Interesting Observations on a mock OSCE Teaching Day

Hi all – so a few days back I had the unique opportunity to organize (OK who am I kidding? I helped to organise) a 1-day course for the FRCA OSCE exam in our deanery. We as the juniors of the department of anaesthetics/ITU/Theaters were called upon to help with various tasks: timekeeper for the different stations, be a patient for history taking, or be one of the relatives for counselling, be a mannequin for examinations, etc. I had a multitude of nominal tasks on the day, but what I found to be invaluable to me that day were a few observations that I made observing the various candidates as they filed through the different stations, and I list those observations here in no particular order to be taken as advice for all my colleagues who have OSCEs to take, bear these in mind:

– Be cognisant of time. As you walk up to the OSCE station, whether it gives you 30 seconds to read through an initial scenario or there is a piece of paper with questions written on it that you are expect to answer, get into the mental zone where you can mould yourself to give what is required of that particular station in the time provided. If there is one question that needs to be answered, you can be a bit relaxed, if there are 3 questions on the paper, make sure you are aware of the time you have to divide amongst them all to do justice to all. If the station requires an interaction with someone like a viva or a direct encounter, make sure you have a framework in mind, a mental checklist to check things off during the actual station so that you are not rambling on about your second point when there are 7 other things you need to be talking about.

–  When asked a question, don’t feel pressured to answer as soon as you sit down – take a breath, pause, ponder over the question for a few seconds, frame your answer for the next few, and then open your mouth to speak. Do not repeat the question back to the examiner in wonderment, as if puzzling it over, you may think you are buying time while you collect your thoughts, but it looks unprofessional. If you need time to answer, take it, but do not insult the examiners’ intelligence by repeating the question back word for word. It is a waste of time.

– When asked a question, avoid using pronouns like ‘you’ as a general term. “If you are on the floor for a long time, your creatinine kinase levels may rise.” While correct, it looks like you are addressing the examiner, whereas a more professional way to answer would be “Patients lying on the floor for extended periods of time may have elevated levels of creatinine kinase.”

– Following on from the previous point – when describing the anatomical location of anything, or a function, it is OK to use your hands to express yourself, but do not gesture towards your own body as a descriptor for your answer. In answer to the question Where can an IO needle be inserted? you may think it is the right answer to point to your sternum, your humerus or your tibial tuberosity, but it won’t score you any points. Also please practise certain expressions or gestures, gesturing towards your crotch for instance when talking about urinary catheterisation is inappropriate. And for goodness sake, it is even worse to point these things out on the examiners body.

– Use proper terminology, use buzzwords if you know them (we all know them) and specific things carry specific marks so make sure you attend some sort of course at least once in your life for OSCE practise so that you know what the examiner is looking for in a particular station when they ask you a particular question. Also, examiners know when you are beating about the bush and not getting to the point – so don’t waste their time (and yours), admit you do not know, and move on.

– Having done poorly in a previous station has no bearing on how you can or should perform in the next one – so do not let anything bother you. Yes, you may well have failed the previous station, but if you continue to mull over it or let it get to you, you may ruin your chances of passing the next one as well. Once you step out of one station, close that chapter, and open the next one with a clean slate.

–  Do not try to impress with big words and fancy terms – be simple, logical and just answer to the best of your knowledge. They are there to test your knowledge and see how good you are with using that knowledge. They are not there to ask for your hand in marriage.

–  If there is a written station, please write clearly. In our current professional examination climate, where usually there is a tick box or a fill-in-the-correct-circle type answer sheets, we forget how to answer the short answer type questions. Make sure it is legible. Your right answer is useless if no one can decipher it.

–  Read up on the simple things (in case of our anaesthetics colleagues, anatomy and physiology, undoubtedly – aside from the usual physics etc) – understand the concept behind why something is done or not done, and it will make it easier for you in these exams.

–  Study. I don’t know why it is so under-rated, that OSCE exams are interaction based and so I just don’t need to read up on how to take a history or do a pre-op assessment or perform a physical examination or test the cranial nerves – we do it everyday, and we get into a comfortable zone – but the exam might need for us to brush up on those skills and make sure we are not missing out on anything. MOST candidates missed an important part of the history taking station, as well as the counselling station – points were docked, valuable points, and for some that can mean the difference between passing and failing.

Guest Blog Post by Dr. Hassan Alraee – “My MRCEM OSCE Experience”

This is our second guest blog post from esteemed colleague Dr. Hassan Alraee – Emergency Medicine Registrar (Ireland). I take no credit for the following text.

Dear Colleagues,
I am sharing my MRCEM OSCE experience with you guys as I realized while preparing for the exam there was not much guidance available online. The aim of this post is to familiarize everyone with what the exam entails and a few tips which may be helpful in your preparation for the OSCE.
This may not be a structured or typical guidance post, it may come out as a random collection of thoughts but I will try my best to note down everything that was helpful to me during the preparation for the OSCE.
First of all to be eligible to appear in the exam you need to have passed the FRCEM Primary exam, passing the FRCEM Intermediate SAQ exam is NOT one of the eligibility criteria. However, in my experience passing the FRCEM Intermediate SAQ exam gives you a baseline in theoretical knowledge that is required for the OSCE. So it would be ideal to attempt the exams in the sequence that has been set, i.e. Primary, Intermediate and OSCE.
Before beginning your preparation for the exam have a look at the MRCEM Information Pack available on the RCEM website. A list of study material that may be helpful includes;
1. MCEM Part C: 125 OSCE Stations by Kiran Somani
2. Mastering Emergency Medicine: A Practical Guide by Mathew Hall
3. Bromley Webinars
4. At least 1 (if not more) of the following courses; The London Clinical Course, The Bromley Course or the Manchester Course.
The exam itself feels like a daunting task during the preparation phase as it is completely different to the previous parts and reading books alone is not the best way to get through it. My advice would be to stick to one of the above mentioned books and go through it once. The next step would be to create a practice group which should comprise of at least 3 members. This would mean all 3 of you would be able to rotate through different roles during the practice sessions, i.e. The candidate, The actor and The examiner. In my humble opinion this practice group is the key to being successful in the exam. The final step would be to book one of the above mentioned courses. In order to maximize the courses you need to be fully prepared for the exam by the time you attend the course and treat it as a Mock Examination.
Each of the courses has their own pros and cons but all of them are helpful in preparing you for the OSCE.
Each OSCE comprises of 18 stations, 2 of which are rest stations. The exam does not test your theoretical knowledge to a great extent, the stations in the OSCE are designed to test various skills. Like all OSCE exams there is a fair degree of play acting and exaggeration of your daily practices is required. By this I mean that the examiner will only mark you on the actions you perform during the exam, so make sure you show every step and tick most boxes in the examiner’s checklist.
The basic outline of the stations encountered within the OSCE are;
1) There are 2 to 3 history taking stations, remember to complete the station by giving the patient a management plan based on the history.
2) A Systemic examination station (CVS, Respiratory, Abdominal, Cranial Nerve or Peripheral Vascular examination)
3) A Joint examination station (Hip, Shoulder, Knee, Back, C-spine or a limb examination)
4) A Breaking Bad News scenario
5) There are 2 or 3 teaching stations which may include teaching a procedure or examination to a student or a junior doctor.
6) There is always a Conflict Resolution in the OSCE as well, which may be a missed fracture or pneumothorax or a difficult referral. This station also includes talking to a patient with Alcohol Dependence or Binge Drinking.
7) 2 scenarios within the OSCE are always Resuscitation Scenarios and test your skills in ACLS, APLS or ATLS. These stations seem like they are the most difficult ones while preparing for the exam, but in my opinion you can easily pass these if you make a good approach towards resus stations during your practice sessions. The Key to the resus scenarios is sticking to the ABCDE approach.
8) ENT and Eye station; in the exam they can check your knowledge on these in various ways it can be a simple otoscopic or ophthalmoscopic examination, teaching may be incorporated into it or history taking could be tested but there will always be a station that will involve ENT or Eye.
9) A quick assessment station; this one is a tricky one, it usually has the task of taking a short history, performing a focused examination and formulating a management plan based on your findings and summarizing it to the patient.
10) An Information Providing station; this station usually involves a relative of the patient to whom you have to explain a new diagnosis or management of a medical condition. Juvenile Diabetes Mellitus and Addision’s Disease are 2 examples that I can recall.
11) A Psychiatric Station is always present in the OSCE, you may be asked to performed a Mental state examination on a patient or assess suicide risk, they may add a conflict resolution component to this station as well.

In my opinion if you divide your preparation according to these 11 types of stations you will be able to cover most of the things required to be successful. Some additional topics that are tested in different ways and I haven’t categorized under the stations include; DVT, major incidents, seizures and driving advice. It would be wise to look up the NICE guidelines on these.
I would also suggest that you reach the city where the exam is being held one day earlier and have a look at your examination center that day. Just so you know how long it takes to get there and don’t have the extra stress of finding the center on the morning of the exam. Please spend your last 2 days traveling and relaxing, there is no point in trying to cram in stuff over the last 2-3 days as this is not a theoretical exam where they expect you to know everything.
On the exam day itself it is understandable to be anxious and stressed and believe me the examiners know that the candidates are under pressure and are not there to fail you. You should know that staying cool and calm is the most important feature that will enable you to be successful. It usually takes 1 or 2 stations to get into the groove of the exam as the 1st station comes up it is normal to feel a little nervous or blank out temporarily. Do not act bold and wing it if you are unsure about something, be safe at this stage and say you are unable to recall at this point in time and that you will consult the department policy or your consultant before implementing it.
Do not worry if any of your stations don’t go as well as you expected them to, leave the previous station behind you and move on to the next one. Do not let your performance on the previous station affect your performance on the next one. I know this is easier said than done but it has to be said as it is human nature to dwell on the past. You should also know that there is not a minimum number of stations that need to be passed to pass the exam, that was how it used to be in the past. The marking scheme has changed to a cumulative score now and a different passing mark is set for every OSCE day so even if you fail a station you carry forward marks from it towards your overall score. Therefore it is imperative that you score marks for the basic things on each station. Some of these include greeting the actor, washing hands before and after examination, wearing personal protective equipment (or at least mentioning it to the examiner), being warm and courteous and thanking the actor at the end. These simple things may be the difference between a pass and fail score in your OSCE.
I hope it was helpful for all those that are reading this post, good luck with your exam, with a bit of structure and practice I’m sure you will pass the OSCE.

Sometimes it is the smallest things that make you the saddest

Ever notice how you can go on being an automaton, robotically engaging in work stuff, moving from one patient to the other, each one a statistic on your ever growing list of patients to see or having had seen – no interaction long enough to actually create a connection other than that of patient/doctor and you professionally enter and exit the cubicle and move on to the next job, next patient, or indeed next shift. And yet sometimes it does happen that something hits the mark, and there is a chink in the armour, the professionalism slips (not outwardly, but it surprises you that you feel something other than empathy towards the patient in front of you – you really look at the patient, not as just a patient but an actual human being with feelings, and thoughts start milling around your head – or your heart? – and you think of the patient’s feelings, their desires and weaknesses, the consequences of their actions – and you realise with a jolt that you are not an automaton, that you are, indeed, human.

I am usually a happy presence at work (if I may say so myself) but I was having a particularly ‘smiling-from-ear-to-ear’ day a few days back. A recent couple of professional achievements, along with being well rested from a full night’s sleep meant I was walking around with a bit more bounce in my step. I was working a late shift, but from the broad smile on my face you would have thought I was about to go home on a 2 week holiday! (I was not, but yes, I am a bit weird – I actually have fun at work!) – I was assigned to see paeds patients in ED, all the minors, majors, ENP ones etc – and I was going about my day when the consultant asked me to come out of Paeds for a bit and see the next adult patient, who was already at 3 hours (that much time had elapsed since she had come in to the hospital) – the brief note from triage nurse said that this was a young female between 25-35 years of age, who had come in with a self harm injury or injuries – she was categorised as a ‘yellow’ which meant there was no imminent threat to her life but she did warrant a thorough assessment.

Treatment/management of such cases is usually 2-pronged: one, manage the obvious injury or insult and treat the current presentation, and two (and more importantly) try to deal with and manage the longterm/shortterm psychological aspects of the presentation (not an ED thing but there are certainly specialist who are better equipped to deal with this and who very kindly assess and evaluate patients from that perspective after they have been treated from a physical ailment point of view. So anyway – I went in to see the patient – it had been mentioned in the notes that she was accompanied by her support worker – but the woman who stood up when I announced the name in the waiting area was alone. And she stood up at once and followed me into the cubicle to be assessed, along the way I introduced myself, and thanked her for her patience in waiting. She was extremely polite, and even offered me a smile, but she kept looking anywhere but at me directly. I asked her what had brought her to the ED that evening and she matter of factly stated that she was here because she had self-harmed. Again. She did not seem to be in any sort of pain, so I assumed (wrongly) that she had a superficial sort of wound that wouldn’t really require too much medical attention. I smiled at her and said something along the lines of ‘well, let’s see what we are dealing with here, and I will try to help you any way I can.” She exposed her left arm unto her shoulder, and I took off her temporary dressings from her upper arm (above her elbow) – while I was doing so, I kept making small talk, and registered the many, many scars from previous self harm attempts there before me were 4 very large, very long, and VERY gaping full thickness lacerations to her upper arm. In places where normally the skin/muscle sags a bit, it was really using the lacerated margins to gape quite widely. The patient had something like an hour left before they breached? NO WAY was I going to be able to administer local anaesthetic AND suture all 4 of these wounds in under an hour. Alone.

This patient completely threw me off my game. I have closed wounds in numerous ways, and in all sorts of weird and wonderful places – I have once years ago even raced my mentor consultant orthopaedic surgeon in bilateral knee replacements to see who closed up their respective knee first! – But this time was different. This patient was different. And the reason will become apparent up ahead.

I called my consultant because he may have been under the impression this was a quick ‘tape-wound-shut-refer-to-psych-move-on’ kind of situation – he stepped into the cubicle and hemmed and hawwed. I was silent throughout. This felt like an operating table scenario with a patient’s body cavity open up in front of me – The smell was exactly the same. Flesh. Blood. Sadness.

Right then, the consultant asked me to stitch the wounds up – I gave the wounds a good thorough clean with some saline and the patient did not flinch. She did however, apologise quite sincerely for wasting my time. I will not go into the details of why she thought she needed to do this today – absolutely no judgements to be passed here on that account. But I did assure her she was well within her rights to be there. I said I would go calculate the amount of local anaesthetic require and get it and get it all ready – and her polite demeanor stiffened up. She absolutely refused any local anesthetic. She said, and I quote: ‘ I am not here to waste any of your valuable resources. Please use them for someone who really deserves it – and anyway, I am not in pain and the stitching can’t hurt me more than I have done myself – also (and I was surprised that she knew this) the amount of local anaesthetic required would be a bit too much and wouldn’t be safe for me – and it would wear off by the time it was done being administered!” She was right on all counts – but I requested my consultant to give me an opinion, since she had me absolutely flummoxed. He agreed, no need for the anaesthesia – and that I would achieve better results with a skin stapler rather than suturing the wounds. I had never used skin staplers outside of an OR before, and never on a patient who was conscious and sitting up and talking to me and FEELING THE STAPLES GOING IN! I took a few deep breaths. Got the stuff ready. Took a few more deep breaths. And a few more. And dove in. I put in upwards of 45 or so staples (yes metallic pins sharp enough to stab through the superficial tissues of skin etc and pull them close to optimise wound healing) – did I mention the wounds were exceptionally gaping? Each staple gun comes with 30 or so staples – and I had to use a second one about halfway as well. Wow. My mind was already blown after the first 2-3 staples. But I went on putting more in. I did my best – and to her credit she did not flinch. There was silence. And that smell. And sometimes she would talk to me.

She kept thanking me, and apologising to me, and kept pushing her other hand through her hair as if berating herself mentally. She told me she had a masters degree in something (I forget what – my ears still start ringing everytime I think back to that cubicle) and we chatted about how I wanted to pursue another degree, maybe a masters of some sort and hadn’t quite decided what. She guided me about which staple to remove because it had been bent at an awkward angle due to how gaping the wound was initially, and so when I had ‘scaffolded’ it with staples next to it either side, I removed the offending staple and put another one in. Like I said, she didn’t flinch. At all. She kept that small polite smile in place, was very respectful and I learnt something new about myself that day. That this had gotten to me beyond what I can express here or anywhere. I had seen dead and dying people almost on a daily basis. People in pain, people vomiting with pain, people trying to process bad news or loss or a shock. I have been the villain in so many stories in peoples lives – the bringer or the news that someone they loved had passed away, or what the reports had shown or why we feel that further aggressive measures would be futile – But I had not been affected by those things as much as this calm young woman had affected me. What about her affected me? Nothing about her situation. It was sad, no doubt. But what really affected me was what I realised about myself: I judge people, I am cynical about them, about their diagnoses, about their mental health problems – I never fully appreciated that when someone comes in to hospital following an overdose or some deliberate attempt at self harm, I focus solely on the physical aspect of the case, and let someone else deal with the mental/psychological/psychiatric aspect of it. But this time, I was metaphorically chained to the situation I usually avoid and judge as a spectator – and I could not escape how normal this young woman appeared. She was well read, had a grace and calm in her manner that belied a good upbringing – yet she was obviously in this mental pain and it got so severe sometimes that like this day, the thought of cutting herself and so brutally was her only way to cope with it, and possibly caused her less pain that she was already in. And to be able to get sutures or staples without any anaesthesia on board – how remarkably strong a pain threshold would you have to bear that? Or that you were so used to it that this was all just commonplace occurrence to her. And this wasn’t even the worst part. The worst part was that this was neither the first time, nor (we both knew) the last time that she went down this route. I could help her physically, suture/staple everything – but did I actually do anything at all to really, truly help her?

So like I said – we are usually automatons, going about our daily drudgery – and then one day a patient really opens our eyes and makes us sit back – and question …absolutely everything we know and believe in and understand. Or don’t understand.

(Edit: The rest of the shift went by in a blur or a haze, I don’t know if it was all too fast or all too slow for me. I am I think back to my usual self now – albeit with one difference. I am maybe not so quick to judge – and maybe not so quick to dismiss mental anguish based upon my perception of the physical consequences of that mental anguish. I admit to not knowing enough – and hope I can change my practise in a way makes all of this worthwhile.)

Blogger Recognition Award

I know this post is fairly late in the day – but better late than never, right? Now this isn’t a formal or official award, but it is a mark of recognition bestowed by our peers, recognising our writing/blog work as something that is worth the time and effort that’s been put into it, and for whatever reason was deemed worthy of a more detailed look rather than a cursory glance over the shoulder. I am ever so grateful to the surprisingly humble Kershelle Mike @ The Angry Marketer Blog for deeming the MDB worthy of that second look – so honoured and surprised (read flabbergasted!) at the nomination!

Now the way this works is that:

Step 1: you give an account of how your blog came into being – and;

Step 2: any advice you want to dole out to new and upcoming and ‘thinking-about-it’ bloggers – and mine is this: be yourself, don’t force yourself, don’t try too hard – discover your strength and play to them, be unique and then be regular, don’t worry about how many people are reading your stuff – if you feel you have the right idea then this will take commitment and time invested! Do think about this long and hard, don’t just jump into it – look at other blogs, look up others’ ideas and see how they implemented their ideas – and find out what works for you, and then, finally;

Step 3: you nominate 15 (or upto 15) other blogs/bloggers that you feel deserve to be recognized. It isn’t an official platform, but it sure is nice to be recognised, don’t you think? So without further ado (and in no particular order) my nominations for the Blogger Recognition Award are:

  • My class fellow, friend and colleague, Dr. Haseeb Ashraf’s blog Medical Solutions: The Medic Helpline (link here)  – which aims at creating awareness about various medical conditions, easing definitions for laypersons/non medical personnel and any guidance/medical queries you may have as a doctor or other medical professional, or even indeed any member of the general public
  • Another friend and superstar colleague Anita Mitra – and all round amazing person – she is an encyclopedia on all things ‘women’s health’ – including some topics oft considered taboo – her blog as The Gynae Geek is maybe even more impressive than the legend herself!
  • One of my juniors in medical school is doing something that I am secretly (OK maybe not so secretly!) proud of and who I think has the capacity to touch so many lives for the better – and not just by means of her medical degree! – she does this by reviewing (after reading) the most amazing books as The Doctor Reads – she writes succinct and amazingly relevant reviews that connect you to the books in a way no review or book recommendation has ever done before – atleast not to my knowledge. Absolutely love her style, and the sense of humour just takes it up another notch. She does not have an official blog, but check out her work here, and here – she takes Instagramming to a whole new level!
  • FifisLounge – An amazing cook, who tries and tests recipes herself all the time, and then recommends the successes to anyone looking for yummy morsels and tasty treats – having tried this chef’s cooking firsthand, I can vouch for this blog with confidence! Check out this blog here, and try out the great tastes!
  • A newcomer to the blogging scene – nevertheless ‘Life as Sid Knows it…’ is someone to follow – day to day musings, and personal experiences and an interesting take on the daily routine things that we take for granted – this blog is also a part of my list.

    Unfortunately I don’t have an extensive list of 15 blogs to recommend – but at least the ones I have recommended I honestly believe are worthy of your attention, whether you are a follower of the MDB or just randomly looking for inspiration. Do check them all out!

Hello world!

Greetings! New blogger in da house, what?!

Three days. That’s when I had this sudden bright idea (read ‘overheard my wife and sister-in-law talking about the benefits of blogging’) of starting my very own blog. I do, after all, have some interesting stories to tell.

I am a doctor by profession, and my chosen poison or…errr…specialty is emergency medicine. Yes, all the stories you have heard are true. We not only deal with the mundane cardiac events and road traffic accidents and strokes, but we also deal with the very interesting (and not so mundane!) foreign bodies in weird places that you ‘accidentally fell on to while climbing a ladder in the middle of the night naked and that’s how it ended up in my bum’. Very classy, and we totally fall for it. Not.

I also have an almost-2 year old, and the combination of sleepless nights due to daddy duty, and that of my lesser evil but equally exhausting shift work that I do, leads to quite a collection of interesting … incidents, shall we say? Some of them I would not breathe a word to anyone, and others, well let’s face it, they do make for great dinner party conversation.

So here I am, sharing my wisdom (or lack thereof). These are my stories, memories, anecdotes, reflections and thoughts – the inner rantings of a 30-something budding (balding?) doctor, trying to be an emergency physician, while also trying to dad.