Structured Practical Exams Reshape How Medical Students Are Tested

Medical schools around the world have spent decades searching for fairer ways to test what students can actually do with their hands and minds, not just what they can memorize. A new study from Al-Quds University in Jerusalem offers a fresh and unusually candid data point in that search. Researchers there tracked a single cohort of third-year medical students as they moved through both a traditional practical examination and two rounds of the Objective Structured Practical Examination, better known in medical education circles as the OSPE. The results, published in BMC Medical Education, paint a nuanced picture: students scored slightly lower on the first structured exam, matched their traditional scores on the second, and overwhelmingly reported that the structured format felt more objective and more useful for learning, even as they complained about time pressure, stress, and fatigue.

The OSPE is a close cousin of the Objective Structured Clinical Examination, the OSCE that has become the gold standard for assessing clinical skills in medical licensing worldwide. Both formats break an assessment into a circuit of timed stations, each targeting a specific skill or piece of knowledge. Instead of one examiner watching a student perform an unstructured practical task, students rotate through stations where the questions, the specimens, the scoring rubrics, and often the examiners themselves are standardized. The theoretical promise is compelling: standardization reduces the idiosyncratic biases of individual examiners, structured checklists make grading more transparent, and a broader sampling of the curriculum can be covered in a single exam. But implementing the format well is demanding, and evidence from different institutions has been mixed, which is precisely why the Al-Quds team set out to measure how the format performs in their own integrated preclinical curriculum.

The study design was a within-cohort comparison with repeated measures, meaning the same students were assessed multiple times under different examination conditions. A total of 315 student records were available for analysis. The cohort first sat a computerized traditional practical examination, or TPE, as part of the Digestive System course. They then completed OSPE-1 in the Endocrine System course and OSPE-2 in the Reproductive System course. Because the same students generated all the scores, the researchers could use paired statistical techniques that control for individual differences in ability, a considerable advantage over comparing separate groups of students. Scores were summarized descriptively and compared using paired-samples t-tests alongside a linear mixed-effects model with student identity as a random intercept, a modern approach that accounts for the fact that repeated observations from the same person are not statistically independent.

The performance findings were subtle rather than dramatic. On OSPE-1, covering the endocrine system, students averaged 6.16 out of a maximum score, with a standard deviation of 1.69, based on 313 valid scores. That was significantly lower than their average of 6.62 on the traditional practical examination, which had a standard deviation of 1.61 across 314 scores. The paired analysis put the mean difference at minus 0.47 points, with a 95 percent confidence interval running from minus 0.68 to minus 0.26 and a p-value below 0.001, indicating the drop was unlikely to be a statistical fluke. Yet on OSPE-2, covering the reproductive system, the picture changed. Students averaged 6.79 with a standard deviation of 1.55 across 311 scores, and the mixed-effects model found no significant difference from their traditional exam performance. In other words, whatever initial dip the structured format produced seemed to disappear the second time around.

One plausible reading of that pattern is a learning-curve effect. The first OSPE a cohort encounters is not just a test of endocrine knowledge; it is also an unfamiliar test format, with new timing rules, new station logistics, and new expectations about how to demonstrate competence. By the second structured exam, students had already navigated the circuit once, and their scores rebounded to match or exceed their traditional exam baseline. Correlations between the different assessment occasions were positive but only weak to moderate, which the researchers interpreted cautiously as exploratory associations rather than firm evidence about how performance in one format predicts performance in another. That caution is characteristic of the paper as a whole, and it is one of its most scientifically valuable features.

Indeed, the authors are unusually explicit about the limits of their own design. Because the traditional exam and the two OSPEs were embedded in different courses covering different body systems at different points in the academic year, examination format was confounded with course content, timing, and the natural progression of the students themselves. A lower score on OSPE-1 could reflect harder material, less accumulated study time, or the novelty of the format, and the study cannot disentangle those possibilities. The researchers therefore frame their results as within-cohort performance comparisons across assessment occasions, not as causal evidence that one examination format is superior to the other. In an era when assessment research is often oversold, that kind of interpretive discipline matters, and it gives the perception data that follows a firmer footing.

That perception data came from a 16-item questionnaire using a five-point Likert scale, completed by 140 of the students, a response rate of 44.4 percent. The responses were generally favorable on the dimensions that matter most to assessment designers. Students reported positive views of the objectivity of the OSPE, the clarity of its instructions, its value as a teaching and learning tool, and its role in building confidence. These findings align with the core rationale for structured assessment: when students believe an exam is fair and transparent, the exam itself becomes a learning experience rather than merely a gatekeeping exercise. The perception that stations sample the curriculum systematically may also encourage broader study habits than traditional practicals, where students can sometimes predict which specimens or demonstrations will appear.

But the questionnaire also surfaced consistent frustrations. Concerns about station timing were common, with students feeling the minutes allotted at each station were tight. Emotional stress and fatigue were also frequently reported, a reminder that a circuit of many timed stations is physically and psychologically demanding in a way a single long practical session is not. These complaints are echoed across the international OSCE and OSPE literature, and they point to concrete design levers: adjusting station durations, building in rest intervals, familiarizing students with the format through formative practice circuits, and monitoring the cognitive load that rapid station-to-station transitions impose. The Al-Quds findings suggest that such refinements could preserve the perceived fairness of the format while softening its stress burden.

The study also carries significance beyond its immediate findings because of where it was conducted. Medical education research from institutions in the Middle East and other underrepresented regions remains comparatively scarce in the global literature, even as those institutions rapidly adopt competency-based frameworks. Al-Quds University’s Faculty of Medicine runs an integrated preclinical curriculum, and this study represents one of the systematic local evaluations of whether structured practical assessment fits that context. The authors, drawn from the university’s Physiology and Pharmacology, Medical Laboratory Sciences, and Microbiology and Immunology departments, note that the research was reviewed by the institution’s Research Ethics Committee and determined exempt from formal approval because it involved non-identifiable data, with informed consent obtained from all participants and no competing interests declared.

Where does this leave the OSPE? The Al-Quds results support continued adoption and refinement rather than a verdict. The authors call for future studies using equivalent examination blueprints across formats, counterbalanced designs in which different student groups take different formats first, and station-level psychometric analyses that can evaluate the validity and reliability of individual stations rather than whole-exam scores. Those methodological upgrades would allow the field to move from asking whether students like the OSPE, which they largely do, to demonstrating precisely when and how it measures competence better than the traditions it replaces. For now, the message from Jerusalem is measured and useful: structured practical examinations can win student trust and hold their own on scores, provided educators treat the first exposure as a learning experience in itself and keep refining the machinery of the format with the same rigor they demand of the students walking the stations.

Subject of Research: Comparison of Objective Structured Practical Examination and traditional practical examination performance and student perceptions among third-year medical students

Article Title: Evaluating student performance and perceptions in objective structured practical examination compared with traditional practical examination among third-year medical students: a within-cohort study at al-quds university

Article References: Rahhal, A., Atallah, A. H., Ghannam, I. A., & Ibrahim, M. A. (2026). Evaluating student performance and perceptions in objective structured practical examination compared with traditional practical examination among third-year medical students: a within-cohort study at al-quds university. BMC Medical Education. https://doi.org/10.1186/s12909-026-10572-5

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10572-5

Keywords: OSPE, medical education, assessment, student perception, practical examination, within-cohort study, Al-Quds University, competency-based education, psychometrics, preclinical curriculum, exam stress, BMC Medical Education