Top Tips for Year 4 OSCEs

1. Top Tips for Year 4 OSCEs Ben Ryan Fran King Amy Kitchen Holly Gibson

2. How are they different from third year? • Two summative OSCEs: M&M and F&C • First OSCE taken in December (4th-7th) and second one in May (1st-4th) • Taken over two days, 8 stations per day • “You are a FY1/FY2 doctor…” – confidentiality is assumed • “Do what you think is appropriate…” ????? BUT • Still 8 minutes per station • Still 1 minute reading time before • Still travel to another base hospital

3. Some types of stations… • History • Examination • Explanation • History + examination • History + explanation • Prescribing • Prescribing + explanation • Explain to examiner/prioritise patients • Mental health stations (risk assessment, MSE)

4. M&M

5. Mental health – Psychosis history “Slow start, but rallied and gave an overall very good performance” “did not elucidate thought withdrawal, did not ascertain drug use” “Could not complete history but well presented summary and differential diagnosis “With alcohol - try to clarify exactly how much is consumed ("1 or 2"...of what?) Comes across non-judgementally Good ICE Could be more focussed with presentation”

6. Depression history + risk assessment “Warm, good rapport established, sensitive Did not get side tracked about back pain Low mood- explored symptoms systematically. Could ask about libido. Asked patient about his ideas- very good for building rapport. Did not respond to cue about alcohol- need to ask more. Also need to ask re drugs. Need to ask about any current psychotic symptoms. Suicide risk assessment- did ask some questions about current risk, but need to ask more about plans and preparation for act eg, will/ suicide note. Did not ask about past event. Summarising- Explored history well and able to come up with diagnosis with confidence. Good suicide risk assessment but could have improved by asking about past which itself makes him a high risk, as well as the other factors.” “be more confident and clear in questions. limited explanation in question section, had to encourage” “More structured approach to MSE would help” “Good communication reassured patient”

7. PTSD history “Good communication reassured patient” “The candidate could improve by asking about expectations of the patient” “Good empathetic and open manner. Some repetition of questions” “Good relaxed manner. Questioning was discrete, maybe a bit overcautious but you seemed to get the information all right. You established the 'traumatic event' but more specific info on avoidance behaviour would have supported the diagnosis.”

8. GAD history “Excellent structure; good knowledge; good use of cues and prompts.” “Good phrasing of questions. Assesses risk. Could improve by asking about specific symptoms such as dry mouth/nausea etc. Good succinct confident explanation of diagnosis and management” “Good rapport with nice flow to the consultation. I am not sure mood was fully explored. Good exploration of OCD possibility. Diagnosis was correct. Few things missed from managmentincl education and self help, short term anti-meds” “enquire about caffeine, relationship with husband, OCD symptoms”

9. Bipolar disorder history + MSE “Reasonable rapport developed, which facilitated an open discussion of experience. History well structured which allowed most material to be covered in good time. Think about the nature of the mental state as a form of phenomenological enquiry and the manner in which you enquire about an individual's experience” “Good exploration of biological symptoms of depression. Good way to explore risk to self. Good structure to history taking. Could have explored past suicide attempt further. Excellent exploration of Insight. You missed the manic episode he had in the past which could have helped you in reaching a firm diagnosis” “Try and use more open questions initially Good listening skills and empathy Good approach to sensitive questions” “did not have to do cognitive assessment, ask about substance abuse instead”

10. Alcohol history “Could improve by exploring social aspects of drinking like job and family. Know the categories of alcohol misuse” “Just be aware that you repeated every bit of info back to the patient in the first half of the consultation this can be helpful sometimes but then becomes very distracting. Good clinical knowledge displayed by use of appropriate questions. Correctly worked out alcohol intake and said that patient was dependent. Good overall” “Alcogel+. Nice intro. Nice initial open question. Nice non verbal. Used elements of cage. Quantified effect on life. Summarised at end. Didn’t quantify exact units used per week” “forgot types of drinking about how to calculate alcohol units”

11. Orthopaedics – shoulder exam “offer to examine joint above and below, mention x-rays and support bandage” “Good examination technique Aware of the actions of the muscles forming the rotator cuff Good management plan Should examine the neurovascular status and the cervical spine for completion” “Dont forget neurovascular exam and joint above and below” “Got the diagnosis. More on management eg use of sling”

12. Osteoarthritis history + explanation “Good use of open questions /good listening and use of ICE Good structured history Excellent explanation of OA Don't necessarily need Xray- not very reliable in terms of indicating severity Excellent management advice” “Would do an X-ray to help diagnose, otherwise very good” “Fluent professional approach. Check for red flag symptoms. X-rays not usually required to diagnose osteoarthritis. Nice summary of management plan” “consider screening for depression. x-ray not usually indicated. give more explanation of diagnosis”

13. Back pain history + explanation (breast mets) “Good that student asked 'what are you worried about?' as allowed patient to give relevant history of breast cancer Missed a few red flag questions but made an appropriate management plan” “Systematic and patient-centred approach.” “Well structured fluent history. Consider discussing differential diagnosis before jumping in with diagnosis of metastasis. Appropriate discussion otherwise with referral to oncology and investigation.” “mentioned scan should say specifically MR. need to mention urgent breast oncology referral”

14. Finger fracture prescribing + explanation “Clarifies allergy status. Establishes good history. Reviews progress of patient. Good choice of medication. Took time to go through bnf. informed SP to stop paracetamol. Patient concerns addressed at the end. Good script writing” “Nice assessment of the pain severity. Checked other regular medications that are being taken. Assessed allergy status and checked what reaction she has to NSAIDs. Remember to specifically ask about other medical conditions. Should explain possible side effects. Good prescription” “hand dominance! no netball 6 wks” “Good knowledge re ibuprofen avoidance. Good explanation about the choices around codeine and paracetamol use. Remember to enquire about patients specific concerns and explore their expectations”

15. Neuro – subarach history + explanation “Excellent approach to patient and history. good undemanding of the diagnosis and explanation to the patient, avoiding jargon, or explaining where necessary.” “Good posture and eye contact. Confident. Empathic. Professional. Sensitively managed questions and concerns. Identified probable SAH and the next steps” “Excellent history taking. Very confident approach. Need a more empathetic approach. Body language a bit laid-back. Talk slowly, especially when talking to a distressed relative. Revise SAH and management” “ establish facts before talking about what patient is currently undergoing”

16. Focussed cranial nerves examination “double vision or pain during eye mvts, lid lag, general inspection at beginning” “Nice confident introduction, to improve revisit reason for patient presentation, offer chaperone & establish what patient knows about examination before starting. Confident fluent methodical examination. Summarised appropriately, to improve relate findings to presentation” “You should be more confident and more organised” “Excellent communication with patient. Well done for reading instructions on Snellen chart. Blind spot test was a little rushed but did remember to perform at end”

17. Epilepsy and driving explanation “Comprehensive” “Only discussed swimming and wotk” “Good empathy. Moved quickly and appropriately onto lifestyle. Would be better to take occupational and social history first to anticipate lifestyle problems, and so was a bit blunt” “advise another appointment, good idea of summary”

18. MS explanation “Well done for picking up on her history that she has relapsing remitting ms. You gave good timescale for progression. Maybe give a little more detail about drugs, good description of wider team. Good emphasis on periods of wellness” “Great! Consider mentioning the MS nurse as a source of support” “Good knowledge of ms subtypes. Elicited previous history. Vague in terms of role of disease modifying therapies. Good description of support available. Didnt really specify uncertainty regarding potential for disease progression according to disease subtypes”

19. Hand examination “Very good systematic exam. Picked up on key clinical findings during exam and communicated with confidence” “Good introduction. Thorough, but could have been quicker (did run out of time for grip). A few terminology slips, carpals mis named. Could have had more findings fed back, e.g. Thumb CMC OA as well as fingers” “Nice intro and manner. Thorough inspection. Checked pt comfortable. Good palpating. Correctly identified Ulnar deviation, wasting, etc boutonnire Tested active and passive movements Good test for function. Answered q correctly. Well done”

20. Delirium history “didnt clarify all aspects of delirium, diagnostic criteria” “More social, family, mood and alcohol history needed. CT is probably not needed if you think delirium is sepsis related.” “You don't need the relatives date of birth. Read the scenario. You have been asked to get a history from this relative. You let the relative tell their story and then asked some clarifying questions. Correct diagnosis and knew about CAM” “No concerns. But not perfect”

21. F&C

22. Paeds – cardiovascular exam “Well structured and fluent.” “Good rapport with child. Comment on scars including chicken pox as you demonstrate you can see positive findings even if they are not relevant to this particular examination” “Good structure to the examination”

23. Bacterial meningitis explanation “Lovely rapport with the parent - you were empathic and listened carefully. You gave clear simple explanations and responded to the parent's concerns. I like the way that you discussed complications in an honest way without causing undue alarm. Good understanding of diagnosis and treatment. Well done” “While its essential you check understanding, you tended to ask too many question. Try to get the balance right. Please read up on complications of bacterial meningitis.- especially deafness and hydrocephalus.” “Good rapport and you explained things in clear simple terms. Very good knowledge of diagnosis and treatment. Perhaps avoid going over the history in too much detail while the parent is anxiously awaiting the result”

24. Paracetamol and antibiotic prescribing “Technically it's suspension, not solution - didn't hold this against you, but you correctly included the concentrations. You asked about tablet form - not for a 3 yr old, but you worked this out! Paracetamol - unfortunately you managed to double the dose of paracetamol from 180mg (which you actually said) (equivalent to 7.5ml) to 15ml (360mg). This would be dangerous in a 3 yr old and could cause liver failure.” “You need to put the concentration of the suspension you're prescribing (i.e. 120mg/ml). It's OK to say "supply 200ml" for the antibiotics - the pharmacist will work out how to do it (i.e. You don't need to say supply 2 packs). Both drugs are suspensions not solutions” “Good prescription. Just a few bits. Just needed the strength on the paracetamol as different strengths available. 120mg/5ml, 250mg/5ml etc. If written 120mg/5ml your volume was correct as you stated verbally. Year is 2017 not 2016 so script would be out of date”

25. IBD history “Improve in clinical reasoning” “Good flow. Nice manner. need to cover directed associated symptoms ( eye, skin, joint)” “Excellent flow in history taking and covered all the aspects. Very well thought out differential.”

26. Physiological jaundice history “Good rapport, detailed history, good explanation, history of weight loss would have been helpful” “Confirmed mother's and baby's identity. Good opening question. Good range of open and closed questions. Good exploration of perinatal, family and social history. Good exploration of feeding and related issues (weight, urine and bowels). Limited exploration of risk factors for neonatal infection, and blood disorders, etc. Did not explicitly explore maternal concerns and expectations. Presentation of history can be improved by using structure. Gave physiological jaundice as top diagnosis. Please remember breast milk jaundice is a cause of prolonged jaundice” “Good history taking, explored haemolytic disease To rule out history of sepsis would be helpful”

27. Febrile convulsion history and explanation “She is competent and cnfident. Almost all criteria are fulfilled” “Develop structured approach. Take structured history including birth, development and family history in any paediatric assessment. This was taken after discussing febrile convulsion as a possible diagnosis.” “Confident and caring. Systematic approach”

28. Patient prioritisation “Correctly prioritised” “Well done for identifying the most emergent patient. You needed to talk about using the ABC approach as well as initial blood investigations in your management in addition to those you have mentioned. While it is concerning that the patient with the chronic condition has not eaten, you should have prioritised the the patient with the breathing issues first. This is indicated, if nothing else, in the EWS” “Well done for good prioritisation of the patients. While you correctly identified the most emergent patient, you needed to realise that this was a pending emergency and needed an ABC approach with senior support.”

29. O&G – HPV vaccine explanation “Showed lots of empathy and adaptability to the patient circumstances” “Good to bring up parental choice at start. Look up connotations of having vaccn later and schedule” “Unique. Used the patient's knowledge and built on it to aid understanding and then address concerns. Coherent. Just lacking only a bit on the medical literature on the HPV”

30. Diabetic preconception counselling “Excellent” “Good communication and info given. Remember shared care of diabetic pregnancies” “Excellent knowledge and advice...perhaps slow down a little to check understanding”

31. Bimanual pelvic examination “Remember to ask if emptied bladder. Well done for remembering to position patient. Remember to comment on os and fornices. Excellent answer to questions” “Excellent communication skills. Competent and confident. Most criteria are fulfilled” “A separate abdominal examination not required. Please cover the patient after. Good answer to questions asked including bloods”

32. Antenatal examination “Comment on whether can see fetal movements. Fundal height 26.5cm measured. Did not know how to work doppler volume to get to switch on. Did not state comparison of maternal heart rate whilst examining. On summary got gestation and measurements mixed up initially then corrected himself correctly. Acknowledged did not measure maternal heart rate. Did not state needed growth scan” “Slightly out with measurement, was 30cm and you got 27.5cm. Was a breech presentation which you failed to identify. Answered the questions well” “Fundal height measured at 27.5 (is actually 32cm) Told patient was normal measurement when is actually large for dates. Stated was breech presentation (was cephalic on earlier midwife exam) Did not state fetal or maternal heart although did check. Remember gestational diabetes in differential. Did not get onto management plan question.”

33. Pre-eclampsia explanation “Excellent consultation Calm, professional attitude Addressed patient concerns well Well done!” “Should elaborate more on initial management; fluid balance monitoring, urine sample monitoring, Bp monitoring and response to bp lowering treatment. Also fetal monitoring with ctgs, us doppler” “Thorough and well timed consultation Sound knowledge Clear explanation and empathetic Could have mentioned antenatal steroids!”

34. Postnatal depression history “Maintains excellent eye contact.asks open questions. Is led by patients responses and frames appropriate questions,needs to cover all parts of history taking esp alcohol and drug history, avoid repetitive questioning, needs to incorporate a structure to presenting the case” “Maintains excellent eye contact, asks open questions,needs more structure to history taking,iscourteous,needs structure to presenting findings,explore social history” “Try to have more structure to consultation, otherwise covered most risk factors”

35. Prolapse history and explanation “Good opening to consultation. Good use of ICE Explored the patients thoughts. Try to use more open questions. A fair few of your questions were closed. Well done for addressing coital issues. Well done for advising to come in to talk about smoking etc. Good use of drawings in explanation.” “Nice relaxed style with good non verbal communication. You signposted well what you intended to do. Just watch your timing I liked how you explored the affect on her lifestyle 'sometimes its not about the symptoms but how it affects your life, can you relate to that?' Similarly you tried to explore ICE, try and avoid the word 'worry', concern is usually a better choice Try and avoid jargon eg 'evacuation of the stool' You nicely followed the patient's cue to discuss the treatment options however this was at the expense of some detail in the history. It would have been helpful at that point to 'park' the problem and go back to the history eg obstetric history, and abdo masses I liked how you checked with thenpatienthwo much she had understood during your explanation. More info on surgical options might have been useful Overall needed more detail in the history but comms skills were good” “good introduction good use of signposting thorough history good use of summarising would have been good to touch on smoking / ETOH history needed to touch on a brief description of what a prolapse is. need to advise that if conservative mx does not work then there are surgical options- pt was Most worried about the consequences of surgery, did not pick up on this cue”

36. Ectopic pregnancy explanation “Using the drawing was v helpful; very clear explanation of problem and planned surgery; very empathetic and kind approach;” “Sensitively approached, be careful being too empathic, patients need to feel you are sensitive but also need some positivity from you that there is a problem and why it needs fixing. Good awareness of medical treatment for this. Be a little more upbeat Amy in these sensitive conversations, keep the consultation positive at the end e.g. I know its a tough time but you understand why it needs fixing and it shouldn't affect tour future ability to have another pregnancy” “It was helpful to use the diagram; you insisted on using "product of conception", for patient it might be "baby" - this creates a gap. Try to share information in less didactic way”