Abstract
Purpose: In 2024, the University of the West Indies transitioned from discipline-specific final examinations to a unified medical exit examination. This study evaluates the feasibility and psychometric performance of this unified format, focusing on written item discrimination and the comparability of multiple Objective Structured Clinical Examination (OSCE) circuits. Methods: A retrospective analysis of de-identified results from all candidates sitting the unified examination at the St Augustine Campus in May/June 2025 was conducted. The assessment comprised a 320-item single best answer paper and a 17-station OSCE delivered concurrently across seven circuits. Inter-circuit differences were tested with one-way analysis of variance (ANOVA). Reliability was estimated using Cronbach’s alpha and Generalizability Theory (G- and phi coefficients). Decision-study modelling estimated the number of OSCE stations required for high-stakes reliability. Pearson’s correlation assessed the relationship between written and OSCE performance. Results: Scores from 157 candidates were analysed. Of 320 MCQs, 163 (50.9%) demonstrated acceptable discrimination with a point-biserial correlation coefficient (PBSC ≥ 0.20) and 26 (8.1%) showed negative discrimination, indicating the need for post-examination item review. Although 16 of 18 OSCE stations showed statistically significant inter-circuit differences, these variances were substantially attenuated upon aggregation; total OSCE scores showed only minor but statistically significant difference in total OSCE scores between circuits. Overall OSCE reliability was moderate (Cronbach’s alpha 0.72; G-coefficient 0.72; phi coefficient 0.69). Decision-study modelling indicated that approximately 20 stations would be required to achieve reliability suitable for high-stakes decisions. Written and OSCE scores correlated positively (r = 0.70, p < 0.001). Conclusions: A unified final exit examination is feasible and psychometrically defensible in large cohorts, but requires adequate OSCE station sampling to support high-stakes decisions.
1. Introduction
Assessment is a central pillar of undergraduate medical education, serving both to certify competence and to direct student learning [1]. Contemporary medical curricula increasingly emphasise integrated assessment strategies that reflect the complexity of real-world clinical practice [2]. Historically, final exit examinations in many medical schools, including the University of the West Indies (UWI), were conducted as discipline-specific assessments within medicine, surgery, and obstetrics and gynaecology [3]. While this model allowed specialty-focused evaluation, it risked reinforcing fragmented learning and did not fully capture the integrative clinical reasoning required of newly qualified doctors.
In response, the Faculty of Medical Sciences at UWI introduced a unified final MBBS (Bachelor of Medicine, Bachelor of Surgery) examination that combined a written multiple-choice question (MCQ) examination with a multi-station objective structured clinical examination (OSCE). OSCEs are widely recognised as a robust approach for assessing clinical competence, with substantial evidence supporting their reliability and validity when appropriately designed and implemented [4,5,6]. However, large candidate numbers often necessitate the use of multiple concurrent circuits, introducing potential concerns related to examiner variability and equivalence across circuits.
Previous assessment research within the Caribbean context has largely focused on the reliability or student perceptions of discipline-specific examinations, such as those in internal medicine and therapeutics or paediatrics [7,8]. Given the high-stakes nature of the final MBBS examination, it is essential that the unified assessment demonstrates acceptable reliability, defensible validity evidence, and feasibility for sustained implementation [9].
To ensure the psychometric defensibility of the transition from discipline-based to integrated assessment, this study was conceptualized as a planned retrospective evaluation of the newly implemented unified MBBS exit examination at UWI. The primary objective was to establish validity evidence for the new format, focusing on OSCE circuit equivalence, overall reliability using classical and generalizability theory approaches [10], and the relationship between written and clinical performance. In addition, the study describes the implementation framework of the unified examination to provide contextual evidence of practicality in a large cohort.
2. Materials and Methods
2.1. Ethics Statement
The Campus Ethics Committee of the University of the West Indies, St. Augustine, approved this study (CREC-SA.3468/08/2025). Informed consent was waived as the study involved retrospective analysis of de-identified, routinely collected assessment data.
2.2. Study Design
This study utilized a retrospective, observational cross-sectional design. While the data were analyzed following the completion of the May/June 2025 examination sitting, this work represents a planned quality assurance evaluation conceptualized to validate the University’s transition from discipline-based to unified assessment models. The evaluation was designed to provide empirical evidence for the psychometric performance and circuit equivalence of the new format.
2.3. Setting
The study was conducted at the St. Augustine Campus, Trinidad and Tobago, during the May/June 2025 examination. This location was selected for its large candidate cohort requiring seven parallel OSCE circuits.
2.4. Variables
Primary outcome variables included total written examination score, total OSCE score, and individual OSCE station scores. Secondary variables included item-level discrimination indices for written examination items, station-level discrimination indices and point-biserial correlations for OSCE stations. Circuit allocation was treated as a grouping variable for inter-circuit comparisons.
2.5. Data Sources and Measurement
Examination data for all final year candidates sitting the unified examination were included. Demographic data were limited to institutional records. The final MBBS exit examination comprised a written component and an objective structured clinical examination (OSCE). The written component consisted of 320 single best answer multiple-choice questions, each with four options, and was delivered online using the Moodle platform under onsite proctored conditions. The OSCE comprised 17 stations, each seven minutes in duration, with one examiner per station. Although the OSCE comprised 17 stations per candidate, one surgical station differed between morning and afternoon circuits, resulting in 18 distinct stations for analysis. A combination of real and simulated patients was used, with an approximate 50:50 distribution. Cognitive, affective, and psychomotor domains were assessed across the stations, with mannequins used for technical skills where appropriate.
To accommodate the cohort, seven OSCE circuits were implemented. Four circuits ran concurrently during the morning session and three during the afternoon session with student sequestration between sessions. Both the written and OSCE components were blueprinted and standard set using the modified Angoff method. Of the 320 written examination questions, 160 sampled medicine and medical subspecialties, 100 sampled surgery and surgical subspecialties, and 60 sampled obstetrics and gynaecology. Point-biserial correlation coefficients (PBSC) were calculated to gauge item performance. OSCE stations covered medicine (8), surgery (5), obstetrics and gynaecology (3), and ethics (1).
2.6. Bias
Several strategies were implemented to minimize potential sources of bias. Random allocation of candidates to OSCE circuits was used to reduce selection bias. All OSCE circuits were designed as mirror images with identical station content, marking schemes, and blueprinting to minimize systematic measurement bias. Examiner calibration sessions were conducted before the start of the OSCE to reduce variability arising from examiner stringency and leniency.
2.7. Study Size
Previous educational measurement research indicates that sample sizes of at least 100–150 candidates are sufficient for stable estimation of internal consistency reliability and generalizability coefficients in OSCEs with more than 12 stations [11,12]. The available cohort of 157 candidates therefore provided an adequate basis for reliability estimation and decision-study modelling. For analyses examining the relationship between written and OSCE performance, a sample size of 157 provides greater than 90% power to detect moderate correlations (r ≥ 0.25) at a two-sided significance level of 0.05.
2.8. Statistical Methods
Descriptive statistics were used to summarize candidate performance in the written examination and OSCE. Continuous variables were summarized using means and standard deviations. Item-level analysis of the written examination was conducted using classical test theory. Written item discrimination was assessed using point-biserial correlation coefficients, calculated as the correlation between dichotomous item scores (correct/incorrect) and total written examination scores. Items with point-biserial correlation coefficients ≥ 0.20 were considered to demonstrate acceptable discrimination. Inter-circuit comparability of OSCE performance was examined using ANOVA to compare mean scores for individual stations and for total OSCE scores across circuits with Bonferroni-adjusted post hoc pairwise comparisons. Internal consistency reliability of the OSCE was assessed using Cronbach’s alpha. Overall examination reliability accounting for multiple sources of variance was evaluated using generalizability theory, with estimation of relative (G-coefficient) and absolute (phi coefficient) reliability. A decision (D) study was conducted to estimate the number of OSCE stations required to achieve reliability thresholds appropriate for high-stakes decision making. The relationship between written examination performance and OSCE performance was examined using Pearson’s product-moment correlation coefficient. Statistical analyses were conducted using SPSS version 31.0 (IBM Corp., Armonk, NY, USA). Statistical significance was set at a two-sided p value < 0.05.
3. Results
3.1. Study Cohort
A total of 157 candidates sat the unified final MBBS examination at the St Augustine Campus during the May/June 2025 examination period. All candidates were final-year MBBS students and had complete written examination and OSCE records. All eligible candidates were included in the analysis, and no participants were excluded due to missing data. Individual demographic characteristics such as age and sex were not collected as part of the routine examination dataset and were therefore not available for analysis.
3.2. OSCE Circuit Comparability
Seventeen OSCE stations were delivered across seven concurrent circuits, and overall performance across circuits was broadly comparable. When total OSCE scores, calculated as the sum of all 17 stations, were compared, inter-circuit variability was limited, with only a small though statistically significant difference observed (p = 0.045).
Table 1 presents station-level discrimination indices calculated across the full cohort and by circuit. Overall, most stations demonstrated acceptable discrimination. Using conventional thresholds, 14 of 18 stations (77.8%) showed good discrimination (DI > 0.20), while 4 stations (22.2%) demonstrated borderline discrimination (DI 0.00–0.20). No stations exhibited negative overall discrimination. Due to a change in one surgical station between the morning and afternoon circuits, a total of 18 distinct stations were analysed at the dataset level. These stations were retained as separate entities in the analysis, as they assessed different competencies and demonstrated different psychometric properties. At the circuit level, discrimination indices varied for several stations, with occasional low or negative values observed within individual circuits; however, these values were not consistent across circuits for the same station.
Table 1.
Station-level discrimination indices (overall and by circuit).
Overall point-biserial correlations between individual station scores and total OSCE performance are shown in Table 2. Similarly, most stations (83.3%) demonstrated acceptable overall correlations (PBSC > 0.20), while 3 stations (16.7%) showed borderline correlations (PBSC 0.00–0.20). No stations demonstrated negative overall PBSC values. At the circuit level, point-biserial correlations varied across stations. Incalculable values occurred in a limited number of circuit-specific analyses due to lack of score variance within those circuits and were not interpreted as evidence of poor station discrimination at the examination level.
Table 2.
Station-level point-biserial correlation coefficients (overall and by circuit).
Supplementary Table S1 summarizes one-way ANOVA comparisons of mean station scores across circuits. Statistically significant inter-circuit differences were observed for the majority of stations (p < 0.001). The Psychiatry History station did not demonstrate a statistically significant difference across circuits. The total OSCE score showed a statistically significant but smaller inter-circuit difference (p = 0.045). Supplementary Table S2 presents Bonferroni-adjusted post-hoc pairwise comparisons for stations with significant overall ANOVA results. The magnitude of statistically significant inter-circuit differences varied by station. For individual stations, mean differences frequently exceeded 10 percentage points, with several comparisons demonstrating differences in the range of approximately 15–30 percentage points. In contrast, the difference in total OSCE score between circuits was smaller, with a mean difference of 6.39 percentage points between the circuits demonstrating the largest disparity.
3.3. Reliability Analysis
The Cronbach’s alpha for the OSCE was 0.718, indicating moderate internal consistency reliability.
Generalizability analysis yielded a relative G-coefficient of 0.718 and an absolute phi coefficient of 0.689, consistent with moderate reliability. For a high-stakes exit examination, this falls below the commonly recommended threshold of ≥0.80.
The D (decision) study demonstrated that increasing the number of OSCE stations would improve reliability. Approximately 20 stations were required to achieve a projected G-coefficient of 0.80, corresponding to strong reliability.
3.4. Relationship Between Written and OSCE Performance
Pearson correlation analysis demonstrated a strong positive correlation between written examination scores and OSCE performance (r = 0.695, p < 0.001), indicating that higher written performance was associated with stronger clinical performance. Of note, 8.1% of the MCQs showed negative discrimination, indicating the need for post-examination item review.
4. Discussion
4.1. Key Results
This study evaluated the unified final MBBS exit examination at the University of the West Indies with respect to OSCE circuit equivalence, examination reliability, and the relationship between written and clinical performance. The unified examination demonstrated moderate overall reliability, with Cronbach’s alpha and generalizability coefficients indicating acceptable internal structure. Although statistically significant inter-circuit differences were observed for most individual OSCE stations, these differences were substantially attenuated when performance was aggregated across stations. Written and OSCE scores demonstrated a strong positive correlation. Decision-study modelling indicated that increasing the number of OSCE stations would improve reliability to levels appropriate for high-stakes decision making.
4.2. Interpretation
This evaluation provides important psychometric evidence supporting the unified final MBBS examination at UWI. The findings can be understood in the context of broader transitions from discipline-based to integrated assessment models in undergraduate medical education. Hudson and Tonkin demonstrated that replacing multiple discipline-specific examinations with integrated written and practical assessments can improve coherence and educational impact when sufficient sampling and careful blueprinting are employed [13]. Subsequent studies have shown that transitions to integrated examination formats may initially be associated with small discipline-specific performance decrements, which tend to attenuate over time as students adapt and assessment better aligns with integrated learning objectives [14].
The finding that most individual OSCE stations differed significantly across circuits indicates the persistence of examiner and examiner–cohort effects, even within well-standardised OSCE designs. This phenomenon is well documented in multi-circuit and multi-institutional studies, which have shown that examiner-related variance can materially influence scores and pass-fail decisions despite shared stations and marking frameworks [15,16]. Examiner stringency and leniency effects are recognised sources of measurement error in performance-based assessments [17]. In Messick’s Validity Framework, this threatens reliability and validity. It can be reduced through examiner training, clear rubrics, and statistical adjustment. Within programmatic assessment, using multiple assessments and overall judgment further minimizes its impact [18].
Crucially, when performance was aggregated across multiple stations, inter-circuit differences were markedly attenuated. This reinforces a central principle of assessment theory: increased sampling across stations reduces the influence of examiner-specific effects and improves fairness and reliability [19]. These findings support the defensibility of the unified examination at the level at which high-stakes decisions are made. Viewed through Messick’s unified validity framework, the observed internal structure, relationships between written and clinical performance, and defensibility of aggregated OSCE decisions provide convergent support for the examination’s intended use [20].
4.3. Comparison with Previous Studies
The psychometric patterns observed in this study are consistent with prior work on integrated assessments and OSCE design. Integrated written and practical examinations have been shown to enhance clinical relevance, fairness, and acceptability by explicitly linking foundational knowledge to applied clinical tasks, provided that assessment integration mirrors curricular integration [21]. The observed relationship between written and OSCE performance in this study aligns with previous findings in undergraduate and postgraduate medical assessments demonstrating moderate to strong correlations between knowledge-based and performance-based measures of competence [22].
Multi-circuit OSCE studies have repeatedly demonstrated that examiner-related variance persists despite standardisation efforts, including shared stations and marking schemes [15,16,17]. The attenuation of circuit-level differences at the aggregate examination level observed in this study mirrors findings from other large-scale OSCE implementations, reinforcing the importance of adequate station sampling as a primary strategy for improving reliability and fairness [19].
4.4. Limitations
This study examined a single cohort at one institution, which may limit generalisability. Institutional context, examiner training practices, and resource availability may influence assessment performance and psychometric outcomes [23]. Although examiner calibration was undertaken on the morning of the OSCE, the persistence of substantial station-level inter-circuit differences is consistent with evidence suggesting that brief, routine calibration has limited impact on examiner stringency and leniency. More structured approaches, such as video-based benchmarking with active examiner engagement, have been shown to be more effective in aligning examiner judgments [24,25].
The study relied on routinely collected examination data, and individual demographic characteristics were not available for analysis. This precluded exploration of subgroup effects but reflects common practice in high-stakes assessment evaluation. Finally, while multiple psychometric analyses were conducted, interpretation focused on convergent patterns across complementary indicators rather than isolated statistical findings, mitigating the risk of overinterpretation.
Despite its conceptual strengths, adopting this model may not be practical in all settings or on a large scale, as it requires adequate funding and strong logistical support.
4.5. Generalizability
Although conducted at a single institution, the findings are likely applicable to other medical schools implementing unified or integrated exit examinations, particularly those managing large cohorts requiring multiple concurrent OSCE circuits. The challenges identified—examiner-related variability, the need for adequate station sampling, and the importance of rigorous blueprinting—are not institution-specific and reflect broader fundamental principles of performance-based assessment. As such, the results may be beneficial to health educators internationally who are designing or refining integrated, high-stakes assessments. Table 3 highlights the implications for other institutions.
Table 3.
Strengths, limitations and transferable lessons from implementing a unified, integrated exit examination.
These considerations highlight both the context-specific factors influencing examination performance and the broader assessment principles that may inform similar transitions in other medical schools.
4.6. Suggestions
Future research should explore additional sources of validity evidence using established frameworks, including predictive relationships between unified examination performance and postgraduate clinical outcomes [26]. Further work is also needed to evaluate the impact of structured examiner training interventions, such as video-based benchmarking, on reducing circuit-level variability [24,25]. Future research should evaluate performance across successive cohorts to determine longitudinal reliability and feasibility.
From a practical perspective, reliability coefficients of >0.80 are widely recommended for high-stakes exit examinations [19,27]. Increasing the number of OSCE stations from 17 to approximately 20 represents a pragmatic, evidence-based strategy to achieve this threshold without fundamentally altering examination structure. The overall pattern of discrimination indices and point-biserial correlations observed in this study supports the adequacy of station design and construct alignment, while highlighting the need for ongoing circuit-level quality assurance in multi-circuit OSCEs.
5. Conclusions
The unified final MBBS examination at the University of the West Indies demonstrates moderate reliability and strong alignment between written and clinical performance. While individual OSCE stations showed inter-circuit variability, aggregation across stations substantially mitigated these effects. Application of Messick’s validity framework supports the examination’s defensibility while identifying clear opportunities for enhancement. Increasing the number of OSCE stations to approximately 20 is recommended to achieve strong reliability appropriate for a high-stakes unified exit examination.
Supplementary Materials
The following supporting information can be downloaded at https://www.mdpi.com/article/10.3390/ime5020048/s1. Table S1. Inter-circuit comparison of OSCE station scores; Table S2. Significant Bonferroni-adjusted pairwise circuit comparisons by OSCE station.
Author Contributions
Conceptualization, R.M.; data curation, R.M.; methodology, formal analysis, and validation, R.M., S.M., D.R., B.S. and M.F.; project administration, R.M.; writing—original draft preparation, R.M.; writing—review and editing, R.M., M.F., D.R., B.S. and S.M. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the Campus Ethics Committee of the University of the West Indies, St. Augustine (CREC-SA.3468/08/2025).
Informed Consent Statement
Patient consent was waived because the study involved retrospective analysis of de-identified, routinely collected assessment data.
Data Availability Statement
The datasets generated and analysed during the current study are available from the corresponding author on reasonable request. Raw assessment datasets should be uploaded with submission if required by the journal.
Conflicts of Interest
The authors declare no conflicts of interest.
Abbreviations
The following abbreviations are used in this manuscript:
| ANOVA | analysis of variance |
| G-coefficient | generalizability coefficient |
| MBBS | Bachelor of Medicine, Bachelor of Surgery |
| MCQ | multiple-choice question |
| OSCE | objective structured clinical examination |
| PBSC | point-biserial correlation coefficient |
| UWI | The University of the West Indies |
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