Getting yourself OSCE ready: passing the fellowship clinical exam (part 1)

As the weeks shorten in the lead up to the next set of OSCEs, I'm getting a number of requests for advice on passing the clinical exam. Since the last post on the matter, our knowledge of the exam has improved and I've had some first-hand experience of the process.

I'm not saying I'm an expert on the matter, and I don't have any definitive advice on how I managed to pass, but I thought I'd put together my thoughts based on the experience and invite other recent candidates and possibly an examiner or two to add their tips in the comments.

This is a 2-part series, this post on preparation, and the next on technique.

Preparation

OSCEs are a new exam technique for many, and need their own technique to be practiced. This article goes into the background and considerations of the OSCE process for examination processes. Those who have done a good amount of simulation may be more comfortable engaging in the process and accepting the 'reality contract' required to immerse in the situation.

In my OSCE preparations, my study partner and I set up our own low-fi simulation on the kitchen counter to practice scenarios. We had pillows as the patient and various balloons playing the roles of nurses and other actors. If, we argued, we could immerse into low-fi sim like this, then it would be easier in the more sophisticated set up of the exam...

DIYOSCE3

An OSCE study group

Having a trusted group of fellow candidates to practice OSCEs with is important to get regular and frequent practice and feedback on your technique. You will learn by watching each other what to do as well as what not to do. They will also motivate you to keep going and to continue studying. Choose wisely.

Our group consisted of 2-3 for each session, meeting at least weekly. We met for countertop sim, more involved sim using the departmental mannequin and iSimulate monitor as well as quizzing and rapid questioning over coffee or lunch.

We used a variety of source for our practice questions—old SCEs, FCEM part C questions,  consultants generous with their time and, most importantly writing our own. You can also now see the stations from the 2015.1 exam in the report from ACEM. These were:

  1. Cranial nerve examination
  2. Intubation or post-intubation of the crashing asthmatic
  3. Psychiatric assessment
  4. Ankle fracture - x-ray and management plan
  5. Paediatric burn/minor head injury
  6. Body fluid exposure
  7. Poorly performing colleague
  8. Counselling family of a dying patient
  9. Hand examination (median or ulnar)
  10. Neonatal / paediatric resuscitation
  11. Jaundiced patient - history
  12. DKA - ABG and mangement
  13. Complaint - parent of inadequately managed child
  14. Threatened miscarriage
  15. Disaster preparation
  16. ECG interpretation - young person with syncope

 

Writing your own OSCEs

In the lead up to the clinical exam, I wrote a lot of OSCEs, practiced uncountable ones (uncountable largely because I've suppressed the memory) and thought through many more. In the haze after the clinical exam, I worked out that I had written, practiced or thought through versions of about 12 of the 16 OSCEs.

You'll note the shameless plugs for the online OSCE bank: ACEM FEx questions. So far there are over 100 OSCEs there for you to practice with, and I'm hoping you can be inspired to add some more so it becomes an even more valuable resource. The facility is there to add SAQs as well...

So how do you work out what to write an OSCE about? I found that for each topic I studied, it was relatively easy to work out what aspect of it could be examined in this style. A good starting point is to consider this for each topic in the fellowship curriculum, and to go through all the procedures listed in the procedure list.

Here's a list of ideas off the top of my head:

Resus stations

  • Trauma
  • ALS
  • Toxicology (TCA overdose, organophophate exposure)
  • Unstable SVT / AF / bradyarrhythmia

Paediatrics

  • Counselling parents of the limping child
  • Gaining consent for an LP in a febrile infant
  • Teaching a junior doctor about Kawasaki's

Obstetrics

And there are plenty of others—ECGs, ABGs, complaints, handover, disaster planning, plus all of the rest of the curriculum.

Other opportunities

There will be some other chances for you to practice your OSCE skills and hone your knowledge. This includes any trial exams run locally and calling in favours from your colleagues. You will find that most FACEM colleagues will be willing to give a little time to help out. Be selfish and keep asking. Your departments may not mind too much if you are a little distracted and use good cases coming through the door as extra practice opportunities (if the patient consents). Some FACEMs will have special interest areas—toxicology, ultrasound, disaster, equipment, pre-hospital—seek out extra time with these people and ask them to focus on these areas.

An important tip I received in the lead up to clinicals is that OSCE practice is not enough—OSCEs are very inefficient ways to test knowledge. It can take easily 15 minutes per person to do and debrief an OSCE, which only covers a small block of knowledge. You will also need to undertake other knowledge-focused sessions.

We found that 1:1 or small group sessions with enthusiastic consultants allowed this, as did going quickly through old SCEs and good old-fashioned quizzing each other over a coffee.

And don't foget to practice your basic examination skills. You might not have time in 7 minutes for a full Talley & O'Connor technique, so work out how you can shortcut it effectively to get quickly to the money.

How much is enough?

How much study and practice you want to do, or is necessary, is individual. In the early build-up to the clinicals (eg pre- or just post-written), you may only want to meet weekly. This will increase as the time approaches. In the last 4-5 weeks prior to the clinical, our study group was doing almost daily activities across OSCE practice, consultant-led sessions or knowledge testing. On days when a face-to-face meeting is not possible, we would often do an online session using Skype or Google Hangouts.

It is important to "pace" yourself somewhat—don't feel guilty for taking some days off. In the last week before the clinicals it is time to wind back and make sure you are well rested and mentally prepared (as much as possible) for the big day. If you have to travel to the clinical—do it a day or so early and make sure you are settled and relaxed for the big day.

 

That's all I've got for now. If you have any further tips, ideas or comments, please add them in the comments below. The next post with my thoughts on OSCE technique is coming soon...

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