Objective Structure Clinical Examination: Non-Directive Pregnancy Options Counseling with Communication and Ethical Challenges

Publication ID Published Volume
9075 January 10, 2012 8


This resource consists of two fully written and developed standardized patients, the first a married woman in her early 20's and the second an unmarried woman in her late 30's, presenting to an urgent care center with vague gastrointestinal complaints, both of whom are diagnosed with unexpected early intrauterine pregnancy. The students is tasked with delivering the news of pregnancy after receiving a sign-out with the medical history, physical and test results, and dispositioning the patient. The patient challenges the student with silence, ambivalence and the questions "what should I do?" and "what would you do?"
The resource was developed with feedback from national colleagues with extensive experience in family planning education of both medical students and residents. One colleague also has served with APGO in the development of medical student curricular objectives in obstetrics and gynecology. It was used to assess skills of 104 3rd year medical students on an obstetrics and gynecology clerkship at the University of Miami Miller School of Medicine.

The following standardized patient cases were developed to assess patient centered counseling skills for non-directive options counseling in the situation of unplanned pregnancy, with special ethical and communication skills challenges to the examinee.

Recognizing that all primary care doctors as well as many specialty practitioners deliver the news of unplanned pregnancy to their patients, the Association of Professors of Gynecology and Obstetrics, in the APGO Medical Student Educational Objectives, 9th Edition, specify that third year medical students should attain a “does” level of competency for pregnancy options counseling.(1) Accordingly, methods of evaluation include standardized patients, direct observation and simulation. These authors could not identify any published standardized patient for evaluation of options counseling skills. The cases and checklists were written by the authors, and reviewed by 3 national colleagues working in family planning and reproductive health, including Dr. Jodi Steinauer of UCSF, Dr. June LaValleur formally of the University of Minnesota, and Dr. Eve Espey who served on the APGO Undergraduate Medical Education Committee. Dr. Monica Broome, Director of Communication Skills Instruction at the University of Miami Miller School of Medicine also contributed to the development of the checklist. All reviewers found the standardized patients realistic and appropriately detailed.

The case was used to assess 104 third year medical students on the third year core clerkship in obstetrics and gynecology as part of randomized trial assessing the impact of a workshop on conscientious refusal in reproductive medicine. The workshop included a structured large group discussion of trigger videos to review the limits of conscientious refusal as defined by the American College of Obstetricians and Gynecologists Committee on Ethics, private values reflection, and helping trios role-play. Student evaluation of the workshop has been published (2) and is separately submitted for MedEdPORTAL publication.

The table below gives the student responses to the post-OSCE survey. No significant differences emerged between the group of students who performed in the OSCE before and after workshop participation.

Student Evaluation of the Station:

  • N=104
  • The scenario created with the standardized patient came across as realistic and believable. 98% Yes 2% No
  • The instructions given at the beginning of the exercise were sufficient to complete the interaction, including disclosing pregnancy results and discussing options with the patient. 96% Yes 4% No
  • The medical information given in the instructions for the scenario was sufficient to handle the interaction with the assumed diagnosis of pregnancy.
  • 100% Yes 0 % No
  • Participation in the standardized patient exercise increased comfort with my skills in non-directive options counseling. 88 % Yes 12% No
  • Participation in the standardized patient exercise increased my moral comfort with non-directive options counseling. 80% Yes 20% No


Lupi C, Schreiber N, Runyan A. Objective structure clinical examination: non-directive pregnancy options counseling with communication and ethical challenges. MedEdPORTAL Publications. 2012;8:9075. http://doi.org/10.15766/mep_2374-8265.9075

Educational Objectives

  1. To evaluate competency in non-directive options counseling.
  2. To appropriately respond to patient silence and ambivalence.
  3. To deliver bad news/unexpected diagnosis.
  4. To respond to patient request for moral guidance.


  • Conscientious Refusal, OSCE, Legal Abortion, Adoption, Pregnancy Continuation

Prior Scholarly Dissemination

Input and feedback were obtained from:

  1. Dr. Eve Espey, M.D., University of New Mexico.
  2. Dr. Jodi Steinauer, M.D., M.A.S., University of California San Francisco.
  3. Dr. June LaValleur, M.D., F.A.C.O.G., formerly of the University of Minnesota.


  1. APGO Medical Student Curricular Objectives, 9th Edition. Accessed December 30, 2010 at www.apgo.org.
  2. Lupi CS, Estes CM, et al. Conscientious refusal in reproductive medicine: an educational intervention. Am J Obstet Gynecol 2009: 201:502, e1-7. http://dx.doi.org/10.1016/j.ajog.2009.05.056

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ISSN 2374-8265