The OSCE

The Fellowship OSCE is the final hurdle to get those letters after your name. As always, content is very important. However just as the written exam required a special skill set and approach, the OSCE does too.
 
It’s not only what you say ie., the content and your knowledge, it’s also about how it’s delivered. In fact, the visual, made up of your performance, is as important, if not more, than the content you deliver. This becomes very important in this exam, given that exact numbers do not form part of the assessment. It’s about varying degrees of capacity ie., it’s a qualitative score, not a quantitative one ( see The Marking Sheet Below).
 
Remember that this is not an MCQ, this is a judgement made by an assessor. That judgement is often made very early in the interaction: “as soon as she opened her mouth…”.(1)
 
The skill set of performance is mostly ignored when you practice with your teachers. However in the examination room, your appearance, confidence and other factors play as big a role as your knowledge, as long as that’s half way reasonable.


The Marking Sheet

The marking system has you having to cover the parts of the curriculum, that are being examined. In the end, however, the mark is QUALITATIVE, i.e.., below standard, at standard and above standard. There is a lot of tolerance in the system.
​Remember that this allows you to get marks with doing nothing more than appearing professional and asking the right 
questions. It is strategy. Add a little compassion and caring, mix in the knowledge you already have and voila- you pass!

General OSCE Tips

Selzer et al(2) give 12 tips for performing in vivas. We add to these from other sources as well as our own knowledge of the exams to come up with the following:
 
  1. Your Behaviour
    1. Always be professional. Some delegates interpret this as being rigid and serious. That’s not the case. Be yourself, the person you present is important. The professionalism comes from knowing you are a doctor. Forget being a viva candidate and you’ll do better- I know that’s easier said than done. First Impressions are lasting and make up a significant part of your mark.
    2. Dress in a way that makes you feel comfortable. Do not wear a suit, if you wear scrubs. Wear what you normally wear at work. Make sure it clean and ironed, even if scrubs.
    3. Be well groomed. If you are a man and usually have a beard fine, but if you have stubble that makes it look like you haven’t slept for 3 days, then shave and clean up. For all, make sure your hair is combed/brushed and tidy. If you are a woman and wear makeup, wear what you normally would on a working day.
    4. Shake hands with everyone in the room. The examiner may not want to do this, or you will be told not to engage the examiner. That’s fine, but a confident, firm handshake with everyone in the room will be the best first step. Please wipe the sweat from you palm if it's there, as the clammy handshake is not a favourite.
    5. Look confident. You may not be, however, how many times have you looked confident in front of a patient without having a clue as to what is happening. “Fake it til you make it” is very important here. PEOPLE THAT LOOK STRESSED GET MARKED DOWN!!
    6. If you sit in a chair, sit like you are at a meeting. Don’t slouch backwards, with legs spread out, just sit up and pay attention, like you have something to contribute.
    7. Smile appropriately, but do smile as it makes you look warmer and more approachable. Be careful about laughing in the exam. Usually there isn’t much there to have a hearty laugh about. Certainly, no fake laughing. Just a smile.
    8. MAKE EYE CONTACT and maintain eye contact, but don’t be creepy. It has to be appropriate for what you are doing. There are some parts in the world where eye contact is not encouraged, but this is the exam. Those candidates that do maintain eye contact are considered more likeable, credible and attractive. Don’t look at the floor, don’t look away. If you are teaching an ECG, look at the candidate and then point out what is happening on the ECG and then see the candidate understands. In a video set we did during the last Pass The OSCE Course, several of the candidates when teaching the ECG, forgot about the resident and almost turned away from them whilst trying to sort a stressful ECG. No eye contact, stress and certainly no positivity. Even though they knew what the ECG was, they didn’t perform as well in the station as the station was a Communication and Scholarship and Teaching station and they ignored all of those things.
    9. Your mannerisms
      1. Do not fidget, moving around and not being able to keep still is the playground of the 5 year old, not the specialist to be.
      2. Use hand motions when necessarily, but keep your hands away from your face and don’t put your fingers in your mouth. If you’re a nail biter, stop it. If you in fact use your hands when you speak, that’s fine, do so. If you don’t then it will be awkward. Look at the gestures of Obama and Clinton, they have specific hand gestures that emphasize points.
      3. Do Not cross your arms across your chest, or your legs. Ankle crossing is fine. These are all closed positions and reflect a negativity to the examiner.
    10. Your Confidence
      1. Confidence is a state of mind. You know you’ve studied hard. You’ve proved you have the knowledge by passing the written, YOU DESERVE TO PASS THIS!
      2. Confidence is about having a positive attitude.
    11. Your Speech
      1. Be aware of how you speak when you are stressed. Some delegates mumble, some are rapid speakers. Some(in the words of Seinfeld) are ‘low talkers’.
      2. Be confident, speak clearly at the right volume so the examiner can hear and give you the marks
      3. Speak like a news reader. They annunciate, speak clearly at the right volume and stop when appropriate.
    12. Being like Mr Spock helps
      1. Keep your answers logical and flowing. Jumping around the place makes you look like you don’t know the answer. For example, if you think that an ECG is a Mobitz block and you are teaching a resident, start by saying that “Mobitz blocks require the P-P interval to be constant, otherwise it’s a pre-mature atrial contraction, we then look at the Pr interval, if it is increasing……..”
      2. Use simple fillers to buy you time to think
        1. “There are several issues we need to deal with here.”
        2. “This is a complex situation and….”
    13. Be a little Mother Teresa
      1. Care for the patients and their families
        1. “Do I need to see this patient immediately as the ECG is worrying me”
        2. In a paediatric case, if you are resuscitating, think about “ Can we please get someone to sit with the mother to explain what is happening”. Remember however, that you may not have that luxury
        3. “Is there someone with the patient at this point?”
    14. The Examiner is your friend
      1. The examiners are there to pass you, not hinder you. They are not trying to find faults, they are trying to find a way to give you that tick. Think of them in that way and smile as you think of them.
    15. I’m not sure of the question being asked.
      1. ​You may need to seek clarification of a question. The first person to ask is the confederate in the room. It is simple to ask them, but do so in specific ways: “ I understand the question to be……. Is that right?”
    16. Why are they prompting me, or asking me questions?
      1. Prompting in the exam is limited to a certain few times. If you are being prompted, it is for the purpose of giving you as many marks as possible.
      2. If you are asked a question, it doesn’t mean that you have made a mistake. The examiner may simply not have heard. It may be that you have made a mistake and this is a prompt. This is the time to think about what you have just said and see if it is true. Don’t get flustered, prepare to repeat what you have just said, but play it in your mind first to see that it makes sense.
    17. What if I make a mistake?
      1. We all make mistakes. If you realise that what you have said is incorrect, or you realise that after a new piece of information is made available that your previous answer was wrong, it’s fine to say that and give the right answer and move on. However do it eloquently: “On reflection, this new piece of information, changes the diagnosis on this ECG..”
 
References
  1. Yaphe J et al. How do Examiners Decide? A qualitative study of the process of decision making in the oral examination component of the MRCGP Examination. Med Educ 379:764-771
  2. Selzer et al. Twelve tips for performing well in vivas. Medical teacher 2014, 1-5.

The Communication OSCE

This can take many forms. It can be about communicating a procedure, a result, bad news or a proposed event.
At this point many Trainees fall into a marshmallow heap and become blubbering messes, that the examiners expect.
Why should that me?
You communicate every waking moment you have. You communicate all the time at work, whether it be with colleagues or patients or their families. Why should this be any different? Because it takes away there natural component and makes you totally self conscious of what you say and do, of how you behave and generally how you hold yourself.

Plato said "An Unexamined Life is Not Worth Living". However when the scrutiny on this fragment of your life is so intense, it is expected that you will be nervous. The key is to use that nervous energy to your advantage and to treat this like everyday.

There are a few rules in basic communication you must obey:
  1. Introduce yourself. Hello I'm Dr ABC
  2. Be polite
  3. Remember that a significant part of communication is listening
  4. Leave space and don't jump in too soon with closed ended questions
    1. Balance this with the need to get information out and across
    2. Respect silence and respect tears
  5. Silence in the right circumstances is music to the examiners ears.
    1. The grieving patient needs time to synthesise. Don't keep jumping in with facts
    2. The upset patient can use silence
  6. Don't be aggressive, even if others are
  7. Don't ever argue with an examiner
  8. Ask "Is there anything else I can do for you?" "Are there any other questions you would like to ask me?"
  9. Say "Thank you"
  10. Say "Please'
    1. The polite, professional and confident doctor always gets the marks
  11. Keep relaxed and focused

The Teaching OSCE

The teaching OSCE will usually involve the education of a junior doctor
  1. This is all about disseminating information.
  2. Its about finding out the skill level of that doctor
  3. Its about giving the information, in a simple understandable fashion and then checking that the person has understood.

General Points

  1. Always make sure you know the knowledge level of your student.
  2. Always make sure the patient is stable
  3. Always make sure the department is being covered.
  4. DO NOT ACT. In some rare cases people try act, after all everyone around them is. DO NOT do this. Don't be more theatrical than you normally are- be yourself.
  5. Prompting does exist, however you will not always be prompted. In fact there are some cases where there will be no challenge or discussion of your management.
    1. The staff that are assigned to you will have strict instructions on what they can and can't say. For example you will have an experienced nurse assigned, however that nurse will not necessarily prompt you if the blood pressure drops, something they would do in real life. So be vigilant.
  6. Be nice to everyone, have a level head and say "please"

Something to Say

  • When the Doctor tells you "I have this patient..." Ask "Is the patient haemodynamically stable?" or "Is someone looking after this patient?"
  • If you are shown an ECG that is potentially a critical one i.e.., VT. You should offer; "I think that this patient is potentially going to be unstable with this wide complex tachycardia, which may be VT and we should go to the patient right now"

The Show

Every show has a beginning a middle and an end. Unlike most shows where you remember the start and finish and the middle is a little hazy, this exam has most of the meat in the middle.

Videos

The Introduction
Be confident and shake the person's hand and introduce yourself. The way you present yourself in the initial interaction leaves a first impression. 
The Substance
This is the knowledge part of the exam. You already have the knowledge, but sometimes people get nervous and forget. You need to overcome those nerves and use them to give you an advantage. More on this next week.
Think of the knowledge part simplistically;
  • If you have an ECG that is slow and the patient is symptomatic, speed it up.
  • If it's slow and the patient is symptomatic, slow them down
  • If you are asked about a piece of equipment and you have no idea- start with 'Knobology' Just name parts of it and what that might mean. You will be surprised at how basic they expect the info to be.
  • If you are faced with a question that requires knowledge of how departments work, for the purposes of this question, your department is the ideal department.

HOMEWORK

There is a lot more that we can say here, however it's more important to be a doer than a planner.
Here is the best way to do this. SOME HOMEWORK

Please use one OSCE, one of your own, or the one in week 1 and do it in timed conditions, but VIDEO TAPE IT on your phone.
This is critical to seeing what you do during the exam.
Watch it and see how professional you look.
DO THIS- IT IS ONE OF THE MOST IMPORTANT THINGS YOU WILL DO IN PREPARATION


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