The viva voce innovation and experience at a new medical school in Rwanda

The viva voce innovation and experience at a new medical school in Rwanda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The viva voce innovation and experience at a new medical school in Rwanda Charles Okot Odongo, Samuel Ntaganira, Nicole Kanyana, Jean Paul Ndayizeye, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5476515/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Medical Education → Version 1 posted 7 You are reading this latest preprint version Abstract Background: Traditional preclinical viva examinations have faced significant criticism due to inherent biases in their format. We developed a novel viva format and gathered insights from students to evaluate its effectiveness. Methods: This study consists of two parts. Part 1 describes the development, implementation and refinement of anovel preclinical viva voce examination at the University of Global Health Equity, in Rwanda, conducted over a four-year period. Part 2 captures students' perspectives through a self-administered online questionnaire. Results: Part 1: The viva format features structured questions related to authentic clinical scenarios, that underscore the application of basic science knowledge to clinical practice. The examination consists of three oral stations plus one image-based station, targeting subjects like embryology, histology, and histopathology that are traditionally difficult to examine. The examination is vertically and horizontally integrated and provides students with multiple opportunities to demonstrate their knowledge. With four or more rotations of this kind, students are simultaneously examined, improving time efficiency, and reducing performance fatigue normally associated with long waiting periods. Real-time scoring and commenting on individual student performances ensure accountability, transparency, and reduces examiner bias. The examination ends with a faculty debrief conference, after which students receive individual feedback on their performance. However, challenges include variability in examiner preferences for cases and the need for a substantial number of faculty members to manage the numerous stations. Part 2: Students reported finding the viva format stressful but acknowledged its long-term benefits, including ability to foster mental agility, promote clinical reasoning, and improvetheir verbal communication skills. Compared to multiple-choice questions (MCQs), many students felt it was a better way of assessing knowledge, as it eliminated guesswork. Group discussions were identified as the most effective viva preparation strategy. Many students expressed a desire for more supportive interactions from examiners during the viva. Despite these challenges, there was broad agreement that the viva format should be retained. Conclusion: The novel preclinical viva format described here enhances the reliability and validity of assessment while providing formative support and early clinical integration. It represents a balanced approach to addressing traditional viva limitations while maintaining educational value. Viva voce preclinical assessment Rwanda University of Global Health Equity Figures Figure 1 Background Viva voce examinations, also referred to as oral exams (or simply as ‘viva’) are a common assessment method in medical education where they are usually deployed right from preclinical education through to advanced professional training. The traditional viva voce exam takes the form of an unstructured interaction in which one or more examiners ask the candidate several questions. These questions are either generated on the spot or initially picked by the candidate at random from a pool consisting of questions of varying levels of difficulty. Proponents of this assessment method have argued that it is useful in assessing knowledge recall and that it fosters the mental agility required for future clinical practice ( 1 ). Compared with the written exam, research shows that the viva voce exam offers additional unique advantages such as its inherent resistance to plagiarism and ability to promote development of the student’s communication skills ( 2 , 3 ). Other unique attributes of the viva voce exam include its ability to assess the development of attitudinal competencies including professionalism and ethics ( 4 , 5 ) and the recognition of safe and competent clinicians ( 6 ), all of which may not be easily achieved with written exams. More recently, studies are emerging to suggest that viva voce may provide a more authentic option for assessing students with learning disabilities such as dyslexia ( 7 ). As with all other forms of assessment, the traditional viva exam has attracted several criticisms, particularly relating to biases inherent within its approach. Most notably, questions on reliability and validity of the traditional viva format remain unresolved. For instance, Evans et.al., showed that viva scores tended to correlate with the number of words spoken by the candidate ( 8 ), while Thomas et al., showed that scores correlated with a candidate’s personality score ( 9 ). Other factors such as the time of day at which the exam is done ( 10 ), verbal style and dress code ( 11 ), as well as sex or physical appearance of the candidate ( 9 ) have all been shown to influence viva scores. Furthermore, it has been shown that examiners are generally prone to several unconscious biases such as the halo effect (a type of cognitive bias where our overall impression about a person, brand or product influences how we feel and think about their character or capabilities), all of which affect viva scores ( 12 ). In this era of evidence-based medical education, such shortcomings leave a lot to be desired and continue to drive debate on the relevance of viva voce assessment in today’s curricular. It is not surprising therefore, that some academic institutions have elected to break with tradition and abandon the viva voce assessment method altogether ( 1 ). Mindful of these challenges and inspired by the need to improve the reliability and validity of our viva voce examinations, faculty from the Division of Bio-Medical Sciences (BMS) at the University of Global Health Equity (UGHE), devised a novel preclinical viva examination format which has been implemented and refined over the past four years. The first part of this paper describes and discusses the rationale behind some of the unique features in our viva assessment exercise. In the second part, we share learners’ views and experiences, something which is often underreported in the literature ( 13 ). Data from students was collected through a self-administered online questionnaire and summarized using quantitative and qualitative methods. The study was reviewed and approved by the UGHE-Institutional Review Board (ref. UGHE-IRB/2024/325) and was conducted in accordance with the ethical principles set out in the World Medical Association’s Declaration of Helsinki (as amended, 2013)`. All students gave voluntary written informed consent prior to participation in the study. A brief introduction of the University of Global Health Equity (UGHE) UGHE is a new kind of health sciences institution located in Butaro, northern Rwanda, with a mission to radically transform global health education and delivery. Founded by Partners In Health in collabouration with the Rwandan government, UGHE integrates rigorous academic training with a strong emphasis on equity, social justice, and community-based care. Along with other programmes, UGHE offers the Bachelor of Medicine and Surgery, and Master of Science in Global Health Delivery dual degree (MBBS/MGHD), where classroom learning is combined with field-based experiences. Its programmes are interdisciplinary, blending public health, clinical and social medicine, leadership, and management skills to prepare future healthcare leaders with a sound sense of social justice and equity. The university attracts a diverse and international student body, including faculty and students from across Africa, the Americas, Asia, and Europe, fostering a collabourative and multicultural learning environment. With a strong emphasis on gender equity and inclusivity, 70% of its admissions are reserved for female students across all programmes. Nearly all students receive scholarships to support access for those from underserved communities. With a campus designed to support immersive and reflective learning in a rural setting, UGHE serves as a model for how education can be a powerful tool for health equity worldwide. The philosophical grounding of UGHE’s preclinical curriculum and grading system UGHE’s preclinical curriculum is delivered in a modular fashion over a two-year period with both instruction and assessment fully integrated across the basic science disciplines. Each module is led by a module director who is a senior faculty and is closely assisted by a junior faculty as module coordinator. Together, they oversee all day-to-day module implementation activities. Each module and classes therein are logically sequenced to ensure that learners acquire new knowledge based on concepts previously covered in earlier classes or preceding modules. Each module typically begins with classes covering relevant topics in anatomy, physiology, and biochemistry, reflecting normal body function. This is followed by topics in microbiology, pathology, and pharmacology where pathophysiology and treatments are discussed. Within each module, longitudinal sequencing of classes is done logically, ensuring that new knowledge is built on existing concepts previously covered in the relevant discipline. For instance, in the module Gastrointestinal System & Nutrition (MED 106), the pharmacology class titled ‘Treatment of peptic ulcer diseases’ is scheduled after the anatomy and physiology of gastric function are covered and the pathophysiology of peptic ulcer diseases is discussed. Each class is delivered by the respective content expert faculty and the relevance of this knowledge to clinical care is emphasized. Classroom instruction is achieved through multiple learner-centreed instructional formats such as interactive lectures, flipped classes, team-based learning (TBL), student-led seminars, and case-based collabourative learning (CBCL). Within each module, laboratory and simulation sessions are also implemented to reinforce key concepts. Of note, each classroom interaction attracts a formative assessment score. For instance, students take a short post-class quiz at the end of each interactive lecture and a pre-class assignment in preparation for each CBCL or flipped class session. Furthermore, TBL sessions commence with the typical readiness-assurance tests designed to ensure that learners prepare prior to coming to class. All quizzes and assignments, plus laboratory activities are graded and contribute up to 60% towards the final score. A mid- and end-module summative assessment, each consisting of 60 MCQs are done for each module. The final module score is obtained by summation of all the different categories of scores as per the standard framework outlined in Table 1 where vivas contribute 10% of the final grades. Attainment of a 60% pass mark allows the student to progress normally to the next module of study. Table 1 The standard grading framework for preclinical modules at UGHE Academic activity Type of assessment Contribution to final score (%) Class attendance & participation Formative 5 In-class quizzes Formative 25 Pre-class assignments Formative 10 Labs, simulation & seminars Formative 20 Mid-module exams Summative 15 End-module exams Summative 15 Viva voce exams Summative 10 Total 100 Development of viva-voce assessment materials Under the stewardship of the module director, all faculty are jointly responsible for developing and moderating viva examination content. This process begins with an open invitation to faculty to develop suitable examination questions along with provisional answers. These are then compiled on a living document and shared with the entire team. In some instances, the module coordinator is tasked to develop potential questions (with or without answers) which are then shared with faculty for their input and approval. Viva questions are typically constructed around a stem consisting of a hypothetical, but authentic clinical scenario referred to as a “case”. Within each case, faculty ensure a balanced mix of questions covering the relevant basic science disciplines (i.e., anatomy, physiology, biochemistry, pathology etc.) as each case may warrant. Furthermore, the module coordinator is tasked with compiling a set of clinical and laboratory images or diagrams that students have met during class instruction. The student is expected to recognize these images and answer a few related questions during the exam. Examples of complete cases and images extracted from 3 different modules are shown in Supplementary file 1 . A few days before the examination date, a meeting is convened to review and moderate the questions. Where gaps are identified, content experts are tagged and required to address them, and any outstanding issues are resolved through discussion and consensus. Such issues typically include improving the clarity of questions or answers, revision of case length viz a viz time allocated, faculty declaration of case preferences (for examination), availability of faculty on examination day, exam logistics etc. Implementation of the viva voce assessment exercise The viva exam is the last academic activity in each module and is typically scheduled on the morning of the last day of that module. At this point, students would have completed the end of module written exam the previous afternoon. For the viva, a student is expected to spend approximately 1 hour moving through four examination stations at which they spend no more than 10 minutes each, interspaced with two-minute intervals between stations. Figure 1 below summarizes students’ flow plan through the viva stations. Three of these stations consist of “cases” as described above, with the fourth being the image station. A fifth station baptized the “Resting station” is normally included to allow the student respite to recompose themselves in case that should be needed. To ensure timely examination of the entire student lot, four sets of such examination stations (each set is referred to as a rotation) are normally set up in different parts of the campus’ teaching and learning spaces. Since 3 out of 5 stations in each rotation are manned by examiners, a minimum of 12 examiners are usually required to effectively conduct the examination across 4 rotations A-D. The entire exercise is managed and coordinated by a dedicated team of examination assistants who also serve as timekeepers and student guides. During the evening before the viva exercise, each faculty receives digital links to all the relevant documents required for their smooth participation. These include details such as the physical location of their examination station, a final version of the case to be examined, as well as grading and comment sheets to be used during the exercise. Students also receive a document showing their rotation and their movement plan through the different examination stations. Examiners are expected to use the two-minute intervals between students visiting their station to award a global score (out of 10) and document any pertinent observations/comments against each student passing through their station. All grading and comments are entered in real-time on a living spreadsheet file. (Insert Fig. 1 here) Lastly, a post-viva examination meeting is usually convened within 30 minutes of concluding the viva exercise. Here, faculty debrief and discuss the examination exercise/experience with a view to optimizing future implementation as well as discussing struggling students who may require tailored feedback or other support to mitigate any challenging circumstances they may be experiencing. Discussion Since 2020 when UGHE opened its doors to the first cohort of MBBS students, deliberate effort has been made to critically re-examine traditional teaching, learning and assessment practices with a view of discarding questionable practices and adopting and promoting evidence-based alternatives. This is the premise upon which the current viva examination format was developed. One of the foremost arguments advanced by proponents of abolishing the traditional viva is the time-consuming nature of the exercise, and the attending stress it exerts on students and faculty alike. We believe that our format where multiple rotations are created to run concurrently addresses this challenge, given that the entire exercise is normally completed within 3–4 hours with each student undergoing approximately 1 hour of examination. With all students simultaneously taking the exam in the morning hours when their minds are presumed to be fresh, everyone has the opportunity for optimum cognitive performance. Previously, Colton & Peterson have reported that students who sit viva exams in the later part of the day tend to perform poorer than those who sit earlier in the day, probably due to fatigue ( 10 ). Also noteworthy is the fact that all students get to answer the same questions presented in a structured manner. Unlike the traditional viva exam which is relatively unstructured, our structured format ensures better sampling and representation of the syllabus given that faculty from different disciplines make input into the exam. Moreover, structured viva exams have now been shown to achieve better reliability scores ( 14 – 16 ). Another novelty with our viva format is the use of multiple viva stations/cases manned by different examiners. This approach, while intensely demanding in number of examiners, ensures that students get multiple opportunities to prove themselves. It also minimizes any biases that individual faculty may harbor against a particular student since the final viva score is an average of scores obtained from all four stations through which a student has traversed. In addition, the use of multiple stations/cases has been shown to improve both reliability ( 17 ) and validity ( 18 ) of viva examinations. Given that all scores are entered in real-time onto a shared spreadsheet, each student’s scores can be easily tracked and inspected for trends. As such, one can easily get a general picture of whether a student is academically weak or strong, or whether they experienced an isolated catastrophic event at a particular viva station. In such instances, the examiner ought to have captured this on the comment spreadsheet. Quite often, these comments provide useful insights and serve as a basis for providing constructive post-viva feedback, regarding any weaknesses observed with a student. Furthermore, the requirement for examiners to comment on each student promotes transparency and accountability for the scores awarded. To this end, as part of the on-going reflections of our four-year experiences, we are undertaking a formal study to assess the reliability and validity of our viva assessment method. Another novel aspect of the UGHE viva is the horizontal and vertical integration of disciplines. Faculty ensure that the questions associated with each case cover all the basic science disciplines in a manner similar to how topics were covered in class. Even though most questions tend to be basic science oriented, they are intentionally assembled around an authentic clinical scenario such that students can appreciate very early on, the direct relevance of the material under examination to future clinical practice. Quite often, students are required to come up with a diagnosis from the clinical scenario presented within the case. We believe this approach supports honing of their clinical reasoning and diagnostic skills. In contrast, critics of the traditional viva format have often pointed to the low taxonomic nature of questions posed, as they tend to be limited to knowledge recall ( 8 ). It is therefore not surprising that during post-module evaluation surveys, some students have contentedly expressed the feeling of evolving into doctors given the balanced mix of recall and clinical reasoning to which they are subjected. The inclusion of an image station is yet another novelty with our viva format. This station affords us the opportunity to examine some otherwise hard-to-assess aspects of the basic sciences curriculum such as embryology, histology, histopathology, and gross pathology. Given that assessment drives learning ( 19 ), we believe that the way students are assessed can re-orient their manner of engagement with the subject matter, such that they begin to focus more thoughtfully, hence, develop the right skills and professional attitudes. Therefore, the challenge posed by the image station ensures that our students pay critical attention to images displayed during classroom instruction and that this also gives them a head start on the future demands of clerkship and professional practice where they will be expected to routinely examine and interpret images. Table 2 below, summarizes the novelty aspects discussed above. Lastly, while it is always challenging to have all 12 examiners physically present during exams, the use of online conferencing platforms such as ZoomÒ and Teams® have enabled faculty who may not be physically present to effectively participate in the assessment process. This is perhaps another novelty that has enabled effective implementation of our viva assessment. In addition, online conferencing platforms have enabled faculty from partner universities in Europe and America (who routinely support our teaching) to conveniently participate in the viva examination process. The robust nature of this online infrastructure was particularly tested during the Covid-19 pandemic when teaching, learning and assessment activities remained relatively uninterrupted despite several institutions suspending academic activities due to lockdown restrictions. Table 2 Summary of key differences between the traditional and the novel UGHE viva format Assessment attributes Traditional viva format Novelty and advantages of the UGHE format Structure of assessment Questions often random and unstructured Same questions for all, presented in a structured manner, improves reliability of assessment Integration of content Very limited. Often discipline specific, administered as one discipline at a time Integrated both vertically and horizontally for enhanced knowledge retention and understanding following the principle of interleaving. Number of assessment stations Students visit one station per discipline to evaluate their knowledge. Presence of multiple viva stations provides multiple opportunities for student to prove themselves. This improves reliability ( 17 ) and validity of assessment ( 18 ) Image-based station No image-based station Inclusion of images fosters a culture of their thoughtful study, as part of a future clinical skillset. Also improves the examination of certain disciplines e.g., histology Validity of assessment Questionable, given the random nature of selecting questions which may have variable levels of difficulty All students subjected to same questions. Assessment is a fair representation of the syllabus as faculty meet to moderate and balance content Taxonomy of questions Lower order questions. Often limited to knowledge recall as it purely examines basic science concepts Association with authentic clinical case scenario allows for high order assessment, e.g., formulating a differential diagnosis. This fosters early clinical reasoning. Faculty debrief Rare, if any Occurs within one hour of completion. Allows faculty to review entire exercise, optimize questions for future cycles and discuss feedback for struggling students Student feedback Rare, if any Comments on individual performance at each station is captured and used to provide constructive feedback post viva. Student fatigue and performance bias Associated with long waiting times as some students wait until the late afternoon, introducing fatigue and performance bias ( 10 ) Short waiting times as most students are examined simultaneously. All students sit viva in the morning hours when mentally fresh, reducing fatigue and performance bias Faculty fatigue Examination proceeds for 1 or 2 days with increased fatigue and potential for bias Minimal fatigue as examination lasts 3–4 hours due to multiple rotations running concurrently. Examiner accountability Difficult to ascertain Both grades and comments entered on shared files, ensuring transparency, and minimizing examiner bias Scores and grading Final grade determined through scores from one viva station, graded by 1 or 2 examiners Final grade derived from mean score from 4 viva stations, further minimizing effect of individual examiner bias Challenges and lessons learnt with UGHE’s preclinical viva assessment format Whereas vertical and horizontal integration of viva content is particularly helpful for development of students’ clinical reasoning skills, its implementation has not been without challenges, particularly for examiners. For instance, examiners with a purely basic science background often feel uncomfortable examining clinical aspects of the viva. Conversely, examiners from clinical specialties may also feel uncomfortable examining some basic science aspects. This challenge is mitigated by allowing faculty to choose case preferences for examination which allows them to prepare optimally and operate within their comfort zones. Other challenges such as the high number of examiners required and the critical reliance on a robust internet service have been alluded to above. The basic sciences division has always been fortunate to receive examination support from the clinical medicine division together with the visiting faculty available from time to time. This partnership has so far worked well. One may argue that viva assessments involving online examiners may differ from face-to-face interactions in terms of stress, attention, or other non-verbal elements of communication. While the two formats are not exactly the same, our faculty debriefs and student feedback sessions have indicated no major differences in terms of deficits of one kind or another. It has also been observed that scores on the image station are consistently the lowest for most students. This may reflect the objective and relatively straightforward nature of the responses which become easy to score. Incidentally, this also happens to be the station where students are required to write down their responses, unlike other stations where all answers are given through verbal communication. Furthermore, since our grading system relies on a global score at each viva station, it may be unduly influenced by the halo effect, a form of cognitive bias that can potentially affect reliability of scores ( 11 ). This bias is normally minimized by limiting the number of questions posed by each examiner. Unlike high stakes examinations, where such biases are a matter of critical concern, we consider our viva assessments a formative exercise, which in addition to gauging learners’ knowledge, is geared towards developing their clinical reasoning and communication skills. Within the first two years of implementation, faculty observed that the possibility of exam leakages across cohorts could not be completely ruled out given the universal access to digital information sharing tools. Considering that such leakages would threaten exam integrity, stringent measures were introduced such as the creation of new viva cases each year to ensure a rich library of cases from which to randomly select. Furthermore, to minimize the possibility of exam leakages within the same sitting, faculty resolved to change cases midcycle during each exam. From the faculty standpoint, we consider the additional work worthwhile as it helps assure the validity of the assessment. Student perceptions and experiences with the preclinical viva voce examination Approximately 40% (43/108) of students who received an online questionnaire shared their views and experiences regarding the preclinical viva voce assessment format and exercise. Females constituted 58% of respondents. Only 5% had ever experienced any kind of viva voce examination prior to joining UGHE. Of these, all agreed that the UGHE format was quite different from what they had previously experienced. At their first encounter with the viva examinations, majority of respondents (74%) reported finding it either stressful or very stressful. Even towards the end of their preclinical studies, 48% reported that the vivas remained stressful. Few (17%) enjoyed the overall viva experience while 39% did not, although they felt calm and focused during these examinations. Overall, 95% of respondents (38/40) agreed that viva examination was a useful way of assessing students' performance while the remaining 5% were simply not sure. Among the reasons advanced in support of vivas, some felt it trained them to manage stress while others indicated that it prepared them for future OSCEs during their clinical clerkship years. Some students reported that vivas helped them link the different aspects of basic sciences while others felt it was a better way of assessing one’s understanding when compared to MCQs. Additional reasons are listed in Table 3 . Asked about the 10% proportion of final grades assigned to vivas, most respondents (70%) felt it was fair while 20% felt it was too small and warranted an increase. In support of their views, some students argued that the entire process (from students’ preparation to sitting exams) was more intellectually draining than any other engagements within a module. Others felt viva was the best assessment tool due to its integrated nature where basic and clinical science aspects were concurrently assessed. Among those who advocated for an increase, one student remarked “ It really takes too much sugar to study for vivas, increasing its percentage would be rewarding at least. It is discouraging to sweat for only 10% of the final grades”. Paraphrasing another response, one learner felt that while they could easily pass MCQs by educated guesswork, this was not possible with vivas, therefore it was a true assessment of one’s knowledge. Overall, 75% of respondents agreed that while they disliked vivas, it was an essential part of assessment that should be maintained. When asked to provide viva tips for future students, preparation through group discussions/study was commonly cited. Another common piece of advice was for the candidate to move on and focus on the next station rather than feel bad about performance at a previous station. Asked for suggestions of how examiners could improve their act during vivas, respondents implored examiners to be more supportive of students. Words like being ‘welcoming’, ‘friendly’, ‘encouraging’, ‘understanding’, and ‘cheerful’ were commonly used to express this point. Others used phrases like “ providing a conducive environment”, “don’t take it too seriously” and “not be intimidating ” to echo the same point. Other suggestions included examiners giving timely direction to students in case one was off track and providing immediate correction during the exam. Whereas in general, students appreciated the guidance and prompting given by examiners whenever they were stuck, there was a general feeling that one’s viva experience was somehow dependent on the examiner they met at a given station. To underscore these complexities, one respondent lamented thus: Faculty should work together to fully understand what is being examined. It takes great humility to acknowledge that one is not well conversant with the topic(s). I believe this would allow the examiner to know when a student is on/off track and give guidance rather than expecting a student to be on script. A student can be offtrack not because they didn't understand the topic but because they didn't understand the question as intended. In this case the faculty could phrase the question differently in a way that helps to elicit the expected responses . Concerning overall viva administration, many respondents felt that all students should be subjected to the same set of questions (in the name of fairness) regardless of cycles while many others suggested that students should switch positions within rotations in subsequent modules i.e., if one was in cycle 1 in the first module, they should be in cycle 2 in the next module. This way, the stress associated with waiting for one’s turn would be evenly shared. Others felt that stations with online examiners should be given more time due to often unexpected connectivity disruptions. Some people felt terrified by the timekeeper’s whistle and proposed that a less stressful alternative be sought. On the contrary, many other respondents felt the current arrangement was fine. Lastly, while students appreciated receiving feedback at the end of each viva exercise, many preferred that it was individualized so that they knew exactly where to improve. In addition, many preferred that feedback be given by someone who actually examined them. Some suggested that comments/feedback notes could be shared with students on email for better reflection and internalization. Table 3 Students’ views regarding various aspects of the preclinical viva voce assessment format Question: Why do you think vivas are a useful method of assessing students’ performance in a module? Responses • it trained us to manage stress • it prepared us for the clinical years, particularly OSCEs • helped us to think and link the different aspects of basic sciences • a better way of assessing understanding compared to MCQs • Allows students to maximize scores since there is room for discussion ( unlike MCQs )* • Examines clinical reasoning and critical thinking/allows us to think in diverse ways • Trains students to speak with confidence/helps us build self confidence • Helps students to express themselves under guidance • Viva captures real-life scenarios better than MCQs • Improve our personal interaction with senior teachers • It is a form of learning • Pushed us to read and memorize information/good for assessing knowledge retention Question : What positive aspects do you think vivas afford students? Responses : • Helps students identify their weaknesses • Improves students’ understanding of content/ Helps retain certain specific facts for life • Improves communication skills/ Improves students’ self-expression • Learn how to apply knowledge to clinical cases/prepares us for clinical studies • Improves clinical reasoning and time management • Learn how to deal with different personalities of instructors • Improve how we approach study materials Question : How can viva examinations in the basic medical sciences division be improved? Responses : • Making sure all examiners use the same techniques/Examiner uniformity • Reduce emphasis on specific details and make it more general to avoid cramming • Provide more guidance/prompting and boost students’ confidence • Examiners should be patient and create a friendly atmosphere for students • Personalizing feedback sessions to suit individual needs • Concentrate on common clinical cases • Improve clarity of questions • Teach students how to approach vivas • Provide detailed and genuine feedback • Examiners should pay more attention • Dedicate a separate day for imaging station Question : How was your experience with the image station in vivas? Responses • Generally okay, as far as I can remember. It was content we had seen in class • Too many images to recall, that's why we struggled a lot at this station • Very challenging, sometimes images appeared totally new • It was fair/It was okay, except for the time factor/I always had shortage of time • It was my worst station, but the blame lies with me • Initially it was new and uncomfortable, later, it was interesting, made more sense and helped a lot at the end • So bad mostly, given an image and you wonder where on earth it came from • Overall good experience, good number of cases • It was intellectually challenging. Although I failed some of them, they were very educative • It used to be my worst station/ Terrible, I used to struggle with recalling or spelling Question : From your perspective, how can the image station be improved? Responses : • Images shouldn’t be about microscopic features but clinical features/ More clinical images • It would be better to give a one liner about the patient’s presentation • Ensure images are from class PowerPoints/ Bring only images encountered in module • If the questions were prepared as clinical cases with an image next to it • Providing more time or less imaging to describe/ Give it enough time/provide more time for thinking/ Generally good but sometimes images are many compared to time/ Reduce number of questions per image/Make questions considerable of time allocated • I suggest making it an MCQ • Eliminate the influence of spelling and handwriting in the assessment • Only use digital images/make sure all images are clear without confusion • Do not use MacBooks as they are hard to navigate during exams • Increase exposure to images during in-class quizzes. • Give clear instructions since there is no one in the station • Do not bring histology slides. They do not assess my understanding and honestly, students will forget them anyway/ I don’t think pathology images are necessary, but I may be wrong • Have a standardized format. Some images have one question while others have five. • Have a separate day for images so that students can prepare well Question : Having passed through the preclinical viva examinations, do you have any tips on passing vivas that you wish to pass on to future students? Responses : • If you are out of a station, you are out. Don't keep thinking of how bad you performed because you still have other stations to go through/ Always stay calm no matter how the previous station went • Review images before exams, read well • Having a study group is helpful, you get to learn from each other • Skip questions you can’t answer to save time • Not really. I think every student is different • It doesn't get any easier, but they will grow into it • Practice explaining concepts/ Practice, practice, practice • Cramming will only make you stressed if a topic is not examined or doesn’t get examined the way you had expected • Make sure you have an idea about all topics covered • Preparing before viva night is not good. • Never ignore anatomy ( assuming )* that it cannot be asked in vivas • Rest well the night before vivas • Pray, study, play then study Legend: * the italic words in parenthesis were added to enhance clarity of statement (Insert Table 3 here) At 40%, we attributed the low rate of questionnaire return to survey fatigue. This is a general trend we have observed in recent times since our students are routinely required to complete an online evaluation at the end of each module. Unlike module evaluation, which has become compulsory and enforceable, the same is not ethically feasible with research questionnaires. Given this context, we find a 40% return rate quite reasonable”. In Table 4 , we elaborate on the different aspects UGHE’s preclinical viva and how they align with key tenets that underlie the different educational theories on adult learning. Conclusion Whereas assessment is a key educational activity required to provide valuable feedback to students and instructors alike, it is important that the method be reliable and valid. We believe that the viva format described here strives to achieve these qualities, in addition to providing students with the right formative support and promoting their early clinical integration. Most students believed that viva voce assessments were an important component of their preclinical education enabling them to develop their clinical reasoning and communication skills. Students shared various views and suggestions on how to improve the UGHE viva format, some of which we hope to adopt to improve the assessment exercise going forward. We encourage other medical schools to critically examine and optimize their viva assessment methods to truly reflect their intended aims. Table 4 Linking UGHE’s novel viva format to current educational theories on adult learning Educational theory and its key tenets Alignment activity in UGHE viva format Principles modelled in the UGHE viva format Andragogy (Malcom Knowles) 1. Learner centeredness Viva involves active engagement and critical thinking Adults are self-directed learners 2. Experiential learning Use of authentic clinical scenarios Students draw on prior experiences and integrate new knowledge 3. Relevance and practicality Integration of basic sciences with clinical scenarios emphasizing real-world application Adults prefer learning that has immediate relevance to their professional roles Constructivist theory (Piaget & Vygotsky) 1. Social interaction & collaboration Involvement of multiple examiners and providing post-viva feedback Promoting social learning through interaction 2. Scaffolding A gradual integration of basic sciences with clinical reasoning in a structured format Students receive cognitive support and build on foundational knowledge systematically Experiential learning theory (Kolb) 1. Concrete examples Students actively engage in answering questions around realistic clinical scenarios The use of concrete examples promotes learning and knowledge retention 2. Reflective experiences Post-viva debriefing and feedback encourages reflection on performance by both faculty and students Reflection is crucial for learning from experience 3. Abstract conceptualization & active experimentation Integration of theory and practice in viva questions Students continuously adapt their approach based on experience and feedback Transformative learning theory (Mezirow) 1. Critical reflection Structured viva promotes self-examination and critical thinking Allows learners to challenge and reassess their clinical reasoning and communication strategies 2. Perspective transformation The stress and challenges of viva exams This pushes students to adapt and grow, leading to personal and professional transformation Social learning theory (Lave & Wenger) 1. Community of practice Involvement of various faculty members and peer discussions Fosters a sense of belonging and shared professional identity 2. Authentic contexts Viva exams are situated within real-world medical scenarios Encourages students to practice in contexts they will encounter in their careers Self-determination theory (Deci & Ryan) 1. Autonomy Students answer the same questions individually at each station Format empowers students to demonstrate their competence independently 2. Competence Viva can be passed or failed and weak students are normally flagged Successfully navigating the exam boosts students’ sense of efficacy 3. Relatedness Interaction with supportive faculty during exam Fosters a sense of connection, reducing anxiety and promoting learning (Insert Table 4 here) Abbreviations BMS: (Division of) Bio-Medical Sciences CBCL: Case-Based Clinical Learning MBBS: Bachelor of Medicine & Bachelor of Surgery MCQs: Multiple Choice Questions MED: Medicine programme OSCEs: Objective Structured Clinical Examinations TBL: Team-Based Learning UGHE: The University of Global Health Equity Declarations Ethics approval and consent to participate : This study received ethical approval from the University of Global Health Equity-Institutional Review Board. Reference number UGHE-IRB/2024/325 Consent for publication : Not applicable Availability of data and materials : The dataset generated and analysed during the current study are available from the corresponding author upon reasonable request Competing interests : The authors declare that they have no competing interests Funding : No funding was obtained/received for this study Authors’ contribution : COO: conceived the study, developed, and piloted data collection tools, analysed data, and wrote the first manuscript draft. SN: participated in data collection and constructed infographics, NK, AN, JPN, JBN: participated in data collection, DR, AM, DFB, PO, DS & AB: revised the manuscript for critical content. All authors read and approved the final version of manuscript. Acknowledgements : Authors wish to acknowledge students from the MBBS programme cohorts 2025, 2026 and 2028 who agreed to participate in this study. References Davis MH, Karunathilake I. The place of the oral examination in today’s assessment systems. Med Teach. 2005; 27(4): 294-7. Huxham M, Campbell F, Westwood J. Oral versus written assessments: a test of student performance and attitudes: Assess. & Eval. in Higher Educ. 2010; 37(1): 1-12. Burke-Smalley LA. Using Oral Exams to Assess Communication Skills in Business Courses. Bus Prof Commun Q. 2014; 77(3): 266–80. Wass V, Wakeford R, Neighbour R, Van der Vleuten C, Royal College of General Practitioners. Achieving acceptable reliability in oral examinations: an analysis of the Royal College of General Practitioners membership examination’s oral component. Med Educ. 2003; 37(2):126–31. Simpson RG, Ballard KD. What is being assessed in the MRCGP oral examination? A qualitative study. Br J Gen Pract. 2005; 55(515): 430–6. Zelenock GB, Calhoun JG, Hockman EM, Youmans LC, Erlandson EE, Davis WK, et al. Oral examinations: actual and perceived contributions to surgery clerkship performance. Surgery. 1985; 97(6): 737–44. Shaw SCK, Malik M, Anderson JL. The exam performance of students with dyslexia: a review of the literature. MedEdPublish. 2017; 6: 116-127. doi: 10.15694/mep.2017.000116. Evans LR, Ingersoll RW, Smith EJ. The reliability, validity, and taxonomic structure of the oral examination. J Med Educ. 1966; 41(7): 651–7. Thomas CS, Mellsop G, Callender K, Crawshaw J, Ellis PM, Hall A, et al. The oral examination: a study of academic and non-academic factors. Med Educ. 1993; 27(5): 433–9. Colton T, Peterson OL. An assay of medical students’ abilities by oral examination. J Med Educ. 1967; 42(11): 1005–14. Burchard KW, Rowland-Morin PA, Coe NP, Garb JL. A surgery oral examination: interrater agreement and the influence of rater characteristics. Acad Med J Assoc Am Med Coll. 1995; 70(11): 1044–6. Muzzin L, Hart L. Oral examinations. In: Neufeld VR, Norman GR, editors. Assessing clinical competence. New York: Springer Publishing Company; 1985. p. 71–93. Iqbal I, Naqvi S, Abeysundara L, Narula A. The Value of Oral Assessments: A Review. Bull R Coll Surg Engl. 2010; 92(7): 1–6. Anastakis DJ, Cohen R, Reznick RK. The structured oral examination as a method for assessing surgical residents. Am J Surg. 1991; 162(1): 67–70. Jefferies A, Simmons B, Ng E, Skidmore M. Assessment of multiple physician competencies in postgraduate training: utility of the structured oral examination. Adv Health Sci Educ. 2011; 16(5): 569–77. Ganji KK. Evaluation of Reliability in Structured Viva Voce As a Formative Assessment of Dental Students. J Dent Educ. 2017; 81(5): 590–6. Daelmans HEM, Scherpbier AJJA, Van der Vleuten CPM, Donker AJM. Reliability of clinical oral examinations re-examined. Med Teach. 2001; 23(4): 422-4. Stillman RM, Lane KM, Beeth S, Jaffe BM. Evaluation of the student: Improving validity of the oral examination. Surgery. 1983; 93(3): 439–42. Galan B, Gurp P, Stuyt P. Assessment in medical education. N Engl J Med. 2007; 356: 2108–9. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.docx Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 17 Apr, 2025 Reviews received at journal 16 Apr, 2025 Reviewers agreed at journal 12 Apr, 2025 Reviewers agreed at journal 09 Apr, 2025 Reviewers invited by journal 09 Apr, 2025 Submission checks completed at journal 07 Apr, 2025 First submitted to journal 05 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5476515","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":440798196,"identity":"d024ec93-84f3-4bc4-91a2-fac3007b0114","order_by":0,"name":"Charles Okot Odongo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAu0lEQVRIiWNgGAWjYHACAxAhx8DAQ6IWY9K1JDYQrYW/vXnj44JfNukbzq89+ICh4p5dAyEtEmeOFRvP7EvL3XDjXbIBw5niZIJaDCRyzKR5ew4DtZwxk2BsS0gm6DCYlnSDG2fMfxCvhefH4QSD8z1mDEAtdgS1gP3C25BmOPMGj7FEwpmEBIJawCHG88dGnu/8GcMPHyoS7AlqAQPGNpB9QPMTwBFEFPgDsu8AmEmkLaNgFIyCUTCSAABaCj4r3OtIEgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":true,"prefix":"","firstName":"Charles","middleName":"Okot","lastName":"Odongo","suffix":""},{"id":440798197,"identity":"e724d27f-e5db-448b-a036-22fe34242417","order_by":1,"name":"Samuel Ntaganira","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Ntaganira","suffix":""},{"id":440798198,"identity":"b3342cf8-9917-43e1-86b9-9e48063a82e6","order_by":2,"name":"Nicole Kanyana","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Nicole","middleName":"","lastName":"Kanyana","suffix":""},{"id":440798199,"identity":"da78fd98-e9e5-4a32-8128-c49b78ed2276","order_by":3,"name":"Jean Paul Ndayizeye","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Jean","middleName":"Paul","lastName":"Ndayizeye","suffix":""},{"id":440798200,"identity":"2d00da82-7c72-4179-a461-75f0048f2d46","order_by":4,"name":"Arlene Nishimwe","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Arlene","middleName":"","lastName":"Nishimwe","suffix":""},{"id":440798201,"identity":"89b18491-cf75-4d9f-8034-5faca65dc333","order_by":5,"name":"Jean Baptiste Niyibizi","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Jean","middleName":"Baptiste","lastName":"Niyibizi","suffix":""},{"id":440798202,"identity":"a971c097-11b1-485d-8bd9-ffbef98944a2","order_by":6,"name":"Deogratias Ruhangaza","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Deogratias","middleName":"","lastName":"Ruhangaza","suffix":""},{"id":440798203,"identity":"3f757985-cbbe-4e35-b6f5-67aa21f58c96","order_by":7,"name":"Abebe Moges Muche","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Abebe","middleName":"Moges","lastName":"Muche","suffix":""},{"id":440798204,"identity":"5b50a454-047b-4fe1-8742-c1e34ca1c40f","order_by":8,"name":"Derbew Fikadu Berhe","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Derbew","middleName":"Fikadu","lastName":"Berhe","suffix":""},{"id":440798205,"identity":"9033075e-4c18-4992-bcac-f0d04a8b63e0","order_by":9,"name":"Patrick Orikiriza","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"","lastName":"Orikiriza","suffix":""},{"id":440798206,"identity":"f0bc3d69-ae2a-491f-98c0-dd5beb11033e","order_by":10,"name":"Daniel Seifu","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Seifu","suffix":""},{"id":440798207,"identity":"9bfa0629-144a-4173-8290-9e12ea3fb0be","order_by":11,"name":"Abebe Bekele","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Abebe","middleName":"","lastName":"Bekele","suffix":""}],"badges":[],"createdAt":"2024-11-18 13:38:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5476515/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5476515/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-07463-6","type":"published","date":"2025-07-01T15:56:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80578600,"identity":"2abc83d4-c3a7-445c-b19f-7272b128bf20","added_by":"auto","created_at":"2025-04-14 23:04:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":282928,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow plan showing movement within Rotation A through the viva stations including actual time allotment\u003c/strong\u003e(a similar arrangement obtains for rotations B, C \u0026amp; D)\u003c/p\u003e","description":"","filename":"Fiigure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5476515/v1/2e1ff6f7e3674c963c442896.jpg"},{"id":86180162,"identity":"1b8cebf5-97f9-40bc-8607-9cea84fecc37","added_by":"auto","created_at":"2025-07-07 16:21:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1503229,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5476515/v1/9e6450b8-cf35-43bc-958e-7dce5eed2944.pdf"},{"id":80577244,"identity":"ecf0ec3a-057b-433f-af34-6084c8ef6a35","added_by":"auto","created_at":"2025-04-14 22:56:08","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20742103,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5476515/v1/1dc6f83850801e3b44253a9b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The viva voce innovation and experience at a new medical school in Rwanda","fulltext":[{"header":"Background","content":"\u003cp\u003eViva voce examinations, also referred to as oral exams (or simply as \u0026lsquo;viva\u0026rsquo;) are a common assessment method in medical education where they are usually deployed right from preclinical education through to advanced professional training. The traditional viva voce exam takes the form of an unstructured interaction in which one or more examiners ask the candidate several questions. These questions are either generated on the spot or initially picked by the candidate at random from a pool consisting of questions of varying levels of difficulty. Proponents of this assessment method have argued that it is useful in assessing knowledge recall and that it fosters the mental agility required for future clinical practice (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Compared with the written exam, research shows that the viva voce exam offers additional unique advantages such as its inherent resistance to plagiarism and ability to promote development of the student\u0026rsquo;s communication skills (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Other unique attributes of the viva voce exam include its ability to assess the development of attitudinal competencies including professionalism and ethics (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) and the recognition of safe and competent clinicians (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), all of which may not be easily achieved with written exams. More recently, studies are emerging to suggest that viva voce may provide a more authentic option for assessing students with learning disabilities such as dyslexia (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs with all other forms of assessment, the traditional viva exam has attracted several criticisms, particularly relating to biases inherent within its approach. Most notably, questions on reliability and validity of the traditional viva format remain unresolved. For instance, Evans et.al., showed that viva scores tended to correlate with the number of words spoken by the candidate (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), while Thomas et al., showed that scores correlated with a candidate\u0026rsquo;s personality score (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Other factors such as the time of day at which the exam is done (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), verbal style and dress code (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), as well as sex or physical appearance of the candidate (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) have all been shown to influence viva scores. Furthermore, it has been shown that examiners are generally prone to several unconscious biases such as the halo effect (a type of cognitive bias where our overall impression about a person, brand or product influences how we feel and think about their character or capabilities), all of which affect viva scores (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In this era of evidence-based medical education, such shortcomings leave a lot to be desired and continue to drive debate on the relevance of viva voce assessment in today\u0026rsquo;s curricular. It is not surprising therefore, that some academic institutions have elected to break with tradition and abandon the viva voce assessment method altogether (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Mindful of these challenges and inspired by the need to improve the reliability and validity of our viva voce examinations, faculty from the Division of Bio-Medical Sciences (BMS) at the University of Global Health Equity (UGHE), devised a novel preclinical viva examination format which has been implemented and refined over the past four years. The first part of this paper describes and discusses the rationale behind some of the unique features in our viva assessment exercise. In the second part, we share learners\u0026rsquo; views and experiences, something which is often underreported in the literature (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Data from students was collected through a self-administered online questionnaire and summarized using quantitative and qualitative methods. The study was reviewed and approved by the UGHE-Institutional Review Board (ref. UGHE-IRB/2024/325) and was conducted in accordance with the ethical principles set out in the World Medical Association\u0026rsquo;s Declaration of Helsinki (as amended, 2013)`. All students gave voluntary written informed consent prior to participation in the study.\u003c/p\u003e\n\u003ch3\u003eA brief introduction of the University of Global Health Equity (UGHE)\u003c/h3\u003e\n\u003cp\u003eUGHE is a new kind of health sciences institution located in Butaro, northern Rwanda, with a mission to radically transform global health education and delivery. Founded by Partners In Health in collabouration with the Rwandan government, UGHE integrates rigorous academic training with a strong emphasis on equity, social justice, and community-based care. Along with other programmes, UGHE offers the Bachelor of Medicine and Surgery, and Master of Science in Global Health Delivery dual degree (MBBS/MGHD), where classroom learning is combined with field-based experiences. Its programmes are interdisciplinary, blending public health, clinical and social medicine, leadership, and management skills to prepare future healthcare leaders with a sound sense of social justice and equity. The university attracts a diverse and international student body, including faculty and students from across Africa, the Americas, Asia, and Europe, fostering a collabourative and multicultural learning environment. With a strong emphasis on gender equity and inclusivity, 70% of its admissions are reserved for female students across all programmes. Nearly all students receive scholarships to support access for those from underserved communities. With a campus designed to support immersive and reflective learning in a rural setting, UGHE serves as a model for how education can be a powerful tool for health equity worldwide.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe philosophical grounding of UGHE\u0026rsquo;s preclinical curriculum and grading system\u003c/h2\u003e \u003cp\u003eUGHE\u0026rsquo;s preclinical curriculum is delivered in a modular fashion over a two-year period with both instruction and assessment fully integrated across the basic science disciplines. Each module is led by a module director who is a senior faculty and is closely assisted by a junior faculty as module coordinator. Together, they oversee all day-to-day module implementation activities. Each module and classes therein are logically sequenced to ensure that learners acquire new knowledge based on concepts previously covered in earlier classes or preceding modules. Each module typically begins with classes covering relevant topics in anatomy, physiology, and biochemistry, reflecting normal body function. This is followed by topics in microbiology, pathology, and pharmacology where pathophysiology and treatments are discussed. Within each module, longitudinal sequencing of classes is done logically, ensuring that new knowledge is built on existing concepts previously covered in the relevant discipline. For instance, in the module Gastrointestinal System \u0026amp; Nutrition (MED 106), the pharmacology class titled \u0026lsquo;Treatment of peptic ulcer diseases\u0026rsquo; is scheduled after the anatomy and physiology of gastric function are covered and the pathophysiology of peptic ulcer diseases is discussed. Each class is delivered by the respective content expert faculty and the relevance of this knowledge to clinical care is emphasized. Classroom instruction is achieved through multiple learner-centreed instructional formats such as interactive lectures, flipped classes, team-based learning (TBL), student-led seminars, and case-based collabourative learning (CBCL). Within each module, laboratory and simulation sessions are also implemented to reinforce key concepts. Of note, each classroom interaction attracts a formative assessment score. For instance, students take a short post-class quiz at the end of each interactive lecture and a pre-class assignment in preparation for each CBCL or flipped class session. Furthermore, TBL sessions commence with the typical readiness-assurance tests designed to ensure that learners prepare prior to coming to class. All quizzes and assignments, plus laboratory activities are graded and contribute up to 60% towards the final score. A mid- and end-module summative assessment, each consisting of 60 MCQs are done for each module. The final module score is obtained by summation of all the different categories of scores as per the standard framework outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e where vivas contribute 10% of the final grades. Attainment of a 60% pass mark allows the student to progress normally to the next module of study.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe standard grading framework for preclinical modules at UGHE\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic activity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContribution to final score (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass attendance \u0026amp; participation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-class quizzes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-class assignments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabs, simulation \u0026amp; seminars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMid-module exams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSummative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-module exams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSummative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eViva voce exams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSummative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDevelopment of viva-voce assessment materials\u003c/h3\u003e\n\u003cp\u003eUnder the stewardship of the module director, all faculty are jointly responsible for developing and moderating viva examination content. This process begins with an open invitation to faculty to develop suitable examination questions along with provisional answers. These are then compiled on a living document and shared with the entire team. In some instances, the module coordinator is tasked to develop potential questions (with or without answers) which are then shared with faculty for their input and approval. Viva questions are typically constructed around a stem consisting of a hypothetical, but authentic clinical scenario referred to as a \u0026ldquo;case\u0026rdquo;. Within each case, faculty ensure a balanced mix of questions covering the relevant basic science disciplines (i.e., anatomy, physiology, biochemistry, pathology etc.) as each case may warrant. Furthermore, the module coordinator is tasked with compiling a set of clinical and laboratory images or diagrams that students have met during class instruction. The student is expected to recognize these images and answer a few related questions during the exam. Examples of complete cases and images extracted from 3 different modules are shown in \u003cb\u003eSupplementary file 1\u003c/b\u003e. A few days before the examination date, a meeting is convened to review and moderate the questions. Where gaps are identified, content experts are tagged and required to address them, and any outstanding issues are resolved through discussion and consensus. Such issues typically include improving the clarity of questions or answers, revision of case length viz a viz time allocated, faculty declaration of case preferences (for examination), availability of faculty on examination day, exam logistics etc.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplementation of the\u003c/b\u003e \u003cb\u003eviva voce\u003c/b\u003e \u003cb\u003eassessment exercise\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe viva exam is the last academic activity in each module and is typically scheduled on the morning of the last day of that module. At this point, students would have completed the end of module written exam the previous afternoon. For the viva, a student is expected to spend approximately 1 hour moving through four examination stations at which they spend no more than 10 minutes each, interspaced with two-minute intervals between stations. Figure\u0026nbsp;1 below summarizes students\u0026rsquo; flow plan through the viva stations. Three of these stations consist of \u0026ldquo;cases\u0026rdquo; as described above, with the fourth being the image station. A fifth station baptized the \u0026ldquo;Resting station\u0026rdquo; is normally included to allow the student respite to recompose themselves in case that should be needed. To ensure timely examination of the entire student lot, four sets of such examination stations (each set is referred to as a rotation) are normally set up in different parts of the campus\u0026rsquo; teaching and learning spaces. Since 3 out of 5 stations in each rotation are manned by examiners, a minimum of 12 examiners are usually required to effectively conduct the examination across 4 rotations A-D. The entire exercise is managed and coordinated by a dedicated team of examination assistants who also serve as timekeepers and student guides. During the evening before the viva exercise, each faculty receives digital links to all the relevant documents required for their smooth participation. These include details such as the physical location of their examination station, a final version of the case to be examined, as well as grading and comment sheets to be used during the exercise. Students also receive a document showing their rotation and their movement plan through the different examination stations. Examiners are expected to use the two-minute intervals between students visiting their station to award a global score (out of 10) and document any pertinent observations/comments against each student passing through their station. All grading and comments are entered in real-time on a living spreadsheet file.\u003c/p\u003e \u003cp\u003e \u003cem\u003e(Insert Fig.\u0026nbsp;1 here)\u003c/em\u003e \u003c/p\u003e\u003cp\u003eLastly, a post-viva examination meeting is usually convened within 30 minutes of concluding the viva exercise. Here, faculty debrief and discuss the examination exercise/experience with a view to optimizing future implementation as well as discussing struggling students who may require tailored feedback or other support to mitigate any challenging circumstances they may be experiencing.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSince 2020 when UGHE opened its doors to the first cohort of MBBS students, deliberate effort has been made to critically re-examine traditional teaching, learning and assessment practices with a view of discarding questionable practices and adopting and promoting evidence-based alternatives. This is the premise upon which the current viva examination format was developed. One of the foremost arguments advanced by proponents of abolishing the traditional viva is the time-consuming nature of the exercise, and the attending stress it exerts on students and faculty alike. We believe that our format where multiple rotations are created to run concurrently addresses this challenge, given that the entire exercise is normally completed within 3\u0026ndash;4 hours with each student undergoing approximately 1 hour of examination. With all students simultaneously taking the exam in the morning hours when their minds are presumed to be fresh, everyone has the opportunity for optimum cognitive performance. Previously, Colton \u0026amp; Peterson have reported that students who sit viva exams in the later part of the day tend to perform poorer than those who sit earlier in the day, probably due to fatigue (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). Also noteworthy is the fact that all students get to answer the same questions presented in a structured manner. Unlike the traditional viva exam which is relatively unstructured, our structured format ensures better sampling and representation of the syllabus given that faculty from different disciplines make input into the exam. Moreover, structured viva exams have now been shown to achieve better reliability scores (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e). Another novelty with our viva format is the use of multiple viva stations/cases manned by different examiners. This approach, while intensely demanding in number of examiners, ensures that students get multiple opportunities to prove themselves. It also minimizes any biases that individual faculty may harbor against a particular student since the final viva score is an average of scores obtained from all four stations through which a student has traversed. In addition, the use of multiple stations/cases has been shown to improve both reliability (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e) and validity (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e) of viva examinations. Given that all scores are entered in real-time onto a shared spreadsheet, each student\u0026rsquo;s scores can be easily tracked and inspected for trends. As such, one can easily get a general picture of whether a student is academically weak or strong, or whether they experienced an isolated catastrophic event at a particular viva station. In such instances, the examiner ought to have captured this on the comment spreadsheet. Quite often, these comments provide useful insights and serve as a basis for providing constructive post-viva feedback, regarding any weaknesses observed with a student. Furthermore, the requirement for examiners to comment on each student promotes transparency and accountability for the scores awarded. To this end, as part of the on-going reflections of our four-year experiences, we are undertaking a formal study to assess the reliability and validity of our viva assessment method.\u003c/p\u003e\n\u003cp\u003eAnother novel aspect of the UGHE viva is the horizontal and vertical integration of disciplines. Faculty ensure that the questions associated with each case cover all the basic science disciplines in a manner similar to how topics were covered in class. Even though most questions tend to be basic science oriented, they are intentionally assembled around an authentic clinical scenario such that students can appreciate very early on, the direct relevance of the material under examination to future clinical practice. Quite often, students are required to come up with a diagnosis from the clinical scenario presented within the case. We believe this approach supports honing of their clinical reasoning and diagnostic skills. In contrast, critics of the traditional viva format have often pointed to the low taxonomic nature of questions posed, as they tend to be limited to knowledge recall (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). It is therefore not surprising that during post-module evaluation surveys, some students have contentedly expressed the feeling of evolving into doctors given the balanced mix of recall and clinical reasoning to which they are subjected. The inclusion of an image station is yet another novelty with our viva format. This station affords us the opportunity to examine some otherwise hard-to-assess aspects of the basic sciences curriculum such as embryology, histology, histopathology, and gross pathology. Given that assessment drives learning (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e), we believe that the way students are assessed can re-orient their manner of engagement with the subject matter, such that they begin to focus more thoughtfully, hence, develop the right skills and professional attitudes. Therefore, the challenge posed by the image station ensures that our students pay critical attention to images displayed during classroom instruction and that this also gives them a head start on the future demands of clerkship and professional practice where they will be expected to routinely examine and interpret images. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e below, summarizes the novelty aspects discussed above. Lastly, while it is always challenging to have all 12 examiners physically present during exams, the use of online conferencing platforms such as Zoom\u0026Ograve; and Teams\u0026reg; have enabled faculty who may not be physically present to effectively participate in the assessment process. This is perhaps another novelty that has enabled effective implementation of our viva assessment. In addition, online conferencing platforms have enabled faculty from partner universities in Europe and America (who routinely support our teaching) to conveniently participate in the viva examination process. The robust nature of this online infrastructure was particularly tested during the Covid-19 pandemic when teaching, learning and assessment activities remained relatively uninterrupted despite several institutions suspending academic activities due to lockdown restrictions.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSummary of key differences between the traditional and the novel UGHE viva format\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAssessment attributes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTraditional viva format\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNovelty and advantages of the UGHE format\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStructure of assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuestions often random and unstructured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSame questions for all, presented in a structured manner, improves reliability of assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntegration of content\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVery limited. Often discipline specific, administered as one discipline at a time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntegrated both vertically and horizontally for enhanced knowledge retention and understanding following the principle of interleaving.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of assessment stations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents visit one station per discipline to evaluate their knowledge.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresence of multiple viva stations provides multiple opportunities for student to prove themselves. This improves reliability (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e) and validity of assessment (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImage-based station\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo image-based station\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInclusion of images fosters a culture of their thoughtful study, as part of a future clinical skillset. Also improves the examination of certain disciplines e.g., histology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eValidity of assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuestionable, given the random nature of selecting questions which may have variable levels of difficulty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll students subjected to same questions. Assessment is a fair representation of the syllabus as faculty meet to moderate and balance content\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTaxonomy of questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower order questions. Often limited to knowledge recall as it purely examines basic science concepts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAssociation with authentic clinical case scenario allows for high order assessment, e.g., formulating a differential diagnosis. This fosters early clinical reasoning.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFaculty debrief\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRare, if any\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOccurs within one hour of completion. Allows faculty to review entire exercise, optimize questions for future cycles and discuss feedback for struggling students\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudent feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRare, if any\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComments on individual performance at each station is captured and used to provide constructive feedback post viva.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudent fatigue and performance bias\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAssociated with long waiting times as some students wait until the late afternoon, introducing fatigue and performance bias (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShort waiting times as most students are examined simultaneously. All students sit viva in the morning hours when mentally fresh, reducing fatigue and performance bias\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFaculty fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExamination proceeds for 1 or 2 days with increased fatigue and potential for bias\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMinimal fatigue as examination lasts 3\u0026ndash;4 hours due to multiple rotations running concurrently.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExaminer accountability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDifficult to ascertain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth grades and comments entered on shared files, ensuring transparency, and minimizing examiner bias\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eScores and grading\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinal grade determined through scores from one viva station, graded by 1 or 2 examiners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinal grade derived from mean score from 4 viva stations, further minimizing effect of individual examiner bias\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eChallenges and lessons learnt with UGHE\u0026rsquo;s preclinical viva assessment format\u003c/h3\u003e\n\u003cp\u003eWhereas vertical and horizontal integration of viva content is particularly helpful for development of students\u0026rsquo; clinical reasoning skills, its implementation has not been without challenges, particularly for examiners. For instance, examiners with a purely basic science background often feel uncomfortable examining clinical aspects of the viva. Conversely, examiners from clinical specialties may also feel uncomfortable examining some basic science aspects. This challenge is mitigated by allowing faculty to choose case preferences for examination which allows them to prepare optimally and operate within their comfort zones. Other challenges such as the high number of examiners required and the critical reliance on a robust internet service have been alluded to above. The basic sciences division has always been fortunate to receive examination support from the clinical medicine division together with the visiting faculty available from time to time. This partnership has so far worked well. One may argue that viva assessments involving online examiners may differ from face-to-face interactions in terms of stress, attention, or other non-verbal elements of communication. While the two formats are not exactly the same, our faculty debriefs and student feedback sessions have indicated no major differences in terms of deficits of one kind or another.\u003c/p\u003e\n\u003cp\u003eIt has also been observed that scores on the image station are consistently the lowest for most students. This may reflect the objective and relatively straightforward nature of the responses which become easy to score. Incidentally, this also happens to be the station where students are required to write down their responses, unlike other stations where all answers are given through verbal communication. Furthermore, since our grading system relies on a global score at each viva station, it may be unduly influenced by the halo effect, a form of cognitive bias that can potentially affect reliability of scores (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). This bias is normally minimized by limiting the number of questions posed by each examiner. Unlike high stakes examinations, where such biases are a matter of critical concern, we consider our viva assessments a formative exercise, which in addition to gauging learners\u0026rsquo; knowledge, is geared towards developing their clinical reasoning and communication skills. Within the first two years of implementation, faculty observed that the possibility of exam leakages across cohorts could not be completely ruled out given the universal access to digital information sharing tools. Considering that such leakages would threaten exam integrity, stringent measures were introduced such as the creation of new viva cases each year to ensure a rich library of cases from which to randomly select. Furthermore, to minimize the possibility of exam leakages within the same sitting, faculty resolved to change cases midcycle during each exam. From the faculty standpoint, we consider the additional work worthwhile as it helps assure the validity of the assessment.\u003c/p\u003e\n\u003ch3\u003eStudent perceptions and experiences with the preclinical viva voce examination\u003c/h3\u003e\n\u003cp\u003eApproximately 40% (43/108) of students who received an online questionnaire shared their views and experiences regarding the preclinical viva voce assessment format and exercise. Females constituted 58% of respondents. Only 5% had ever experienced any kind of viva voce examination prior to joining UGHE. Of these, all agreed that the UGHE format was quite different from what they had previously experienced. At their first encounter with the viva examinations, majority of respondents (74%) reported finding it either stressful or very stressful. Even towards the end of their preclinical studies, 48% reported that the vivas remained stressful. Few (17%) enjoyed the overall viva experience while 39% did not, although they felt calm and focused during these examinations. Overall, 95% of respondents (38/40) agreed that viva examination was a useful way of assessing students\u0026apos; performance while the remaining 5% were simply not sure. Among the reasons advanced in support of vivas, some felt it trained them to manage stress while others indicated that it prepared them for future OSCEs during their clinical clerkship years. Some students reported that vivas helped them link the different aspects of basic sciences while others felt it was a better way of assessing one\u0026rsquo;s understanding when compared to MCQs. Additional reasons are listed in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. Asked about the 10% proportion of final grades assigned to vivas, most respondents (70%) felt it was fair while 20% felt it was too small and warranted an increase. In support of their views, some students argued that the entire process (from students\u0026rsquo; preparation to sitting exams) was more intellectually draining than any other engagements within a module. Others felt viva was the best assessment tool due to its integrated nature where basic and clinical science aspects were concurrently assessed. Among those who advocated for an increase, one student remarked\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIt really takes too much sugar to study for vivas, increasing its percentage would be rewarding at least. It is discouraging to sweat for only 10% of the final grades\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParaphrasing another response, one learner felt that while they could easily pass MCQs by educated guesswork, this was not possible with vivas, therefore it was a true assessment of one\u0026rsquo;s knowledge. Overall, 75% of respondents agreed that while they disliked vivas, it was an essential part of assessment that should be maintained. When asked to provide viva tips for future students, preparation through group discussions/study was commonly cited. Another common piece of advice was for the candidate to move on and focus on the next station rather than feel bad about performance at a previous station. Asked for suggestions of how examiners could improve their act during vivas, respondents implored examiners to be more supportive of students. Words like being \u0026lsquo;welcoming\u0026rsquo;, \u0026lsquo;friendly\u0026rsquo;, \u0026lsquo;encouraging\u0026rsquo;, \u0026lsquo;understanding\u0026rsquo;, and \u0026lsquo;cheerful\u0026rsquo; were commonly used to express this point. Others used phrases like \u0026ldquo;\u003cem\u003eproviding a conducive environment\u0026rdquo;, \u0026ldquo;don\u0026rsquo;t take it too seriously\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;not be intimidating\u003c/em\u003e\u0026rdquo; to echo the same point. Other suggestions included examiners giving timely direction to students in case one was off track and providing immediate correction during the exam. Whereas in general, students appreciated the guidance and prompting given by examiners whenever they were stuck, there was a general feeling that one\u0026rsquo;s viva experience was somehow dependent on the examiner they met at a given station. To underscore these complexities, one respondent lamented thus:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eFaculty should work together to fully understand what is being examined. It takes great humility to acknowledge that one is not well conversant with the topic(s). I believe this would allow the examiner to know when a student is on/off track and give guidance rather than expecting a student to be on script. A student can be offtrack not because they didn\u0026apos;t understand the topic but because they didn\u0026apos;t understand the question as intended. In this case the faculty could phrase the question differently in a way that helps to elicit the expected responses\u003c/em\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eConcerning overall viva administration, many respondents felt that all students should be subjected to the same set of questions (in the name of fairness) regardless of cycles while many others suggested that students should switch positions within rotations in subsequent modules i.e., if one was in cycle 1 in the first module, they should be in cycle 2 in the next module. This way, the stress associated with waiting for one\u0026rsquo;s turn would be evenly shared. Others felt that stations with online examiners should be given more time due to often unexpected connectivity disruptions. Some people felt terrified by the timekeeper\u0026rsquo;s whistle and proposed that a less stressful alternative be sought. On the contrary, many other respondents felt the current arrangement was fine. Lastly, while students appreciated receiving feedback at the end of each viva exercise, many preferred that it was individualized so that they knew exactly where to improve. In addition, many preferred that feedback be given by someone who actually examined them. Some suggested that comments/feedback notes could be shared with students on email for better reflection and internalization.\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStudents\u0026rsquo; views regarding various aspects of the preclinical viva voce assessment format\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuestion: Why do you think vivas are a useful method of assessing students\u0026rsquo; performance in a module?\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponses\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; it trained us to manage stress\u003c/p\u003e\n \u003cp\u003e\u0026bull; it prepared us for the clinical years, particularly OSCEs\u003c/p\u003e\n \u003cp\u003e\u0026bull; helped us to think and link the different aspects of basic sciences\u003c/p\u003e\n \u003cp\u003e\u0026bull; a better way of assessing understanding compared to MCQs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Allows students to maximize scores since there is room for discussion (\u003cem\u003eunlike MCQs\u003c/em\u003e)*\u003c/p\u003e\n \u003cp\u003e\u0026bull; Examines clinical reasoning and critical thinking/allows us to think in diverse ways\u003c/p\u003e\n \u003cp\u003e\u0026bull; Trains students to speak with confidence/helps us build self confidence\u003c/p\u003e\n \u003cp\u003e\u0026bull; Helps students to express themselves under guidance\u003c/p\u003e\n \u003cp\u003e\u0026bull; Viva captures real-life scenarios better than MCQs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improve our personal interaction with senior teachers\u003c/p\u003e\n \u003cp\u003e\u0026bull; It is a form of learning\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pushed us to read and memorize information/good for assessing knowledge retention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e: What positive aspects do you think vivas afford students?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponses\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Helps students identify their weaknesses\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improves students\u0026rsquo; understanding of content/ Helps retain certain specific facts for life\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improves communication skills/ Improves students\u0026rsquo; self-expression\u003c/p\u003e\n \u003cp\u003e\u0026bull; Learn how to apply knowledge to clinical cases/prepares us for clinical studies\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improves clinical reasoning and time management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Learn how to deal with different personalities of instructors\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improve how we approach study materials\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e: How can viva examinations in the basic medical sciences division be improved?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponses\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Making sure all examiners use the same techniques/Examiner uniformity\u003c/p\u003e\n \u003cp\u003e\u0026bull; Reduce emphasis on specific details and make it more general to avoid cramming\u003c/p\u003e\n \u003cp\u003e\u0026bull; Provide more guidance/prompting and boost students\u0026rsquo; confidence\u003c/p\u003e\n \u003cp\u003e\u0026bull; Examiners should be patient and create a friendly atmosphere for students\u003c/p\u003e\n \u003cp\u003e\u0026bull; Personalizing feedback sessions to suit individual needs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Concentrate on common clinical cases\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improve clarity of questions\u003c/p\u003e\n \u003cp\u003e\u0026bull; Teach students how to approach vivas\u003c/p\u003e\n \u003cp\u003e\u0026bull; Provide detailed and genuine feedback\u003c/p\u003e\n \u003cp\u003e\u0026bull; Examiners should pay more attention\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dedicate a separate day for imaging station\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e: How was your experience with the image station in vivas?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponses\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; Generally okay, as far as I can remember. It was content we had seen in class\u003c/p\u003e\n \u003cp\u003e\u0026bull; Too many images to recall, that\u0026apos;s why we struggled a lot at this station\u003c/p\u003e\n \u003cp\u003e\u0026bull; Very challenging, sometimes images appeared totally new\u003c/p\u003e\n \u003cp\u003e\u0026bull; It was fair/It was okay, except for the time factor/I always had shortage of time\u003c/p\u003e\n \u003cp\u003e\u0026bull; It was my worst station, but the blame lies with me\u003c/p\u003e\n \u003cp\u003e\u0026bull; Initially it was new and uncomfortable, later, it was interesting, made more sense and helped a lot at the end\u003c/p\u003e\n \u003cp\u003e\u0026bull; So bad mostly, given an image and you wonder where on earth it came from\u003c/p\u003e\n \u003cp\u003e\u0026bull; Overall good experience, good number of cases\u003c/p\u003e\n \u003cp\u003e\u0026bull; It was intellectually challenging. Although I failed some of them, they were very educative\u003c/p\u003e\n \u003cp\u003e\u0026bull; It used to be my worst station/ Terrible, I used to struggle with recalling or spelling\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e: From your perspective, how can the image station be improved?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponses\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Images shouldn\u0026rsquo;t be about microscopic features but clinical features/ More clinical images\u003c/p\u003e\n \u003cp\u003e\u0026bull; It would be better to give a one liner about the patient\u0026rsquo;s presentation\u003c/p\u003e\n \u003cp\u003e\u0026bull; Ensure images are from class PowerPoints/ Bring only images encountered in module\u003c/p\u003e\n \u003cp\u003e\u0026bull; If the questions were prepared as clinical cases with an image next to it\u003c/p\u003e\n \u003cp\u003e\u0026bull; Providing more time or less imaging to describe/ Give it enough time/provide more time for thinking/ Generally good but sometimes images are many compared to time/ Reduce number of questions per image/Make questions considerable of time allocated\u003c/p\u003e\n \u003cp\u003e\u0026bull; I suggest making it an MCQ\u003c/p\u003e\n \u003cp\u003e\u0026bull; Eliminate the influence of spelling and handwriting in the assessment\u003c/p\u003e\n \u003cp\u003e\u0026bull; Only use digital images/make sure all images are clear without confusion\u003c/p\u003e\n \u003cp\u003e\u0026bull; Do not use MacBooks as they are hard to navigate during exams\u003c/p\u003e\n \u003cp\u003e\u0026bull; Increase exposure to images during in-class quizzes.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Give clear instructions since there is no one in the station\u003c/p\u003e\n \u003cp\u003e\u0026bull; Do not bring histology slides. They do not assess my understanding and honestly, students will forget them anyway/ I don\u0026rsquo;t think pathology images are necessary, but I may be wrong\u003c/p\u003e\n \u003cp\u003e\u0026bull; Have a standardized format. Some images have one question while others have five.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Have a separate day for images so that students can prepare well\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e: Having passed through the preclinical viva examinations, do you have any tips on passing vivas that you wish to pass on to future students?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponses\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e\u0026bull; If you are out of a station, you are out. Don\u0026apos;t keep thinking of how bad you performed because you still have other stations to go through/ Always stay calm no matter how the previous station went\u003c/p\u003e\n \u003cp\u003e\u0026bull; Review images before exams, read well\u003c/p\u003e\n \u003cp\u003e\u0026bull; Having a study group is helpful, you get to learn from each other\u003c/p\u003e\n \u003cp\u003e\u0026bull; Skip questions you can\u0026rsquo;t answer to save time\u003c/p\u003e\n \u003cp\u003e\u0026bull; Not really. I think every student is different\u003c/p\u003e\n \u003cp\u003e\u0026bull; It doesn\u0026apos;t get any easier, but they will grow into it\u003c/p\u003e\n \u003cp\u003e\u0026bull; Practice explaining concepts/ Practice, practice, practice\u003c/p\u003e\n \u003cp\u003e\u0026bull; Cramming will only make you stressed if a topic is not examined or doesn\u0026rsquo;t get examined the way you had expected\u003c/p\u003e\n \u003cp\u003e\u0026bull; Make sure you have an idea about all topics covered\u003c/p\u003e\n \u003cp\u003e\u0026bull; Preparing before viva night is not good.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Never ignore anatomy (\u003cem\u003eassuming\u003c/em\u003e)* that it cannot be asked in vivas\u003c/p\u003e\n \u003cp\u003e\u0026bull; Rest well the night before vivas\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pray, study, play then study\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"1\"\u003eLegend: * the italic words in parenthesis were added to enhance clarity of statement\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e(Insert\u003c/em\u003e Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cem\u003ehere)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt 40%, we attributed the low rate of questionnaire return to survey fatigue. This is a general trend we have observed in recent times since our students are routinely required to complete an online evaluation at the end of each module. Unlike module evaluation, which has become compulsory and enforceable, the same is not ethically feasible with research questionnaires. Given this context, we find a 40% return rate quite reasonable\u0026rdquo;. In Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e, we elaborate on the different aspects UGHE\u0026rsquo;s preclinical viva and how they align with key tenets that underlie the different educational theories on adult learning.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhereas assessment is a key educational activity required to provide valuable feedback to students and instructors alike, it is important that the method be reliable and valid. We believe that the viva format described here strives to achieve these qualities, in addition to providing students with the right formative support and promoting their early clinical integration. Most students believed that viva voce assessments were an important component of their preclinical education enabling them to develop their clinical reasoning and communication skills. Students shared various views and suggestions on how to improve the UGHE viva format, some of which we hope to adopt to improve the assessment exercise going forward. We encourage other medical schools to critically examine and optimize their viva assessment methods to truly reflect their intended aims.\u003c/p\u003e \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLinking UGHE\u0026rsquo;s novel viva format to current educational theories on adult learning\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEducational theory and its key tenets\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAlignment activity in UGHE viva format\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePrinciples modelled in the UGHE viva format\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eAndragogy (Malcom Knowles)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. Learner centeredness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eViva involves active engagement and critical thinking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdults are self-directed learners\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. Experiential learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUse of authentic clinical scenarios\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents draw on prior experiences and integrate new knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3. Relevance and practicality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntegration of basic sciences with clinical scenarios emphasizing real-world application\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdults prefer learning that has immediate relevance to their professional roles\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eConstructivist theory (Piaget \u0026amp; Vygotsky)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. Social interaction \u0026amp; collaboration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInvolvement of multiple examiners and providing post-viva feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePromoting social learning through interaction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. Scaffolding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA gradual integration of basic sciences with clinical reasoning in a structured format\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents receive cognitive support and build on foundational knowledge systematically\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eExperiential learning theory (Kolb)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. Concrete examples\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents actively engage in answering questions around realistic clinical scenarios\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe use of concrete examples promotes learning and knowledge retention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. Reflective experiences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost-viva debriefing and feedback encourages reflection on performance by both faculty and students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReflection is crucial for learning from experience\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3. Abstract conceptualization \u0026amp; active experimentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntegration of theory and practice in viva questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents continuously adapt their approach based on experience and feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eTransformative learning theory (Mezirow)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. Critical reflection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStructured viva promotes self-examination and critical thinking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAllows learners to challenge and reassess their clinical reasoning and communication strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. Perspective transformation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe stress and challenges of viva exams\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis pushes students to adapt and grow, leading to personal and professional transformation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSocial learning theory (Lave \u0026amp; Wenger)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. Community of practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInvolvement of various faculty members and peer discussions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFosters a sense of belonging and shared professional identity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. Authentic contexts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eViva exams are situated within real-world medical scenarios\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEncourages students to practice in contexts they will encounter in their careers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSelf-determination theory (Deci \u0026amp; Ryan)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. Autonomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents answer the same questions individually at each station\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFormat empowers students to demonstrate their competence independently\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. Competence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eViva can be passed or failed and weak students are normally flagged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuccessfully navigating the exam boosts students\u0026rsquo; sense of efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3. Relatedness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInteraction with supportive faculty during exam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFosters a sense of connection, reducing anxiety and promoting learning\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003e \u003cem\u003e(Insert\u003c/em\u003e Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e \u003cem\u003ehere)\u003c/em\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMS: (Division of) Bio-Medical Sciences\u003c/p\u003e\n\u003cp\u003eCBCL: Case-Based Clinical Learning\u003c/p\u003e\n\u003cp\u003eMBBS: Bachelor of Medicine \u0026amp; Bachelor of Surgery\u003c/p\u003e\n\u003cp\u003eMCQs: Multiple Choice Questions\u003c/p\u003e\n\u003cp\u003eMED: Medicine programme\u003c/p\u003e\n\u003cp\u003eOSCEs: Objective Structured Clinical Examinations\u003c/p\u003e\n\u003cp\u003eTBL: Team-Based Learning\u003c/p\u003e\n\u003cp\u003eUGHE: The University of Global Health Equity\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: This study received ethical approval from the University of Global Health Equity-Institutional Review Board. Reference number UGHE-IRB/2024/325\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The dataset generated and analysed during the current study are available from the corresponding author upon reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No funding was obtained/received for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e: COO: conceived the study, developed, and piloted data collection tools, analysed data, and wrote the first manuscript draft. SN: participated in data collection and constructed infographics, NK, AN, JPN, JBN: participated in data collection, DR, AM, DFB, PO, DS \u0026amp; AB: revised the manuscript for critical content. All authors read and approved the final version of manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Authors wish to acknowledge students from the MBBS programme cohorts 2025, 2026 and 2028 who agreed to participate in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDavis MH, Karunathilake I. The place of the oral examination in today\u0026rsquo;s assessment systems. Med Teach. 2005; 27(4): 294-7. \u003c/li\u003e\n\u003cli\u003eHuxham M, Campbell F, Westwood J. Oral versus written assessments: a test of student performance and attitudes: Assess. \u0026amp; Eval. in Higher Educ. 2010; 37(1): 1-12. \u003c/li\u003e\n\u003cli\u003eBurke-Smalley LA. Using Oral Exams to Assess Communication Skills in Business Courses. Bus Prof Commun Q. 2014; 77(3): 266\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eWass V, Wakeford R, Neighbour R, Van der Vleuten C, Royal College of General Practitioners. Achieving acceptable reliability in oral examinations: an analysis of the Royal College of General Practitioners membership examination\u0026rsquo;s oral component. Med Educ. 2003; 37(2):126\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eSimpson RG, Ballard KD. What is being assessed in the MRCGP oral examination? A qualitative study. Br J Gen Pract. 2005; 55(515): 430\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eZelenock GB, Calhoun JG, Hockman EM, Youmans LC, Erlandson EE, Davis WK, et al. Oral examinations: actual and perceived contributions to surgery clerkship performance. Surgery. 1985; 97(6): 737\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eShaw SCK, Malik M, Anderson JL. The exam performance of students with dyslexia: a review of the literature. MedEdPublish. 2017; 6: 116-127. doi: 10.15694/mep.2017.000116.\u003c/li\u003e\n\u003cli\u003eEvans LR, Ingersoll RW, Smith EJ. The reliability, validity, and taxonomic structure of the oral examination. J Med Educ. 1966; 41(7): 651\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eThomas CS, Mellsop G, Callender K, Crawshaw J, Ellis PM, Hall A, et al. The oral examination: a study of academic and non-academic factors. Med Educ. 1993; 27(5): 433\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eColton T, Peterson OL. An assay of medical students\u0026rsquo; abilities by oral examination. J Med Educ. 1967; 42(11): 1005\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eBurchard KW, Rowland-Morin PA, Coe NP, Garb JL. A surgery oral examination: interrater agreement and the influence of rater characteristics. Acad Med J Assoc Am Med Coll. 1995; 70(11): 1044\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eMuzzin L, Hart L. Oral examinations. In: Neufeld VR, Norman GR, editors. Assessing clinical competence. New York: Springer Publishing Company; 1985. p. 71\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eIqbal I, Naqvi S, Abeysundara L, Narula A. The Value of Oral Assessments: A Review. Bull R Coll Surg Engl. 2010; 92(7): 1\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eAnastakis DJ, Cohen R, Reznick RK. The structured oral examination as a method for assessing surgical residents. Am J Surg. 1991; 162(1): 67\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eJefferies A, Simmons B, Ng E, Skidmore M. Assessment of multiple physician competencies in postgraduate training: utility of the structured oral examination. Adv Health Sci Educ. 2011; 16(5): 569\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eGanji KK. Evaluation of Reliability in Structured Viva Voce As a Formative Assessment of Dental Students. J Dent Educ. 2017; 81(5): 590\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eDaelmans HEM, Scherpbier AJJA, Van der Vleuten CPM, Donker AJM. Reliability of clinical oral examinations re-examined. Med Teach. 2001; 23(4): 422-4. \u003c/li\u003e\n\u003cli\u003eStillman RM, Lane KM, Beeth S, Jaffe BM. Evaluation of the student: Improving validity of the oral examination. Surgery. 1983; 93(3): 439\u0026ndash;42. \u003c/li\u003e\n\u003cli\u003eGalan B, Gurp P, Stuyt P. Assessment in medical education. N Engl J Med. 2007; 356: 2108\u0026ndash;9. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Viva voce, preclinical, assessment, Rwanda, University of Global Health Equity","lastPublishedDoi":"10.21203/rs.3.rs-5476515/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5476515/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Traditional preclinical viva examinations have faced significant criticism due to inherent biases in their format. We developed a novel viva format and gathered insights from students to evaluate its effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This study consists of two parts. Part 1 describes the development, implementation and refinement of anovel preclinical viva voce examination at the University of Global Health Equity, in Rwanda, conducted over a four-year period. Part 2 captures students' perspectives through a self-administered online questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePart 1:\u003c/strong\u003e The viva format features structured questions related to authentic clinical scenarios, that underscore the application of basic science knowledge to clinical practice. The examination consists of three oral stations plus one image-based station, targeting subjects like embryology, histology, and histopathology that are traditionally difficult to examine. The examination is vertically and horizontally integrated and provides students with multiple opportunities to demonstrate their knowledge. With four or more rotations of this kind, students are simultaneously examined, improving time efficiency, and reducing performance fatigue normally associated with long waiting periods. Real-time scoring and commenting on individual student performances ensure accountability, transparency, and reduces examiner bias. The examination ends with a faculty debrief conference, after which students receive individual feedback on their performance. However, challenges include variability in examiner preferences for cases and the need for a substantial number of faculty members to manage the numerous stations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePart 2:\u003c/strong\u003e Students reported finding the viva format stressful but acknowledged its long-term benefits, including ability to foster mental agility, promote clinical reasoning, and improvetheir verbal communication skills. Compared to multiple-choice questions (MCQs), many students felt it was a better way of assessing knowledge, as it eliminated guesswork. Group discussions were identified as the most effective viva preparation strategy. Many students expressed a desire for more supportive interactions from examiners during the viva. Despite these challenges, there was broad agreement that the viva format should be retained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The novel preclinical viva format described here enhances the reliability and validity of assessment while providing formative support and early clinical integration. It represents a balanced approach to addressing traditional viva limitations while maintaining educational value.\u003c/p\u003e","manuscriptTitle":"The viva voce innovation and experience at a new medical school in Rwanda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-14 22:56:02","doi":"10.21203/rs.3.rs-5476515/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-17T10:39:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-16T18:33:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22943681077000288643811546945961570156","date":"2025-04-12T13:30:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308563245082687751746118506090364988732","date":"2025-04-09T19:17:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-09T18:56:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-07T09:54:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-04-05T18:01:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c81002a2-8cb8-47b7-92f8-ccc1a662730d","owner":[],"postedDate":"April 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:16:06+00:00","versionOfRecord":{"articleIdentity":"rs-5476515","link":"https://doi.org/10.1186/s12909-025-07463-6","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-07-01 15:56:53","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-04-14 22:56:02","video":"","vorDoi":"10.1186/s12909-025-07463-6","vorDoiUrl":"https://doi.org/10.1186/s12909-025-07463-6","workflowStages":[]},"version":"v1","identity":"rs-5476515","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5476515","identity":"rs-5476515","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}