Perceived and actual value of Student‐led Objective Structured Clinical Examinations

Student‐led Objective Structured Clinical Examinations (OSCEs) provide formative learning opportunities prior to Faculty‐led OSCEs. It is important to undertake quality assurance measurements of peer‐led assessments because, if they are found to be unreliable and invalid, they may have detrimental impacts. The objectives of this study were to explore and evaluate Student‐led OSCEs hosted by fifth‐year medical students.


| INTRODUCTION/BACKGROUND
2][3] OSCEs offer a measurable, reliable and valid evaluation of students' clinical skills and competence through direct observation. 4The inclusion of OSCEs in curricula may also positively impact student learning behaviours. 5wever, OSCEs are known to cause a significant degree of anxiety in students, which may adversely affect student performance, mental health and well-being. 6An increasingly common, student-led response to address this issue is the organisation of practice OSCEs prior to the summative versions. 7These Student-led OSCEs are usually prepared and assessed by students' near-peers and are intended to emulate University Faculty-led OSCES. 7Student-led OSCEs provide a formative learning opportunity for students in preparation for Facultyled OSCEs and may mitigate the anxiety associated with this assessment format. 6,8Students perceive Student-led OSCEs as a valuable revision tool with opportunities to receive appropriate and constructive feedback. 9Students report that Student-led OSCEs are critical to their Faculty-led OSCE preparation, allowing for improved understanding of expectations and identification of gaps in knowledge, with participation likely improving their Faculty-led OSCE performance. 10Peer assessors (examiners) similarly perceive benefit from participating in Student-led OSCEs, as an opportunity to apply and build on prior knowledge whilst improving clinical skills. 9However, it is unclear if these benefits extend beyond subjective perceptions.There is limited and conflicting evidence regarding the objective benefit of Student-led OSCEs, and studies in this area have demonstrated significant variation in reported Student-led OSCE reliability and benefits in subsequent Faculty-led OSCEs. 7,11,12ere is limited and conflicting evidence regarding the objective benefit of Student-led OSCEs.
It is important to undertake quality assurance measurements of peer-led assessments because, if they are found to be unreliable and invalid, they may be detrimental to student learning. 13A lack of correlation between Student-led and Faculty-led OSCEs would call into question the quality, defensibility, reliability and validity of the activities with potential detrimental impacts on student learning and progress.Conversely, if appropriately reliable and valid, Student-led   OSCEs could open additional avenues for student-faculty collaboration and promote reflective practitioner development. 14 The aim of this study was to investigate participants' perceived and actual value of Student-led OSCEs in the medical program.In Student-led OSCEs, students receive verbal feedback for 1 minute at the conclusion of each station.Peer examiners are also encouraged to provide detailed, written, personalised feedback.The assessment method used and constructed by MBBS VI students to assess the MBBS V participants is designed to emulate the Faculty-OSCE assessment.A 7-point ordinal scale, ranging from 'well below expected standard' to 'well above expected standard', is used to assess three domains: 'Clinical Practice', 'Clinical Reasoning' and 'Professionalism' in addition to a global rating scale for 'Overall Performance'.This differs slightly from the Faculty-led OSCE assessment that additionally assesses a 'Knowledge' domain and uses a 5-point ordinal scale.
In 2022, 105 Student-led OSCE places were made available to MBBS V students and advertised through social media channels, on a first come first served basis.Student-led OSCEs are held 1 month before Faculty-led OSCEs.The limitation on places was due to the number of MBBS VI students volunteering as examiners and the ability to access Adelaide Health Simulation resources.

| Reflective statement/authors background
The research team consisted of the primary author BS, who is a basic physicians trainee, ex-student of UofA with an interest in medical education research.They undertook a significant amount of their training in rural sites around South Australia.JK is a surgical resident and SB is a neurology advanced trainee with an interest in medical education research.AK and JL are experienced statisticians, with experience in OSCEs and medical education assessment.NB was an intern at the time of manuscript production and was a medical student and student body representative during this project.JT is the Central Adelaide Local Health Networks' director of physician education with a PhD in medical education.AM is the Director of Adelaide Health Simulation (AHS) and ED is the Research Program Lead for AHS.

| Participant selection
MBBS V students were eligible to participate in the study if they attended both the Student-led and OSCE and Faculty-led OSCE examinations.All eligible participants were provided with information about the study on completion of the Student-led OSCE and were included if they provided written consent.Written consent included consent to access Student-led and Faculty-led OSCE results and consent to participate in semi-structured interviews and for survey data to be included in the study.All prospective participants had previously been exposed to OSCE-style assessments.

| Data collection
Student-led OSCEs were hosted in one location, and data were extracted from Laerdal's digital software 'SimCapture'.Faculty-led OSCEs were hosted in two locations-metropolitan students were examined using SimCapture, and rurally placed students were examined using CAE's 'Learning Space'.Data for Faculty-led OSCEs were extracted from these software.
An online survey was administered via SurveyMonkey ® (Momentive Global Inc., San Mateo, CA, USA) and included Likertscale and short answer questions designed to explore student experiences (available in the Supporting Information).Qualitative data were collected via individual, semi-structured interviews.Interview prompt questions can be found in the supplemental material.Interviews were transcribed, de-identified and issued a unique participant code.To maximise the trustworthiness and confirmability of the qualitative data, member checking was undertaken, with transcripts being returned to participants for feedback and verification prior to analysis.
The survey and interviews were administered in isolation from each other, such that the results and discussions did not influence the conduct of the other.No financial re-imbursement or incentive was offered or provided to participants in this study.Surveys were conducted immediately after the Student-led OSCE.Interviews were mostly conducted after the Student-led but prior to the Faculty-led OSCEs, between the 23rd of October and the 18th of November 2022.Enrolment in this study did not influence access and was not a requirement to undertake the Student-led OSCE.Qualitative data were analysed using an inductive content analysis approach (ICA), as described by Vears and Gillamn. 17This method involved a systematic process of coding and categorising the data to identify emerging themes and patterns.Initially, the data were read through several times to gain a deep understanding and to immerse in the content.Subsequent readings involved coding the data, where segments of text were labelled with codes that represented their core meaning.These codes were then grouped into categories based on their similarities and differences.As new data were analysed, the codes and categories were continuously revised and refined in an iterative process.To ensure rigour in our analysis, several strategies were employed.Firstly, multiple researchers independently coded a portion of the data, followed by discussions to reach a consensus on the codes and categories.This approach enhanced the credibility and reliability of the findings.Additionally, we maintained a detailed audit trail to document the coding process, decisions made and the development of categories.This allowed for the traceability of conclusions back to the raw data.The reporting of qualitative elements of this project adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. 18

| RESULTS
Across two separate Student-led OSCEs, a total of 105 Student-led OSCE positions (47 for primary care and 58 for HRH) were offered and all positions (100%) were filled.These positions were filled by 91 students (some students completed both Student-led OSCEs), of which, 85 (94%) agreed to participate in this study through consenting to the access of their Student-led and Faculty-led OSCEs; 25 participated in the online survey, and 12 participated in a semi-structured interview.The 91 students reflect a large proportion of the overall MBBS V cohort (118).Of the participants, 66 (78%) were metro and 19 (21%) were rural.

Across two separate
Student-led OSCEs, a total of 105 Student-led OSCE positions were offered and all positions were filled.

| Quantitative results
The borderline regression analysis for the two Student-led OSCEs can be found in Table 1.The resultant reliability (Cronbach alpha) for the Primary care Student-led OSCE was 0.12.Notably, the reliability of this Student-led OSCE could be improved to 0.47 with the removal of Station F (Hypertension) as this station demonstrated poor performance with little evidence of a relationship between global rating and station score (Supporting Information).After standard setting, results <76.45 (63.7%) would be deemed below standard.Results between 76.45 (63.7%) and 82.05 (68.4%) would be considered for further remediation assessments if it was a summative, faculty-level assessment (Figure 1a).The Cronbach alpha for the HRH Student-led OSCE was 0.54, which could be improved to 0.61 with the removal of Station A. After standard setting, Student-led OSCE results of <77.38 (64.5%) would be considered below standard and results greater than this but <82.42 (68.7%) would be considered for remediation (Figure 1b).
The relationship between Faculty-and Student-led OSCEs is plotted in Figure 2.
A linear regression model was used to predict the Faculty-led OSCE score (raw percentage) using the Student-led OSCE score (raw percentage).The model estimated the relationship between Student-led OSCE and Faculty-led OSCE scores separately by cohort (rural and metropolitan students) by including an interaction term (Student-led OSCE by cohort).In the Primary care OSCE, the raw Faculty-led OSCE result is expected to increase by 0.50% [95% CI = (0.25%, 0.75%), p = <0.001]for each percentage increase in the Student-led OSCE result for metropolitan participants.However, the increase is more substantial in rural participants, with an expected increase of 1.09% [95% CI = (0.67%, 1.52%), p = <0.001]for each percentage increase in the Student-led OSCE result.The difference in relationship between rural and metropolitan students was statistically significant (interaction p = 0.019).
Like the Primary care Student-led OSCE, there is a statistically significant relationship between Student-led HRH OSCE grade and Faculty-led OSCE grade for both rural and metropolitan students.The raw Faculty-led OSCE result is expected to increase by 0.49% [95% CI = (0.18%, 0.80%), p = 0.003] for each percentage increase in the Student-led OSCE result for metropolitan students.A similar increase in the raw Faculty-led OSCE result of 0.67% [95% CI = (0.12%, 1.21%), p = 0.017] for each percentage increase in the Student-led OSCE result was observed for rural students; the difference in relationship between metropolitan and rural students was not statistically significant (interaction p = 0.235).

| Survey responses
Twenty-five participants responded to the survey, 24 of whom participated in the Student-led OSCE (Figure 3).To have that preparation, that was less of a stress when you got to the exam itself.

Perceived value of OSCEs and Student-led OSCEs
( A salient, recurring point that distinguishes itself from the benefits of Student-led OSCEs specifically, and refers to OSCEs in general, was how participants perceived OSCEs as beneficial to their competence as clinicians.A distinction was made between the level of medical knowledge assessable with written examinations and the degree of clinical competence required to pass OSCEs.
It forces me to make good, structured ways to approach different clinical scenarios that I very easily could just not do if the OSCEs weren't a thing.

Receiving feedback from peers
Only one of the participants reported disregarding feedback received from peer assessors.
I don't particularly pay much attention to the overall marks that I might be getting.
(Participant 1) Otherwise, participants reported peer feedback to be beneficial.
Receiving feedback from senior students who had in turn themselves passed the same series of examinations a year prior was particularly notable, providing what was perceived as an appropriate benchmark for performance required to pass the Faculty-led OSCE.The quantitative analysis of the Student-led OSCEs demonstrated that they can be moderately reliable and their results are positively related to subsequent Faculty-led OSCE grades.Notably, participants routinely reference an anxiolytic benefit from Student-led OSCE participation.Our results suggest this is a function of two key factors: firstly, an exposure to the OSCE environment (the physical environment, the logistics of station timing and increased pressure above regular peer group practice), and secondly, the change in preparation that occurs in response to Student-led OSCE participation.This observation is consistent with other studies that have reported improved confidence and reduced exam-related stress in response to undertaking near-peer assessed OSCEs. 10,22,23e authentic experiences of near-peer OSCEs portend to both a subjective increase in sense of preparedness and objective change in their preparation behaviours before Faculty-led OSCEs.This study, however, was unable to discern whether Student-led OSCEs improved subsequent Faculty-led OSCE scores.
There is a notable difference between improved confidence for where possible, offer assistance to improve the quality and delivery of these events.Further collaborative efforts between faculty and students could include programs that guide, and further capitalise on, the reflective process that appears to be an inherent when undertaking Student-led OSCEs.
Student-led OSCEs may provide a formative (low stakes or safe-to-fail), authentic, metacognitively reflective and collaborative form of assessment.
Demonstration of the Student-led OSCE model of peer-led teaching may encourage wider adoption and articulation of the model and facilitate replication in other health professions' education programs.An additional consideration in this study was any differences that students in rural and metropolitan placements might have in relation to OSCE performance and experience.The Adelaide Rural Clinical School (ARCS) program is offered to 40 (20%-30% of the total cohort) students in their fifth (penultimate) year of medical school.Students complete a 36-week rural longitudinal integrated clinical placement program based primarily in general practice, following supervisors and patients into local hospitals. 15They undertake their training in a rural community, with between one and six colleagues (depending on location).Their placements are therefore largely oriented in primary care services, and their curriculum is supplemented with a variety of clinical placements, tutorials and wider learning experiences.The rurally placed student experience contrasts the more structured/'blocked' training that metro students receive, with a majority of their placements occurring in major tertiary hospitals. 16Both groups have the same overall learning objectives and sit the same final exams.The difference in exposure to clinical cases and available peers (by virtue of geographical separation) requires consideration.The aim of this study was to investigate participants' perceived and actual value of Student-led OSCEs in the medical program.Subsequently, derived research questions included the following: What is the reliability (Cronbach's α) of our institution's Student-led (and assessed) OSCEs?; What is the relationship between Student-led OSCE and Faculty-led OSCE results (and are they predictive of subsequent Faculty-OSCE performance)?;What (if any) behaviour changes are associated with participating in Student-led OSCEs?; What preparations do students undertake before their formative, peer-led OSCEs?; and What factors contribute to the perceived value (or lack thereof) in Student-led OSCEs?
Setting The University of Adelaide's Medical Student Society co-ordinates annual Student-led OSCEs for fifth-year students (MBBS V) which are written, administered and examined by MBBS VI students.The MBBS VI students who develop, implement, examine and provide feedback to the MBBS V students are not trained in assessment practices by the University's Faculty.The peer-led intervention is based on students' lived experiences from previous OSCEs.Faculty support for these practice OSCEs is provided in the form of access to the venue and electronic marking system.The Student-led OSCE format closely emulates the Faculty-led OSCE (2 minutes to read the stem and task, 8 minutes to perform the task), and the same venue is used (Adelaide Health Simulation).The Student-led OSCEs mirror the content of Faculty-led OSCEs, with one covering anaesthetics, geriatric medicine and general practice (Primary care OSCE) and the other human reproductive health and paediatrics (HRH OSCE).
Borderline regression analysis was first undertaken on each set of Student-led OSCE stations separately, with the overall score calculated as the sum of borderline scores for each station.Cronbach's alpha and Standard Error of Measurement (SEM) were then calculated for each of the Student-led OSCEs.OSCE station reliability was assessed by recalculating Cronbach's alpha with each station in turn removed.In order to determine the relationship between Student-led OSCE and Faculty-led OSCE performance (i.e.predictive), a linear regression model was used.The model used Faculty-led OSCE (total percentage score) as the outcome (dependent variable) and Studentled OSCE (total percentage score) as the independent variable.Cohort (metropolitan vs. rural students) was included in the model, along with an interaction term (cohort by Student-led OSCE score) to test for differences in relationship between Student-led OSCE and Faculty-led OSCE between metropolitan and rural students.The mean increase in Faculty-led OSCE score for each 1% increase in Student-led OSCE score was estimated separately for rural and metropolitan students, along with 95% confidence interval.Statistical analysis and visualisation were performed using R (version 4.2.2).
This study meets the requirements of the National Statement on Ethical Conduct in Human Research 2007 (Updated 2018).The University of Adelaide Low-Risk Human Research Ethics Review Group (Faculty of Health and Medical Sciences) provided ethical approval (H-2022-141).

A
significant motivator for participation in the Student-led OSCE was 'preparation for the Faculty-led OSCE'.More specifically, the Studentled OSCE was undertaken to provide participants with insight into 'what to expect for the real OSCE' and identify 'the standard required' to pass, utilising the Student-led OSCE as a source of revision and help identify 'areas of weakness to focus on'.The Student-led OSCE was undertaken to provide participants with insight into 'what to expect for the real OSCE' and identify 'the standard required' to pass, utilising the Student-led OSCE as a source of revision and help identify 'areas of weakness to focus on'.Participants reported approaching the Student-led OSCE in a fundamentally different way than the Faculty-led OSCEs.The Student-led OSCE was treated as a launchpad for active revision and preparation.The function of the Student-led OSCE was viewed as a barometer for evaluating current knowledge, skill and readiness for the Faculty-led OSCE.T A B L E 1 Summary statistics by station: mean and standard deviation, minimum and maximum score, and the borderline regression estimate and 95% confidence interval.

I
like to do any sort of mock scenario without too much study just to actually assess what my real base foundation knowledge and ability is.(Participant 2) Participating in Student-led OSCEs without specific preparation was reported to afford participants with an opportunity to identify gaps in existing knowledge and to learn from perceived mistakes and the 'feedback directly after from the examiners'.

F I G U R E 1 (Participant 6 )
Distribution of Student-led OSCE results and the subsequently derived remediation and below-standard grades.Once we do our student-led OSCEs, we know a bit more of what we need to focus on, what part of the station we need to work on more.(Participant 1) A key value that participants placed on the Student-led OSCE was the replication of the Faculty-led OSCE structure and environment.A majority of the participants stated 'practicing stations in the same environment', 'under conditions as close as possible to the summative OSCEs', as the chief benefit.This reduced anxiety around how the OSCE would be conducted and with what equipment, whilst also providing students with an opportunity to practice OSCEs beyond the equipment limitations posed by practicing in peer groups.But really having it set out in the way that it will be when it's summative is really important.So rotating around the rooms where you'll be doing it.(Participant 4) Although a less stressful environment than the Faculty-led OSCE, the increased pressure compared to practice in peer groups was also perceived as beneficial.It was super helpful to know what eight minutes actually feels like, in a high stress situation.Clinical placements are often heterogenous by function of the specialty, department and staff.Subsequently, skills developed during these clinical terms can similarly be heterogenous between students despite undertaking the same rotation.This discrepancy is further exacerbated by the construction of close peer study groups and the geographical isolation experienced by students undertaking rural rotations.The Student-led OSCE was found to ameliorate this issue, providing students from different peer groups and geographical sites with an opportunity to converse with peers about their perceptions of the Student-led OSCE, collaborate and exchange skillsets.

F(Participant 2 )
I G U R E 2 (a) The relationship between Student-led OSCE and Faculty-led OSCEs.(b) The relationship between Student-led OSCE and Faculty-led OSCEs for rural and metropolitan students respectively.The Student-led OSCE [provided] students from different peer groups and geographical sites an opportunity to converse with peers about their perceptions of the Student-led OSCE, collaborate and exchange skillsets.It was good to have that sort of conversation to be like, Oh, what did you find easy?They're like, oh, we found this pretty hard or whatever.And then you could exchange knowledge, basically, based on your experiences.Participating in the Student-led OSCE improved the confidence and alleviated much of the stress associated with the Facultyled OSCE.

F I G U R E 3 (Participant 9 )
Likert survey results.Note: X axis represents the percent of cohort.The examiners [are] usually sort of in a grade above you.So they've been through it all before, and they've experienced it.So they really know what sort of expected of you.And then because of that, they're able to give valid feedback, which actually helps you understand more of what the examiners are looking for, as well, and helps you know what to expect in the OSCEs.(Participant 2) Despite this opinion, there was not a consensus regarding the congruency of feedback and marking, with a majority of participants believing peer assessors to be more lenient than Faculty-led OSCE assessors.The marking is quite accurate as to what you get in the, in the Faculty-led OSCE, although sometimes the marking in the student-led OSCE can be a little bit more lenient.(Participant 7) Students report tailoring their subsequent Faculty-led OSCE study in accordance with their performance and feedback from the Student-led OSCE.That grade you receive for certain stations allows you to identify areas of weakness, and areas of strength.And then sort of adjust your study accordingly.(Participant 3) It's really good to look at how you perceived what happened compared to what the examiners are seeing and what they value so that you can you know, adjust that for the proper OSCEs.(Participant 4) One participant noted that the nature of peer assessment in the Student-led OSCE had precluded them from participating in past Student-led OSCEs and may be a shared experience amongst other students.That kind of self-conscious, and not yet feeling super comfortable in front of my peers, because of how I felt that I wasn't doing very well.So that's probably an element of it.But I kind of got over that.(Participant 10) Quality Participants regarded the Student-led OSCE as 'very professional', noting how 'the facilitators work extremely hard to recreate a professional environment' and 'simulate the Faculty-led OSCEs as much as is practical', with high-quality stations.Using the simulation rooms and B-line, a pre hold room and general expectation of students to conduct themselves under exam conditions.The timing of each room with the bell truly does make it feel exactly like the summative OSCE.(Participant 8) Unfortunately, despite being held in the interest of anxiety mitigation, the ability for students to emulate the Faculty-led OSCE so well did confer a sense of anxiety onto some students.I always get a bit nervous at the start when you're waiting in line, and like, why am I doing this to myself again.Just because it really does mimic the real thing quite well.Participants agreed 'the standard is very high of the student led OSCEs', with 'the same sim capture technology used, with the same timing of stations at the same location' and 'stations [that] are the same level of difficulty of Faculty-led OSCE stations and the prompts and tasks for each station are just as thorough'.Disagreements however are evident in perceptions of marking, which are well surmised by the following; Whilst I agree that the stations and marking rubric are written to the same standard as the summative OSCEs, by nature of having older students (who are often peers!) acting as examiners, I don't believe the marking is to the same standard.As someone who also volunteers as an examiner in other year level Student-led OSCEs, there is a fair inclination to mark 'nicely' so as to not crush anyone's confidence before their summative exam.(Survey response) Discrepancies between the Student-led OSCE and Faculty-led OSCE were particularly notable with station structure and the standard of performance from simulated patients.Students felt that on some occasions, the Student-led OSCE required a more holistic understanding of a clinical condition, whereas the Faculty-led OSCEs may focus on one particular area and could be more nebulous in their requirements.The simulated patients in the Student-led OSCE were not trained actors, but rather students in lower year levels, with which students had variable experiences.The Student-led OSCEs almost seemed to be like almost better planned, had like clearer structure.And you know, you knew what you had to do.(Participant 10) Each volunteer actor kind of thing will act out a bit differently.So, it's less standardised, I suppose than what the actual faculty-led OSCE is.(Participant 2) 4 | DISCUSSION Through a multi-methods approach, this study characterised the perceived and objective value of Student-led OSCE participation.The quantitative analysis of the Student-led OSCEs demonstrated that they can be moderately reliable and their results are positively related to subsequent Faculty-led OSCE grades.Participants reported significant value from participating in Student-led OSCEs as evidenced in their interview responses and the complete uptake of allocations.
Our institution's Student-led OSCEs demonstrated a lowto-moderate reliability that closely approximates the reliability of previously published Student-led OSCE studies.In an internal consistency assessment of their institution's own student designed and implemented five station Student-led OSCE, Lee et al. calculated a Cronbach's alpha of 0.443.9Although the maximum reliability for the Student-led OSCE in this study exceeds this result at 0.61 (specifically the HRH Student-led OSCE), it is pertinent to note that faculty level assessments are generally expected to provide a minimum reliability of 0.80.19The low-to-moderate Student-led OSCE reliability is consistent with the perceptions of the participants that the assessment is more lenient and of lower quality than Faculty-led OSCEs.Although participants perceived the Student-led OSCE grading to be inaccurate and of lower quality, they nevertheless utilised the results and verbal feedback from peers to identify and ameliorate gaps in knowledge.The targeted preparation students undertake after Student-led OSCE participation appears to be guided by both peer feedback and selfidentified areas for improvement.In the latter, students describe acknowledging the internal and external influences on an experience and, in turn, identify areas for improvement and further learning.The process of engaging in reflection is a quality of increasing importance for medical graduates.This form of near-peer assessment seems to encourage the metacognitive process of reflection amongst participants, which is then implemented to direct further study.The quantitative results suggest that the significant relationship between Student-led and Faculty-led OSCEs is potentially a product of student characteristics.It is unclear what characteristics are attributable to this relationship; however, the contextualisation of the qualitative analyses suggests that multiple factors such as internal consistency, environmental factors and peer interactions may influence the relationship between Student-led OSCE participation and Faculty-led OSCE performance.These factors cumulatively produce a change in study behaviour after Student-led OSCE participation with the perception of value garnered from undertaking this peer-led assessment.This objective and perceived value in response to Student-led OSCE participation may be explained by the educational theory of collaborative work and peer assessment, Sameroff's Unified Theory of Development.Sameroff's theory states that during such collaborative work (between participants of different skills in a community of practice), mediation of metacognitive and cognitive abilities occurs and subsequently improves participants' capability for selfregulated learning.20,21 subsequent Faculty-led OSCE and clinical practice.The survey and interview demonstrated that participants believed Student-led OSCEs helped them to prepare for the summative, Faculty-led OSCEs but less so their clinical placements.Particularly, the survey indicated a perceived gap between meeting the requirements of OSCEs and clinical preparedness.The disconnect and lack of authenticity between OSCEs and clinical practice were noted in both survey data and in interviews with participants.Potentially, the participants maintained a summative assessment focus versus a formative mindset.Faculty and student cohorts may benefit from reflecting on the disconnect between these activities and whether the authenticity of this type of summative performance could be or should be enhanced to reflect clinical practice.Collaborative efforts between Faculty-and Student-led OSCE organisers provide a potential mechanism to identify and provide support to 'at risk' students.With the predictive ability and moderate reliability demonstrated in this study, Student-led OSCEs could be utilised by faculty to identify effective, targeted, student-specific support for those who appear to be at risk of failing their summative assessment.Subsequent support programs could seek to harness and capitalise on the reflection promoted by Student-led OSCE participation.Additionally, our results suggest that the Student-led OSCE promotes interactions between peer groups, which might otherwise not have occurred.This has the potential to promote peer or nearpeer mentorship relationships and the development of informal peer support networks.The promotion of peer interaction in low-stakes environments as observed in our Student-led OSCEs is one possible, low-cost support option that could help improve medical student confidence and promote informal community supports through purposeful student networking.Such collaboration and exposure to students who have developed an alternative and complementary skillset appear to have been significant source of value for the rural cohort in our study.With the predictive ability and moderate reliability demonstrated in this study, Student-led OSCEs could be utilised by Faculty to identify effective, targeted, student-specific support.This study has limitations.These relate to the sample recruited into the project and limitations to data that were accessed for analysis.The sample included in this study volunteered to participate in the place-limited Student-led OSCEs and therefore may not be representative of their own cohort of MBBS V students.This study did not investigate the difference between Faculty-led OSCE results in those who did and did not participate in the Student-led OSCE, an option for future research, subject to governance and ethics board review.The findings of this study are likely not all generalizable to other centres that employ different OSCE formats.Future research could also explore how faculty perceive Student-led OSCEs (although this is a student-focused paper, the voices and perceptions of faculty are absent).Based on the quantitative and qualitative findings of this study, Student-led OSCEs may provide a formative (low stakes or safe-tofail), authentic, metacognitively reflective and collaborative form of assessment.Students gain confidence and adjust their study behaviours in response to participating in a peer-led, administered and examined, formative OSCE.Despite moderate reliability, Student-led OSCEs can correlate with subsequent Faculty-led OSCE performance.Medical students would benefit from faculties collaborating with their student bodies to facilitate the conduct of Student-led OSCEs and,