Cognitive OSCE

Enhancing Clinical Decision-Making Under Pressure: A Future-Focused OSCE Station

In the complex and fast-paced environment of modern healthcare, physicians are frequently required to function under intense cognitive demands. They must rapidly process incoming information, identify and prioritize critical issues, and act decisively while managing interruptions and limited resources. The "Managing an Overwhelmed Ward" OSCE station has been carefully designed to assess and cultivate these essential executive and cognitive competencies.

Drawing upon foundational principles from cognitive psychology, this station simulates real-world ward handovers where key information is delivered under time pressure. The setup intentionally induces cognitive load to examine how trainees engage their working memory, exercise selective and divided attention, and apply clinical reasoning under constrained conditions.

The integration of audio-visual stimuli mimics actual clinical scenarios where information is often received orally or via fast-paced multidisciplinary exchanges. By capturing how candidates retrieve and prioritize this data, the station evaluates not just medical knowledge, but the underlying cognitive architecture that supports high-functioning clinical judgment.

Furthermore, this station promotes the development of metacognitive strategies by encouraging reflection on decision-making processes through follow-up discussions or written justifications. This dual-layered format — combining performance with reasoning — aligns with modern assessment frameworks that seek to bridge the gap between clinical competence and cognitive capability.

Relevance Across All Disciplines

The competencies assessed in this station are universally applicable across medical specialties, making it a critical assessment tool for all disciplines. However, it holds importance for many specialties for example :

• Emergency Medicine, where fast triage, real-time prioritization, and decision-making under extreme time pressure are essential to patient survival.

• General Medicine, where managing multiple patients with complex conditions requires mental flexibility, prioritization skills, and clinical vigilance.

• General Surgery, where quick recognition and response to post-operative complications can be critical in preventing deterioration.

By simulating the challenge of managing multiple critically ill patients, this station trains and evaluates core skills that are essential for frontline clinical practice, particularly in high-stakes and unpredictable healthcare environments.

 OSCE Station: Managing an Overwhelmed Ward

Purpose of the Station

This station aims to assess the physician’s ability to use their working memory, focus attention selectively and in parallel, prioritize tasks under cognitive stress, and demonstrate clinical reasoning and executive decision-making.

Duration

The total duration is 10 minutes, broken down as follows:

• 2 minutes to receive the audio or visual handover.

• 5 minutes to complete the task.

• 3 minutes for examiner-led discussion or submission of written responses.

Cognitive Abilities Assessed

The working memory component assesses the candidate’s ability to retain multiple pieces of patient data while forming a plan.
Selective and divided attention refer to the candidate’s skill in identifying the most urgent clinical problems in a multitasking setting.
Executive function is evaluated by observing how candidates plan, switch between tasks, and appropriately defer non-urgent matters.
Clinical reasoning involves synthesizing findings to determine appropriate next steps for patient care.

Station Setup

The station is presented in a simulated format, using either audio or video to mimic a rapid ward handover. The candidate listens to a brief, high-intensity report involving four patients, each with two to three critical data points. The handover is deliberately delivered at a fast pace to replicate real clinical conditions and induce cognitive load.

Sample Handover:

“Bed 3: 68-year-old man with chest pain, ECG pending, blood pressure 100/60.
Bed 5: 27-year-old woman, post-operative, febrile with a heart rate of 120.
Bed 7: 82-year-old woman, confused, sodium 118.
Bed 8: 52-year-old diabetic, blood glucose 45 mg/dL, slurring speech.”

 Candidate Task

Upon hearing or watching the handover, the candidate is informed:

"You’ve just taken over a busy ward with multiple critical issues."

The candidate must then:

1. List the four patients in order of priority for review.

2. State the main clinical concern for each patient.

3. Propose the most appropriate first management step for the highest-priority patient.

Scoring Rubric

Candidates are evaluated across five key domains:

1. Recall Accuracy – Did the candidate recall at least three out of four key patient data sets accurately? (2 points)

2. Prioritization – Did the candidate correctly identify and triage the most urgent case first (e.g., hypoglycemia)? (2 points)

3. Reasoning – Did the candidate offer appropriate reasoning to justify their prioritization? (2 points)

4. Management Plan – Was the proposed first step for the highest-priority patient both safe and appropriate? (2 points)

5. Organization and Clarity – Was the candidate’s explanation clear and structured? (1 point)

Total possible score: 9 points

Optional Examiner Prompts

To explore the candidate’s reasoning, the examiner may use optional prompts such as:

• “Why did you choose to see that patient first?”

• “What are the potential risks if this patient is delayed?”

• “If a fifth emergency arises, how would you adapt your prioritization?”

Looking Ahead: ABHS’s Future Vision

As part of the future development of clinical examinations within the Arab Board of Health Specializations (ABHS), stations like this one will play an increasingly prominent role. ABHS is moving toward an evaluation model that reflects real clinical complexity by incorporating assessments of cognitive resilience, executive functioning, and adaptability under stress.

This evolution reflects a broader vision of precision, innovation, and human-centered assessment, where cognitive skills and decision-making capacity are recognized as equally vital to technical knowledge. By integrating cognitive psychology tools and simulation-based assessment, ABHS is not only modernizing its examination strategy but also preparing a generation of physicians who are clinically competent and cognitively agile.