACT

Introduction:   Competency-based medical education requires methods capable of assessing students’ clinical performance in a valid and reliable manner. The Objective Structured Clinical Examination (OSCE) has become internationally established as one of the main instruments for assessing the shows how level of Miller’s pyramid.

Development:   This essay discusses the role of the OSCE in the assessment of clinical competencies, reviews its international and Latin American trajectory, highlights the pioneering Brazilian contribution to the introduction of the method in Latin America, and analyses its use in formative, summative, informative (diagnostic), and proficiency assessments. We argue that the current Brazilian debate should not frame the need for practical assessment as incompatible with the logistical impracticality of a single nationwide centralized OSCE. Given the extremely large number of medical schools in Brazil, together with marked institutional heterogeneity, a hybrid model appears more feasible: a national cognitive assessment combined with decentralized assessment of clinical skills conducted within individual medical schools or regional consortia, but under a national competency framework, standardized documentation requirements, and strict external regulation and auditing. We further argue that the historical experience of the OSCE in Brazil, particularly the pioneering initiatives developed at the Ribeirão Preto Medical School, University of São Paulo, provides valuable evidence regarding both the strengths and limitations of the method, including operational costs, the need for faculty development, standardized patient training, blueprinting, standard setting, and psychometric analysis.

Conclusion:  We contend that the future of practical assessment in Brazil depends less on the mere quantitative expansion of the OSCE and more on the establishment of a national quality governance structure based on shared station banks, interinstitutional consortia, post-implementation review, and integration of the examination into programmatic assessment systems.

Keywords:
Educational Measurement; Clinical Skill; Clinical Competence; Students

RESUMO

Introdução:  A educação médica baseada em competências exige métodos capazes de avaliar, de forma válida e confiável, o desempenho clínico do estudante. O Objective Structured Clinical Examination (OSCE) consolidou-se internacionalmente como um dos principais instrumentos para aferir o nível shows how (demonstrar como faz) da pirâmide de Miller.

Desenvolvimento:  Este ensaio discute o lugar do OSCE na avaliação das competências clínicas, revisa sua trajetória internacional e latino-americana, resgata o protagonismo brasileiro na introdução do método na América Latina e analisa seus usos em avaliações formativas, somativas, informativas (diagnósticas) e de proficiência. Sustenta-se que o debate brasileiro atual não deve contrapor a necessidade de avaliação prática à inviabilidade de um OSCE de âmbito nacional centralizado. Alternativamente, o elevadíssimo número de escolas médicas no Brasil, com forte heterogeneidade institucional, faz com que um modelo híbrido pareça mais factível: avaliação cognitiva de âmbito nacional associada à avaliação descentralizada das habilidades clínicas nas próprias escolas ou em escolas organizadas em microrregiões, mas sob matriz nacional, documentação padronizada e estrita regulação e auditoria externas. Argumenta-se que a experiência histórica do OSCE no Brasil, especialmente a partir das iniciativas pioneiras da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, oferece evidências valiosas sobre potencialidades e limites do método, incluindo custo operacional, necessidade de capacitação docente, treinamento de pacientes padronizados, blueprinting, definição de padrões de desempenho e análise psicométrica.

Conclusão:  Defende-se que o futuro da avaliação prática no Brasil dependa menos da simples expansão quantitativa do OSCE e mais da construção de uma governança nacional de qualidade, baseada em bancos compartilhados de estações, consórcios interinstitucionais, revisão pós-implementação e integração do exame a sistemas de avaliação programática.

Palavras-chave:
Avaliação Educacional; Avaliação de Desempenho Profissional; Competência Clínica; Estudantes de Medicina

INTRODUCTION

The assessment of medical students is increasingly understood as a continuous process of gathering and interpreting information on performance, aimed at at least three objectives: to promote learning, to inform decisions on progression and certification, and to provide evidence on the quality of the education offered by medical schools^1)-(4. In the contemporary context, these objectives are not satisfactorily met by a single tool, but rather by assessment systems capable of combining multiple sources of evidence and integrating their results into justifiable educational decisions^{1), (5)-(7}.

The spread of competency-based education has reinforced this need. When the aim of training is to develop the ability to apply knowledge, skills, attitudes and values in specific professional situations, assessment cannot be limited to the cognitive domain. It must capture how the student performs, communicates, examines patients, prioritises problems, makes decisions and behaves in a variety of clinical situations^5)-(7. From this perspective, the Objective Structured Clinical Examination (OSCE) has become the benchmark method for the standardised assessment of clinical skills and competencies in a simulated environment, playing a key role in assessment programmes and in high-stakes decision-making processes^7)-(14.

In Brazil, this discussion has taken on renewed importance with the deepening of the debate on the quality of medical education, the revision of the National Curriculum Guidelines and the resumption of external evaluation mechanisms, notably the ENAMED^15)-(19. At the same time, the country has a broad, diverse and rapidly expanding medical education system, which makes the task of developing valid, reliable and feasible assessments for all graduates even more challenging.

In this essay, we review the rationale for using the OSCE in the assessment of clinical skills, examine aspects of its introduction and dissemination in Brazil, and discuss possible links between local performance assessments and national regulatory mechanisms. We maintain that the OSCE should become a standard part of medical education in Brazil, but not through a single, centralised national practical examination. In a country of continental dimensions and marked institutional diversity, it seems more realistic to combine a nationwide cognitive examination with a decentralised practical assessment, carried out at medical schools or within regional arrangements, under a national framework, with standardised documentation, psychometric quality assurance and external auditing.

Student assessment: quality requirements

Regardless of the method used, student assessment must meet well-established quality criteria: validity, reliability, feasibility, acceptability, educational impact and catalytic effect^{2)-(4), (7}. Validity refers to the correspondence between what is intended to be assessed and what is actually observed. Reliability refers to the consistency of the measurements obtained. Feasibility depends on the availability of sufficient human, material and organisational resources. Acceptability refers to the extent to which students, teachers and institutions embrace the method used. The educational impact and catalytic effect, on the other hand, refer to the assessment’s capacity to positively influence learning, teaching and the curriculum itself^{2), (3), (7}.

It is beyond the scope of this essay to discuss all the attributes, but there are two strategies that are very useful in practice for ensuring quality in assessment: the use of Miller’s pyramid (Figure 1) and blueprinting. In 1990, George Miller proposed a framework for classifying assessment into four levels: knows, knows how, shows how and does¹¹. Using this framework helps to align the assessment method with the domain being assessed, thereby ensuring validity. In this framework, the levels knows and knows how are best assessed using cognitive instruments, whilst the shows how level requires structured observation of performance in simulated or controlled situations.

Figure 1
Schematic diagram of the modified Miller pyramid¹¹*. The modification involves placing the pyramid on a circular background representing the affective-attitudinal domain, expressed by the Portuguese verbs ser (to be - permanent state), estar (to be - temporary state) and relacionar-se (to relate). For each level of the pyramid and this framework, examples of methods that can be used are provided, with particular emphasis on the OSCE at the shows how level.

The other strategy, blueprinting, is derived from engineering and involves constructing a map or structured representation (blueprint) of what is to be assessed. By using blueprinting, it is possible to specify, right from the test-planning stage, the range of content, contexts and competencies that will be assessed. In the OSCE, which assesses clinical skills (rather than specialities), blueprinting must ensure a balanced representation of essential clinical competencies, such as history-taking, physical examination, communication, clinical reasoning, decision-making and professionalism^12)-(14. For example, it is more important to ensure an appropriate distribution of stations that assess essential skills (such as the ability to carry out a physical examination, communication and clinical reasoning) than simply to organise the stations around specific areas or specialities (Figure 2).

Figure 2
Example of a blueprint or specification matrix for an OSCE designed to assess the clinical skills of final-year undergraduate medical students. The examination comprises 14 stations, set in different scenarios, which assess six broad areas of clinical competence (rather than specialities). In this examination, each skill is assessed in a variety of contexts, across a minimum of five stations and a maximum of seven stations.

The combination of conceptual alignment and appropriate blueprinting does not eliminate all methodological problems, but it does reduce significant threats to the validity and fairness of the process. In high-stakes exams, this planning must be accompanied by examiner training, an explicit definition of pass criteria, an analysis of station performance, and systematic monitoring of inter-examiner and inter-circuit variability^7),(12)-(14. In psychometric terms, this means recognising that the reliability of the OSCE stems less from the format itself and more from the quality of its implementation: the number of stations, the sampling of the domain, case standardisation, the behaviour of the assessors and the consistency of the assessment criteria. Therefore, in high-stakes examinations, it is advisable to supplement traditional indicators with more robust approaches, such as generalisation studies, inter-assessor reliability analysis and systematic reviews of poorly performing stations.

Student assessment in the context of competency-based education

Contemporary medical education has shifted its focus from a predominantly content-centred curriculum to a competency-based approach⁵. This development has profoundly altered the assessment logic. It is no longer sufficient to assess knowledge retention or problem-solving ability through written examinations; it has become necessary to observe how students integrate knowledge, skills, communication, professionalism and clinical decision-making in directly observable situations^{1), (5)-(7}.

This is precisely where the OSCE can offer its greatest contribution. Since it was first proposed in the 1970s, the method has made it possible to structure the assessment of clinical performance into stations with clearly defined tasks, explicit criteria and relatively standardised conditions. This has alleviated some of the traditional limitations of bedside examination, which is heavily dependent on the complexity of each clinical case, the observer and the context in which it is conducted^8)-(10. In Miller’s pyramid, the OSCE is predominantly situated at the shows how level: it allows the student to be observed taking a medical history, carrying out a focused physical examination, explaining procedures, communicating risks and management options, counselling patients and interpreting findings under comparable conditions amongst candidates^8)-(10.

This conceptual framework clarifies a crucial point: the OSCE does not assess the full range of clinical competence, but rather a structured and intentional sample of observable performances. Its value stems precisely from this ability to assess, with reasonable objectivity, aspects of the construct of clinical competence that cognitive tests fail to adequately capture. Conversely, its quality depends on rigorous decisions regarding the purpose of the examination, the content of the stations, the training of standardised patients and assessors, and the appropriate use of checklists and global scales^12)-(14. From this perspective, the OSCE should not be seen as an alternative to assessment in a real-world setting, but rather as a complementary component of a broader system. Documented in-service assessments, portfolios, longitudinal monitoring and overall judgements remain essential for the does level. The particular benefit of the OSCE lies in making comparable aspects of clinical practice that are usually presented to students in an uneven and ad hoc manner.

Accordingly, there is no such thing as “the” OSCE in the abstract. There are different designs, each suited to a different purpose. In training contexts or those involving low-stakes exams, it is possible to work with smaller circuits, place greater emphasis on feedback and have lower requirements for overall reliability. In summative or high-stakes contexts, such as progression, certification or selection, it is essential to have a larger sample size for each domain, greater psychometric rigour, formal processes for setting cut-off marks, quality control and detailed documentation of the examination and its post-implementation analyses^{7), (12)-(14}.

Introduction and dissemination of the OSCE in Brazil and Latin America

The international history of the OSCE is relatively well known. In Dundee, in the mid-1970s, Ronald Harden and his colleagues formalised an objective and structured examination to overcome the limitations of the traditional clinical examination, later named the OSCE^{8), (20), (21}. In the decades that followed, this approach became established as a benchmark and was extended to different contexts, including the assessment of technical skills, the clinical assessment of students and trainees, and medical licensing processes in North America^22)-(27. This development demonstrated that the method could be integrated into results-based curricula and assessment systems spread out over the course of the programme^{10), (28}.

In Latin America, however, the spread of the OSCE was slower and more uneven. A recent review has identified an increase in the use of this method, which remains concentrated in a few countries and is often accompanied by incomplete methodological descriptions, making it difficult to assess the quality of the examinations and compare experiences²⁹. This weakness in reporting is not trivial: without sufficient information on blueprinting, assessor training, station characteristics, the definition of standards and reliability analyses, the apparent objectivity of the OSCE may lead to overly optimistic interpretations of its quality^{13), (29}.

In the context of Latin America, the Brazilian experience deserves special historical recognition. Between 1989 and 1995, the Carlos Chagas Institute of Postgraduate Medical Education participated, in partnership with the Educational Commission for Foreign Medical Graduates (ECFMG), in international applications of a structured clinical examination based on standardised patients, with common stations in different countries²⁶. Although this experience was subsequently documented only to a limited extent, it suggests that Brazil was an early participant in the international movement towards standardised practical assessment.

The best-documented pioneering initiative took place at the Ribeirão Preto School of Medicine, part of the University of São Paulo. In 1995, a group led by Luiz Ernesto de Almeida Troncon implemented a six-station OSCE for the final assessment of students on the General Semiology course. In 1996, the study was published in two articles in the Revista Brasileira de Educação Médica: the first described the design of the examination, which comprised two stations involving the taking of medical histories from simulated patients and four stations involving physical examinations of real, standardised patients; the second presented the results of the examination and the perceptions of the 41 students assessed^{30), (31}. The authors noted that, to their knowledge, this was the first time this approach had been used in the country.

Also at FMRP-USP, the OSCE has been incorporated into the final institutional assessment of medical undergraduates, including in studies comparing curricula^{32), (33}. At the same time, institutions with innovative curricula, such as the State University of Londrina and the Marília School of Medicine, have introduced structured assessments of clinical skills inspired by the OSCE model, with local adaptations consistent with their educational programmes^{34), (35}. The wider adoption of this format for selection processes, however, occurred mainly following the introduction of practical tests into medical residency entrance examinations, as stipulated by the National Medical Residency Commission in 2004³⁶. It is worth noting that Brazil’s trajectory has not been linear. There have been some high-quality institutional initiatives, but also a lack of continuity, inconsistencies in terminology and a dearth of published data on validity and reliability, which helps to explain why some of the national output has remained largely overlooked in international reviews.

Lessons learnt from the OSCE in Brazil and international examples

The early Brazilian contributions were significant not only because they predated much of the subsequent regional literature, but also because they highlighted issues that remain relevant today. Studies carried out by FMRP-USP have shown that the OSCE provides detailed information on student performance and can identify weaknesses in the curriculum with greater accuracy than traditional cognitive assessments. At the same time, they highlighted significant operational, cultural and institutional challenges. The students rated the relevance of the clinical cases and content positively, but reported significant difficulties with time management and the stress inherent in the format; while faculty recognised the method’s ability to assess specific skills, they also highlighted its high cost and limitations in capturing a more integrated approach to the patient^{30), (31), (37}.

The 2004 study, also conducted by Troncon, is particularly instructive because it analysed three consecutive years of OSCE use at a traditional medical school, involving 258 students and teaching staff from the institution³⁷. Even following organisational changes, difficulties persisted in relation to the duration of each station, student stress, resource consumption and the low level of institutional uptake of the results. Perhaps the main lesson is that the usefulness of the OSCE depends not only on its intrinsic characteristics, but also on the context in which it is implemented. A successful OSCE requires educational governance, administrative support, teacher training and an institutional culture of consistent use of the results.

This conclusion helps us to understand the distinction between formative and summative use of the method. In educational settings, the OSCE can have a significant educational impact when combined with structured feedback and genuine opportunities for remedial work. In such circumstances, shorter, more targeted assessments may be sufficient to guide learning. In summative contexts, and particularly in high-stakes situations, the requirements reach a new level: it is necessary to broaden the scope of the assessment, reduce sources of irrelevant variability, define defensible pass criteria, and carry out more robust post-implementation analyses, including attention to the behaviour of stations, assessors, checklists and global scales^{7), (12)-(14}.

The issue becomes even more sensitive when proficiency and licensing examinations are taken into account. In Brazil, the second stage of the Revalida programme retains the requirement for practical demonstration of competencies through structured stations, reaffirming that cognitive mastery alone is insufficient for high-stakes regulatory decisions^{38), (39}. This lends legitimacy to the argument in favour of practical assessments for graduates from Brazilian schools as well. On the other hand, international experience suggests that caution is warranted regarding the idea of a large, centralised national OSCE. In the United States and Canada, national clinical components have been phased out, against a backdrop of high costs, logistical complexity and the gradual strengthening of clinical assessments carried out throughout the training programme^{40), (41}. These changes do not mean that practical assessment has lost its importance. On the contrary, they suggest that mature systems tend to distribute it more intelligently.

By contrast, other countries with a long tradition of assessment and well-established regulatory processes have retained OSCE-style assessments, such as the United Kingdom, Australia, Switzerland and Japan, albeit with different formats. Some countries, such as Switzerland and Japan, continue to hold examinations that are highly standardised at national level, albeit at different stages of a doctor’s training; whilst others, such as the United Kingdom and Australia, use OSCE in a decentralised manner, often with national guidelines and governance, but without a single, centralised examination for all candidates.

The UK model combines two components: the Applied Knowledge Test and the Clinical and Professional Skills Assessment. In the latter, the medical schools themselves organise and conduct the assessment of clinical and professional skills, whilst the national regulatory body acts as an external guarantor of the quality, consistency and fairness of the process^42)-(44. This arrangement demonstrates that it is possible to combine a common national framework with decentralised implementation, without the need to bring together all the country’s graduates within a single national OSCE.

We therefore believe that the British model is particularly relevant to the Brazilian debate, not as a model to be copied mechanically, but as evidence that a common national framework and decentralised implementation can coexist effectively. Conversely, its viability depends on robust institutional prerequisites, including accreditation, external quality assurance and the systematic monitoring of educational processes. In Brazil, the increased number of medical degree programmes without a robust, mandatory accreditation system makes this challenge even greater^{45), (46}. International literature itself shows that the consolidation of high-quality OSCE depends on continuous cycles of design, testing, implementation, review and redesign; in other words, it is not simply a matter of administering a practical test, but of maintaining an assessment programme capable of learning from its own data^{7), (14), (42)-(44}.

A proposal for Brazil

The establishment of the ENAMED has reignited the debate on how to coordinate external evaluation and certification of medical training in the country^{16), (18}. Although the examination has, to date, been predominantly cognitive in focus, it highlights the need for a coherent national framework for the assessment of clinical skills at the end of undergraduate training. In our view, the main pitfall to avoid is the false dichotomy between two equally unsatisfactory alternatives: on the one hand, a single, centralised national OSCE for all candidates; on the other, the absence of a nationally regulated practical component.

Given the scale of the Brazilian medical education system, the number of medical schools, the variation in infrastructure and the annual number of graduates, a centralised national OSCE appears to be logistically unfeasible and likely to be excessively costly. However, this impracticability does not justify abandoning practical assessment. A more consistent alternative might be a hybrid model: a centralised national cognitive examination and the assessment of clinical skills through local or regional OSCEs, conducted by medical schools either individually or in consortia, but subject to a national competency framework, minimum blueprinting requirements, common documentation standards and independent external audit mechanisms.

This model offers clear advantages. It retains the practical assessment as a requirement for certification, promotes greater integration between the curriculum, teaching and longitudinal assessment, reduces the complexity of a single nationwide examination, and encourages inter-institutional cooperation in the sharing of assessment stations, assessor training and standardised patient training. Furthermore, it allows some of the technical work to be centralised or shared, such as the development of a national database of stations, blueprinting guidelines, reference frameworks for setting cut-off grades, and post-implementation analysis protocols. It is also important to recognise that decentralisation will only be legitimate if it is accompanied by transparency and comparability. It is not enough for each school simply to state that it conducts an OSCE; it will be necessary to demonstrate, with auditable evidence, which skills were assessed, under what conditions, by whom, using which instruments, with what pass mark, and with what aggregate results.

For this arrangement to be credible, certain elements are essential (Table 1): a national matrix of clinical competencies; standardised documentation of the planning and conduct of examinations; ongoing faculty development programmes and standardised patient training; post-implementation analysis, including the setting of a pass mark, reliability measures and an assessment of station performance; and external mechanisms for audit, regulation and, ideally, accreditation^{7), (14), (43), (45)-(47}.

Table 1
Essential elements for ensuring the quality of the proposal to implement the assessment of clinical skills by medical schools, within a national framework for verifying the adequacy of undergraduate training.

STAGES	ELEMENTS
1	Development of a national competency framework for clinical skills and competencies and proposal for a minimum blueprint for their assessment
2	Proposal for standardised minimum requirements to enable schools to document the key stages of the planning and administration of examinations
3	Establishment of local faculty development programmes and standardised patient training programmes, with a specific focus on the assessment of clinical skills and competencies
4	Incorporation of a system for post-examination analysis (setting the pass mark, reliability measures, inter- and intra-examiner variability, measures of educational impact, etc.)
5	Establishment of external bodies at national level to oversee and monitor activities (auditing and regulation)

• Source: The Authors

Finally, given the Herculean task of structuring and refining the assessment of clinical skills in a vast country with over 450 medical schools, this challenge should not be delegated to a single institution. It requires coordination between the Ministry of Education, the Brazilian Association of Medical Education, the Federal Council of Medicine, regulatory bodies, medical schools, students and accreditation bodies. However, given the complexity of an examination such as this, it is essential that there also be an independent technical group responsible for setting quality standards, monitoring implementation and continuously reviewing the quality of the system.

CONCLUSIONS

Brazil’s experience with the OSCE offers a twofold lesson. On the one hand, it shows that the country was an early adopter of the method in Latin America and has gained sufficient experience to make a valuable contribution to the design of contemporary solutions. On the other, it shows that simply adopting the format does not, in itself, solve the problems of clinical assessment. Without a supportive institutional environment, investment, technical rigour and a culture of consistent application of the results, the examination loses its legitimacy and sustainability. In summary, the OSCE remains a key tool for assessing clinical skills in medical education. Its current relevance, however, calls for responses commensurate with the scale and diversity of the Brazilian education system. A hybrid approach, with centralised cognitive assessment and decentralised practical assessment under strict national regulation, appears to be the most realistic option for reconciling validity, feasibility and social responsibility in the certification of future doctors.

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• 9
  Evaluated by double blind review process.
• FUNDING
  We declare that there is no funding.
• STATEMENT OF DATA AVAILABILITY
  Research data is available in the body of the document.

• Editora-chefe:
  Rosiane Viana Zuza Diniz.

• Editor associado:
  Fernando Almeida.

Data availability

Research data is available in the body of the document.

Publication Dates

• Publication in this collection
  27 July 2026
• Date of issue
  2026

History

• Received
  20 May 2026
• Accepted
  23 June 2026