---
title: "Improving Oral Exam Outcomes in Medical Education: Evidence-Based Structured Approaches"
id: "plos-one-18-structured-approaches-to-improving-outcomes-of-oral-exam-in-medical-and"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-18-structured-approaches-to-improving-outcomes-of-oral-exam-in-medical-and"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355461"
published_at: "2026-08-10T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Improving Oral Exam Outcomes in Medical Education: Evidence-Based Structured Approaches
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-18-structured-approaches-to-improving-outcomes-of-oral-exam-in-medical-and
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355461)
- **Published At:** 2026-08-10T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This systematic review synthesized 102 studies from an initial 25,594 records to map challenges, requirements, and solutions for oral examinations in medical and paramedical education. - Most studies were in **medicine** (70.6%) and focused on undergraduate (44.1%) and postgraduate (37.3%) learners. Publications increased notably after 2000. - **Structured oral examinations (SOEs)** were the predominant format (56.9%) and showed superior psychometric performance compared with traditional formats: median Cronbach’s alpha 0.75 and inter-rater ICC range 0.47–0.82. - Convergent validity with **OSCEs** was modest to strong across studies (correlations r = 0.10–0.74), indicating varying degrees of agreement with other objective assessments. - Top challenges identified: examiner variability (66.7%), student anxiety (41.2%), and logistical constraints (34.3%). Quality concerns included lack of standardization, examiner training gaps, and potential bias. - Core requirements for improvement included thoughtful assessment design, examiner calibration, technological integration, and fairness/equity considerations. - Most-cited solutions were examiner and rater **training** (60.8%), standardization and rubrics (56.9%), and use of **technology** (27.5%), with reported improvements in pass rates (50–100%) and learner/ faculty satisfaction (72–96%). - The authors propose a comprehensive framework favoring multi-station **objective structured viva examinations (OSVEs)**, hybrid (in-person and digital) delivery, combined analytic rubrics, and **AI-assisted** scoring to enhance reliability and scalability. - Reported limitations across the literature included concerns about generalizability (91.3%), small sample sizes (49.5%), and incomplete validation of predictive validity and AI tools. - The review concludes that standardized, technology-supported oral assessments can improve fairness and reliability but calls for further validation studies and exploration of AI-driven, bias-mitigating solutions.
## Clinical Analysis & Structured Key Points
Structured approaches to improving outcomes of oral exam in medical and paramedical education: A systematic review and evidence-based framework | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Introduction Oral examinations are central to medical and paramedical education for assessing reasoning, communication, and professional competencies, but remain challenged by issues of reliability, bias, and standardization. This systematic review synthesizes evidence on issues, requirements, and solutions to optimize oral exam outcomes in these fields. Materials and methods Following PRISMA guidelines, a comprehensive search was conducted across 14 databases (e.g., PubMed, Scopus, Web of Science) up to June 23, 2025, using PICO-framed queries focused on medical and paramedical students. Inclusion criteria encompassed English-language full text studies on oral assessments; exclusions included editorials and reviews. Three independent reviewers screened titles, abstracts, and full texts, extracting data on study characteristics, challenges, requirements, solutions, and outcomes. Quality appraisal utilized QUADAS, with thematic analysis and matrix patterns to identify correlations. Results From 25,594 records, 102 studies were included after deduplication and screening. The number of publications increased substantially after 2000, with the majority originating from the field of medicine (70.6%) and primarily addressing undergraduate (44.1%) and postgraduate (37.3%) education. Structured oral examinations (SOEs) dominated (56.9%), outperforming traditional formats in reliability (median Cronbach’s alpha 0.75; inter-rater interclass correlation coefficient (ICC) 0.47–0.82) and validity (modest correlations with objective structured clinical examinations (OSCEs), r=0.10–0.74). Key challenges included examiner variability (66.7%), student anxiety (41.2%), and logistical constraints (34.3%). The important requirements included assessment design, examiner calibration, technological integration, and equity. Solutions were emphasized on training (60.8%), standardization (56.9%), and technology (27.5%), yielding improved pass rates (50–100%) and satisfaction (72–96%). A comprehensive framework recommends multi-station objective structured viva examinations (OSVEs), hybrid delivery, combined rubrics, and artificial intelligence (AI)-assisted scoring for optimization. Limitations included generalizability (91.3%) and small samples (49.5%). Conclusions This review outlines key challenges and strategies to improve the quality of oral examinations. Standardized oral examinations, supported by technology, offer fair and reliable assessments. The findings provide a framework for educators and researchers to optimize their use, while future studies should validate predictive validity and explore AI-driven solutions to reduce bias and enhance scalability. Citation: Torab-Miandoab A, Ghafourifard M, Habibi-Chenaran S, Ghaffarifar S (2026) Structured approaches to improving outcomes of oral exam in medical and paramedical education: A systematic review and evidence-based framework. PLoS One 21(8): e0355461. https://doi.org/10.1371/journal.pone.0355461 Editor: Santhi Silambanan, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), INDIA Received: May 12, 2026; Accepted: July 22, 2026; Published: August 10, 2026 Copyright: © 2026 Torab-Miandoab et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The dataset supporting the conclusions of this article is included within the article (and its additional file). Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Abbreviations: PRISMA, preferred reporting items for systematic reviews and meta-analyses; QUADAS, quality assessment of diagnostic accuracy studies; SOE, structured oral examinations; OSCE, objective structured clinical examination; ICC, interclass correlation coefficient; OSVE, objective structured viva examination; AI, artificial intelligence; MBBS, bachelor of medicine, bachelor of surgery; PGY, post-graduate year; USA, United states of America; COVID-19, coronavirus disease-SARS-CoV-2; App, application; EPA, entrustable professional activities; PhD, doctor of philosophy; MSc, master of science; VR, virtual reality; AR, augmented reality; SJT, situational judgment tests; OSCJ, objective structured clinical judgment; EBM, evidence-based medicine; NLP, natural language processing; BARS, behaviorally anchored rating scales; CTT, classical test theory; IRT, item response theory; SP, standardized patient; AV, audiovisual; PPE, personal protective equipment; LMS, learning management systems; UPS, uninterruptible power supply; GDPR, general data protection regulation; HIPAA, health insurance portability and accountability act; IRR, inter-rater reliability; SEM, standard error of measurement; DIF, differential item functioning; IT, information technology; IRB, institutional review board; QA, quality assessment; CEX, clinical evaluation exercise; ACGME, Accreditation Council for Graduate Medical Education; CanMEDS, Canadian Medical Education Directives for Specialists Introduction An oral examination—also known as a viva or oral assessment—is a face-to-face evaluation method in which students verbally respond to examiners’ questions. It can be conducted one-on-one or in front of a panel and often involves discussion, case analysis, or problem-solving tasks [ 1 ]. The format allows examiners to probe the depth of understanding, clarify ambiguous responses, and assess how students organize and express their thoughts under pressure [ 2 ]. Oral exams are widely utilized across various disciplines and levels of education, particularly in high-stakes contexts [ 3 ]. In the medical and paramedical fields—including medicine, nursing, dentistry, physiotherapy, pharmacy, and public health—oral assessments play a critical role in evaluating students’ clinical decision-making, ethical reasoning, and professional judgment. They are also commonly used in interprofessional education settings, interdisciplinary case conferences, and competency-based assessments, reflecting their broad applicability and value in healthcare education [ 4 ]. The oral examination format offers several advantages over written and multiple-choice tests. It provides the opportunity for interactive assessment, immediate feedback, and tailored questioning based on student responses [ 5 ]. Oral exams closely mirror real-world clinical interactions, making them superior in assessing non-cognitive skills such as empathy, communication, professionalism, and the ability to think on one’s feet [ 6 ]. Its adaptability also allows examiners to explore complex reasoning processes, identify misconceptions, and evaluate critical thinking in ways that traditional written exams often fail to achieve [ 7 ]. Despite these strengths, oral exams have been persistently scrutinized for issues related to objectivity, reliability, inter-examiner variability, and susceptibility to bias. Concerns about consistency in questioning, examiner subjectivity, and limited standardization have raised questions about their fairness and validity, particularly when used in high-stakes settings [ 8 ]. Furthermore, the evolving complexity of medical education—with increased emphasis on competency-based assessment, digital innovation, and equity—has underscored the need for structured, evidence-informed improvements to oral examination methods [ 9 ]. Several educational frameworks and assessment models have been proposed to optimize oral exams, including structured oral examinations (SOEs), objective structured clinical examinations (OSCEs), and digital or video-recorded formats. However, the implementation of these strategies varies widely across institutions and regions, and the evidence regarding their effectiveness, feasibility, and educational impact remains scattered across the literature. A comprehensive understanding of the current challenges, best practices, and innovations is essential to inform educators, accreditation bodies, and policy-makers aiming to enhance the quality and outcomes of oral assessments [ 10 ]. In spite of their critical role in professional qualification and competency assurance, oral examinations in medical and paramedical sciences face persistent challenges related to standardization, validity, and educational effectiveness [ 11 ]. The lack of uniform criteria, examiner training, and robust quality assurance mechanisms has led to variability in outcomes and concerns about fairness and reliability. Moreover, emerging educational demands—such as competency-based learning, interprofessional collaboration, and technological integration—require updated and evidence-based approaches to oral assessment format [ 12 ]. While numerous interventions and modifications have been suggested in the literature to address these issues, there is a paucity of systematically synthesized evidence that comprehensively maps the existing challenges, stakeholder requirements, and viable solutions. Without such synthesis, efforts to reform oral examination practices risk being fragmented, inconsistent, or misaligned with educational goals. This systematic review aims to critically evaluate and integrate current research on the issues, requirements, and potential solutions to optimize oral examinations in the context of medical and paramedical education. Materials and methods This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which outline a standardized framework for reporting systematic reviews and meta-analyses [ 13 ]. This study was approved by the Ethics Committee of Tabriz University of Medical Sciences (Approval Code: IR.TBZMED.VCR.REC.1404.283). Review question This systematic review was guided by the following PICO question: Among medical and paramedical students undergoing oral examinations (Population), what assessment strategies, requirements or interventions (Intervention), compared to traditional methods or no interventions (Comparison), are effective in improving oral examination outcomes (Outcome)? Sources of information A thorough literature search was performed across multiple electronic databases up to June 23 2025. These databases included PubMed, Web of Science, Scopus, CINAHL, ERIC, BIE, PsycINFO, IEEE, ProQuest, MEDLINE, Cochrane Library, Embase, SID, and ISC. In addition to peer-reviewed publications, we searched grey literature sources, including conference proceedings, books, dissertations, university repositories, institutional reports, and Google Scholar to reduce publication bias. These sources were identified through database searches, manual reference screening, and institutional repositories. Although grey literature was screened, only studies meeting all predefined eligibility criteria were included in the final review. To maintain awareness of new research, email alerts were configured in the databases to notify the authors of new studies matching the inclusion criteria, based on saved search queries as of June 23, 2025. Inclusion and exclusion criteria Studies were eligible for inclusion if they focused on oral examinations within the context of medical and paramedical education. Only English-language articles with full text availability were considered. The editorials, commentaries, review papers, and opinion pieces were excluded from the review. There were no limitations on the year of publication. Search strategy Search keywords were developed based on the study objectives, previously published literature, and input from subject-matter experts in medical informatics, health information management, and medical education. The detailed search syntax is outlined in Table 1 . A medical librarian and an information specialist reviewed and approved the final search strategy. It is also noted that this search protocol was not pre-registered. Download: PNG larger image TIFF original image Table 1. The syntax of search strategy. https://doi.org/10.1371/journal.pone.0355461.t001 Initially, potentially relevant articles were identified based on their titles and imported into EndNote. Duplicate entries were then removed. A more detailed screening followed, which involved reviewing the abstracts and full texts to further refine the list of eligible studies. Data collection procedure Three researchers (A.T-M., S.Gh., and M.Gh.) independently evaluated the articles using a standardized spreadsheet. Each researcher assessed the titles for the inclusion and exclusion criteria, and articles that received two or more votes for exclusion were removed. In the next phase, the abstracts of the remaining studies were assessed independently using the same criteria, and those with at least two exclusion votes were discarded. Finally, the full texts were independently reviewed by all three authors, and studies flagged by at least two researchers were excluded. A uniform data extraction form was employed to gather pertinent details from the selected articles. Information extracted included title, authors, year, country, study objective, study design, target population, educational setting, type of exam, technological component, challenges, requirements and needs, solutions, outcomes/key findings and limitation. All extracted data were consolidated and reviewed for accuracy by an independent investigator to ensure completeness and correctness. No data were missing from the final dataset. Quality evaluation To support the inclusion and exclusion decisions, a formal quality appraisal was performed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist. This tool is designed to assess the methodological rigor and trustworthiness of diagnostic studies, either as a whole or by evaluating their validity and reliability separately [ 13 ]. The checklist comprises 14 questions, each scored as “yes,” “no,” or “unclear.” Two researchers independently assessed each study for potential sources of bias. A “yes” was assigned when the required information was clearly reported, “no” if the information was absent, and “unclear” if the report lacked sufficient detail. Based on existing guidelines, studies scoring 7 or more out of 14, with a majority of “yes” responses, were considered high quality, while those scoring below 7 were classified as low quality. Any disagreements between the reviewers were resolved through mutual discussion and consensus. To visualize and report the findings, various software tools were used, including Microsoft Excel, XMind, an online word cloud generator, and the yED Graph Editor. Results PRISMA-based study selection The comprehensive literature search across all databases identified 25,594 records. Following the removal of duplicates (n = 14,842), 10,752 unique records remained for initial title screening. Of these, 9,973 were excluded due to irrelevance based on title review, leaving 779 records for abstract screening. After evaluating abstracts, 598 records were excluded, resulting in 181 articles subjected to full text assessment for eligibility. Among these, 79 articles were excluded for the following reasons: non-English language (n = 3), failure to meet inclusion criteria (n = 72), and unavailability of the full text (n = 4). Ultimately, 102 studies fulfilled the eligibility criteria and were included in the systematic review. The study selection process is illustrated in the PRISMA flow diagram ( Fig 1 ). Download: PNG larger image TIFF original image Fig 1. PRISMA flow diagram. https://doi.org/10.1371/journal.pone.0355461.g001 Trends in scholarly output and global research distribution The histogram provided in Fig 2 illustrates the temporal distribution of publications on oral examinations in medical and paramedical education, based on data retrieved from multiple databases spanning 1890 to 2025. The findings indicate that research on oral examinations in medical and paramedical education was virtually absent prior to the mid-20th century, after which a gradual increase in scholarly output emerged. This growth accelerated markedly from the late 20th century onward, culminating in a peak in recent years, particularly approaching 2025. Early contributions during this period often focused on problem-solving formats within specific disciplines, such as family medicine, before evolving toward more diverse approaches in the late 20th and early 21st centuries. These later developments encompassed structured group examinations, as well as the integration of technological tools into viva voce assessments. Collectively, reviewing the trend reflects a sustained and expanding academic emphasis on oral assessment methods, driven by shifts in educational paradigms, advancements in assessment methodologies, and the growing recognition of oral examinations as a critical element of competency-based evaluation. Moreover, the accompanying world map depicts the geographical distribution of publications, with notable concentrations in North America, Europe, Oceania and selected regions of Asia, underscoring the global reach and collaborative nature of research in this domain ( Fig 2 ). Download: PNG larger image TIFF original image Fig 2. The trend of articles in the field of oral exam in medical and paramedical education in databases (The world map shown in Fig 2 was created by the authors using a public-domain base map (Natural Earth - http://www.naturalearthdata.com/ )). https://doi.org/10.1371/journal.pone.0355461.g002 Keyword mapping and thematic patterns The word cloud, derived from a comprehensive analysis of literature on oral examinations in medical and paramedical education retrieved from multiple databases, visualizes the most frequently used terms in this research domain ( Fig 3 ). Prominent keywords such as “Examine,” “Oral,” “Assess,” “Exam,” “Question,” “Student,” “Score,” “Valid,” and “Reliable” highlight core themes related to assessment methodologies, evaluation criteria, and the reliability of oral testing. Additional terms, including “Structure,” “Performance,” “Feedback,” and “Skill,” indicate an emphasis on structured assessment frameworks, performance appraisal, and the provision of constructive feedback. The presence of context-specific terms such as “Clinical,” “Medical,” “Case,” and “Viva” reflects the integration of oral examinations into clinical training and applied educational contexts. Collectively, this visualization underscores a sustained scholarly interest in the development and refinement of valid, reliable, and structured oral assessment tools tailored to the pedagogical requirements of medical and paramedical education. Download: PNG larger image TIFF original image Fig 3. Frequent words cloud based on findings. https://doi.org/10.1371/journal.pone.0355461.g003 Overview of study designs Analysis of the study designs reported in the 102 included articles revealed a diverse methodological landscape. Observational studies were the most common (n = 31), often incorporating inter-rater reliability assessments, generalizability analyses, and performance evaluations to examine real-world assessment practices. Experimental and quasi-experimental designs (n = 15) encompassed randomized controlled trials, crossover studies, and other interventional approaches, frequently aimed at comparing structured versus traditional examination formats and their effects on validity, relia
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