“Assessment” is at the center stage of any form of education. As aptly put by George E. Miller (1919–1998), Assessment drives learning but for that it needs to be planned and implemented strategically. Additionally, the assessment tool should be reliable and valid, only then can it be used as a tool to enhance learning.

Oral viva voice has been used as an assessment tool since ages and is unabatingly being used in most undergraduate and postgraduate medical colleges across India. This form of assessment often feels appropriate because it gives a lot of flexibility to the examiner [1,2]. The student can be scored immediately as opposed to in a written exam, the depth and breadth of knowledge can be tested, the viva can be steered according to the student’s responses, and it appears to check clinical competence better than the written exams [2,3]. It has the added advantage of testing student’s reasoning and communication skills as it offers one on one interaction with the examiner [1-4].

Despite all the apparent benefits of oral viva voice, there are lot of pitfalls that come with it. To begin with, different questions with different difficulty levels create an unequal platform on which students are judged. Most of the time, the question test recall capability rather than critical thinking and higher order thinking skills [1]. The questions do not cover the syllabus as they are impromptu and not planned. The bias is further broadened by the different temperaments of the examiners. Some are more strict or lenient in awarding scores than others [5]. More often, the viva converts into a confrontation between the examiner and student turning the examination atmosphere unconducive [6]. The high level of stress experienced by a student during the traditional viva offers no additional educational benefit as it does not motivate the student to study better. Additionally, the time given to each student is not uniform and often decreases as the day progresses, with the students at the end being scored based on a few questions [7]. Traditional oral exam (TOE) has also been found more likely to be affected by performance of the previous student affecting the score of next one and personal biases. A student’s appearance and confidence also greatly affect the exam scores and agreement between examiners is found to be poor [8]. All in all, these attributes result in a score that is unrelated to the competency of the student.

These shortcomings of oral exams can be minimized by application of structured oral examination (SOE). In SOE, the questions and the correct answers with their scores are predetermined to ensure standardized examination process and consistency from one examiner to another and from one examinee to another. It involves pre-deciding the syllabus and competencies to be assessed and fixing the time spent on each student [9-11]. This is a relatively newer method of assessment tested in small groups with both faculty and students showing a positive perception [2,3,12].

Being a time-consuming and labor-intensive exercise, limited studies are available on the application of SOE in medical education in India, especially in the subject of biochemistry. The objective of this study was to evaluate SOE as an assessment tool in the department of biochemistry via feedback from faculty and students.

There were 87 students (57 medical and 30 dental) in total appearing for the SOE. They were randomly divided into six groups with three groups having 14 students each and three groups having 15 students each.

The results of the feedback questionnaire from the students have been depicted in (Table 1, Fig. 1). The majority (96.4%) of the students experienced less stress with SOE as an assessment method compared to traditional viva. Out of these, 64% strongly agreed, and 83.9% of students felt that the SOE was comprehensive and covered all aspects of the chosen topics. Nearly all students (98.7%) felt that there was uniformity of questions being asked with 69% agreeing strongly. There was agreement amongst 99.9% students who felt that SOE is fair and unbiased and a less subjective assessment tool.

Seventy percent of students found the time allotted per question was not enough. Only 3.4% found the time allotted to be appropriate. Seventy-eight percent felt that the examiners’ mood did not affect their performance. While 40.2% of students felt that this method will lead to preparing the topic more thoroughly, 49.43% were neutral about this. In all, 90.8% of students felt that they would prefer SOE over traditional viva.

Most of the comments from students to open-ended questions were positive. They are summarized in Table 2. The students found SOE to be an exciting and less stressful assessment tool. Only one student commented that the buzzer gave them stress. Many students commented that more time per question should have been given.

The perception of faculty conducting the SOE is shown in (Table 3, Fig. 2). There was 100% agreement between examiners regarding SOE being comprehensive. They found the questions to be uniform and less subjective compared to the traditional viva. The examiners also felt that there was no carryover effect (performance of previous student affecting that of next) from one student to another. Most examiners (83.3%) also felt that SOE was fair and unbiased and agreed to recommend it as one of the formative assessment tools for future batches. Twothirds of the examiners (66.6%) preferred this method over the traditional viva.

Most examiners, specifically 83.3% were neutral about whether time allotted for each question was less, and 16.6% found the time to be inadequate and 33.3% felt that they were not able to assess the depth and breath of student's knowledge.

The specific comments from the examiners, as shown in Table 2, show that they found it to be a good method but insisted on blueprinting the questionnaire and increasing the time allotted. Half (50%) of the faculty agreed on using it as a summative assessment tool in conjunction with other methods but also found it to be a labor-intensive exercise.

For an assessment to be fair, it must be both reliable and valid. Numerous studies affirm that structuring oral exams enhances their reliability and validity in both undergraduate and postgraduate settings [6,9,14-17]. While TOE have the potential to assess the depth and breadth of a student’s knowledge, they are often criticized for their lack of reliability and susceptibility to subjective bias [1,4-8]. Scoring inconsistencies in TOEs arise from psychological biases, the subjective nature of oral assessments, and variability in examiner expectations. Due to these limitations, TOEs have been largely discontinued as a summative assessment tool in many specialties in the United States [12]. These issues can be somewhat mitigated by employing structured rating scales [4].

In response to these challenges, various alternative assessment methods have been explored, such as multiplechoice questions (MCQs) and direct observation. However, MCQs often fail to measure higher-order thinking since the options provided can cue the student to recognize correct answers, and direct observation is limited by the availability and time constraints of trained faculty [12].

This study introduced a SOE, a relatively new assessment method, in undergraduate medical biochemistry and evaluated its reception among students and faculty. In our study, a significant majority of students (96.4%) reported lower stress levels with SOE compared to traditional viva, with 64% in strong agreement. Additionally, 78% of students felt unaffected by the examiner’s mood, a significant improvement over the stress typically associated with TOEs as seen in previously done studies [5,7,11]. However, Waseem and Iqbal [18] noted that although fear of the examination was still present in both SOE and TOE, SOE was more effective in distinguishing between average and high performers. Boulais et al. [19] found that while SOE was a source of stress, some students considered it less stressful than oral structured clinical examinations. Another study found that SOE did not significantly reduce stress, likely due to students’ unfamiliarity with the new system [20].

A large proportion of students in our study (83.9%) felt that SOE provided comprehensive coverage of the syllabus, consistent with findings by Wang et al. [8], who also noted improvements in communication skills and practical application of theoretical knowledge. Furthermore, nearly all our students (98.7%) observed uniformity in the questions, and 99.9% found SOE to be fair and unbiased, aligning with previous studies that highlight the fairness of SOE over TOE in undergraduate medical and dental education [5,10,15].

Faculty feedback was overwhelmingly positive, with 100% agreeing that SOE was comprehensive, uniform, and less subjective than TOE. These results are in line with similar perspective observed by other authors where faculty noted that SOE reduced bias, minimized the luck factor, and ensured that each student was assessed on the same criteria [5-7]. In our study, the examiners also noted that there was no carryover effect, meaning that the performance of one student did not influence the assessment of the next student. This has been reported as another major drawback of traditional viva [8].

In our study, 70.2% of students and 16.6% of faculty found the time allotted per question inadequate, while 83.3% of faculty were neutral. We acknowledge that while concerns about time constraints were raised, extending the time per question could make it challenging to accommodate all students in a single session, especially considering the logistical challenges posed by a higher number of students and a limited number of available faculty. Despite similar concerns about time restraints observed by some other authors, SOE was still regarded as a valuable addition to assessment methods [12]. Future research should explore the impact of extended time on overall performance.

Interestingly, nearly half of the students in our study were unsure if SOE helped them prepare better, although prior research suggests that SOE promotes greater engagement with the material [8,19]. Our faculty (33.3%) felt that this method would enhance students’ learning.

Overall, 90.8% of students in our study preferred SOE over TOE. This was consistent with positive student feedback observed by Dhasmana et al. [14] with 83% overall acceptability and 66% of students expressing a preference for SOE over TOE. In a study investigating use of SOE in pediatric endocrinology fellowship programs, most fellows (94%) and faculty (86%) recommended the integration of SOE into their curriculum, citing its effectiveness in preparing fellows for unsupervised clinical practice [12]. Similarly, 88% of students and 83.3% of examiners preferred SOE over traditional viva due to its perceived fairness, uniformity, and reduced bias in a study by Khan and Mirza [20].

Despite acknowledging the labor-intensive nature of SOE, the majority of faculty (66.6%) in our study preferred SOE to TOE and 83.2% recommended it for future use. Concerns about SOE being labor and resource-intensive have been shown by faculty in other studies where they opine that SOE leads to examiner fatigue [4,6,8,11]. Availability of human resources and time is an important factor in overall feasibility of using SOE routinely. Shenwai and Patil [5] similarly concluded that, despite requiring extensive groundwork, SOE is a more effective assessment tool and can be widely adopted in medical education with some modifications. Another study by Boulais et al. [19] identified significant logistic challenges with SOE but concluded that extensive planning can overcome these limitations. We are convinced that advanced preparation of the question bank and answer checklists can alleviate some of these concerns. Also, once the process is planned and well conducted for a batch, it may become easier to conduct for the subsequent batches.

Numerous studies have compared SOE with TOE, yielding varied results regarding the scores obtained by students through each method. Khilnani et al. [6] and Muzzin and Hart [7] found SOE to yield lower marks than the traditional viva. But at the same time, students felt that SOE required in-depth preparation of the topic. Puppalwar et al. [21] observed higher scores in TOE, indicating examiner leniency, while fewer students passed SOE, reflecting its stricter and more objective approach. Ganji [10] demonstrated strong test-retest reliability with SOE in dental education with improvement in scores after implementation of SOE. Another study observed significant disparity in scores obtained with TOE compared to SOE and found the latter to be a fairer evaluation of students’ knowledge [14]. Imran et al. [15] found SOE had the highest discriminatory power, categorizing more students as appropriately assessed compared to unstructured viva and structured theory exams.

This study is limited by its single-institution scope, and the lack of a direct comparison between SOE and TOE scores.

This study’s strength is its focus on examining the use of SOE as a formative assessment tool in undergraduate medical biochemistry, a relatively under explored area thereby contributing valuable insights into its applicability in this discipline. This research provides comprehensive feedback from both students and faculty, providing a well-rounded view of the SOE’s effectiveness in reducing stress, increasing fairness, and ensuring uniformity. Additionally, it addresses practical challenges like faculty workload and time constraints, offering realistic solutions like advance preparation of question banks for implementing SOE effectively in educational settings. The study highlights the significant reduction in subjective bias and variability in examiner expectations, which has been a major limitation in TOEs and supports the use of SOE for consistent and equitable assessment.

In conclusion, SOE is an effective formative and summative assessment tool and can be integrated into undergraduate biochemistry as a fair, objective, and comprehensive method of assessment, aligned with the current trend of competency-based education.