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THE DEFINITIVE GUIDE
TO THE OSCE
For Elsevier
Content Strategist: Laurence Hunter
Content Development Specialist: Carole McMurray
Project Manager: Anne Collett
Designer/Design Direction: Miles Hitchen
Illustration Manager: Amy Faith Naylor
Illustrator: Suzanne Ghuzzi
THE DEFINITIVE GUIDE
TO THE OSCE
The Objective Structured Clinical Examination
as a performance assessment

Ronald M. Harden OBE MD FRCP (Glas) FRCPC FRSCEd

Professor Emeritus Medical Education, University of Dundee, UK;
General Secretary, Association for Medical Education in Europe (AMEE)

Pat Lilley BA (Hons)

Operations Director, Association for Medical Education in Europe (AMEE)

Madalena Patrício PhD

Professor of Education, Faculty of Medicine, University of Lisbon, Portugal

Foreword by

Geoff Norman PhD

Professor Emeritus, Department of Clinical Epidemiology and Biostatistics,
McMaster University, Hamilton, Ontario, Canada

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto

2016
SECTION A Atrophies and Disorders of Dermal Connective Tissues

© 2016 Elsevier Ltd. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any

means, electronic or mechanical, including photocopying, recording, or any
information storage and retrieval system, without permission in writing from the
publisher. Details on how to seek permission, further information about the Publisher’s
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Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).

ISBN 978-0-7020-5550-8

Notices
Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised
to check the most current information provided (i) on procedures featured or (ii) by the
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formula, the method and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and knowledge of their
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individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors,
or editors, assume any liability for any injury and/or damage to persons or property as
a matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

The
publisher’s
policy is to use
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Printed in China
 Contents

Foreword vii
Preface xi
About the Authors xiv
Contributors to Case Studies xvi
Acknowledgements xix

SECTION A
An introduction to the OSCE 1

1 What is an OSCE? 1
An introduction to the OSCE for readers unfamiliar with the concept and, for those already familiar with
the OSCE, a more in-depth insight into the characteristics that define the OSCE as an assessment tool.

2 The inside story of the development of the OSCE 13

An account of how the OSCE was conceived and developed in the 1970s in response to the assessment
challenges facing educators in the healthcare professions.

3 The OSCE as the gold standard for performance assessment 23

The OSCE with its multiple samples of performance has come to dominate performance assessment
and merits a place in every assessor’s toolkit.

4 How the OSCE can contribute to the education programme 35

The OSCE can be adopted as an assessment tool in any situation or phase of education where an
assessment of the learner’s clinical or practical skills is important.

5 What is assessed in an OSCE? 49

The OSCE can be used to assess a range of learning outcomes, including communication skills, physical
examination, practical procedures, problem solving, clinical reasoning, decision making, attitudes and
ethics and other competencies or abilities.

SECTION B
Implementation of an OSCE 65

6 Choosing a format for an OSCE 65

Flexibility is a major advantage of the OSCE. Many factors influence the choice of format. These include
the number of examinees, the purpose of the examination, the learning outcomes to be assessed, the
resources available and the context of the local situation.

7 The setting for an OSCE 83

The OSCE can be located in a range of settings. The selection of a venue will depend on the nature of
the examination and the local circumstances.

v
 8 The patient 91
Patients in an OSCE may be represented by real or simulated patients, computer representations, video
recordings, medical records and investigation results or a combination of all these. Each has a specific
role to play.

9 The examiner 105

Health professionals, simulated patients and students can serve as examiners in an OSCE. Their roles
and responsibilities should be defined and training provided.
Contents

10 Implementing an OSCE 115

There are ‘good’ and ‘bad’ OSCEs. Advance planning and effective organisation on the day are neces-
sary to deliver a ‘good’ OSCE.

11 Evaluating the examinee’s performance 127

Different approaches can be adopted for assessing performance in an OSCE, making pass/fail decisions
and setting standards.

12 Providing feedback to the learner 149

The OSCE can be a powerful learning experience, and a variety of approaches can be adopted for the
provision of feedback to the learner.

13 The examinee’s perspective 161

Communicating with learners about the OSCE is important. Examinees can prepare for and maximise
their performance during an OSCE.

14 Evaluating an OSCE 169

Evaluation and quality control of an OSCE is important, and constant monitoring and improvement are
necessary.

15 Costs and implementing an OSCE with limited resources 181

The resources required and the costs incurred can be tailored to the local situation. The OSCE can, but
need not, be expensive to administer. Many OSCEs are run at little or no additional cost.

SECTION C
Some final thoughts 193

16 Limitations of the OSCE 193

The OSCE has an important role to play in the examiner’s toolkit alongside other assessment approaches.
If recognised, the limitations of the OSCE can be addressed.

17 Conclusions and looking to the future 203

The OSCE will continue to evolve and have a major role to play in response to changes in medical
education.

SECTION D
Case studies 213

SECTION E
References 323

SECTION F
Bibliography 345

Index 353

vi
 Foreword

When Ron Harden approached me to write the foreword, I viewed it as a distinct

honour. It was also a bit of a watershed. There was a time, now two decades ago,
when I would have been the last person Ron would have asked (and, yes, it’s Ron
to me, not Professor Harden – entirely as a result of the incident I am about to
relate). And if he had asked me to write the foreword, to paraphrase Lyndon Johnson,
“If asked, I would not write”. But something happened twenty years ago that has a
bearing on both the book itself and my authoring of the foreword.

Prior to 1995, Ron and I were at opposite poles. With my PhD in physics, I was a
purist ivory-tower researcher whose goal was to advance the science of education.
Consequences of my actions were of no consequence. Ron’s goals were almost dia-
metrically opposed. He genuinely wanted to improve the education of medical stu-
dents and physicians, and the more people he could influence, the more impact he
could have. I was the elitist; Ron the populist. To me, no standards could be rigorous
enough; to Ron, engagement was the issue, and so he would bring in the novices
and nurture them to higher standards.

Then, in 1995, we met at a small conference in Islamabad, and ended up in my

hotel room – just me, Ronald and a third participant named Johnnie Walker. And
we have become good friends and confidants ever since. In hindsight, I began to
understand better where he was coming from, and moreover, I began to realize that
the inclusiveness of meetings like AMEE and the Ottawa Conference, both of which
had a large Harden imprimatur (along with Ian Hart, rest in peace, one of the loveli-
est men ever to grace this planet), served an ulterior motive. By making a conference
presentation accessible to almost all, he created a venue where even novices could
come and fall under the influence of some of the masters. Moreover, the large
number of participants enabled the conference to “buy” top class people as plenary
speakers. So my arrogance was misplaced and arguably Ron, with his inclusiveness,
has done more to improve the quality of medical education than all of us
academics.

At another level, perhaps we were both right. Both of us went on to be awarded the
Karolinska Prize, the highest award in medical education research. We have both
been widely recognized for our contributions – far more than I (and my wife) could

vii
 ever have dreamed possible. And despite the fact that our world views remain dis-
tinct, each has come to appreciate the contribution of the other.

Back to Ron, and the underlying rationale for this book. Nowhere is his genuine
concern more evident than in the development and success of the OSCE. Ron
describes the concerns he had about assessment in Chapter 2. Recognizing the fail-
Foreword

ings of the traditional clinical examination, which bore more resemblance to the
Spanish Inquisition than anything in education, he devised the OSCE strategy to
provide a more equitable test of clinical skills.

However, left unstated in his narrative is just why the OSCE became so popular.
(And it is popular. I do a workshop on assessment around the world. I used to ask
people if they know what an OSCE is. I don’t anymore. Everyone, in every land,
knows what OSCE is.) To understand its popularity requires an expanded history
lesson.

Back in the early 1970s when I was first hired into medical education, we were all
preoccupied with “skills” – problem-solving skills, critical thinking skills, commu-
nication skills, physical examination skills, evidence-based medicine skills, etc. I
was hired (Why me, Lord? Goodness knows.) to investigate clinical problem-solving
skills. We put doctors and students into rooms with simulated patients, videoed
them, reviewed their tapes, and pored over the transcripts seeking the mysterious
elixir of problem-solving skill. We never found it. Instead what we found, looming
large, was “content specificity”, as identified by the group at Michigan State (Elstein
et al. 1978). In brief, successful problem-solving was dictated as much by the specific
knowledge required to solve the problem as by any general intellectual skill. And
when we looked at other measures of “problem-solving” we found the same issue.
Patient Management Problems or PMPs (McGuire and Babbott 1967) were a written
objective case-based test, requiring about 45 minutes per case. For them as well, the
correlation of performance measures across problems was 0.1 to 0.3. Since each
PMP took about 45 minutes, it was not long before PMPs were dropped from licens-
ing and specialty examinations.

The solution to the psychometric problem was simply one of sampling. To get good
measurement required multiple samples rated by multiple observers (and, inciden-
tally, sampling across cases was more important than sampling across raters). The
larger issue, as noted by Ron in Chapter 2, was that removing the PMP meant that
most examinations were now multiple choice only. While that may be acceptable
for a specialty examination where the goal is just precise and valid measurement, it
is not acceptable for educational programs because of the potential steering effect
(Newble and Jaeger 1983). What was required was something that, on the one hand,
efficiently sampled over cases and raters, and on the other, measured actual perform-
ance. Enter OSCE! And as they say, the rest is history.

Not surprisingly, though, as an innovation gets disseminated, it also gets diluted

and mutated. Strategies like problem-based learning, small group learning,

viii
multiple-choice tests – just about everything we do in education – eventually get
reborn in so many variations as to be almost unrecognizable. It’s not like a drug – 
there is no equivalent of 300 mg t.i.d. As a result, it is critical to develop standards
of best practice, based on evidence. To some degree this is achieved by approaches
like Best Evidence Medical Education (another Harden innovation), although the
constraints of systematic review methodology limit the usefulness of these reviews

Foreword
as guidelines for educational practice. And that is where this book is an invaluable
addition. It pulls together in one place pretty well everything that is known about
the OSCE; what works and what doesn’t. It is a welcome addition to the bookshelf
of any educational leader. Please enjoy!

Geoff Norman
Professor Emeritus, Department of Clinical Epidemiology and
Biostatistics, McMaster University, Hamilton, Ontario, Canada

References
Elstein, A.S., Shulman, L.S., Sprafka, S.A., 1978. Medical Problem Solving: An Analysis of
Clinical Reasoning. Harvard University Press, Cambridge MA.
McGuire, C.H., Babbott, D., 1967. Simulation technique in the measurement of clinical
problem-solving skills. J. Educ. Meas. 4, 1–10.
Newble, D.I., Jaeger, K., 1983. The effect of assessments and examinations on the learning
of medical students. Med. Educ. 17, 165–171.

ix
This page intentionally left blank
 Preface

The assessment of the competence of a student, trainee or healthcare professional,

it can be argued, is the most challenging task facing the teacher or educator today.
There are many reasons why it is an important task. The public needs to be reas-
sured that the doctor certified by the medical school as competent to practise has
the necessary knowledge, skills and attitudes. In the undergraduate curriculum, the
student has to show that he/she has achieved the competencies necessary to move
on to the next stage of the curriculum. The junior doctor or trainee has to demon-
strate that he/she is qualified to work as a specialist in medicine, surgery, general
practice or some other field. Assessment of the learner is a key element in the move
to outcome-based or competency-based education, with an answer to the question
– has the learner achieved the necessary learning outcomes?

There are other reasons why assessment is important. What we choose to assess
is perceived by the learner as an indication of what we value in a training pro-
gramme, and this impacts directly on the learner’s behaviour and study pattern.
There is also a new understanding of the relationship between learning and
assessment that embraces more than ‘assessment of learning’. In ‘assessment for
learning’, or ‘assessment as learning’, assessment is an integral part of the overall
educational programme. So, although this book is about assessment and, indeed,
one approach to assessment, it is relevant to everyone who is engaged with cur-
riculum planning, teaching and learning, instructional design, quality assurance
and student selection.

Over the years there has been an increasing interest in both the theoretical principles
underpinning assessment and the tools used to implement assessment in practice
(McGaghie 2013). Whilst much has changed, much has remained the same. Reliabil-
ity (consistency), validity (measuring what we need to measure) and feasibility or
practicality remain key criteria on which an assessment tool can be judged, with the
acceptability and impact that the assessment method has on the learner also attract-
ing attention. In the past, much emphasis had been placed on reliability as an
assessment matrix and on the assessment of knowledge acquisition. The importance
of the validity of an assessment and the need to assess clinical skills and competen-
cies rather than simply knowledge acquisition, however, is now recognised. It was
with this in mind that the OSCE was developed as a reliable and valid tool to assess

xi
 the clinical skills of the learner (Harden et al. 1975). The OSCE has come to domi-
nate performance assessment (Norman 2002) and is recognised as the best method
of formally assessing clinical skills (Reznick et al. 1997). The OSCE has proved to
be a useful tool for both summative assessment with judgements as to the exami-
nee’s competence to practise or move on to the next step of training and for formative
assessment with feedback to the examinee. The OSCE has also been used extensively
Preface

in the evaluation of curricula, courses or teaching methods and is now used also as
a tool to select students for admission to medical studies.

A key factor in the acceptance and increasing use made of the OSCE has been its
flexibility, with the process being readily adapted to meet local needs, simple or
complex, and to assess a range of learning outcomes in different phases of the cur-
riculum. Outcomes assessed include traditional competencies relating to communi-
cation and physical examination skills and also competencies attracting attention
more recently, including patient safety, professionalism and teamwork. There has
been increasing interest, too, in the selection of students for admission to medical
studies, and a version of the OSCE – the multiple mini-interview (MMI) approach
– has been used for this purpose. For all of these reasons the OSCE and this book
have a place in the assessor’s toolkit.

When administered well, the OSCE is a powerful and valuable tool to assess a
learner’s competence in the area tested. Examples can be found where the OSCE is
administered in an inappropriate manner and one that does not reflect best practice
(Gupta et al. 2010; Huang et al. 2010; Sturpe 2010). This can be a serious problem,
particularly when the OSCE is used as a summative assessment to certify that a
graduating doctor has the skills necessary to practise or that a trainee is competent
to practise as a specialist. The adoption of the approaches presented in the book
should ensure that problems are avoided in the implementation of an OSCE and
only high-quality OSCEs are used in the assessment of students and trainees.

We have written the book to provide the reader with an easily accessible account of
the basic concepts underpinning the OSCE and how an OSCE can be implemented
in practice. We thought that the reader might also be interested in the story of how
the OSCE was initially developed and introduced as an assessment tool in medicine.
The practical guidelines and tips provided are based on the extensive experience that
we and others have gained over the past 40 years. You will find in the text, as well
as in the case studies, information and ideas about how the OSCE can be used in
a wide range of settings and in different professions to assess the expected learning
outcomes. In the boxes, you will find personal accounts and anecdotes that illustrate
the points made in the text.

We look at the OSCE from the perspectives of the examiner, the student and the
patient and address issues, including advance planning, possible venues, the design
of stations, alternative approaches to scoring the examinee’s performance, the provi-
sion of feedback and the evaluation of the OSCE. We also look at how the OSCE
can be implemented when the available resources are constrained. The OSCE has

xii
not been without its critics, and in Section C of the book we address limitations on
the use of the OSCE and common misconceptions. Finally, we look at the continu- 
ing development of the OSCE and the changes we might see in the years ahead.

The book will be of interest to teachers or trainers in the healthcare professions

working in undergraduate, postgraduate or continuing education. Many teachers,

Preface
trainers or clinical supervisors will be engaged with an OSCE as an OSCE station
developer, an examiner, a curriculum or programme planner, a student/trainee
advisor or counsellor or an education researcher. The book should also have a
wider appeal outside the healthcare professions and be of value in any context
where there is an interest in performance assessment. As demonstrated by the
police force in England and Wales, the approach can be readily adapted for use
in different situations.

More than 1,800 papers have been published on the OSCE. This book is based on
our own personal experience with OSCEs and informed by the work of others from
around the world. The case studies included in Section D and referred to throughout
the book provide valuable examples of how the OSCE can be implemented in practice
in different situations.

It is not our intention to provide a complete systematic review of the published

literature on the OSCE. We have studied the publications on the OSCE, however,
and have referred to papers where we feel they add to an understanding of the OSCE
as it is presented in this book. We refer throughout the text to key papers in the area
and to examples that illustrate the different ways in which an OSCE can be employed
in practice, highlighting the use of the OSCE in different subjects and professions.
There are many more examples of its use that we could have included but have had
to omit them because of space constraints.

You may choose to read systematically through the book and address the themes as
we have presented them or to dip into the chapters and topics most relevant to your
needs. Whatever approach you adopt, we hope that you find the book an interesting
read and that it includes ideas that you can employ with advantage in your own
setting.

Ronald Harden
Pat Lilley
Madalena Patrício

xiii
 About the Authors

Ronald M. Harden
Professor Ronald Harden graduated from medical school in Glasgow, Scotland, UK.
He completed training and practised as an endocrinologist before moving full time
to medical education. He is Professor of Medical Education (Emeritus), University
of Dundee, Editor of Medical Teacher and General Secretary and Treasurer of the
Association for Medical Education in Europe (AMEE).

Professor Harden has pioneered ideas in medical education, including the Objective
Structured Clinical Examination (OSCE), which he first described in 1975; has
published more than 400 papers in leading journals; is co-editor of A Practical
Guide for Medical Teachers; and is co-author of Essential Skills for a Medical
Teacher: An introduction to learning and teaching in education. His contributions
to excellence in medical education have attracted numerous international awards,
including the Hubbard Award by the National Board of Medical Examiners, USA;
an OBE by Her Majesty the Queen for services to medical education, UK; the
Karolinska Institute Prize for Research in Medical Education, which recognises
high-quality research in medical education; and a Cura Personalis Honour, the
highest award given by Georgetown University, Washington, DC, USA.

Pat Lilley
Pat Lilley joined the University of Dundee in 1995 and worked on a range of projects
in the Centre for Medical Education. In 1998 she joined the Association for Medical
Education in Europe (AMEE) and has been part of its development into a leading
healthcare educational association with members in over 90 countries. Now AMEE
Operations Director, Pat is closely involved in all of AMEE’s projects and initiatives.
Since 2006 she has assisted in the development and execution of the AMEE Essential
Skills in Medical Education (ESME) face-to-face courses for teachers and is a course
tutor for the online ESME Course. Pat is also Managing Editor of AMEE’s journal
Medical Teacher.

Madalena Patrício
Madalena Folque Patrício is Past President of AMEE and an ex officio member of its
Executive Committee. She is Chair Elect of the Best Evidence Medical Education
(BEME) Collaboration, a member of the Editorial Board of the journal Medical

xiv
Teacher and external adviser to the World Federation for Medical Education. She is
Professor at the Institute of Introduction to Medicine at the Faculty of Medicine of 
the University of Lisbon and Head of the Lisbon BEME Group at the Center for
Evidence Based Medicine (CEMBE), where she coordinates a systematic review on
the reliability, validity and feasibility of the Objective Structured Clinical Examina-
tion (OSCE). Her special interests are evidence-based teaching, humanization of

About the Authors

medicine, community-based teaching, social accountability of medical schools and
the Objective Structured Clinical Examination (OSCE). She was awarded the 2013
AMEE Lifetime Achievement Award.

xv
 Contributors to
Case Studies

Case Study 1: Dundee Medical Mohi M.A. Magzoub, MBBS MSC

School – Year 2 OSCE PhD MFPHM
Professor of Medical Education, College of
Rob Jarvis, MA MB ChB MPH FHEA Medicine, King Saud bin Abdulaziz
Academic Mentor (Educational Guidance University for Health Sciences, Ministry of
and Support Tutor), Medical School, National Guard Health Affairs, Riyadh,
University of Dundee, UK Kingdom of Saudi Arabia

Case Study 2: King Saud bin Case Study 3: Manchester Medical

Abdulaziz University for Health School MBChB – Phase 2
Sciences Cardiovascular System Formative OSCE
Block Phase 2 OSCE
Alison Quinn, MBBS FRCA
Tarig Awad Mohamed, BSc (Hons)
FCARCSI PgC Med Edu
MSc MHPE
Honorary Lecturer, Medical School,
Lecturer, Department of Medical
University of Manchester, UK
Education, College of Medicine, King
Saud bin Abdulaziz University for Health
Clare McGovern, FRCA
Sciences, Ministry of National Guard
Consultant Anaesthetist, Medical School,
Health Affairs, Riyadh, Kingdom of Saudi
University of Manchester, UK
Arabia

Bashir Hamad, MB BS MD DTPH Emyr Wyn Benbow, BSc MB ChB

DCMT DET FRSTM FFSMSB FRCPath
Senior Lecturer in Pathology, Medical
Professor of Medical Education, College of
School, University of Manchester, UK
Medicine, King Saud bin Abdulaziz
University for Health Sciences, Ministry of
National Guard Health Affairs, Riyadh,
Kamran Khan, MBBS FRCA
Kingdom of Saudi Arabia
MMedEd FAcadMed
Consultant Anaesthesiologist, James Paton
Ali I AlHaqwi, MD MRCGP(UK) Memorial Hospital, Gander, NL, Canada
ABFM MHPE PhD (Med Edu)
Associate Professor, Chairman, Department
of Medical Education, College of Medicine,
King Saud bin Abdulaziz University for
Health Sciences, Ministry of National
Guard Health Affairs, Riyadh, Kingdom of
Saudi Arabia

xvi
Case Study 4: Monash Lisa Altshuler, PhD
University Malaysia Formative Associate Director of Evaluation and 
OSCE Assessment, Program for Medical Education
Innovations and Research (PrMeir), New
Wee Ming Lau, MD MMed AM Grad York University School of Medicine,
Dip FP Derm PG Dip Occ Health NY, USA
GCHE

Contributors to Case Studies

Senior Lecturer, Jeffrey Cheah School of Ingrid Walker-Descartes, MD MPH
Medicine and Health Sciences, Monash Program Director, Pediatrics Residency
University Malaysia, Malaysia Training Program, Maimonides Medical
Center, NY, USA
Case Study 5: UCL Medical School
Final Examinations – Short Station Lita Aeder, MD
OSCE Director, Board Review Course,
Brookdale University Hospital and
Kazuya Iwata, BSc(Hons) MBBS Medical Center, NY, USA
MRCPsych MSc FHEA Members of the Maimonides
Honorary Clinical Lecturer in Medical
Pediatrics OSCE Committee
Education, University College London
Medical School, UK
Case Study 7: Medical Council of
Canada’s Qualifying Examination
Daniel S. Furmedge, MBBS Part II
MRCP(UK) DRCOG MAcadMEd
FHEA AKC Sydney Smee, PhD
Honorary Clinical Lecturer in Medical
Assessment Advisor, Medical Council of
Education, University College London
Canada (MCC), ON, Canada
Medical School, UK
Members and Consultants of MCC OSCE
Alison Sturrock, BSc(Hons) MRCP Test Committee who are Faculty members
PGCMedEd FHEA of Canadian Medical Schools
Clinical Senior Lecturer in Medical
Education, University College London Case Study 8: OSCE for
Medical School, UK Postgraduate Year-1 Resident
Physicians – Madigan Army
Deborah Gill, MBBS MRCGP MMEd Medical Center
FHEA EdD
Interim Director of University College Matthew W. Short, MD FAAFP
London Medical School, University College Madigan Army Medical Center, WA, USA
London Medical School, UK
Patricia A. Short, MD FACP
Case Study 6: Culture OSCE for Madigan Army Medical Center, WA, USA
Pediatric Residents

Elizabeth K. Kachur, PhD

Medical Education Consultant –
Maimonides Medical Center/Director,
Medical Education Development, National
& International Consulting, NY, USA

xvii
 Case Study 9: Dundee Mohamad Haniki Nik Mohamed,
Undergraduate BSc in Nursing PharmD BPharm
Programme – First-Year OSCE Associate Professor and Deputy Dean
(Academic Affairs), Faculty of Pharmacy,
Arlene Brown, MPhil BSc Nursing International Islamic University Malaysia,
PGCert(THE) RGN Kuantan, Malaysia
Lecturer in Nursing, School of Nursing and
Contributors to Case Studies

Midwifery, University of Dundee, UK Case Study 13: Postgraduate Year

1 – Patient Safety OSCE
Iain Burns, MSc Nursing BA
Business Organisation DipEd Dianne P. Wagner, MD
DipNurs RGN Professor of Medicine, Associate Dean for
Senior Lecturer in Nursing, School of College-wide Assessment, College of Human
Nursing and Midwifery, University of Medicine, Michigan State University, East
Dundee, UK Lansing, MI, USA

Case Study 10: OSCE in Ruth B. Hoppe, MD

Undergraduate Dentistry Professor of Medicine, Senior Associate
Dean for Academic Affairs Emeritus, College
Anthony Damien Walmsley, BDS of Human Medicine, Michigan State
MSc PhD FDSRCPS University, East Lansing, MI, USA
Professor of Restorative Dentistry, School of
Dentistry, University of Birmingham, UK Carol J. Parker, MPH
Executive Director of Academic Affairs,
Case Study 11: Diploma in College of Human Medicine, Michigan State
Veterinary Nursing University, East Lansing, MI, USA

Martin Barrow, BVM&S Case Study 14: Basic Abdominal

Chair of Governors, Central Qualifications Ultrasound Course
(CQ), Examination Board and Awarding
Organisation, UK Matthias Hofer, PD Dr med MPH
MME
Denise Burke Arzt für Diagnostische Radiologie, Leiter der
Quality Assurance Manager, Central AG Medizindidaktik, Studiendekanat,
Qualifications (CQ), Examination Board and Heinrich-Heine-Universitat Düsseldorf,
Awarding Organisation, UK Germany

Case Study 12: Summative OSCE Case Study 15: Dundee Medical
for a Clinical Pharmacy Course, School Multiple Mini-Interview
Malaysia (MMI)

Ahmed Awaisu, PhD MPharm Adrian Husbands, MSc

BPharm Lecturer in Medical Education, School of
Assistant Professor of Clinical Pharmacy Medicine, University of Dundee, UK
and Practice, College of Pharmacy, Qatar
University, Doha, Qatar Jon Dowell, MRCGP MD FHEA
Chair of UK Medical Schools Electives
Siti Halimah Bux Rahman Bux, Council, and Admissions Convener, School
BPharm of Medicine, University of Dundee, UK
Senior Academic Fellow and Deputy Dean
(Student Affairs), Faculty of Pharmacy,
International Islamic University Malaysia,
Kuantan, Malaysia

xviii
 Acknowledgements

Over the past 40 years we have benefitted from working with many colleagues in
different settings and have gained from them a wealth of experience on the OSCE.
We are indebted to those who made possible the early efforts to introduce the OSCE
into the medical school assessment programme in Dundee. In particular we would
like to thank Sir Alfred Cuschieri, Paul Preece, Robert Wood and James Crooks, who
played a leading role in the initial implementation of the OSCE in Dundee. As a
senior member of staff in the Dundee Centre for Medical Education, Fergus Gleeson
worked on the development of the OSCE and its implementation and co-authored
one of the two initial key publications on the topic. We would also like to acknowl-
edge the other members of staff of the Centre for Medical Education who have sup-
ported the ongoing work on the OSCE.

Special thanks should go to two medical educators who are, sadly, no longer
with us. Ian Hart spent several sabbaticals in Dundee working on the OSCE,
amongst other things. As described in the text, Ian made a significant contribu-
tion to the dissemination of the OSCE internationally through the Ottawa Con-
ferences, the first of which was held in 1985. Miriam Friedman Ben-David also
spent a sabbatical in Dundee, and her contributions to the OSCE and to assess-
ment more widely deserve special mention. We remember both Ian and Miriam
with great fondness, and the discipline of medical education is all the richer
for their contributions.

On our last count, more than 1,800 papers had been published on the OSCE. We
are grateful to everyone who took the time and effort to record their experiences on
paper, and we have learned a lot from these reports. In the same way, the OSCE has
featured prominently in medical education conferences, and this, too, has provided
a powerful learning opportunity for us. We are also grateful for the many invitations
we have received to visit other schools to see the OSCE in action in different loca-
tions throughout the world.

We are grateful to the students who have given us constructive feedback on the
OSCE over the years and hope that all examinees, whatever their stage of training,
believe the OSCE contributed to their development as learners, rather than remem-
bering it as a traumatic method of assessment.

xix
 The case studies described in Section D, we believe, represent an important part of
the book, and we would like specially to thank the contributors who have openly
shared their experiences with us.

Finally, we would like to thank everyone who supported us in the preparation of this
book, including Cary Dick from AMEE for help with typing and preparation of
Acknowledgements

graphics; Alex Haig and Valerie Harden, who undertook an initial review of the
papers published on the OSCE; Jim Glen, who drew the cartoons, which we hope
will entertain the reader; Geoff Norman who has written the Foreword; and Laurence
Hunter, Carole McMurray and Anne Collett from Elsevier.

Ronald Harden
Pat Lilley
Madalena Patrício

xx
 SECTION A AN INTRODUCTION TO THE OSCE

What is an OSCE?
1

An introduction to the OSCE for readers unfamiliar with the concept

and, for those already familiar with the OSCE, a more in-depth
insight into the characteristics that define the OSCE as an assess-
ment tool.

A definition
This book is about the Objective Structured Clinical Examination, or the ‘OSCE’,
the acronym by which the approach has become widely known. The concept is well
established in health professions education and the approach is familiar to many
teachers. We start, however, by defining an OSCE and outlining the features that set
it aside from other assessment tools. It is as Hodges (2003) suggested, ‘An examina-
tion like no other.’ In short, the OSCE is a performance-based examination in which
examinees are observed and scored as they rotate around a series of stations accord-
ing to a set plan (Figure 1.1). Each station focuses on an element of clinical compe-
tence, and the learner’s performance with a real patient, a simulated patient (SP),
a manikin or patient investigations is assessed by an examiner. An example of a
20-station OSCE is given in Table 1.1.

To understand better what an OSCE is and the features that characterise the
approach, it is helpful to look more closely at the elements in the name (Table 1.2).

Objective
The OSCE was introduced, as described in Chapter 2, to replace the traditional
clinical examination, which had been demonstrated to be an unreliable form of
assessment. Problems with the traditional clinical examination included the small
sample of skills assessed and the subjectivity or bias associated with the examiner’s
rating of the candidate. The OSCE was designed to avoid these problems. It has
attracted attention as the ‘gold standard’ in performance assessment at least in part
because of its perceived objectivity. The notion of objectivity is, however, a relative
one. Even multiple-choice questions and other so-called objective tests are not as
truly objective as their designers may claim. The issues of objectivity and reliability
in an OSCE are discussed in more depth in Chapter 3.

1
SECTION A

Figure 1.1 In an OSCE students rotate around a series of stations. At each

station an element of competence is assessed.

Figure 1.2 In any clinical

examination there are three variables:
Student
the patient, the examiner and the
candidate.

OSCE

Patient Examiner

In any clinical examination there are three variables: the patient, the examiner and
the candidate (Figure 1.2). In the OSCE, any bias as a result of the patients seen
and the examiners is reduced so that the result is a truer assessment of the exami-
nee’s clinical competence.

A number of stations
The first key feature of the OSCE is that examinees are assessed over a number of
stations. The OSCE has sometimes been referred to as a multistation clinical exami-
nation. This is very different from the traditional clinical examination with a single
long case. In a typical OSCE, there may be 20 or more such stations. The number

2
 Table 1.1 Example of a 20-station OSCE
1
Station Description Patient Examiner
1 History from a patient with pain in the hip SP Yes
2 Questions relating to Station 1 – –
3 Auscultation of chest in a patient with a Harvey manikin Yes

What is an OSCE?
murmur
4 Explain insulin administration to a diabetic SP Yes
patient
5 Examination of neck in a patient with goitre Real patient Yes
6 Questions relating to Station 5 – –
7 Examination of hands in a patient with Real patient Yes
rheumatoid arthritis
8 Preparation of case notes relating to – –
Station 7
9 History from a patient with dysuria SP Yes
10 Referral letter to hospital for a patient in – –
Station 9
11 Catheterisation of a patient Cystoscopy manikin Yes
12 Interpretation of chest X-ray X-rays –
13 Interview with a psychiatric patient Video recording –
14 Discuss interview with examiner – Yes
15 Questions relating to ward prescription Patient’s drug chart –
chart
16 Questions relating to drug advertisement Drug advertisement –
17 Examination of leg for a patient with Real patient Yes
hemiplegia
18 Questions relating to Station 17 – –
19 Measurement of blood pressure in a patient Real patient Yes
with hypertension
20 Questions relating to Station 19 – –
SP, simulated patient.

Table 1.2 The OSCE

Objective A number of stations
Examinees assessed on the same stations
Clear specification of what is assessed
A number of examiners
Specification of standards required
Structured OSCE blueprint
Clinical Students watched performing a clinical task on real and standardised
patients

3
 of stations may vary, as described in Chapter 6; this may be as low as 6 or as high
as 40. What is known, however, is that the reliability of the examination increases
as the number of stations increases. Each domain to be assessed, such as commu-
nication skills or physical examination skills, is usually tested at several stations.

To allow a smooth rotation of examinees around the OSCE stations, the time allo-
SECTION A

cated to each station is uniform. In some examinations this may be 5 minutes and
in other examinations it may be 15 to 20 minutes. Each examinee starts at a dif-
ferent station and on a given signal at the end of the set time period they move
forward to the next station. The exception to this is a double station where exami-
nees spend double the amount of time at a station. How this works in practice is
described in Chapter 6. Stations can also be arranged as linked stations where the
examinee’s competence in relation to a patient is assessed over two stations.

Uniform examination
A key feature of an OSCE is that all examinees are assessed on the same set of
stations. In one circuit of 20 stations, 20 candidates can be assessed in an examina-
tion. Where more than 20 candidates have to be assessed, two or more circuits with
matched stations can be run in parallel. Alternatively, the same circuit can be
repeated sequentially with a further set of candidates examined after the first circuit
has been completed (Box 1.1).

Specification of what is assessed

Another key feature of an OSCE is that what is to be assessed at each station is
agreed upon in advance of the examination. The examinee may be assessed carrying
out a practical procedure, such as the measurement of a patient’s blood pressure.
Decisions need to be taken in advance of the examination as to what is to be assessed
at the station (Box 1.2). Should the examinee’s attitude and communication with
the patient be taken into account or is the assessment to be based only on the
examiner’s observation of the technical aspect of how the candidate undertakes
the procedure? Is the accuracy of the blood pressure measurement arrived at by the
examinee and his/her interpretation of the results also to be taken into considera-
tion? What is to be assessed will be reflected in the checklist and rating scale to be
used by the examiner at the station, and this is described in Chapter 11.

Box 1.1

When the OSCE was introduced as the final medical examination in Dundee, more than
120 students were examined in one morning. Three circuits, each with 20 stations, were
used simultaneously. Stations were identical in terms of the tasks expected of the student
and the scoring sheets. Patients or simulated patients (SPs) were carefully matched
across different circuits. Following a short break, another group of 60 students was
assessed later in the morning on the same three circuits. To ensure that the matched
stations were comparable, an analysis of students’ performance at each of the matched
stations in different circuits was undertaken.

4
 Box 1.2
1
In a study carried out by RMH and co-workers at Glasgow University, a significant variation
was found between the marks awarded by different examiners to students in a traditional
clinical examination (Wilson et al. 1969). One of the reasons for the variations was that
there had been no decision in advance as to what was to be assessed in the examination.
Some examiners took into account the student’s dress, how the students presented them-

What is an OSCE?
selves and their attitudes towards the patient whilst others restricted their assessment of
the student to the technique demonstrated by the student.

A number of examiners
During the examination each candidate sees a number of examiners. This is a key
feature of an OSCE. With a 20-station OSCE there may be 10 examiners or more
at one circuit. Each examiner is carefully briefed as to what is expected of them at
the station and training is given in advance of the OSCE with regard to what the
examiner should be looking for and how the checklist and rating scale should be
interpreted. This is discussed further in Chapter 9.

Specification of standards required

The standard expected of the examinee in the overall examination and in individual
stations is specified. This can be determined by using an established approach to
standard setting, as described in Chapter 11. The minimum requirements for a pass
can be set and excellence can also be recognised.

Structured
What was assessed in a traditional clinical examination was often opportunistic and
depended on the patients available in the hospital or as outpatients. In contrast, a
key feature of the OSCE is that what is to be assessed during the examination is
carefully planned and agreed upon before the examination is implemented.

OSCE blueprint
A blueprint or a grid for the OSCE is prepared in advance. This outlines the learning
outcomes and core tasks to be assessed at each station in the OSCE, for example in
the domains of communication skills, physical examination, practical procedures
and analysis and reflection. This important feature of an OSCE is discussed further
in Chapter 6.

The grid maps on one axis the key learning outcome domains and on the other axis
the elements of the course, e.g. the body systems or context in which the learning
outcomes are to be assessed. For example, patient education skills may be assessed
in the endocrine system with a diabetic patient, history taking in the cardiovascular
system in a patient with chest pain, and physical examination in the respiratory
system in a patient with asthma (Table 1.3).

5
 Table 1.3 Section of a blueprint showing content of an OSCE as tested at
Stations 1, 2, 3, 4, 6, 8, 10 and 12
Learning Body system
outcome CVS RS NS AS ENDO
History (2) Chest pain (10) Diarrhoea
SECTION A

taking
Patient (1) Diabetes
education
Physical (4) Asthma (6) Hemiplegia
examination
Practical (8) BP (12) FEV
procedures
Problem (3) Headache
solving
.
.
.
AS, Alimentary system; BP, Blood pressure; CVS, Cardiovascular system; ENDO, Endocrine
system; FEV, Forced expiratory volume; NS, Nervous system; RS, Respiratory system.

Box 1.3

A common and important comment from students following an OSCE is that the examina-
tion is perceived as ‘fair’. One reason for this is that students in general see that the OSCE
reflects the teaching and learning programme and the stations overall address the learning
outcomes of the course.

What is assessed in the OSCE should reflect the content covered in the teaching
and learning programme (Box 1.3). The learning outcomes assessed can be related
on a curriculum map to the relevant learning opportunities for the examinee, for
example a session in the clinical skills unit, a simulator, a ward-based experience,
a video available online or even a lecture.

Clinical
The OSCE is a clinical or performance-based examination. It tests not only what
examinees know, but also their clinical skills and how they put their knowledge into
practice. Think outside medicine for a moment. If we were to design a test to assess
students’ ability to tie their shoelaces, it would not be sensible to assess their knowl-
edge relating to the task as shown in Table 1.4, rather than their technical skill. To
assess students’ competence what we need is to observe their skill as they tie their
shoelaces.

Whilst this may seem obvious, all too often in medicine we fall into the trap and
rely on testing the students’ knowledge with written assessments when what we are
interested in is their clinical competence. This represents the bottom of Miller’s
Pyramid (Miller 1990) at the ‘knows’ and ‘knows how’ levels rather than the ‘shows

6
 Table 1.4 The assessment of a student’s competence in tying shoelaces
1
Objective: The student should be able to tie his/her shoelaces
Assessment options
• Write short notes on the origin of shoelaces.
• Describe the materials from which shoelaces are made.

What is an OSCE?
• Write an essay to explain how shoelaces are tied.
• Answer an MCQ relating to tying a shoelace.
• Observe an individual tying his/her shoelaces.

how’ level, as described in Chapter 5. The OSCE is a performance measure of what

the individual would do in a clinical context. Examples of the range of clinical skills
that can be assessed in an OSCE are given in Table 1.5.

In an OSCE, it is the examinee’s clinical skills and what he/she does when faced
with a patient or clinical situation and the competence demonstrated that are
assessed – not simply what he/she knows as tested by a written or theoretical ques-
tion on the subject. It is the application of the knowledge to practice that is assessed
in an OSCE.

In ‘procedure’ stations, examinees are watched and assessed by the examiner as they
take a history, examine a patient, or carry out a practical procedure. In a history
taking station, for example, the history taking techniques used by the examinees
and the questions they ask as well as their approach to the patient are taken into
consideration. A ‘procedure’ station may be followed by a ‘question’ station, where
the examinee is asked about their findings at the previous station and the conclu-
sions they have reached based on their findings. The examinee’s response may be
in the form of:

• a multiple-choice question (MCQ).

• a short constructed response to a question.

• a note about the patient they have seen – sometimes called a ‘post-encounter
note’.

• a letter referring the patient for further investigation or treatment; or

• an oral report to an examiner.

In addition to the use of real patients, simulated or standardised patients may be

used to provide examinees with a standardised experience. This is discussed further
in Chapter 8. The emphasis placed on the use of standardised patients varies. In
the USA the OSCE is often equated with a standardised patient examination.

7
 Table 1.5 Examples of clinical skills assessed in an OSCE (Harden 1988)
Skill Action Example
History taking History taking from a patient Abdominal pain
who presents a problem
History taking to elucidate a Hypothyroidism
SECTION A

diagnosis
Patient Provision of patient advice Discharge from hospital following a
education myocardial infarction
Educating a patient about Use of an inhaler for asthma
management
Provision of patient advice Endoscopy
about tests and procedures
Communication Communication with other Brief to nurse with regard to a
members of healthcare teams terminally ill patient
Communication with relatives Informing a wife that her husband
has bronchial carcinoma
Writing a letter Referral or discharge letter
Physical Physical examination of a Hands of a patient with rheumatoid
examination system or part of the body arthritis
Physical examination to follow Congestive cardiac failure
up a problem
Physical examination to help Thyrotoxicosis
confirm or to help confirm or
refute a diagnosis
Diagnostic Diagnostic procedure Ophthalmoscopy
procedure
Interpretation Interpretation of findings Charts, laboratory reports or findings
documented in patient’s records
Patient Patient management Writing a prescription
management
Critical Critical appraisal Review of a published article or
appraisal pharmaceutical advertisement
Problem Problem solving Approach adopted in a case where
solving a patient complains that her weight
as recorded in the hospital was not
her correct weight

A flexible format
The OSCE is not a rigid prescription for how a candidate is examined. One is
unlikely to see two OSCEs which are identical in the skills tested and the ways in
which they are assessed. Within the principles set out above, there is the opportunity
to adapt the process to a particular context and to suit the needs associated with:

• a particular discipline or specialty whether this is general practice, surgery or

psychiatry.

8
• a phase of education (undergraduate, postgraduate or continuing education).
1
• a different educational purpose (summative or formative assessment, etc. as
described in Chapter 4); and

• the resources available (number of examiners, patients and accommodation).

What is an OSCE?
Each of the case studies provided in Section D illustrates its own different interpreta-
tion of the OSCE concept.

The OSCE and the eight Ps

The features that characterise an OSCE can be highlighted as the ‘eight Ps’. At the
5th Ottawa Conference Harden described in a paper, ‘The OSCE – a 15 year retro-
spective’, 7 Ps that characterised an OSCE (Harden 1992). An eighth ‘P’ is added
below:

• Performance assessment: The OSCE may be identified with a move from

theory to practice. Examinees are assessed not just on what they know but
also on what they can do.

• Process and product: Assessed in the OSCE are the learner’s technical skills,
for example how they take a history, how a patient is examined or how the
learner carries out a practical procedure. The learner’s findings, the results
and their interpretation can also be assessed.

• Profile of learner: The OSCE not only provides a single global rating for the
learner but can also present a picture of his/her strengths or weaknesses in
the different learning outcome domains.

• Progress of learner: The OSCE assesses the learner’s progress during the
curriculum and training programme and provides feedback to the learner and
teacher as to strengths and weaknesses in the learner’s performance.

• Public assessment: In the OSCE there is transparency as to what is being

assessed. A discussion about what is assessed in an OSCE can lead to
clarification of aims and expected outcomes relating to the course.

• Participation of staff: Examinees are seen by a number of examiners, and

staff from different specialties and healthcare professions can participate as
examiners in the OSCE.

• Pressure for change: The introduction of an OSCE can help to focus the
learner’s attention on the competencies to be assessed. Poor overall
performance in an OSCE by a class of students highlights a need for a change
in the education programme or a revision of the assessment.

9
 • Pre-set standards of competence: What is expected of a learner and the
standard of performance appropriate for a pass in an examination are specified
in advance.

OSCE variations
SECTION A

A number of variations to an OSCE have been described, some of which are noted
below.

Objective Structured Practical Examination (OSPE)

When first introduced, the OSCE was considered to be essentially a clinical exami-
nation for use primarily in the later or clinical years of the course. It was found,
however, that the format could be applied also in the early years of the course to
assess the student’s ability with regard to the application of the basic sciences to
clinical medicine. The term ‘Objective Structured Practical Examination’ was used
to refer to this approach (Harden and Cairncross 1980). Malik et al. (1988) described
the use of the OSPE to assess students’ mastery of physiology in India. Over the
years, with the emphasis on vertical integration of clinical skills into the early years
of the course, this distinction has become less appropriate, and the term OSCE is
now applied to the assessment of students’ competence in the early as well as the
later years of the course.

Objective Structured Practical Veterinary Examination (OSPVE)

The OSCE approach has been adopted for use in veterinary medicine. May and Head
(2010) described its use to assess technical skills required for diagnosis and treat-
ment in veterinary practice. Case Study 11 in Section D provides an example of the
use of the OSCE in veterinary nurse education.

Clinical Assessment of Skills and Competencies (CASC)

The examination for membership of the Royal College of Psychiatrists in the UK
– the Clinical Assessment of Skills and Competencies (CASC) – uses a 16-station
OSCE for the clinical assessment component of the examination in addition to three
written papers.

Practical Assessment of Clinical Examination Skills (PACES)

The MRCP(UK) Part 2 Clinical Examination of the Royal College of Physicians in
the UK – the Practical Assessment of Clinical Examination Skills (PACES) examina-
tion – uses a modified version of the OSCE to test clinical knowledge and skills for
entry to higher specialist training (Royal College of Physicians of the United Kingdom
2014).

Objective Structured Assessment of Technical Skill (OSATS)

OSATS was developed at the University of Toronto to meet the need for a reliable
and valid method to assess operative technical skills. Surgical trainees perform

10
structured tasks applicable to general surgery in a standardised ‘Bench Station’
examination consisting of eight 15-minute stations (Martin et al. 1997; Ault et al. 1
2001). Examinees are rated by direct observation with task-specific checklists and a
global rating scale for each station. Feedback is given on performance.

Multiple Mini-Interview (MMI)

What is an OSCE?
The MMI is a type of OSCE used to assess students for admission to medical studies
(Eva et al. 2004a,b). Tests of the competencies expected of a student on entry to
medical studies are illustrated in Case Study 15 in Section D. The introduction of
the MMI is part of the move away from relying solely on academic achievements
for selection purposes and is covered in more detail in Chapter 4.

Group Objective Structured Clinical Experience (GOSCE)

The GOSCE assesses individuals in a group setting and was designed for self-
assessment and learning in both undergraduate and postgraduate education. It is
discussed in more detail in Chapter 6.

Team Objective Structured Clinical Examination (TOSCE)

This has similar characteristics to the GOSCE. Singleton et al. (1999) described a
TOSCE for third-year medical students to enhance general practice consultation
skills. Teams of five students rotated around five simulated patient (SP) stations as a
group, each taking on the role of the General Practitioner, receiving feedback and pro-
moting self-reflection.

Team Observed Structured Clinical Encounter (TOSCE)

This shares the same acronym as the Team Objective Structured Clinical Examina-
tion. The McMaster–Ottawa Team Observed Structured Clinical Encounter (TOSCE)
is used to assess team skills and interprofessional practice and is discussed further in
Chapter 5 when the use of the OSCE to assess team skills is considered.

Team Objective Structured Bedside Assessment (TOSBA)

Miller et al. (2007) described a TOSBA which provides a real patient experience
for final-year medical students who spend 30 minutes in groups of five with a
hospital in-patient at three different stations, each student performing a clinical
task. They receive a grade and individual feedback on performance in a group
setting.

Interprofessional Team Objective Structured Clinical

Examination (ITOSCE)
The Interprofessional Team Objective Structured Clinical Examination (ITOSCE)
was described by Symonds et al. (2003) and Cullen et al. (2003) as a shared learning
experience for teams of seven or eight medical students and student midwives, who
rotated around five stations presenting different clinical scenarios. Simmons et al.

11
 (2011) described a different initiative, the Interprofessional Objective Structured
Clinical Examination (iOSCE) to assess interprofessional competence.

Objective Structured Teaching Encounter (OSTE)

In line with the move to professionalism in medical education and the establishment
of faculty development programmes, the OSTE has been introduced as an approach
SECTION A

to assessing teaching skills. It has been labelled ‘Objective Structured Teaching

Encounter’, ‘Objective Structured Teaching Exercise’ and ‘Objective Structured
Teaching Evaluation’. In the OSTE, students are trained to serve as standardised
learners in a scripted teaching scenario, providing feedback to the teacher. Sessions
may be observed by faculty members, who also give feedback. This is discussed
further in Chapter 4 in the section on faculty development.

Take-home messages
The OSCE is a performance-based examination designed to assess the examinee’s
clinical competence. Key elements are:

• Examinees rotate around a number of stations with each station focusing on

one or more elements of competence.

• The examination is structured and a blueprint or grid is used to plan the

learning outcomes to be assessed in the examination.

• Examinees are assessed by a number of examiners who assess their

performance at each station using a checklist or rating scale.

• Patients in the examination are real patients, simulated patients or manikins.

• All examinees are assessed in the same set of stations.

A number of variations on the OSCE have been developed for use in specific con-
texts, including the assessment of surgical skills, interprofessional skills and teach-
ing skills.

If you have an OSCE in your institution, does it conform to the above

features?

12
 SECTION A AN INTRODUCTION TO THE OSCE

The inside story of the development

of the OSCE 2

An account of how the OSCE was conceived and developed in the

1970s in response to the assessment challenges facing educators in
the healthcare professions.

The traditional clinical examination

The clinical examination conducted at the bedside in the UK was seen traditionally
as the keystone, or most important, component in the assessment of a student’s
competence to qualify and practise as a doctor, or of a trainee doctor’s competence
to practise as a specialist in their chosen area (Stokes 1974). Whilst a borderline
performance in a written examination paper with essays, short answers or multiple-
choice questions (MCQs) could be compensated, a clear pass in the clinical compo-
nent was a requirement in the final qualifying examination in medicine, surgery,
obstetrics and gynaecology and paediatrics. A failure to achieve a pass mark in any
of these subjects resulted in the student being unable to take up a post as resident
house officer and required him or her to re-sit the examination 6 months later. In
the traditional clinical examination, the candidate spent about an hour with a single
‘long case’, and at the end of the time, the student met the examiners and over 20
minutes discussed the details of the history and the physical signs, the possible
diagnosis and the management plan. The candidate was then asked to conduct a
more focussed examination with several patients for a further 20 minutes and to
discuss the findings with the examiners.

Problems with the clinical examination

In the 1960s and 1970s, this established approach to student assessment attracted
increasing criticism with regard to its reliability. Moreover, its validity was ques-
tioned, as the student was not actively observed communicating with the patient.
Stokes, a highly respected clinician and experienced examiner, described the clinical
examination as the ‘half-hour disaster session’ and the ‘sacred cow of British medi-
cine’ (Stokes 1974). He attributed a lack of earlier criticism of the traditional
approach to the clinical examination, at least in part, to ‘examiners instinctively
recognising that this part of the examination provides them with the best chance of
preserving the traditional species by making appropriate phenotype judgements’

13
 (p. 2.3). In the assessment of the student’s ability to obtain a relevant history, elicit
any abnormal physical signs, synthesise the information into a differential diagnosis,
devise an investigation plan and suggest the treatment and prognosis, the examiner
also took into account:

‘... whether the candidate is clean, gentle, assured or over-confident,

SECTION A

talkative or taciturn, whether his hands are more often in his pockets than
on the patient’s pulse, whether his tie indicates membership of an
acceptable club and, in the case of a female, whether she is neatly or
ostentatiously clad. Some examiners fail wholly to control the atavistic
feelings which come to the surface when confronted with a woman at
their mercy, others act out deep-seated Galahad complexes of which they
remain blissfully unaware.’ (Stokes 1974, p. 2.4)

Stokes also highlighted the ‘luck of the draw’ nature of the examination with the
candidate meeting only one ‘long case’ and the power that the patient could have
over the student by suppressing or providing key information for the student (as
illustrated in the 1954 film Doctor in the House). As Petrusa (2002) noted:

‘The time-honored method of oral examination after a single patient

suffers from several measurement shortcomings. Too little sampling, low
reliability, partial validity and potential for evaluator bias undermine the
oral examination.’

In a World Health Organisation (WHO) publication ‘A review of the nature and uses
of examinations in medical education’ by Charvat et al. (1968, p. 7), it was reported:

‘Those responsible for the health services of a country are concerned

above all with the quantity and quality of the young physicians who
graduate from the medical schools. One of the most effective methods of
measuring quality is the evaluation of the students’ academic performance
by means of examination techniques. The older examination systems
suffered from the disadvantages that they were not sufficiently objective
and often conditioned the student to memorize only those facts that he
believed would best satisfy the examiner.’

In North America, as in the UK, concern was also being expressed about the problems
and the unreliability associated with the assessment of the candidate’s clinical skills
at the bedside. In 1963, the bedside examination was finally abandoned by the
National Board of Medical Examiners (Hubbard et al. 1965). In the chapter on the
evaluation of clinical competencies in his book Measuring Medical Education:
The Tests and Experience of the National Board of Medical Examiners, Hubbard
(1978) dismisses the use of a bedside clinical examination because of its unreliability.
Written, paper-based tests were developed as a substitute to test students’ accuracy
of observation, their recognition of abnormalities in the pictures of patients and their
investigation, clinical reasoning and clinical judgement skills. Graham (1971)

14
working in the New Mexico School of Medicine argued, to no avail, for a systematic
evaluation of a student’s clinical competence. Decisions about the approach to assess- 2
ment to be adopted were dictated by the psychometrics, and written examinations
in the USA dominated as the tool to assess a student’s competence to practise.

Evidence of the unreliability of the clinical examination

The inside story of the development of the OSCE

Stokes had recognised that in the UK, greater prestige was attached to clinical skills.
The General Medical Council, which was responsible for the standard of medical
education in the UK, included in its 1967 report the recommendation that the clini-
cal knowledge and skills attained by the student should be tested in the final qualify-
ing examinations. The deficiencies in the traditional clinical examinations had
become apparent to me (RMH), working as a senior lecturer in the University of
Glasgow with responsibility for the organisation of the clinical examinations. With
co-workers, I carried out a study in which we explored the reliability (or rather the
unreliability) of the marks awarded by clinical examiners (Wilson et al. 1969).
Twenty-eight students were assessed independently by two examiners and subse-
quently by a further 12 examiners, who watched a videotape of the students’ per-
formance. The videotape performance was also marked by the two original examiners
2 weeks and 2 months later. As illustrated in Figure 2.1, a wide variation in the
marks awarded by the different examiners was noted, with variations between exam-
iners for an individual student as great as 25 marks, the difference between ‘excel-
lent’ and a ‘bad fail’, and with all the candidates having a score that varied between
examiners by at least 10 marks. It was estimated that to have a 99% chance of
scoring a pass mark of 50% in the examination, the student would need to achieve

75

70

65

60
% Mark

55

50

45

7 29 8 3 5 9 15 22 25
Student

Figure 2.1 A wide variation in the marks awarded by the different examiners
was noted, with variations between examiners for an individual student as
great as 25 marks. Each dot represents one examiner’s score for a student
(Wilson et al. 1969).

15
 a mark of 62%. Even the same examiner awarded different scores on repeat marking.
This study confirmed for me (RMH) the problems associated with the traditional
clinical examination.

The development of the OSCE

SECTION A

It seemed to me (RMH) wrong to follow the American lead and abandon the assess-
ment of clinical skills at the bedside in favour of a written assessment where the
emphasis was on a student’s knowledge. The ability to answer correctly a set of
MCQs was a poor measure of how a student would interact with a patient, take an
appropriate history, carry out a relevant examination and come to a management
plan in discussion with the patient. What was required was an alternative approach
which preserved the key aims of a clinical examination whilst avoiding the problems
relating to the traditional approach. In the clinical examination, the three variables
are the examinee, the patient and the examiner. The challenge was to find an
approach that controlled, as far as possible, the variables of the patient and examiner.
What came to be known as the Objective Structured Clinical Examination, or OSCE,
was designed with this in mind. The examination was developed with the following
features:

• Students should be assessed on a number of patients, and all students should

see the same patients. It was important to remove the ‘luck of the draw’ that
characterised the traditional examination.

• A large sample of the required competencies should be assessed to allow a

more reliable inference to be made as to the student’s competence.

• A combination of real patients and simulated patients should be used to

create an authentic assessment.

• To avoid the possibility of examiner bias, with a candidate being examined by

a ‘hawk’ or a ‘dove’, each student should be assessed by multiple examiners.

• A blueprint for the examination should serve as a basis for the design of the
examination, and the competencies to be tested should be agreed upon in
advance. Checklists or rating scales should specify the examiners’ expectations
of the examinee and the learning outcomes to be assessed at each station.

• The approach adopted has to be practical and feasible and capable of

adaptation to meet the needs in different contexts and situations.

The outcome was the development of an examination built round a series of stations
– initially about 20 – with an aspect of competence assessed at each station, for
example history taking in a patient with dyspnoea, examination of the leg in a
patient with a hemiplegia or advising a patient on discharge from hospital following
admission because of a myocardial infarction. During the examination, the student

16
rotated round the stations spending a standard specified time – initially 5 minutes
– at each station. On an agreed audible signal, the student moved to the next station. 2
In this way, 20 students could be assessed simultaneously in one circuit. An exam-
iner stayed at the same station for the duration of the examination. This approach,
combining the above features, was subsequently named the Objective Structured
Clinical Examination, or OSCE (Harden et al. 1975; Harden and Gleeson 1979).

The inside story of the development of the OSCE

Two types of station were included. The first type was a ‘procedure’ station, where
students, watched by an examiner, undertook an activity, e.g. history taking or physi-
cal examination. This observation of the student by the examiner was seen as a key
feature of the approach. The student’s findings and conclusions were also seen as
important, and these were assessed at a ‘question’ station that followed the ‘proce-
dure’ station. The response of the student was in the form of an MCQ, a constructed
response question, or a case history note or a referral letter prepared by the student.

Early work on the OSCE was undertaken in the Department of Medicine in the
Western Infirmary at the University of Glasgow. When first introduced in Glasgow,
the examination was conducted in a hospital ward and was used as an in-course
assessment.

The OSCE as the final qualifying examination

My (RMH) move to Dundee, in 1972, provided an opportunity to develop further
the approach and, working with Sir Alfred Cuschieri and James Crooks, to introduce
it as part of the final qualifying examination for students, replacing the traditional
clinical examination.* Alfred Cuschieri had been recently appointed as Professor of
Surgery in Dundee, and he, with his two senior lecturers Robert Wood and Paul
Preece, was enthusiastic to replace the traditional final qualifying examination in
surgery with an OSCE. In the UK, there is no national examination, and the respon-
sibility for the final examination is left to each school, with external examiners from
other schools involved and the process monitored by the General Medical Council.
The senior professors in the Faculty of Medicine at Dundee, not unexpectedly, were
reluctant to change from the traditional approach to clinical examinations with
which they had become familiar. However, the Faculty Board agreed to a pilot study
where a final surgery OSCE was run alongside the traditional final surgery examina-
tion with students and examiners volunteering to participate in the pilot. This
allowed the OSCE to be introduced quickly. All students agreed to take part, and
junior and senior members of staff agreed to participate as examiners, some because
of their concerns with the traditional clinical examination and others from a curios-
ity about the new approach.

The result was a major success. The pilot examination proceeded smoothly with no
significant problems. Positive feedback was received from students and examiners.

*An interview with RMH discussing the development of the OSCE is available at https://
vimeo.com/67224904.

17
 Students noted advantages over the traditional long case, including the wide range
of knowledge and skills tested, the provision of a comparable test for all students, a
reduction in examiner bias and the opportunity for feedback. Encouraging comments
received from students were ‘realistic’, ‘helped me to think I was learning to be a
doctor’, ‘tested what I had been taught in my clinical attachments’, ‘a fair test’, ‘I
liked having a number of examiners’, ‘showed that being a doctor is much more
SECTION A

than learning from the books’, ‘to my surprise I enjoyed the experience’, ‘helped me
to see gaps in my abilities’, ‘made me think on my feet’. The advantages as noted
by the examiners included the wide range of competencies tested, including the
minor specialties, efficient use of the examiner’s time and greater reliability com-
pared to the traditional long case (Cuschieri et al. 1979). There was no hesitation
on the part of the Faculty Board to formally approve the adoption for subsequent
years of the OSCE as the final qualifying examination in surgery. Fifteen years’
experience using the surgery OSCE in Dundee was reported by Preece et al. (1992).

The use of the OSCE as the final examination in other disciplines quickly followed
the lead given by surgery, and by the 1980s, medicine, therapeutics, obstetrics and
gynaecology, and psychiatry had all adopted the OSCE (Peden et al. 1985; Davis
2003). With the introduction in Dundee of an integrated systems-based curriculum,
in addition to its use as a final examination, the OSCE was used during Year 2, Year
3 and Year 4 to assess the development in the students of the clinical skills as they
related to the cardiovascular, the respiratory and other body systems.

I was joined in Dundee by Fergus Gleeson, a clinician and enthusiastic teacher from
Ireland. He contributed to the development of the OSCE and together we co-authored
the Association for the Study of Medical Education (ASME) Guide on the OSCE
(Harden and Gleeson 1979). The recollections of members of the faculty concerned
with the development of the OSCE in Dundee over this period of time are recorded
by Brian Hodges (2009) in his book The Objective Structured Clinical Examination:
A Socio-History. This provides a valuable insight into the development of the OSCE,
including how, in the 1970s, the UK and the USA went in different directions in
the assessment of students, with examinations in the USA focussing on the use of
MCQs.

Dissemination of the OSCE approach

Following its successful adoption in Dundee, the OSCE approach became adopted
widely as an examination tool to assess students’ clinical competence. Teachers
became aware of the approach through the publication of papers on the OSCE and
presentations on the subject at meetings and conferences. The staff in Dundee with
a commitment to the OSCE who transferred to other schools and the external
examiners from other schools who participated in the Dundee initiative made a
significant contribution to the spread of the approach to their schools. Ian Hart, a
leading Canadian physician with an interest in medical education, spent a sabbatical
in Dundee. During this time, he became an important OSCE convert and master-
minded the organisation of a conference held in Ottawa in 1985, which had the aim

18
 Box 2.1 An ode to clinical assessment
2
From Lagos to Sweden
From McMaster to Dundee
It seems as if everyone’s
Using an OSCE.
For Family Practice

The inside story of the development of the OSCE

And Obstetrics – Gyn
Is definitely ‘in’.
Short stations, long stations
For knowledge, affect, and skills
Is the OSCE the cure?
For our measurement ills?
SAs and PMPs
MCQs and O-S-C-Es
Rs and Ps and significant Ts
Are any letters missing after all these?
If one more was in it
The tool kit, I’d buy
We know all the others
Now let us hear ‘Y’.

Reproduced from Berner, E.S., 1985. Newer developments in assessing clinical competence. Proceed-
ings of the First Ottawa Conference. Heal Publications Ltd.

of sharing across the Atlantic approaches to the assessment of clinical competence,

including the OSCE. At the conference in 1985 (Box 2.1), 23 papers described the
use in five countries of an OSCE in medicine, physiotherapy and nursing.

The conference proved successful and aroused much interest in the OSCE. Since
then, a conference on the theme of assessing competence, now referred to as the
Ottawa Conference, has been held biennially (www.ottawaconference.org). The 2012
conference took place in Kuala Lumpur, and in 2014 it returned to its roots in
Ottawa. An interesting development presented at the second Ottawa Conference in
1987 was the adoption of the OSCE approach in the UK by the police as a promo-
tion examination to replace a written examination previously used for this purpose.
This acknowledged that the general competencies required in the police of observing,
examining, communicating, problem solving and investigating – were similar to the
general competencies required in medicine. The OSPRE (the Objective Structured
Performance Related Exam), as it became known in the police force, featured in an
episode of a British television drama Inspector Morse (see page 46).

Increasing popularity of the OSCE

Since the OSCE was first described in 1975, the importance of student assessment
has become increasingly recognised, as highlighted by Wass et al. (2001):

‘Assessment drives learning. Many people argue that this statement is

incorrect and that the curriculum is the key in any clinical course. In

19
 reality, students feel overloaded by work and respond by studying only for
the parts of the course that are assessed. To promote learning, assessment
should be educational and formative – students should learn from tests
and receive feedback on which to build their knowledge and skills.
Pragmatically, assessment is the most appropriate engine on which to
harness the curriculum.’
SECTION A

The need to assess a student’s clinical skills was widely recognised, and during the
1980s and 1990s, the OSCE resonated with an increasing number of practitioners
around the world as the answer to the challenge of finding a practical solution to
the assessment of a student’s clinical competence. Its allure in offering something
different from the MCQ-based examination in an authentic voice was appreciated.
In South Africa, for example, at least 20 departments in six of the seven South
African Medical Schools had implemented an OSCE into their school in the 2 years
to 1983 (Lazarus and Harden 1985). The OSCE was seen as a factor that ‘enhanced
a paradigm shift from the assessment of knowledge to the assessment of physicians’
performance’ (Friedman Ben-David 2000a). As Hodges (2003) noted, ‘Because of the
intense focus on performance, OSCEs have had a powerful influence on doctor train-
ing and practice.’

Evidence for the growing interest in the OSCE is the increase in the number of
papers published each year since 1975. The number of papers retrieved through
PubMed is illustrated in Figure 2.2. This is an underestimate of the number of
papers published. For example, in 1998, 28 papers were noted in PubMed, but 55
references could be found with a more detailed search of the literature, with an
additional 70 papers published in the grey literature. Since 2011, in excess of 400
papers have been published on the topic – almost one new paper every 3 days
(Figure 2.2)! The figures also underestimate the use made of the approach, as not
all schools adopting the technique have published their experiences. In the chapter
that follows, the uses made of the OSCE since its inception are illustrated in dif-

Figure 2.2 The increasing

500
Number of Papers Published

489 popularity of the OSCE is

400 shown. The number of
307
papers listed in PubMed
300 236 (http://www.ncbi.nlm.nih.
gov/pubmed) on the topic
200 is an indicator.
112
100 62
3 11 15
0
1975 1980 1985 1990 1995 2000 2005 2010 2014
Year

20
ferent countries, in different subjects, in different professions and for different
purposes. 2

Regional variations
Whilst the basic principles remained the same, fundamental variations appeared in

The inside story of the development of the OSCE

different countries. In most countries, patients were represented by both real patients
and simulated or standardised patients (Harden and Gleeson 1979). As described by
Hodges (2009), in the USA the OSCE became identified widely as a standardised
patient examination. This is discussed further in Chapter 8. Regional variations
also appeared as to who should observe and rate the students’ performance in the
OSCE – a clinician or trained standardised patient – and this is discussed further in
Chapter 9.

Why the OSCE has been adopted widely

How education ideas and results of research are adopted in teaching practice
was examined by Schneider (2014). Using examples, Schneider showed how pen-
etration of an innovation into the world of practice is determined less by scholarly
merit of the innovation than by its particular set of traits. The examples he
studied were Bloom’s taxonomy, Howard Gardner’s theory of multiple intelli-
gences, the project method and Direct Instruction. He found common to all of
the developments were four characteristics crucial to the adoption of the initia-
tive by teachers – perceived significance, philosophical compatibility, occupational
realism and inference portability.

The same analysis when applied to the OSCE can explain its wide adoption as an
assessment tool. The first characteristic is perceived significance. Schneider argues
that ideas that are adopted stand out not because they are but rather because they
seem significant. The OSCE was seen by teachers as addressing an important
problem – the assessment of a learner’s clinical competence. Schneider’s second
characteristic was philosophical compatibility. He argued that for education research
to gain traction in practice, teachers must view it as reasonable and appropriate
for use. Research must not be perceived as the work of outsiders and must not
clash with teachers’ values and commitments. In the case of the OSCE, clinical
teachers and examiners could easily identify with the approach and the principles
underpinning it. Schneider’s third crucial characteristic was occupational realism.
Ideas must be practical and easy to put into immediate use. This was certainly
true of the OSCE. Its application in practice required neither extensive training
nor the overhaul of existing practices. The fourth characteristic described by Sch-
neider was transportability. He argues that for an educational approach to be widely
adopted it should have simple principles that can be explained easily to a busy
colleague and can be adapted for use in different situations relatively easily. The
OSCE is a user-friendly tool and, as shown in this book, can be adapted for use
in many different contexts.

21
 Take-home messages
The OSCE was introduced in the 1970s as a tool to assess a student’s clinical com-
petence. It was recognised that:

• How a student is assessed is key to the success of an education programme.

SECTION A

• The reliability (consistency) of an assessment tool is important and so also is

its validity – is it measuring what we want it to measure? It is essential to
have an assessment tool that tests not only knowledge but also the clinical
competence of the student.

• The OSCE was developed as a valid, reliable and practical approach to

assessing a student’s clinical competence.

• The OSCE has been widely adopted worldwide, partly because of its perceived
significance, philosophical compatibility, occupational realism and
transportability.

How has an OSCE been promoted in your institution?

22
 SECTION A AN INTRODUCTION TO THE OSCE

The OSCE as the gold standard for

performance assessment 3

The OSCE with its multiple samples of performance has come to

dominate performance assessment and merits a place in every
assessor’s toolkit.

The gold standard

Over the last 40 years, the OSCE has been widely adopted as the recommended
approach to the assessment of clinical competence in different phases of education,
in different specialties and in different parts of the world. Indeed, it has been recog-
nised as the gold standard for performance assessment (Sloan et al. 1995; Medical
Council of Canada 2011; Humphrey-Murto et al. 2013), and its impact on education
has been immense.
In this chapter, we examine the characteristics of a ‘good’ assessment and how the
OSCE matches each of these features. Some of the concepts were introduced in
Chapter 1.

Characteristics of a good assessment

A decade ago the established criteria for a good assessment emphasised:

• Reliability – was it consistent?

• Validity – did it measure what should be measured?

• Feasibility – was it practical?

Today an assessment method is also judged on its educational qualities:

• What impact does it have on the students’ learning and on the curriculum?

• Is it perceived as fair, and is it acceptable to staff and students?

• Is the approach flexible, and can it be adapted to local needs?

23
 Valid

Reliable Feasible
SECTION A

Educational The Flexible

impact OSCE

Provision
Fair
of feedback

Acceptable

Figure 3.1 The OSCE is the gold standard for performance assessment.

• Is it cost effective?

• Can it be used to provide students with feedback as to their strengths and

weaknesses?

This expanded view of what should be looked for in an assessment tool, as sum-
marised in Figure 3.1, has been highlighted by van der Vleuten (1996), Norcini et al.
(2011), the General Medical Council (2011) and others.

Reliability and the OSCE

The reliability of an assessment is the extent to which the results are considered
consistent, dependable and free from error. The reliability of the OSCE has been
extensively studied and well established (Walters et al. 2005; Pell et al. 2010; Bour-
sicot et al. 2014). Measures used to assess the reliability of the OSCE are discussed
in Chapter 14.

The OSCE was initially introduced, as described in Chapter 2, as a response to the

problem of poor reliability in the traditional clinical examination. Features of the
OSCE contributing to its greater reliability include:

24
Another Random Scribd Document
with Unrelated Content
nor loudly protesting, but this in no way derogated from their loyal
and unquestioning acceptance of the supremacy of the Holy See.
History shows that up to the very eve of the rejection of this
supremacy the attitude of Englishmen, in spite of difficulties and
misunderstandings, had been persistently one of respect for the
Pope as their spiritual head. Whilst other nations of Christendom had
been in the past centuries engaged in endeavours by diplomacy, and
even by force of arms, to capture the Pope that they might use him
for their own national profit, England, with nothing to gain,
expecting nothing, seeking nothing, had never entered on that line
of policy, but had been content to bow to his authority as to that of
the appointed Head of Christ’s Church on earth. Of this much there
can be no doubt. They did not reason about it, nor sift and sort the
grounds of their acceptance, any more than a child would dream of
searching into, or philosophising upon, the obedience he freely gives
to his parents.
That there were at times disagreements and quarrels may be
admitted without in the least affecting the real attitude and
uninterrupted spiritual dependence of England on the Holy See. Such
disputes were wholly the outcome of misunderstandings as to
matters in the domain rather of the temporal than of the spiritual, or
of points in the broad debatable land that lies between the two
jurisdictions. It is a failure to understand the distinction which exists
between these that has led many writers to think that in the
rejection by Englishmen of claims put forward at various times by
the Roman curia in matters wholly temporal, or where the temporal
became involved in the spiritual, they have a proof that England
never fully acknowledged the spiritual headship of the See of Rome.
That the Pope did in fact exercise great powers in England over
and above those in his spiritual prerogative is a matter of history. No
one has more thoroughly examined this subject than Professor
Maitland, and the summary of his conclusions given in his History of
English Law will serve to correct many misconceptions upon the
matter. What he says may be taken as giving a fairly accurate picture
of the relations of the Christian nations of Christendom to the Holy
See from the twelfth century to the disintegration of the system in
the throes of the Reformation. “It was a wonderful system,” he
writes. “The whole of Western Europe was subject to the jurisdiction
of one tribunal of last resort, the Roman curia. Appeals to it were
encouraged by all manner of means, appeals at almost every stage
of almost every proceeding. But the Pope was far more than the
president of a court of appeal. Very frequently the courts Christian
which did justice in England were courts which were acting under his
supervision and carrying out his written instructions. A very large
part, and by far the most permanently important part, of the
ecclesiastical litigation that went on in this country came before
English prelates who were sitting not as English prelates, not as
‘judges ordinary,’ but as mere delegates of the Pope, commissioned
to hear and determine this or that particular case. Bracton, indeed,
treats the Pope as the ordinary judge of every Englishman in
spiritual things, and the only ordinary judge whose powers are
unlimited.”
The Pope enjoyed a power of declaring the law to which but very
wide and very vague limits could be set. Each separate church might
have its customs, but there was a lex communis, a common law, of
the universal Church. In the view of the canonist, any special rules
of the Church of England have hardly a wider scope, hardly a less
dependent place, than have the customs of Kent or the bye-laws of
London in the eye of the English lawyer.[94]
We have only to examine the Regesta of the Popes, even up to
the dawn of difficulties in the reign of Henry VIII., to see that the
system as sketched in this passage was in full working order; and it
was herein that chiefly lay the danger even to the spiritual
prerogatives of the Head of the Church. Had the Providence of God
destined that the nations of the world should have become a
Christendom in fact—a theocracy presided over by his Vicar on earth
—the system elaborated by the Roman curia would not have tended
doubtless to obscure the real and essential prerogatives of the
spiritual Head of the Christian Church. As it was by Providence
ordained, and as subsequent events have shown, claims of authority
to determine matters more or less of the temporal order, together
with the worldly pomp and show with which the Popes of the
renaissance had surrounded themselves, not only tended to obscure
the higher and supernatural powers which are the enduring heritage
of St. Peter’s successors in the See of Rome; but, however clear the
distinction between the necessary and the accidental prerogatives
might appear to the mind of the trained theologian or the perception
of the saint, to the ordinary man, when the one was called in
question the other was imperilled. And, as a fact, in England popular
irritation at the interference of the spirituality generally in matters
not wholly within the strictly ecclesiastical sphere was, at a given
moment, skilfully turned by the small reforming party into national, if
tacit, acquiescence in the rejection of even the spiritual prerogatives
of the Roman Pontiffs.
It is necessary to insist upon this matter if the full meaning of the
Reformation movement is to be understood. Here in England, there
can be no doubt, on the one hand, that no nation more fully and
freely bowed to the spiritual supremacy of the Holy See; on the
other, that there was a dislike of interference in matters which they
regarded, rightly or wrongly, as outside the sphere of the Papal
prerogative. The national feeling had grown by leaps and bounds in
the early years of the sixteenth century. But it was not until the
ardent spirits among the doctrinal reformers had succeeded in
weakening the hold of Catholicity in religion on the hearts of the
people that this rise of national feeling entered into the ecclesiastical
domain, and the love of country could be effectually used to turn
them against the Pope, even as Head of the Christian Church. With
this distinction clearly before the mind, it is possible to understand
the general attitude of the English nation to the Pope and his
authority on the eve of the overthrow of his jurisdiction.
To begin with some evidence of popular teaching as to the Pope’s
position as Head of the Church. It is, of course, evident that in many
works the supremacy of the Holy See is assumed and not positively
stated. This is exactly what we should expect in a matter which was
certainly taken for granted by all. William Bond, a learned priest, and
subsequently a monk of Syon, with Richard Whitford, was the author
of a book called the Pilgrimage of Perfection, published by Wynkyn
de Worde in 1531. It is a work, as the author tells us, “very
profitable to all Christian persons to read”; and the third book
consists of a long and careful explanation of the Creed. In the
section treating about the tenth article is to be found a very
complete statement of the teaching of the Christian religion on the
Church. After taking the marks of the Church, the author says:
“There may be set no other foundation for the Church, but only that
which is put, namely, Christ Jesus. It is certain, since it is founded on
the Apostles, as our Lord said to Peter, ‘I have prayed that thy faith
fail not.’ And no more it shall; for (as St. Cyprian says) the Church of
Rome was never yet the root of heresy. This Church Apostolic is so
named the Church of Rome, because St. Peter and St. Paul, who
under Christ were heads and princes of this Church, deposited there
the tabernacles of their bodies, which God willed should be buried
there and rest in Rome, and that should be the chief see in the
world; just as commonly in all other places the chief see of the
bishop is where the chief saint and bishop of the see is buried. By
this you may know how Christ is the Head of the Church, and how
our Holy Father the Pope of Rome is Head of the Church. Many,
because they know not this mystery of Holy Scripture, have erred
and fallen to heresies in denying the excellent dignity of our Holy
Father the Pope of Rome.”[95]
In the same way Roger Edgworth, a preacher in the reign of
Henry VIII., speaking on the text “Tu vocaberis Cephas,” says: “And
by this the error and ignorance of certain summalists are
confounded, who take this text as one of their strongest reasons for
the supremacy of the Pope of Rome. In so doing, such summalists
would plainly destroy the text of St. John’s Gospel to serve their
purpose, which they have no need to do, for there are as well texts
of Holy Scripture and passages of ancient writers which abundantly
prove the said primacy of the Pope.”[96]
 When by 1523 the attacks of Luther and his followers on the
position of the Pope had turned men’s minds in England to the
question, and caused them to examine into the grounds of their
belief, several books on the subject appeared in England. One in
particular, intended to be subsidiary to the volume published by the
king himself against Luther, was written by a theologian named
Edward Powell, and published by Pynson in London. In his preface,
Powell says that before printing his work he had submitted it to the
most learned authority at Oxford (eruditissimo Oxoniensium). The
first part of the book is devoted to a scientific treatise upon the
Pope’s supremacy, with all the proofs from Scripture and the Fathers
set out in detail. “This then,” he concludes, “is the Catholic Church,
which, having the Roman Pontiff, the successor of Peter, as its head,
offers the means of sanctifying the souls of all its members, and
testifies to the truth of all that is to be taught.” The high priesthood
of Peter “is said to be Roman, not because it cannot be elsewhere,
but through a certain congruity which makes Rome the most fitting
place. That is, that where the centre of the world’s government was,
there also should be placed the high priesthood of Christ. Just as of
old the summus Pontifex was in Jerusalem, the metropolis of the
Jewish nation, so now it is in Rome, the centre of Christian
civilisation.”[97]
We naturally, of course, turn to the works of Sir Thomas More for
evidence of the teaching as to the Pope’s position at this period; and
his testimony is abundant and definite. Thus in the second book of
his Dyalogue, written in 1528, arguing that there must be unity in
the Church of Christ, he points out that the effect of Lutheranism
has been to breed diversity of faith and practice. “Though they
began so late,” he writes, “yet there are not only as many sects
almost as men, but also the masters themselves change their minds
and their opinions every day. Bohemia is also in the same case: one
faith in the town, another in the field; one in Prague, another in the
next town; and yet in Prague itself, one faith in one street, another
in the next. And yet all these acknowledge that they cannot have the
Sacraments ministered but by such priests as are made by authority
derived and conveyed from the Pope who is, under Christ, Vicar and
head of our Church.”[98] It is important to note in this passage how
the author takes for granted the Pope’s supreme authority over the
Christian Church. To this subject he returns, and is more explicit in a
later chapter of the same book. The Church, he says, is the
“company and congregation of all nations professing the name of
Christ.” This church “has begun with Christ, and has had Him for its
head and St. Peter His Vicar after Him, and the head under Him; and
always since, the successors of him continually. And it has had His
holy faith and His blessed Sacraments and His holy Scriptures
delivered, kept, and conserved therein by God and His Holy Spirit,
and albeit some nations fall away, yet just as no matter how many
boughs whatever fall from the tree, even though more fall than be
left thereon, still there is no doubt which is the very tree, although
each of them were planted again in another place and grew to a
greater than the stock it first came off, in the same way we see and
know well that all the companies and sects of heretics and
schismatics, however great they grow, come out of this Church I
speak of; and we know that the heretics are they that are severed,
and the Church the stock that they all come out of.”[99] Here Sir
Thomas More expressly gives communion with the successors of St.
Peter as one of the chief tests of the true Church.
Again, in his Confutation of Tyndale’s Answer, written in 1532
when he was Lord Chancellor, Sir Thomas More speaks specially
about the absolute necessity of the Church being One and not able
to teach error. There is one known and recognised Church existing
throughout the world, which “is that mystical body be it never so
sick.” Of this mystical body “Christ is the principal head”; and it is no
part of his concern, he says, for the moment to determine “whether
the successor of St. Peter is his vicar-general and head under him,
as all Christian nations have now long taken him.”[100] Later on he
classes himself with “poor popish men,”[101] and in the fifth book he
discusses the question “whether the Pope and his sect” (as Tyndale
called them) “is Christ’s Church or no.” On this matter More is
perfectly clear. “I call the Church of Christ,” he says, “the known
Catholic Church of all Christian nations, neither gone out nor cut off.
And although all these nations do now and have long since
recognised and acknowledged the Pope, not as the bishop of Rome
but as the successor of St. Peter, to be their chief spiritual governor
under God and Christ’s Vicar on earth, yet I never put the Pope as
part of the definition of the Church, by defining it to be the common
known congregation of all Christian nations under one head the
Pope.”
I avoided this definition purposely, he continues, so as not “to
entangle the matter with the two questions at once, for I knew well
that the Church being proved this common known Catholic
congregation of all Christian nations abiding together in one faith,
neither fallen nor cut off; there might, peradventure, be made a
second question after that, whether over all this Catholic Church the
Pope must needs be head and chief governor and chief spiritual
shepherd, or whether, if the unity of the faith was kept among them
all, every province might have its own spiritual chief over itself,
without any recourse unto the Pope.…
“For the avoiding of all such intricacies, I purposely abstained from
putting the Pope as part of the definition of the Church, as a thing
that was not necessary; for if he be the necessary head, he is
included in the name of the whole body, and whether he be or not is
a matter to be treated and disputed of besides” (p. 615). As to
Tyndale’s railing against the authority of the Pope because there
have been “Popes that have evil played their parts,” he should
remember, says More, that “there have been Popes again right holy
men, saints and martyrs too,” and that, moreover, the personal
question of goodness or badness has nothing to say to the office.
[102]

In like manner, More, when arguing against Friar Barnes, says that
like the Donatists “these heretics call the Catholic Christian people
papists,” and in this they are right, since “Saint Austin called the
successor of Saint Peter the chief head on earth of the whole
Catholic Church, as well as any man does now.” He here plainly
states his view of the supremacy of the See of Rome.[103] He
accepted it not only as an antiquarian fact, but as a thing necessary
for the preservation of the unity of the Faith. Into the further
question whether the office of supreme pastor was established by
Christ Himself, or, as theologians would say, de jure divino, or
whether it had grown with the growth and needs of the Church,
More did not then enter. The fact was sufficient for him that the only
Christian Church he recognised had for long ages regarded the Pope
as the Pastor pastorum, the supreme spiritual head of the Church of
Christ. His own words, almost at the end of his life, are the best
indication of his mature conclusion on this matter. “I have,” he says,
“by the grace of God, been always a Catholic, never out of
communion with the Roman Pontiff; but I have heard it said at times
that the authority of the Roman Pontiff was certainly lawful and to
be respected, but still an authority derived from human law, and not
standing upon a divine prescription. Then, when I observed that
public affairs were so ordered that the sources of the power of the
Roman Pontiff would necessarily be examined, I gave myself up to a
diligent examination of that question for the space of seven years,
and found that the authority of the Roman Pontiff, which you rashly
—I will not use stronger language—have set aside, is not only lawful
to be respected and necessary, but also grounded on the divine law
and prescription. That is my opinion, that is the belief in which, by
the grace of God, I shall die.”[104]
Looking at More’s position in regard to this question in the light of
all that he has written, it would seem to be certain that he never for
a moment doubted that the Papacy was necessary for the Church.
He accepted this without regard to the reasons of the faith that was
in him, and in this he was not different from the body of Englishmen
at large. When, in 1522, the book by Henry VIII. appeared against
Luther, it drew the attention of Sir Thomas specially to a
consideration of the grounds upon which the supremacy of the Pope
was held by Catholics. As the result of his examination he became so
convinced that it was of divine institution that “my conscience would
be in right great peril,” he says, “if I should follow the other side and
deny the primacy to be provided of God.” Even before examination
More evidently held implicitly the same ideas, since in his Latin book
against Luther, published in 1523, he declared his entire agreement
with Bishop Fisher on the subject. That the latter was fully
acquainted with the reasons which went to prove that the Papacy
was of divine institution, and that he fully accepted it as such, is
certain.[105]
When, with the failure of the divorce proceedings, came the
rejection of Papal supremacy in England, there were plenty of people
ready to take the winning side, urging that the rejection was just,
and not contrary to the true conception of the Christian Church. It is
interesting to note that in all the pulpit tirades against the Pope and
what was called his “usurped supremacy,” there is no suggestion
that this supremacy had not hitherto been fully and freely
recognised by all in the country. On the contrary, the change was
regarded as a happy emancipation from an authority which had
been hitherto submitted to without question or doubt. A sermon
preached at St. Paul’s the Sunday after the execution of the
Venerable Bishop Fisher, and a few days before Sir Thomas More
was called to lay down his life for the same cause, is of interest, as
specially making mention of these two great men, and of the
reasons which had forced them to lay down their lives in the Pope’s
quarrel. The preacher was one Simon Matthew, and his object was
to instruct the people in the new theory of the Christian Church
necessary on the rejection of the headship of the Pope. “The
diversity of regions and countries,” he says, “does not make any
diversity of churches, but a unity of faith makes all regions one
Church.” “There was,” he continued, “no necessity to know Peter, as
many have reckoned, in the Bishop of Rome, (teaching) that except
we knew him and his holy college, we could not be of Christ’s
Church. Many have thought it necessary that if a man would be a
member of the Church of Christ, he must belong to the holy church
of Rome and take the Holy Father thereof for the supreme Head and
for the Vicar of Christ, yea for Christ Himself, (since) to be divided
from him was even to be divided from Christ.” This, the preacher
informs his audience, is “damnable teaching,” and that “the Bishop
of Rome has no more power by the laws of God in this realm than
any foreign bishop.”
He then goes on to speak of what was, no doubt, in everybody’s
mind at the time, the condemnation of the two eminent Englishmen
for upholding the ancient teachings as to the Pope’s spiritual
headship. “Of late,” he says, “you have had experience of some,
whom neither friends nor kinsfolk, nor the judgment of both
universities, Cambridge and Oxford, nor the universal consent of all
the clergy of this realm, nor the laws of the Parliament, nor their
most natural and loving prince, could by any gentle ways revoke
from their disobedience, but would needs persist therein, giving
pernicious occasion to the multitude to murmur and grudge at the
king’s laws, seeing that they were men of estimation and would be
seen wiser than all the realm and of better conscience than others,
justifying themselves and condemning all the realm besides. These
being condemned and the king’s prisoners, yet did not cease to
conceive ill of our sovereign, refusing his laws, but even in prison
wrote to their mutual comfort in their damnable opinions. I mean
Doctor Fisher and Sir Thomas More, whom I am as sorry to name as
any man here is to hear named: sorry for that they, being sometime
men of worship and honour, men of famous learning and many
excellent graces and so tenderly sometime beloved by their prince,
should thus unkindly, unnaturally, and traitorously use themselves.
Our Lord give them grace to be repentant! Let neither their fame,
learning, nor honour move you loving subjects from your prince; but
regard ye the truth.”
The preacher then goes on to condemn the coarse style of
preaching against the Pope in which some indulged at that time. “I
would exhort,” he says, “such as are of my sort and use preaching,
so to temper their words that they be not noted to speak of stomach
and rather to prate than preach. Nor would I have the defenders of
the king’s matters rage and rail, or scold, as many are thought to do,
calling the Bishop of Rome the ‘harlot of Babylon’ or ‘the beast of
Rome,’ with many such other, as I have heard some say; these be
meeter to preach at Paul’s Wharf than at Paul’s Cross.”[106]
The care that was taken at this time in sermons to the people to
decry the Pope’s authority, as well as the abuse which was hurled at
his office, is in reality ample proof of the popular belief in his
supremacy, which it was necessary to eradicate from the hearts of
the English people. Few, probably, would have been able to state the
reason for their belief; but that the spiritual headship was fully and
generally accepted as a fact is, in view of the works of the period,
not open to question. Had there been disbelief, or even doubt, as to
the matter, some evidence of this would be forthcoming in the years
that preceded the final overthrow of Papal jurisdiction in England.
Nor are direct declarations of the faith of the English Church
wanting. To the evidence already adduced, a sermon preached by
Bishop Longland in 1527, before the archbishops and bishops of
England in synod at Westminster, may be added. The discourse is
directed against the errors of Luther and the social evils to which his
teaching had led in Germany. The English bishops, Bishop Longland
declares, are determined to do all in their power to preserve the
English Church from this evil teaching, and he exhorts all to pray
that God will not allow the universal and chief Church—the Roman
Church—to be further afflicted, that He will restore liberty to the
most Holy Father and high-priest now impiously imprisoned, and in a
lamentable state; that He Himself will protect the Church’s freedom
threatened by a multitude of evil men, and through the pious
prayers of His people will free it and restore its most Holy Father.
Just as the early Christians prayed when Peter was in prison, so
ought all to pray in these days of affliction. “Shall we not,” he cries,
“mourn for the evil life of the chief Church (of Christendom)? Shall
we not beseech God for the liberation of the primate and chief ruler
of the Church? Let us pray then; let us pray that through our prayers
we may be heard. Let us implore freedom for our mother, the
Catholic Church, and the liberty, so necessary for the Christian
religion, of our chief Father on earth—the Pope.”[107]
 Again, Dr. John Clark, the English ambassador in Rome, when
presenting Henry’s book against Luther to Leo X. in public consistory,
said that the English king had taken up the defence of the Church
because in attacking the Pope the German reformer had tried to
subvert the order established by God Himself. In the Babylonian
Captivity of the Church he had given to the world a book “most
pernicious to mankind,” and before presenting Henry’s reply, he
begged to be allowed to protest “the devotion and veneration of the
king towards the Pope and his most Holy See.” Luther had declared
war “not only against your Holiness but also against your office;
against the ecclesiastical hierarchy, against this See, and against that
Rock established by God Himself.” England, the speaker continued,
“has never been behind other nations in the worship of God and the
Christian faith, and in obedience to the Roman Church.” Hence “no
nation” detests more cordially “this monster (Luther) and the
heresies broached by him.” For he has declared war “not only
against your Holiness but against your office; against the
ecclesiastical hierarchy, against this See, that Rock established by
God Himself.”[108]
Whilst the evidence goes to show the full acceptance by the
English people of the Pope’s spiritual headship of the Church, it is
also true that the system elaborated by the ecclesiastical lawyers in
the later Middle Ages, dealing, as it did, so largely with temporal
matters, property, and the rights attaching thereto, opened the door
to causes of disagreement between Rome and England, and at times
open complaints and criticism of the exercise of Roman authority in
England made themselves heard. This is true of all periods of English
history. Since these disagreements are obviously altogether
connected with the question, not of spirituals, but of temporals, they
would not require any more special notice but for the
misunderstandings they have given rise to in regard to the general
attitude of men’s minds to Rome and Papal authority on the eve of
the Reformation. It is easy to find evidence of this. As early as 1517,
a work bearing on this question appeared in England. It was a
translation of several tracts that had been published abroad on the
debated matter of Constantine’s donation to the Pope, and it was
issued from the press of Thomas Godfray in a well-printed folio.
After a translation of the Latin version of a Greek manuscript of
Constantine’s gift, which had been found in the Papal library by
Bartolomeo Pincern, and published by order of Pope Julius II., there
is given in this volume the critical examination of this gift by
Laurence Valla, the opinion of Nicholas of Cusa, written for the
Council of Basle, and that of St. Antoninus, Archbishop of Florence.
The interest of the volume for the present purpose chiefly consists in
the fact of the publication in England at this date of the views
expressed by Laurence Valla. Valla had been a canon of the Lateran
and an eminent scholar, who was employed by Pope Nicholas V. to
translate Thucydides and Herodotus. His outspoken words got him
into difficulties with the Roman curia, and obliged him to retire to
Naples, where he died in 1457. The tract was edited with a preface
by the leader of the reform party in Germany, Ulrich von Hutten. In
this introduction von Hutten says that by the publication of Pincern’s
translation of the supposed donation of Constantine Julius II. had
“provoked and stirred up men to war and battle,” and further, he
blames the Pontiff because he would not permit Valla’s work against
the genuineness of the gift to be published. With the accession of
Leo X. von Hutten looked, he declares, for better days, since “by
striking as it were a cymbal of peace the Pope has raised up the
hearts and minds of all Christian people.” Before this time the truth
could not be spoken. Popes looked “to pluck the riches and goods of
all men to their own selves,” with the result that “on the other side
they take away from themselves all that belongs to the succession of
St. Peter.”
Valla, of course, condemns the supposed donation of Constantine
to the Pope as spurious, and declares against the temporal claims
the See of Rome had founded upon it. He strongly objects to the
“temporal as well as the spiritual sword” being in the hands of the
successors of St. Peter. “They say,” he writes, “that the city of Rome
is theirs, that the kingdom of Naples is their own property: that all
Italy, France, and Spain, Germany, England, and all the west part of
the world belongs to them. For all these nations and countries (they
say) are contained in the instrument and writ of the donation or
grant.”
The whole tract is an attack upon the temporal sovereignty of the
head of the Christian Church, and it was indeed a bold thing for
Ulrich von Hutten to publish it and dedicate it to Pope Leo X. For the
present purpose it is chiefly important to find all this set out in an
English dress, whilst so far and for a long while after, the English
people were loyal and true to the spiritual headship of the Pope, and
were second to no other nation in their attachment to him. At that
time recent events, including the wars of Julius II., must certainly
have caused men to reflect upon the temporal aspect of the Papacy;
and hearts more loyal to the successor of St. Peter than was that of
Von Hutten would probably have joined fervently in the concluding
words of his preface as it appeared in English. “Would to God I
might (for there is nothing I do long for more) once see it brought to
pass that the Pope were only the Vicar of Christ and not also the
Vicar of the Emperor, and that this horrible saying may no longer be
heard: ‘the Church fighteth and warreth against the Perugians, the
Church fighteth against the people of Bologna.’ It is not the Church
that fights and wars against Christian men; it is the Pope that does
so. The Church fights against wicked spirits in the regions of the air.
Then shall the Pope be called, and in very deed be, a Holy Father,
the Father of all men, the Father of the Church. Then shall he not
raise and stir up wars and battles among Christian men, but he shall
allay and stop the wars which have been stirred up by others, by his
apostolic censure and papal majesty.”[109]
Evidence of what, above, has been called the probable searching
of men’s minds as to the action of the Popes in temporal matters,
may be seen in a book called a Dyalogue between a knight and a
clerk, concerning the power spiritual and temporal.[110] In reply to
the complaint of the clerk that in the evil days in which their lot had
fallen “the statutes and ordinances of bishops of Rome and the
decrees of holy fathers” were disregarded, the knight exposes a
layman’s view of the matter. “Whether they ordain,” he says, “or
have ordained in times past of the temporality, may well be law to
you, but not to us. No man has power to ordain statutes of things
over which he has no lordship, as the king of France may ordain no
statute (binding) on the emperor nor the emperor on the king of
England. And just as princes of this world may ordain no statutes for
your spirituality over which they have no power; no more may you
ordain statutes of their temporalities over which you have neither
power nor authority. Therefore, whatever you ordain about temporal
things, over which you have received no power from God, is vain
(and void). And therefore but lately, I laughed well fast, when I
heard that Boniface VIII. had made a new statute that he himself
should be above all secular lords, princes, kings, and emperors, and
above all kingdoms, and make laws about all things: and that he
only needed to write, for all things shall be his when he has so
written: and thus all things will be yours. If he wishes to have my
castle, my town, my field, my money, or any other such thing he
needed, nothing but to will it, and write it, and make a decree, and
wot that it be done, (for) to all such things he has a right.”
The clerk does not, however, at once give up the position. You
mean, he says in substance, that in your opinion the Pope has no
power over your property and goods. “Though we should prove this
by our law and by written decrees, you account them for nought. For
you hold that Peter had no lordship or power over temporals, but by
such law written. But if you will be a true Christian man and of right
belief, you will not deny that Christ is the lord of all things. To Him it
is said in the Psalter book: ‘Ask of me, and I will give you nations for
thine heritage, and all the world about for thy possession’ (Ps. ii.).
These are God’s words, and no one doubts that He can ordain for
the whole earth.”
Nobody denies God’s lordship over the earth, replied the knight,
“but if be proved by Holy Writ that the Pope is lord of all
temporalities, then kings and princes must needs be subject to the
Pope in temporals as in spirituals.” So they are, in effect, answered
the clerk. Peter was made “Christ’s full Vicar,” and as such he can do
what his lord can, “especially when he is Vicar with full power,
without any withdrawing of power, and he thus can direct all
Christian nations in temporal matters.” But, said the knight, “Christ’s
life plainly shows that He made no claim whatever to temporal
power. Also in Peter’s commission He gave him not the keys of the
kingdom of the earth, but the keys of the kingdom of heaven. It is
also evident that the bishops of the Hebrews were subjects of the
kings, and kings deposed bishops; but,” he adds, fearing to go too
far, “God forbid that they should do so now.” Then he goes on to
quote St. Paul in the Epistle to the Hebrews to prove that St. Peter
was Christ’s Vicar only in “the godly kingdom of souls, and that
though some temporal things may be managed by bishops, yet
nevertheless it is plain and evident that bishops should not be
occupied in the government of the might and lordship of the world.”
And indeed, he urges, “Christ neither made St. Peter a knight nor a
crowned king, but ordained him a priest and bishop.” If the
contention that “the Pope is the Vicar of God in temporal matter be
correct,” then of necessity you must also grant that “the Pope may
take from you and from us all the goods that you and we have, and
give them all to whichever of his nephews or cousins he wills and
give no reason why: and also that he may take away from princes
and kings principalities and kingdoms, at his own will, and give them
where he likes.”[111]
This statement by the layman of the advanced clerical view is
somewhat bald, and is probably intentionally exaggerated; but that it
could be published even as a caricature of the position taken up by
some ecclesiastics, shows that at this time some went very far
indeed in their claims. It is all the more remarkable that the
argument is seriously put forward in a tract, the author of which is
evidently a Catholic at heart, and one who fully admits the supreme
jurisdiction of the Pope in all matters spiritual. Of course, when the
rejection of Papal jurisdiction became imminent, there were found
many who by sermons and books endeavoured to eradicate the old
teaching from the people’s hearts, and then it was that what was
called, “the pretensions” of the successors of St. Peter in matters
temporal were held up to serve as a convenient means of striking at
the spiritual prerogatives. As a sample, a small book named a Mustre
of scismatyke bysshops of Rome may be taken. It was printed in
1534, and its title is sufficient to indicate its tone. The author, one
John Roberts, rakes together a good many unsavoury tales about
the lives of individual Popes, and in particular he translates the life of
Gregory VII. to enforce his moral. In his preface he says, “There is a
fond, foolish, fantasy raging in many men’s heads nowadays, and it
is this: the Popes, say they, cannot err. This fantastical blindness was
never taught by any man of literature, but by some peckish pedler or
clouting collier: it is so gross in itself.” And I “warn, advise, beseech,
and adjure all my well-beloved countrymen in England that men do
not permit themselves to be blinded with affection, with hypocrisy,
or with superstition. What have we got from Rome but pulling,
polling, picking, robbing, stealing, oppression, blood-shedding, and
tyranny daily exercised upon us by him and his.”[112]
Again, as another example of how the mind of the people was
stirred up, we may take a few sentences from A Worke entytled of
the olde God and the new. This tract is one of the most scurrilous of
the German productions of the period. It was published in English by
Myles Coverdale, and is on the list of books prohibited by the king in
1534. After a tirade against the Pope, whom he delights in calling
“anti-Christ,” the author declares that the Popes are the cause of
many of the evils from which people were suffering at that time. In
old days, he says, the Bishop of Rome was nothing more “than a
pastor or herdsman,” and adds: “Now he who has been at Rome in
the time of Pope Alexander VI. or of Pope Julius II., he need not
read many histories. I put it to his judgment whether any of the
Pagans or of the Turks ever did lead such a life as did these.”[113]
The same temper of mind appears in the preface of a book called
The Defence of Peace, translated into English by William Marshall
and printed in 1535. The work itself was written by Marsilius of
Padua about 1323, but the preface is dated 1522. The whole tone is
distinctly anti-clerical, but the main line of attack is developed from
the side of the temporalities possessed by churchmen. Even
churchmen, he says, look mainly to the increase of their worldly
goods. “Riches give honour, riches give benefices, riches give power
and authority, riches cause men to be regarded and greatly
esteemed.” Especially is the author of the preface severe upon the
temporal position which the Pope claims as inalienably united with
his office as head of the Church. Benedict XII., he says, acted in
many places as if he were all powerful, appointing rulers and officers
in cities within the emperor’s dominions, saying, “that all power and
rule and empire was his own, for as much as whosoever is the
successor of Peter on earth is the only Vicar or deputy of Jesus
Christ the King of Heaven.”[114]
In the body of the book itself the same views are expressed. The
authority of the primacy is said to be “not immediately from God,
but by the will and mind of man, just as other offices of a
commonwealth are,” and that the real meaning and extent of the
claims put forward by the Pope can be seen easily. They are
temporal, not spiritual. “This is the meaning of this title among the
Bishops of Rome, that as Christ had the fulness of power and
jurisdiction over all kings, princes, commonwealth, companies, or
fellowships, and all singular persons, so in like manner they who call
themselves the Vicars of Christ and Peter, have also the same fulness
of enactive jurisdiction, determined by no law of man,” and thus it is
that “the Bishops of Rome, with their desire for dominion, have been
the cause of discords and wars.”[115]
Lancelot Ridley, in his Exposition of the Epistle of Jude, published
in 1538 after the breach with Rome, takes the same line. The Pope
has no right to have “exempted himself” and “other spiritual men
from the obedience to the civil rulers and powers.” Some, indeed, he
says, “set up the usurped power of the Bishop of Rome above kings,
princes, and emperors, and that by the ordinance of God, as if God
and His Holy Scripture did give to the Bishop of Rome a secular
power above kings, princes, and emperors here in this world. It is
evident by Scripture that the Bishop of Rome has no other power
but at the pleasure of princes, than in the ministration of the Word
of God in preaching God’s Word purely and sincerely, to reprove by it
evil men, and to do such things as become a preacher, a bishop, a
minister of God’s Word to do. Other power Scripture does not
attribute to the Bishop of Rome, nor suffer him to use. Scripture wills
him to be a bishop, and to do the office of a bishop, and not to play
the prince, the king, the emperor, the lord, and so forth.”[116] It is
important to note in this passage that the writer was a reformer, and
that he was expressing his views after the jurisdiction of the Holy
See had been rejected by the king and his advisers. The ground of
the rejection, according to him—or at any rate the reason which it
was desired to emphasise before the public—would appear to be the
temporal authority which the Popes had been exercising.
In the same year, 1538, Richard Morysine published a translation
of a letter addressed by John Sturmius, the Lutheran, to the
cardinals appointed by Pope Paul III. to consider what could be done
to stem the evils which threatened the Church. As the work of this
Papal commission was then directly put before the English people,
some account of it is almost necessary. The commission consisted of
four cardinals, two archbishops, one bishop, the abbot of San
Giorgio, Venice, and the master of the Sacred Palace, and its report
was supposed to have been drafted by Cardinal Caraffa, afterwards
Pope Paul IV. The document thanks God who has inspired the Pope
“to put forth his hand to support the ruins of the tottering and
almost fallen Church of Christ, and to raise it again to its pristine
height.” As a beginning, the Holy Father has commanded them to lay
bare to him “those most grave abuses, that is diseases, by which the
Church of God, and this Roman curia especially, is afflicted,” and
which has brought about the state of ruin now so evident. The initial
cause of all has been, they declare, that the Popes have surrounded
themselves with people who only told them what they thought
would be pleasant to them, and who had not the honesty and loyalty
to speak the truth. This adulation had deceived the Roman Pontiffs
about many things. “To get the truth to their ears was always most
difficult. Teachers sprung up who were ready to declare that the
Pope was the master of all benefices, and as master might by right
sell them as his own.” As a consequence, it was taught that the Pope
could not be guilty of simony, and that the will of the Pope was the
highest law, and could override all law. “From this source, Holy
Father,” they continue, “as from the Trojan horse, so many abuses
and most grievous diseases have grown up in the Church of God.”
Even pagans, they say, scoff at the state of the Christian Church as it
is at present, and they, the commissioners, beg the Pope not to
delay in immediately taking in hand the correction of the manifest
abuses which afflict and disgrace the Church of Christ. “Begin the
cure,” they say, “whence sprung the disease. Follow the teaching of
the Apostle St. Paul: ‘be a dispenser, not a lord.’”
They then proceed to note the abuses which to them are most
apparent, and to suggest remedies. We are not concerned with
these further than to point out that, as a preliminary, they state that
the true principle of government is, that what is the law must be
kept, and that dispensations should be granted only on the most
urgent causes, since nothing brings government to such bad repute
as the continual exercise of the power of dispensation. Further, they
note that it is certainly not lawful for the Vicar of Christ to make any
profit (lucrum) by the dispensations he is obliged to give.
Sturmius, in his preface, says he had hopes of better things, now
that there was a Pope ready to listen. “It is a rare thing, and much
more than man could hope for, that there should come a Bishop of
Rome who would require his prelates upon their oath to open the
truth, to show abuses, and to seek remedies for them.” He is
pleased to think that these four cardinals, Sadolet, Paul Caraffa,
Contarini, and Reginald Pole had allowed fully and frankly that a
great portion of the difficulty had come from the unfortunate
attitude of the Popes in regard to worldly affairs. “You acknowledge,”
he says, “that no lordship is committed to the Bishop of Rome, but
rather a certain cure by which he may rule things in the church
according to good order. If you admit this to be true and will entirely
grant us this, a great part of our (i.e. Lutheran) controversy is taken
away; granting this also, that we did not dissent from you without
great and just causes.” The three points the cardinals claimed for the
Pope, it may be noted, were: (1) that he was to be Bishop of Rome;
(2) that he was to be universal Bishop; and (3) that he should be
allowed temporal sovereignty over certain cities in Italy.[117] Again
we find the same view put before the English people in this
translation: the chief objection to the admission of Papal
prerogatives was the “lordship” which he claimed over and above
the spiritual powers he exercised as successor of St. Peter. On this
point we find preachers and writers of the period insisting most
clearly and definitely. Some, of course, attack the spiritual
jurisdiction directly, but most commonly such attacks are flavoured
and served up for general consumption by a supply of abuse of the
temporal assumptions and the worldly show of the Popes. This
appealed to the popular mind, and to the growing sense of national
aims and objects, and the real issue of the spiritual headship was
obscured by the plea of national sentiment and safeguards.
To take one more example: Bishop Tunstall, on Palm Sunday,
1539, preached before the king and court. His object was to defend
the rejection of the Papal supremacy and jurisdiction. He declaimed
against the notion that the Popes were to be considered as free from
subjection to worldly powers, maintaining that in this they were like
all other men. “The Popes,” he says, “exalt their seat above the stars
of God, and ascend above the clouds, and will be like to God
Almighty.… The Bishop of Rome offers his feet to be kissed, shod
with his shoes on. This I saw myself, being present thirty-four years
ago, when Julius, the Bishop of Rome, stood on his feet and one of
his chamberlains held up his skirt because it stood not, as he
thought, with his dignity that he should do it himself, that his shoes
might appear, whilst a nobleman of great age prostrated himself
upon the ground and kissed his shoes.”[118]
To us, to-day, much that was written and spoken at this time will
appear, like many of the above passages, foolish and exaggerated;
but the language served its purpose, and contributed more than
anything else to lower the Popes in the eyes of the people, and to
justify in their minds the overthrow of the ecclesiastical system
which had postulated the Pope as the universal Father of the
Christian Church. Each Sunday, in every parish church throughout
the country, they had been invited in the bidding prayer, as their
fathers had been for generations, to remember their duty of praying
for their common Father, the Pope. When the Pope’s authority was
finally rejected by the English king and his advisers, it was necessary
to justify this serious breach with the past religious practice, and the
works of the period prove beyond doubt that this was done in the
popular mind by turning men’s thoughts to the temporal aspect of
the Papacy, and making them think that it was for the national profit
and honour that this foreign yoke should be cast off. Whilst this is
clear, it is also equally clear in the works of the time that the purely
religious aspect of the question was as far as possible relegated to a
secondary place in the discussions. This was perhaps not unnatural,
as the duty of defending the rejection of the Papal supremacy can
hardly have been very tasteful to those who were forced by the
strong arm of the State to justify it before the people. As late as
1540 we are told by a contemporary writer that the spirituality under
the bishops “favour as much as they dare the Bishop of Rome’s laws
and his ways.”[119]
Even the actual meaning attached to the formal acknowledgment
of the king’s Headship by the clergy was sufficiently ambiguous to be
understood, by some at least, as aimed merely at the temporal
jurisdiction of the Roman curia. It is true it is usually understood that
Convocation by its act, acknowledging Henry as sole supreme Head
of the Church of England, gave him absolute spiritual jurisdiction.
Whatever may have been the intention of the king in requiring the
acknowledgment from the clergy, it seems absolutely certain that the
ruling powers in the Church considered that by their grant there was
no derogation of the Pope’s spiritual jurisdiction.
A comparison of the clauses required by Henry with those actually
granted by Convocation makes it evident that any admission that the
crown had any cure of souls, that is, spiritual jurisdiction, was
specifically guarded against. In place of the clause containing the
words, “cure of souls committed to his Majesty,” proposed in the
king’s name to his clergy, they adopted the form, “the nation
committed to his Majesty.” The other royal demands were modified
in the same manner, and it is consequently obvious that all the
insertions proposed by the crown were weighed with the greatest
care by skilled ecclesiastical jurists in some two and thirty sessions,
and the changes introduced by them with the proposals made on
behalf of the king throw considerable light upon the meaning which
Convocation intended to give to the Supremum Caput clause. In one
sense, perhaps not the obvious one, but one that had de facto been
recognised during Catholic ages, the sovereign was the Protector—
the advocatus—of the Church in his country, and to him the clergy
would look to protect his people from the introduction of heresy and
for maintenance in their temporalities. So that whilst, on the one
hand, the king and Thomas Cromwell may well have desired the
admission of Henry’s authority over “the English Church, whose
Protector and supreme Head he alone is,” to cover even spiritual
jurisdiction, on the other hand, Warham and the English Bishops
evidently did intend it to cover only an admission that the king had
taken all jurisdiction in temporals, hitherto exercised by the Pope in
England, into his own hands.
Moreover, looking at what was demanded and at what was
granted by the clergy, there is little room for doubt that they at first
deliberately eliminated any acknowledgment of the Royal
jurisdiction. This deduction is turned into a certainty by the
subsequent action of Archbishop Warham. He first protested that the
admission was not to be twisted in “derogation of the Roman Pontiff
or the Apostolic See,” and the very last act of his life was the
drafting of an elaborate exposition, to be delivered in the House of
Lords, of the impossibility of the king’s having spiritual jurisdiction,
from the very nature of the constitution of the Christian Church.
Such jurisdiction, he claimed, belonged of right to the Roman See.
[120]
 That the admission wrung from the clergy in fact formed the thin
end of the wedge which finally severed the English Church from the
spiritual jurisdiction of the Holy See is obvious. But the “thin end”
was, there can be hardly any doubt, the temporal aspect of the
authority of the Roman See; and that its insertion at all was possible
may be said in greater measure to be due to the fact that the
exercise of jurisdiction in temporals by a foreign authority had long
been a matter which many Englishmen had strongly resented.
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