Andrew Perry and I worked together on a recent Clinical Trial Exam, examining one of these single station simulations, and we have come up with 5 pointers that we came up with from observing the days' candidates.
In addition, you can find ACEM's advice on single station OSCEs on the eLearning site.
1. You only have 7 minutes
In only 7 minutes, there is a limit to how far the scenario can stretch, and what you can be expected to do. From the stem, you should be able to picture where things are heading, to some degree. For instance, if the case is a critically unwell obstetrics patient, then the case may be leading towards a peri-mortem c-section... but if you walk in the room, and they are not in arrest, it seems unlikely that you would be progressing to actually performing the procedure in the next 7 minutes – the focus will be more on the resuscitation and preparation.
As with all other stations, you need to use your 4 minutes of reading time to prepare your approach and line up key points that you foresee being important. In this short timeframe, you will likely only address 1 or 2 specific problems.
2. What an entry!
Given the time limit, you need a smooth and efficient way to enter into the scenario. Make a script to introduce yourself and orient yourself to the team - including skills, capabilities and assigning general roles - within the first 20 seconds. Don't waste time having the confederates reiterate the story you've already read on the stem – summarise what you know and ask for updates or further information; this is much more efficient.
Part of your entry should be to assess the "room", gathering what information you can from the scenario, as you would in real life. What does the monitor show? What is the patient's position, do they have IV access and oxygen? These things can be checked off your mental checklist, and anything that is not evident can be sought.
3. Assume competence
The confederates are normally "competent but with no initiative" – this means if you ask for something to be done, it is safe to assume it is done. You can also depend on confederates to tell you the truth. I think it is reasonable to use these two assumptions to ensure expected activities have already been completed. For instance, in a trauma scenario, you could ask your confederate registrar if they have completed a primary survey, and if so, what significant findings they encountered – this would save you time directing or questioning a detailed primary survey. If they don't provide a definitive response, then you may need to go into it in more detail, as this forms part of the assessment. Of course, if there are specific items to the case you want to explore, then ask for these in particular – the state of the abdomen, the BSL or the pupil responses, for instance.
4. Listen to the prompts
Most of what confederates say is scripted to give you specific information to act upon. Listen for these prompts. This also means that you need to ensure you don't rush and that you speak slowly to give the opportunity for them to speak; then listen to what is said.
The other (somewhat frustrating) prompt is the absence of something you would like or normally have in this situation. Why is the ultrasound, CTG, radiographer or specialist always unavailable? How can we be expected to work in such terrible conditions? When something you ask for is unavailable, this means that it is not being assessed – to provide you with a gas result, imaging or other results would then require interpretation and action based on the results. Not all of this can be tested in 7 minutes.
When something is unavailable, this means it is not being assessed. Be thankful and move on.
5. Patient outcome ≠ performance
Just like in real life, the patient outcome should not be used as a measure of your performance. It is reasonable to expect that some scenarios will end poorly, no matter what actions you take. Your goal is to provide the best possible care, and not judge your performance on ROSC – not every scenario can have a fairy tale ending.
This is important to realise, so that you can quickly clear your mind and de-stress as you leave the room, without impacting on your performance in the next 11 minutes.
Trigger Words and Expertise Spiels
Finally, I am going to patent the concept of Trigger Words and ExpErtise Spiels (TWEES™... must work on a better acronym). By this, I mean practiced and smoooth 10-15 second scripted expertise nuggets that you can roll out when appropriate trigger words come into a scenario. This quickly demonstrates a large amount of relevant medical expertise in an efficient manner. Then, once done, you don't need to go over it again.
Trigger Word: MTP in trauma
"Scribe, please order the Massive Transfusion Pack. When it arrives we are going to give it in a 1:1:1 ratio through a warmer. We are also going to give 1g of tranexamic acid IV and consider the use of ROTEM to guide further products. Please warn me when the pack is nearly complete so we can assess the need for a further pack and consider calcium given the amount of bloods transfused."
Then, when the MTP arrives, you can just ask for it to be given as was outlined before (because you can assume competence to do so).
Trigger Word: Perimortem caesarian section
"Team, we have to consider the possibility of performing a perimortem c-section. We will do this if our patient is over 20 weeks gestation and is in cardiac arrest for 4 minutes. To prepare for this eventuality, please arrange... (insert equipment, teams, post-procedural care)"
Trigger Word: Multi-trauma
"Scribe, please activate a Level 1 Trauma team. Let's avoid the lethal triad and ensure the patient is kept warm - so let's put the bed warmer on and increase the ambient room temperature.... (etc)"
Trigger Word: Procedure
Ok, this is not a spiel, but you should have a set framework for doing/teaching all procedures (see the list in the curriculum framework) that includes:
- Indications / contraindications
- Informed consent
- Preparation (patient, position, team, equipment, location)
- Doing the procedure
- Post-procedural care (position, slings, discharge criteria or disposition)
- Pearls of wisdom that demonstrate you've done this many times before
Other triggers to consider might be preparing for intubation, lung-protective ventilation strategies, potential sepsis, neuro-protective strategies and so much more; anyone want to share some examples in the comments?
Hope that helps!