2012. Vol.3, Special Issue, 937-942
Published Online October 2012 in SciRes (http://www.SciRP.org/journal/ce) http://dx.doi.org/10.4236/ce.2012.326142
Copyright © 2012 SciRes. 937
Inter-Rater Reliability: Comparison of Checklist and Global
Scoring for OSCEs*
Bunmi S. Malau-Aduli1, Sue Mulcahy2, Emma Warnecke1, Petr Otahal3,
Peta-Ann Teague4, Richard Turner1, Cees Van der Vleuten 5
1School of Medicine, Faculty of H ea l th S ci e n ce , University of Tasmania, Hobart, Austra lia
2Centre for the Advancement o f Learning and Teaching, University of Tasmania, Hobart, Australia
3Menzies Research Institute, Hobart, Australia
4School of Medicine and Dentistry, Fa cult y of Medicine, Health and Molecular S cien ces,
James Cook University, Townsville, Australia
5School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University,
Email: email@example.com, sue.mul ca firstname.lastname@example.org, email@example.com,
firstname.lastname@example.org u , email@example.com, firstname.lastname@example.org,
Received July 31st, 2012; revised August 28th, 2 01 2; a cc ep ted S ep tember 14th, 2012
Objective Structured Clinical Examinations (OSCEs) have been used globally in evaluating clinical com-
petence in the education of health professionals. Despite the objective intent of OSCEs, scoring methods
used by examiners have been a potential source of measurement error affecting the precision with which
test scores are determined. In this study, we investigated the differences in the inter-rater reliabilities of
objective checklist and subjective global rating scores of examiners (who were exposed to an online
training program to standardise scoring techniques) across two medical schools. Examiners’ perceptions
of the e-scoring program were also investigated. Two Australian universities shared three OSCE stations
in their end-of-year undergraduate medical OSCEs. The scenarios were video-taped and used for on-line
examiner training prior to actual exams. Examiner ratings of performance at both sites were analysed us-
ing generalisability theory. A single facet, all random persons by raters design [PxR] was used to measure
inter-rater reliability for each station, separate for checklist scores and global ratings. The resulting vari-
ance components were pooled across stations and examination sites. Decision studies were used to meas-
ure reliability estimates. There was no significant mean score difference between examination sites.
Variation in examinee ability accounted for 68.3% of the total variance in checklist scores and 90.2% in
global ratings. Rater contribution was 1.4% & 0% of the total variance in checklist score and global rating
respectively, reflecting high inter-rater reliability of the scores provided by co-examiners across the two
schools. Score variance due to interaction and residual error was larger for checklist scores (30.3% vs
9.7%) than for global ratings. Reproducibility coefficients for global ratings were higher than for checklist
scores. Survey results showed that the e-scoring package facilitated consensus on scoring techniques. This
approach to examiner training also allowed examiners to calibrate the OSCEs in their own time. This
study revealed that inter-rater reliability was higher for global ratings than for checklist scores, thus pro-
viding further evidence for the reliability of subjective examiner ratings.
Keywords: Objective Structured Clinical Examination; Inter-Rater Reliability; Checklist Scores; Global
The Objective Structured Clinical Examination (OSCE) is
recognised by medical educators as an opportunity to evalu-
ate essential clinical skills and competencies necessary for
progression in the medical course (Harden & Gleeson, 1979;
Hodges, 2003; Newble, 2004). Its widespread use to sur-
mount many of the inherent validity problems of oral clinical
examinations is due to its desirable characteristics of objec-
tive testing in which examinees are exposed to the same test
conditions (Harden et al., 1975; Ki rby & Curry , 1982; Down-
ing & Yudkowsky, 2009).
The OSCE format comprises a student rotating through a se-
ries of time limited clinical “stations”. At each station the stu-
dent is faced with a simulated scenario, usually involving a
simulated patient (SP). The student has to perform the required
clinical task under the direct observation of a clinical assessor
(examiner), who scores student performance against a checklist
and/or global rating scale. There is a body of research on the
use of checklists, which describe precisely the occurrence of
particular behaviours and global rating scales which describe
the quality of a performance, allowing for more interpretation
by the examiner (Regehr et al., 1999; Hodges et al., 1999;
Hodges et al., 2002). Checklists are designed and incorporated
into OSCE to increase the objectivity and reliability of marking
by different examiners. However some researchers have criti-
cised the validity of checklists due to their tendency to become
objectified and trivial in the evaluation of clinical competence
(Van der Vleuten et al., 1991; Cohen et al., 1997; Cunnington
*Declaration of Interest: The a u t h ors report no conflicts of interest.
B. S. MALAU-ADULI ET AL.
et al., 1997; Cushing, 2002). These authors have demonstrated
the reliability and validity of global rating scales, thereby pro-
viding evidence that subjectivity may not be inherently unreli-
able. Global ratings have also been reported to better evaluate
the performance of advanced students as well as negate some of
the nuances associated with checklists (Van der Vleuten et al.,
1991; Regehr et al., 1998; Hodges et al., 1999). Some studies
have compared the psychometric properties of checklists and
global rating scales on OSCEs and concluded that global rating
scales scored by experts showed higher inter-station reliability,
better construct validity and better concurrent validity than did
checklists (Hodges et al., 1997; Regehr et al., 1998).
Intensive examiner training improves inter-rater reliability as
it ensures that all raters interprete item descriptions similarly
and apply similar standards on students’ performance (Williams
et al., 2003; Spencer & Silverman, 2004). Although earlier
studies have indicated that examiner training varied in effec-
tiveness as a function of medical experience (Newble et al.,
1980; Van der Vleuten et al., 1989), more recent studies have
demonstrated the high impact of examiner training on the con-
sistency of scoring (Humphrey-Murto et al., 2005; Chesser et
However, establishing excellent examiner training sessions
still remains a major problem for medical schools with increas-
ing number of students, difficulty finding sufficient number of
experienced examiners for multi-site exams and the challenges
of getting time-poor clinicians away from their other activities
to attend examiner-training sessions. Innovative and feasible
approaches to tackling these tasks are necessary. The primary
purpose of this study was to compare the inter-rater reliabilities
of checklist and global rating scores of examiners who were
exposed to an online training program (to standardise scoring
techniques) across two medical schools. The study also exam-
ined examiners’ perceptions of the feasibility and usability of
the e-scoring pro g ra m.
In November 2010, two Australian medical schools (A and B)
participated in a collaborative inter-school study of clinical
competence in which three OSCE stations were developed and
embedded in the (3rd and 4th years respectively) end-of-year
clinical examinations. School A runs a five-year undergraduate
medical programme, while School B runs a six-year under-
graduate programme. Both schools have similar horizontally
and vertically integrated outcomes-based curricula. The se-
lected year groups were chosen because of their comparable
levels of intended learning outcomes.
The Shared OSCE Stations
The three OSCEs (chest pain, diabetic foot and gallstones)
comprised of eight-minute stations and were administered to a
total of 119 third year medical students at School A and 94
fourth year medical students at School B. The three OSCE sta-
tions covered a range of core clinical competencies with which
examiners at both schools were familiar. Between five to nine
task-specific checklist items were developed for each case. The
behaviourally anchored 4 - 7-point rating scales assessed degree
of coherence, empathy, verbal and non-verbal expressions.
The examination at School A was conducted over a two-day
period to two different cohorts of students, while at School B it
was a one day event with the three shared OSCEs embedded in
a 12-OSCE station examination. Two concurrent sessions of
each station were conducted at School A and four were con-
ducted at School B, each with one SP and one examiner.
Clearance was obtained from the relevant ethics committee for
Three examiners were independently selected from each
school to serve as external examiners, one on each of the shared
stations, and double mark with the internal examiners at the
other school. Each external examiner independently double
marked a total of 20 student observations. Each examiner rated
student performance by first scoring the task-specific checklist
and then completing a global rating. The two components were
then summed to generate an overall performance score.
To aid examiner training and standardise marking across the
two examination sites, an OSCE e-scoring tool was developed
and set up in a secure intranet site, in the on-line Blackboard
Learning System Vista environment. The three shared OSCE
scenarios were videotaped and used for the on-line examiner
training; PGY1 residents (interns) were recruited to role play as
medical students and SPs were recruited from the SP pool.
Informed consent and confidentiality agreement were obtained
from all the video participants.
A total of 24 examiners were involved in the on-line OSCE
training program. All the internal (on only the shared OSCEs)
and external examiners were invited via email, given login
access and instructions on how to use the program; the video
clips were made accessible to the examiners one week prior to
the examination. The examiners were able to view the record-
ings in their own time and assess the interns’ performances.
Each examiner was asked to watch two unlabelled scenarios
(poor and good performance) of the OSCE case which they had
been assigned to examine. After watching each scenario, they
were required to assess the performance using the marking
sheet that was provided in another window. The station infor-
mation and criteria for marking were also made available. After
completing and submitting their marking/scoring sheet, the
examiners were then able to view and compare the scores they
had given for the checklist task and the global rating with oth-
ers already submitted. This enabled examiners at both sites to
achieve consensus regarding what constituted unsatisfactory,
borderline or satisfactory performance. The SPs on the shared
OSCE stations were allowed to view the video clips and they
discussed face-to-face with the internal examiners about ex-
Descriptive statistics of the on-line training scores, compara-
tive analysis for checklist scores and global ratings in both
schools were calculated using SAS. The difference between
internal and external examiners’ scores was tested using 2- sam pl e
Copyright © 2012 SciRes.
B. S. MALAU-ADULI ET AL.
Copyright © 2012 SciRes. 939
t-test. Generalisability analysis was used to test for inter-rater
reliability across sites. Multilevel mixed-effects linear regres-
sion in STATA was used to calculate the variance components
and to evaluate the magnitude of the different sources of varia-
tion affecting the measurement. Different pairs of raters as-
sessed examinees at each of the three stations and the examina-
tion at school A was conducted over two days with a different
cohort on each day. Due to the disconnected design, variance
components for each station within each site were estimated
separately and the estimates were pooled across sites to elimi-
nate confounding of the proficiency of examinee groups and the
stringency of examiner groups across sites. For both checklist
scores and globa l ratings, a single facet, random, rate rs / ex am in e rs
(R) by persons/examinees (P) design [PxR] and the interaction
effect of person by rater with residual effect (PxR,e) was used
to assess inter-rater reliability. D-study was used to measure
reliability estim a tes .
To capture their perceptions of the on-line training/e-scoring
program, examiners were prompted to provide anonymous
responses to four open-ended on-line survey questions which
were administered to them immediately after completing their
scoring of the OSCE scenarios. The examiners were asked to 1)
comment on aspects they liked most about the e-scoring pro-
gram; 2) comment on aspects they didn’t like; 3) proffer sug-
gestions on improvement of the program and 4) provide their
views on the effect of the program on future assessments. The
survey data were collated and emerging themes independently
coded and confirmed by two researchers. Illustrative quotes are
reported verbatim in Appendix 1.
Table 1 portrays the mean checklist scores and global ratings
± the standard deviation (SD) given by co-examiners during the
actual examination. There were no statistical differences in the
mean scores given by the internal and external examiners in
The estimated variance components from generalisability
analyses for checklist scores and global ratings are presented in
Table 2. Pooled score variance attributed to student ability was
higher on global ratings in comparison to checklist scores
Descriptive statistics for checklist scores and global ratings at both sites (mean scores ± standard deviation).
Station Examiner School A c hecklist score School B checklist score School A global rating School B global rati ng
Chest pain Internal 74.3 ± 9.7 70.0 ± 9.9 4.3 ± 1.0 4.3 ± 1.0
N = 20 External 71.15 ± 10.2 72.6 ± 10.6 4.4 ± 0.8 4.3 ± 0.8
Diabetic foot Internal 65.0 ± 12.3 69.0 ± 15.2 3.5 ± 1.3 3.6 ± 1.4
N = 20 External 63.3 ± 13.1 67.7 ± 14.9 3.4 ± 1.3 3.6 ± 1.4
Gallstones Internal 72.0 ± 11.9 77.0 ± 12.4 4.2 ± 1.0 4.4 ± 1.0
N = 20 External 72.15 ± 10.4 75.4 ± 11.1 4.1 ± 0.9 4.2 ± 1.2
Total Score s 69.6 ± 11.3 71.9 ± 12.4 3.9 ± 1.1 4.0 ± 1.1
Variance component estimates and G coefficients for checklist scores and global r atings.
Checklist Scores Global ratings
estimates* G coefficients as a
function of rate rs Variance component estimates* G coefficients as a
function of rate rs
School Station P R PxR, e 1 2 P R PxR,e 1 2
1 66.88 0 43.35 0.607 0.755 0.733 0 0.075 0.907 0.951
2 81 0 54.8 0.596 0.747 0.717 0 0.15 0.827 0.905
3 110.795.38 14.87 0.882 0.937 1.553 0.0030.172 0.9 0.947
stations 258.665.38 113.02 0.696 0.821a 3.003 0.0030.397 0.883 0.938a
% variation 68.60%1.40% 30.00% 88.20%0.10%11.70%
1 69.87 0 53.55 0.566 0.723 0.749 0 0.05 0.937 0.968
2 78.39 0 54.03 0.592 0.744 0.822 0 0.15 0.846 0.916
3 124.255.38 14.87 0.893 0.944 1.895 0 0.1 0.95 0.974
stations 272.525.38 122.44 0.69 0.817a 3.466 0 0.3 0.92 0.959a
% variation 68.10%1.30% 30.60% 92.00%0.00%8.00%
Note: aG-coefficients for this study with 2 raters; *Variance component estimates for per sons (P); raters (R); and residual (PR,e), reflecting variance due to person-by-rater
nteraction (PR ) and un i dent ifie d sourc e s of error. i
B. S. MALAU-ADULI ET AL.
(90.2% vs 68.3%). Rater effect accounted for 1.4% and 0% of
total variance in checklist score and global rating respectively.
Score variance due to interaction and residual error was larger
for checklist scores (30.3% vs 9.7%) than for global ratings.
G coefficients for checklist scores and global ratings are also
presented in Table 2. G coefficients varied from each case,
with the lowest values been obtained on the diabetic foot station
across the two schools. In addition, reliability estimates for the
global ratings were higher than for the checklists.
Survey results showed that examiners valued the process be-
cause it gave them an opportunity to see a “dry run” of the sta-
tion and allowed them to set the “expected standard” for the
station prior to the actual exam (Appendix 1). They also indi-
cated that this sort of tool should be used more widely in OS-
CEs. However, they pointed out that scoring borderline per-
formance, rather than good or poor performance would make
the e-scoring process more useful.
The observed low variance in rater effect in our study indi-
cates high inter-rater reliability, meaning each rater’s scores are
consistent across different students. The results also indicate
that there are no significant differences in average scores across
raters; hence the assessment clearly reveals the competence of
each examinee. Our results show higher inter-rater agreement
for global ratings in comparison to checklist scores. A growing
body of literature has reported that global ratings have higher
reliability than checklist scores and are better able to discrimi-
nate between examinees (Hodges et al., 1999; Govaerts et al.,
2002; Hodges et al., 2003; Wilkinson et al., 2003). The higher
examinee and lower residual variance estimates observed in the
global ratings in this study in comparison to the checklist scores
echoes these findings.
McManus et al. (2006) reported that thorough selection,
monitoring and training did not eliminate examiner stringency/
leniency effect. However, our study indicates otherwise, with
the observed lower variance due to examiner difference. This
might be as a result of the online training, which allowed ex-
aminers to agree on the “expected standard” for each station
prior to the actual examination. The use of two examiners to
reduce examiner bias has been proposed (Norcini, 2002; Wil-
kinson et al., 2003), but our findings clearly demonstrate that
using on-line examiner training, higher reliabilities of 0.7 and
above for high stakes examinations can be achieved even with
the use of one examiner per station, indicating that there is little
or no benefit in using examiners to double mark. Interestingly,
our study showed that external examiners gave lower scores
than internal examiners; this may indicate the effect of exam-
iner familiarity with candidates as a potential source of bias
(Stroud et al., 2011).
Researchers have suggested that variability in performance
across cases is not simply related to content variation, but to
other factors, such as pattern recognition based on irrelevant
contextual features of the case (Govaerts et al., 2002). The ob-
served varying magnitudes of estimated variance components
across stations (cases) may indicate that the relative ordering of
cases and the specificity of case content have a large effect on
the variance. There is therefore the need to explore the magni-
tude of variance attributable to case, content and/or context
The survey results showed that the e-scoring program offered
training for both quality assurance and appraisal purposes. The
examiners valued the process as it allowed them to reach con-
sensus about their scoring techniques and resulted in similar
trends of scoring in both schools. Furthermore, given the busy
schedule of clinicians and the challenges of getting away from
their other activities to attend examiner-training sessions, the
e-scoring package allowed examiners to use it in their own time.
Most of them found it easy to navigate through the program,
but a few expressed difficulties in understanding the technology
as well as the statistics generated for comparison of scores.
The examiners also suggested that scoring of borderline per-
formances would be more useful, indicating that it was easier
for the examiners to identify and agree on their ratings, particu-
larly for good performance. This is a valid point, given the fact
that borderline students are the ones medical educators are most
concerned about. It is important for examiners to be able to
make accurate pass/fail decisions so that only competent stu-
dents are allowed to progress academically. On the whole, the
examiners concurred on the efficacy and possibility of wider
use of the e-scoring program.
The major limitation of this study is the small number of sta-
tions used. In addition, the rating of the global scales after the
checklists could have affected examiner scoring of student per-
formance. Due to the design of the study, inter-case reliability
and the comparison between trained and non-trained examiners
could not be determined. Further studies should explore these
The results of this study suggest that global rating scales are
a more appropriate summative measure than checklists in as-
sessing examinees on performance based tests, providing fur-
ther support for the reliability of subjective examiner judgments.
This study also indicates possible elimination of examiner
variance measurement error with the use of on-line examiner
training program. The tool holds great promise for high stakes
performance-based assessments conducted across multiple sites
and will afford time-poor geographically separated clinicians
the opportunity to better engage in the assessment process.
The authors would like to thank Jo Hanuszewicz, Di Madden,
Kathy Spencer, Felicity Ey, Donna-May Brown, Kaspar Will-
son, Matt Holmes, Milford McArthur, Theresa Mokry, Stefan
Blechinger, Leslee Wells, Gail Richardson and Florence Sc h a e f f e r
for their contributions to the video recordings and data collation.
The authors also acknowledge the contributions of the examin-
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B. S. MALAU-ADULI ET AL.
Aspects liked most about the e-scoring program:
Having the opportunity to see a “dry run” of the station;
Easy to view DVD;
Reasonably easy to work, and
Scenario Information was well presented prior to the ac-
Aspects not liked about the e-scoring program:
A bit tricky to understand the technology but once I had
worked it out it was fine;
Really poor student and really good one—might be better to
have one in between,
I think a discussion with other examiners immediately after
marking both candidates would be beneficial for me;
Difficulty juggling the various windows.
Suggestions on improvement:
Great idea—nice to see scenarios and grade them before the
day of the exam, takes away the issue of taking the first few
scenarios to get comfortable with it;
I would have found it more useful to have candidates that
were borderline in performance, rather than see candidates
that were clearly very good or clearly very poor;
Make the feedback in pictorial form i.e., this is where you
are on the graph;
Start with the good candidate for better standardisation.
Effect of program on future assessments:
Hope to use this sort of tool more widely in OSCEs;
Helps set the expected standard;
I found it very useful to reflect on my assessment of stu-
dents, particularly how I would approach a candidate who
was really better than expected with his verbal communica-
tion and approach to patient-focused examination, but might
not necessarily have got all the marks he deserved because
of time constraints or the criteria of the marking sheet-I
guess this is where the global score comes into it;
It may obviate the need for time-poor examiners being
available real-time for OSCEs—if all stations could be
filmed. It would be much more preferable than spending all
Saturday in a stuffy clinic cubicle!
Very little as I haven’t understood the feedback.
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