Objective Structured Clinical Examination Case Writing

Lessons from Dungeons and Dragons

Abstract

The Objective Structured Clinical Examination (OSCE) is a commonly utilized modality to assess learner clinical skills in a simulated environment. It is important that OSCE cases are well written; A poorly constructed case can frustrate the learner, lack realism, and lead to disrupted narrative flow. An ideal response process in an OSCE case, or for any assessment, takes the learner to the patient’s bedside or puts them into the cognitive and affective state similar to that of clinical work. There are several parallels between writing OSCEs and creating Dungeons and Dragons (D&D) adventures. From determining the central conflict to designing D&D adventures using the classic three part structure, from creating challenging yet solvable challenges to distributing loot and treasure, the approaches and lessons of being a DM align with being an OSCE case writer.

INTRODUCTION

The Objective Structured Clinical Examination (OSCE) is a commonly utilized modality to assess learner clinical skills in a simulated environment.[¹] Its utility in a program’s assessment framework belies its potentially resource intensive nature and complex implementation.[¹] Renewal of the clerkship OSCE in our local context has uncovered challenges in recruiting station writers to revitalize our station bank due to logistical, funding and resource challenges. Furthermore, it can be challenging to write a well-performing OSCE case with excellent discrimination of learner competency levels. Poor case writing impacts an important and often under-supported component of validity: the response process.[^2,3] A poorly constructed case can frustrate the learner, lack realism, and lead to disrupted narrative flow. An ideal response process in an OSCE case, or for any assessment, takes the learner to the patient’s bedside or puts them into the cognitive and affective state similar to that of clinical work.

OSCE case writers require support and faculty development through case writing workshops, near peer mentoring and the use of a standardized station development template.[⁴]

Interestingly, the classic role-playing group game Dungeons and Dragons (D&D) has several lessons on how to account for response process and address case writing challenges. A Dungeon Master (DM) is one of the players in the classic role-playing group game. Other players create characters who interact in an imaginary world created by the DM. The DM acts as a story designer and storyteller, describing scenes as they unfold, challenging the other players with scenarios involving villains, monsters, and other non-player characters (NPC) that populate the imaginary world. The players navigate and complete the challenges according to the game rules. The DM does not compete against the other players; they set-up interesting and challenging situations.

D&D is one of the most popular role-playing games worldwide. It is therefore likely that many clinicians recruited to help with OSCE case writing will have had experience playing D&D. There are several parallels between writing OSCE cases and creating D&D adventures.

LESSONS FROM DUNGEONS AND DRAGONS

There are several free resources for Dungeon Masters including an excellent summary of tips for how to create a D&D adventure.[^5,6] We have drawn from these tips to provide OSCE writing lessons.

1. A key to good DMing is to “steal ruthlessly from things you love.”[⁵]
1. OSCE writing lesson: It is important for OSCE writers to have competence or expertise as it pertains to case development. If writers know the clinical presentation well, and recently managed a similar case, the case development will flow more naturally and will more closely mimic a real-life scenario.
2. Determine the central conflict of the adventure. “It is not your job to determine HOW the players overcome this problem. That’s up to them. You simply set the situation up, introduce the conflict into the game world, and then turn the reins over to your players to determine how it gets resolved.”[⁶]
1. OSCE writing lesson: It is important to determine the central “conflict” of the case, which is analogous to writers identifying the key features of each case.[⁷] Inexperienced OSCE case writers can become distracted with “world-building,” drafting the character backgrounds and back stories of the standardized patients. However, more efficient and more experienced case writers will start by establishing the key features of the case and then build outward from those key features. While additional refinement of the details and wording of the key features continues to occur through the writing process, a solid foundation of the “central conflict” is necessary. To draw a parallel to D&D adventure creation: The OSCE writer need not dive deep into HOW candidates achieved various educational competencies through their clinical training. The OSCE writer builds using the key features as the foundation, allowing candidates to uncover the key features however they were trained.
3. Use the Three Act Structure. The Three Act Structure refers to a story having a clear beginning, middle and end. Guiding questions for this structure include: What is the rising action? Where is the climax?[⁶] Good D&D adventures follow this ancient storytelling three act structure. Within each act is a particular plot event. Aristotle describes each plot event as potentially sending the narrative in different directions. In Poetics, Aristotle proposes that stories need a chain of cause-and-effect plot events where one scene leads to the next, just as one act leads to the next; there should not be any standalone plot points or events. The traditional three-act structure includes: Act I - Setup: Exposition or Inciting Incident, Act II - Confrontation: Rising Action or Midpoint, and Act III - Resolution: Denouement.
1. OSCE writing lesson: Map out how you would like the OSCE to unfold in three acts:
1. Act I - Setup: Exposition or Inciting Incident: Have a good stem (i.e. the instructions to the candidate). Think carefully about the SP opening statement; does this lead the learner too quickly into Act II? Does the opening statement guide the learner to better explore the details of Act I?
2. Act II - Confrontation: Rising Action or Midpoint: Build in “must ask” or “may ask” questions for the standardized patient to help guide candidates into the rising action. Think about the timing of the “must ask” or “may ask” questions; too early and Act III begins without adequate time and preparation for the learner; too late and the OSCE case is over before Act III begins.
3. Act III - Resolution: Denouement: From the three-act structure, this phase of the OSCE encounter can be considered the portion where the learner moves into managing the case, counseling the standardized patient (SP), or answering examiner questions. OSCE writers should consider the preceding acts: has the narrative of Act I and Act II properly equipped the learner for Act III?
4. Distribute Loot throughout the adventure.[⁶] D&D players need to be rewarded as they go through the adventure, not just at the very end. Gold coins, magical weapons, and armor along the journey are helpful to keep players motivated and engaged. The “loot” gathered along the journey should also ultimately aim the players in surmounting the final challenges and battles.
1. OSCE writing lesson: OSCE candidates need to be rewarded for asking the right questions and using good communication skills – standardized patients need robust backstories and scripts that provide depth and answers. How easily should SPs “give up” answers? These are details which should be written into the OSCE case.
5. Make the puzzles challenging but solvable.[⁶] The DM needs to create a compelling storyline, but offer flexibility in completion, and provide challenging but ultimately solvable scenarios. In D&D, players progress their characters through different “levels.” A level 1 character would be inexperienced, while a level 10 character would have already had many adventures. A level 1 character should not be faced with a dragon on the first adventure.
1. OSCE writing lesson: The OSCE writer needs to create a compelling storyline, but offer flexibility in completion, and provide challenging but ultimately solvable scenarios. How is the OSCE case being benchmarked in terms of difficulty? Are the tasks appropriately dialed-in for junior trainees? Senior trainees? To modify the difficulty of the case, consider how much information the SP will “give up.” Consider also where you are situating the clinical case: at initial presentation? After initial investigations? In preparation for discharge?
6. Use a variety of monsters and build interesting encounters.[⁶] For DMs, throwing a homogenous stream of orcs at players throughout an adventure can become monotonous. Also, not all encounters need to involve combat.
1. OSCE writing lesson: Increase case complexity through multiple mechanisms (e.g., assessing different CanMeds roles, physician activities or dimensions of care).[⁸] Thinking even more broadly, what about the use of props? What about the use of a second standardized individual in the room to provide a different dynamic?

CALLING ALL DUNGEON MASTERS

The approaches and lessons of being a DM align with being an OSCE case writer. The writer is creating a world without magic or dragons, but it is an act of creation nonetheless. Success is determined when the candidate is transported in their own mind to the world you are weaving. There are numerous D&D players and fans around the world, many of them physicians. As we look to recruit more OSCE writers, D&D Dungeon Masters represent a cohort who have already engaged in masterful storytelling and world building. Perhaps these individuals are an untapped next generation of leaders in medical assessment?

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.