PART I OSCE: My experience of the actual exam
I thought it would be complimentary to David Christmas's excellent OSCE topic notes to add my own experience of the first OSCE exam from Spring 2003. I wish to emphasise that this is designed to give an insight into the actual day, and not to be taken as 'the way to pass'. I may well have scraped through quite a few of the stations, either that or dazzled the examiners with my wonderful tie!
Please remember also that the vignettes are from memory, but whilst they may differ in fine details, the fundamentals of the task are accurate.
Overall the exam was like any other - you get through it on adrenaline and caffeine, before realising in retrospect that it had been a rather intense and exhausting experience. There were 12 stations, no rest stations, and no indication of any stations which may have been 'unmarked' trial stations. Before each station, you were given 1 minute to read the vignette posted on the door. Notebooks and pens were provided to make notes (and were collected on the way out). There didn't seem to be an option of re-reading the vignette once in the booth. A bell rang when 30 seconds remained. All the booths involved talking to someone, usually an actor, or in one case, a phantom head. By the 10th or 11th station, everything was starting to feel somewhat surreal.
Don't be perturbed by the examiner's behaviour: Ignore them other than to confirm your name and number on entry, with the occasional exception (at fundoscopy, you were instructed to describe to the examiner what you saw).
Some examiners tick their mark sheet boxes with an audible flourish when you 'push the right button' (Tell me, do you hear things that others don't hear?....TICK!), whilst other examiners sat there, catatonic, ready to furiously scribble in your marks in the minute before the next victim stumbles in.
My overall advice is to really try and get into your 'part' as an actor in each miniature play: try to smile at everyone a little (it makes you look at ease, and may encourage the actor to throw you a lifeline every now and then) and, finally, READ THE QUESTION!
Station 1
Station 2
Station 3
Station 4
Station 5
Station 6
Station 7
Station 8
Station 9
Station 10
Station 11
Station 12
Station 1:Mrs Gallardo is the mother of a young man with schizophrenia on oral haloperidol. He has just relapsed for the second time due to non-compliance. Explain to her the nature of a diagnosis of schizophrenia, and the management of the disease with regard to her son.
(The vignette was actually longer than this -a lot to take in when you only have a minute!) Back to Top
What I did: Took a note of the woman's name, and a brief list of the tasks during the time outside the station. Confirm candidate no. with examiner, no other contact. Greet Mrs G by name and handshake, introduce myself by name and as 'one of the junior doctors on the team'.
Apologised for having too little time.
Open discussion with ice breaking 'I understand your son has been unwell again, very sorry to hear it, you must be very worried' Ask if she has any particular issues to raise: She does.
Wants to know what
schizophrenia is, has heard lots of conflicting things.
schizophrenia as term applies to quite a range of symptoms of mental illness.
These take different forms in different people. In general it effects the
way people think about and sense the world around them. It is often separated
into two different groups of symptoms called 'positive' and 'negative' symptoms.
I explained both briefly. Symptoms caused by an imbalance of the chemicals
that control nerve pathways in the brain. We think an important one is called
Dopamine. This imbalance is probably sometimes caused by something we inherit
from our parents, just like we inherit eye colour , and sometimes by problems
that might occur when baby is developing or being born. I stressed that she
should not feel responsible for his illness, however.
Wants to know does it mean 'split mind'.
Not at all, an unfortunate hangover from the exact meaning of the word 'schizophrenia'
Says she is annoyed at him not taking his meds.
What should she do? Firstly told her to try and not be so hard on him, taking
long term meds difficult for anyone, I myself rarely complete antibiotic courses,
etc.
Told her we will perhaps try a different medication, especially if he is suffering from side effects. I SHOULD have explained depot at this point, but forgot in the heat of the moment!
30 second bell goes:
Anything else she is needing to know, happy to meet up again when more time is
available, will provide written info, and details of some support groups. Shake
hands and thank her for her time.
Station 2: Ms. Islero is a young woman who has attended casualty having taken a small overdose of paracetamol, following a fight with her boyfriend. She did not require treatment and is medically fit for discharge. She has a bruise over her right eye. Assess her level of risk. Back to Top
What I did: Took a note of the woman's name, and a brief list of the tasks during the time outside the station. Confirm candidate no. with examiner, no other contact. Greet Ms. I by name and handshake, introduce myself by name and as 'one of the junior doctors from Psychiatry - we are usually called when someone takes an overdose; this is actually quite a routine call.' Apologise for having too little time.
Open discussion with I'm sorry that you were in a situation where you came to take an overdose. I want to ask about the details of the overdose just now, I hope you feel up to answering some questions?
Then work through the Becks suicide rating scale - see Trickcyclist - using the 'open to closed question progression', and reflective statements so that the patient knows you are listening and to help them focus their thoughts.
Assess mental state, obviously seeking symptoms of depression et al.
By this time it was dawning on me (in retrospect I can't believe it took so long) that this was a very NON serious suicide attempt in a euthymic girl who was clearly at much greater risk from physical abuse from her alcoholic boyfriend. Remember, the college loves risk, in ALL its different guises.
I rapidly changed tack, and asked her about previous violent situations : degree, frequency and preciptating factors of attacks. Her story was serious enough to prompt me to gently persuade her to stay in A+E for an examination for further injuries, and for her to strongly consider pressing charges, possibly involving the Police then and there.
30 second bell goes:
Ask her if there's anything else she wants to mention or ask. Tell her you will
return to talk to her after you have spoken to A&E staff. Shake hands and thank
her for her time.
Station 3: Fundoscopy. Please perform an examination of the fundi on this model head. Speak to the model as if it were a real person, and explain your findings to the examiner as you go. Back to Top
OK - this isn't all about fundoscopy! You need to be a really good actor to speak to a polystyrene head empathically, and you need to be focussed enough to have taken in the instruction 'explain your findings as you go'.
I went through the routine of explaining to the head what fundoscopy involved, and how they should try and keep their eye still. Important to say - 'let me know if you find this uncomfortable and I will stop', 'please try and focus on the wall even tho' all you see is the light from the 'scope', and 'it's OK to blink if you like'.
I ONLY JUST remembered to tell the examiner my findings. This is a rare exception in the 'don't speak to the examiner' rule. You should use the standard protocol to examine and describe the fundus of both eyes. Its sounds posh to conclude with 'in summary I feel my findings are consistent with a diagnosis of ..'
In this case there was evidence of both diabetic retinopathy and hypertension.
Don't forget to pretend to shake hands with the model head and thank it for it's time!
(NB The clinical skills centre at NWH medical school has phantom heads and is
happy for us to visit for some practice - after 'phoning first.)
Station 4 Mr S.V. Muira presents with problems at his work as a management consultant. He gets very anxious when he leaves to get in his car in the mornings. Take an appropriate history and advise Mr M of your thoughts on his case. Back to Top
What I did: Took a note of the man's name, and a brief list of the tasks during the time outside the station. Confirm candidate no. with examiner, no other contact. Greet Mr M by name and handshake, introduce myself by name and as 'one of the junior doctors on the team'. Apologise for being restricted for time.
Open discussion with empathic statement, eg I hear work has become a problem for you? I'm sure this is the last thing you need in what is probably a pretty stressful job.
Then - open questions. The vignette described anxiety, so I started asking about that and screened for related neurotic symptoms. The story unfolded of a man who has recently been bothered by flashbacks from a car accident, and now finds it difficult to get into his car without feeling anxious. More opportunities for reflective statements and empathy at this point! EG Gosh, I don't know what I would do if I couldn't drive to work -its something we all take for granted I suppose..
As it became clear that this is a case of possible PTSD, I then asked about the other symptoms of PTSD. Although I only remembered this at the end, I should have inquired about co-morbid depressive symptoms at this time. A passing diplomatically phrased check for self-harm thoughts didn't go amiss at this point.
This may sound silly, but all of this hasn't made you think that you couldn't go on at any point, has it?
Once I thought I had enough for a presumptive diagnosis, I described my thoughts in lay terms to Mr M (but not totally dumbed down). He asked about treatments - I described a probable combination of antidepressants and CBT.
Again, last 30 seconds a good time to 'arrange' a further consultation, to allow him to collect his thoughts, and offer literature and support group info.
Station 5 Please examine this patient's cranial nerves, from II to XII. Fundoscopy will not be necessary at his station, nor will sharp sensation/corneal reflex. Back to Top
This was the only station at which I had enough time! There was a tired-looking actress, and various implements around her including tuning forks.
You should be able to examine cranial nerves with your hands tied behind your back by now - it takes 30 minutes the weekend before the exam, making sure you are slick at it. What else are husbands/ wives for??
NB Testing for the olfactory nerve will demonstrate that you didn't read the question. Stabbing at her maxillary division of trigeminal with a blunt needle may well get you arrested.
I heard evidence of 'tuning forkery' during the exam, whilst I was in other stations, but did not perform rinnes/webers tests myself: I don't believe they should be part of the basic cranial nerve examination, unless the basic 8th nerve test is failed - I used the rustling fingers method, as whispering sweet nothings in her ear seemed inappropriate in the exam.
As this is a Psych OSCE, probably just as important to put the patient at ease - gentle humour may be a start: "Hello, I'm Dr Blah, I would like to examine the nerves that control the muscles in your face and neck. You may feel that you are pulling faces at me at times, for which I apologise! You may in fact want to pull faces at me, which of course is up to you! This won't take long, and it certainly won't hurt."
Don't forget - grin, shake hands on entering and leaving, and ignore the examiner as if they are your worst enemy.
Station 6 Mrs Espada is a 34 year old secretary with diabetes. Her GP is concerned that she may be abusing her insulin to maintain her weight - she has a BMI of 15.5. Take an appropriate history from this woman. Back to Top
What I did: Took a note of the woman's name, and a brief list of the tasks during the time outside the station. Confirm candidate no. with examiner, no other contact. Greet Mrs E by name and handshake, introduce myself by name and as 'one of the junior doctors on the team'. Apologise for being restricted for time
OK - so a slight spin on the eating disorder history-taking task. What helped here was remembering basic categories and working through them systematically.
See trickcyclist, but for EG;
- Current eating pattern, knowledge of calorie content, self imposed weight limit.
- Other methods of restricting weight, other than insulin abuse.
- Physical symptoms, previous obesity.
- Psychology - self image, ideas re: fatness
- Other stressors at home - get the empathometer out at this stage particularly.
- Comorbid depression/anxiety/ocd and VITAL, but tactful, suicide enquiry.
Probably useful at the 30 second bell to explain that we are very concerned about her physical health (I.E. leave no doubt that you agree that she has a (lack of) weight problem), and also to ask if any questions, promise further appointment, literature and support group info.
Station 7 Mr Diablo works as a postman, but was referred by the police having made several odd telephone calls to workmates, who raised the alarm. Examine his mental state. Back to Top
What I did: Took a note of the man's name, and a brief list of the tasks during the time outside the station. Confirm candidate no. with examiner, no other contact. Greet Mr D by name and handshake, introduce myself by name and as 'one of the junior doctors on the team'. Apologise for being restricted for time
Before I could field an open question, this gentleman, who was obviously getting paid more than the other actors, asked me in worried tones 'Are they out there? The Police? Are you with them? I'm sick of it you know. And I haven't done anything wrong' (You get the idea)
Basically he was representing a deeply delusional and insightless man who was very pressured in his speech. There was a suggestion of auditory hallucinations, but this was quite ambiguous. A large part of what was being tested was the ability to prevent oneself being wound up by him; to remain calm and objective. Also, of course, it was important to try and explore the nature of his delusions and hallucinations; (he was convinced the police were after him because he had misdirected some mail..)
In practice, it was nigh on impossible to get answers to most of the questions I had, because he was so 'pressured'. I spent perhaps too long a time testing the strength of his delusions, and reminding him that I actually thought he was unwell.
I forgot to ask him about command hallucinations that might have made him a risk to others, and also forgot to ask him about suicidal ideas as a result of his delusions - I later figured that was a bad mistake, and lost some sleep over it after the exam.
At the 30 second bell, I think I asked him if he was prepared to stay until after I came back to interview him further. He agreed (and seemed relieved that the 7 minutes was up!
Station 8 Miss Urraco has been referred for behavioural treatment of her phobia of birds. She is very concerned about the treatment, and you have been asked to explain to her what is involved. Back to Top
This station was largely designed to test the candidate's skill in calming a tearful, hysterical patient, IMO. The actress was obviously instructed that she should get herself wound up and anxious about the proposed treatment; she repeatedly talked along the lines of 'What if they make me do something I don't want to do...I would hate that..I don't think I like the idea of this at all, oh my, oh my'
I spent part of the time explaining what little I knew about desensitisation therapy (mainly came from a video we saw on a wednesday pm teaching session) and an equally large part of the time attempting to defuse her anxious outbursts. Being calm, consistent, empathic and repeatedly but not blindly reassuring seemed to vaguely work
Station 9 Mr Jarama has been recommended by his consultant for a course of ECT, having not responded to several courses of antidepressants. You have been asked to explain this treatment to him. Back to Top
Once again, take care to remember the man's name and use it to greet him with a handshake on entering the booth. The actor in here was also giving an oscar-nominated performance portraying depressed affect and psychomotor retardation.
My initial approach was an empathy-loaded reflection of the story so far: I understand that you have been struggling with depression for some time, Mr J. This unfortunately is sometimes the case, despite our best efforts. I'm sure you have probably forgotten what it feels like to be normal?
Then a brief first pass over what I wanted to speak about: My consultant feels that we should try a different approach to your treatment - this is quite a routine step in situations such as yours. It has been known for hundreds of years that the experience of having an epileptic-type fit can actually resolve depressive symptoms, and we have a modern and very effective equivalent of this treatment available - it's called ECT..
And so on. This station is a very good one for stopping at intervals and asking what the patient makes of it so far - remember that ECT is a big concept for a lay person to become comfortable with.
Trickcyclist has a list of the things you must mention in this scenario, and very usefully the college website has an on-line video of such this as an OSCE. Don't forget to clearly differentiate between ECT, ECG and Defibrillation. The GA and muscle relaxant side of things are important, too, IMO. The college are very keen that, when explaining a treatment, that you give a balanced view of it's advantages and disadvantages.
Once again on leaving this patient, you should offer further sources of info., and another appointment, once they have had time to think it over/talk with friends and family.
Station 10 Mrs Countach has recently been diagnosed with bowel cancer, and has been strongly advised that she should consider hemicolectomy as a treatment option. She had a previous history of depression, which required in-patient treatment several years ago. She has been off antidepressant medication for some time. You have been asked to assess her ability to accept or refuse consent to this procedure. Back to Top
Fairly close to a trickcyclist one, this.
Important at the start to explain diplomatically why she is been seen by
a Psychiatrist. Something like - 'Good morning, I am Dr Blah from Psychiatry;
I fully understand that you have the right to make your own decision about
this - however it is important to make sure that the decision is being
made for the right reasons, when someone has a history of mental health
problems. I hope you don't mind me asking you a few questions.'
This lady was intelligent and clearly in full possession of the facts. The
procedure carried a 50 % success rate (she and her supportive partner had
found out all about it) and she was repulsed by the idea of a colostomy.
There were no ongoing depressive symptoms apparent. There was perhaps some
evidence that she had a reactive depression following her diagnosis, but
much different in nature to her previous 'endogenous' illness.
In retrospect, there was a lot to be said for not be patronising to this lady, and resisting the temptation to railroad her into a procedure that she had obviously plenty of insight into. A slight exception to this was that I gently tested the boundaries of her knowledge, and found that she hadn't spoken to a colostomy nurse/advisor.
At the end, I acknowledged to her that she indeed appeared to be making a decision which although difficult, was right for her. I mentioned that Colostomies are often described as being less of a problem as some people think, and that she should take this into account before coming to a final decision (no harm in demonstrating a little broad-mindedness in the exam!)
I wish I had directly asked her 'I need to know that this decision is not being taken as an attempt to deliberately shorten your life' - as this might have got another box ticked on the examiner's mark sheet.
Station 11 Mr Jalpa has recently lost his job as a part time librarian, having been unreliable in his attendance and work practices. His wife feels he has taken to drinking excessively. Investigate the nature of Mr J's problem.
Not much to say on this one - well covered in Trickcyclist. Mr. J had a problem, but didn't realise it - don't they all? One bone of contention might be whether or not to begin with the CAGE questionnaire. Its quite hard to do whilst sounding like you are not a computer reciting a well-learned script, but may well be a tick-box. I didn't do it.
Plenty of opportunity for empathy, here, again: Yes, alcohol is a real problem
- its so common in our society, but so easy for an alcohol addiction to
creep up on you, especially if life is stressful..
He will know that your empathy is accurate, you're a Doctor after all!
I finished by advising Mr Jalpa that I thought that he may well have a problem with alcohol dependence, and that I would organise some help for him, plus some literature and support group info.
Station 12 Miss Murcielago has just recovered from a bout of hypomania and then depression, following previous depressive episodes. She has been advised that she may require treatment with Lithium, and your consultant has asked you to explain the nature of this treatment to her.
What I did: Took a note of the woman's name, and a brief resume of the vignette during the time outside the station. Greeted Miss M by name and handshake, introduce myself by name and as 'one of the junior doctors on the team'.
Quite nice in that this lady/actress was portraying someone who was currently mentally well. The 'rules' for explaining lithium therapy are well documented elsewhere. At the 30 second bell, I realised that I hadn't asked about her plans for a family (she may have helped me out, by mentioning that she was thinking of marrying her boyfriend soon: look out for helpful hints like this!). Sure enough, yes she was planning on having a child and breastfeeding - which gave me exactly 30 seconds to explain about another 10 minutes' worth of stuff.
Finally, probably important to remember to talk a bit about her learning ways to make relapse less likely, especially when mentioning the long term nature of lithium treatment.
By Dr John Graham
To receive information about new, or updated OSCEs, please subscribe to the mailing list:
