OSPE Guideline

1. Prof. A.H.M.Shamsul Alam OSPE Guideline

2. OSPE • Objective: Responses are measurable • Structured: Responses are in uniform format • Practical: Practical aspects of Surgery • This examination format focuses on testing the practical skills of examinee while using diagnostic tools, laboratory data , procedural techniques and communication modes

3. OSPE: fields of evaluation • Surgical pathology • Specimen • Illustration of pathological lesions • Diagnostic tools • Images • X-ray • CT scan/MRI • Data interpretation • Communication skills • Verbal counseling • Written • Verbal Interactive( with colleagues) • Surgical skills (procedures)

4. Surgical pathology • This is to test your pathological background while you manage a surgical problem • Usually, a surgically removed specimen containing a pathological lesion is displayed • You need to • Identifying the organ: see all around and look evidences of surgery and read all the questions in the script- you will find the clues • Take your time and observe the morphology • Describe methodically: organ> nature of lesion> involved area> characteristics of lesion> surrounding tissue

5. Example: Specimen Find three significant features in this pathological specimen What is your gross pathological diagnosis? What could be the possible presentation with such a lesion? Mention diagnostic investigations for such a disease. How do you stage this disease? What are the principles of treating this disease?

6. Example: specimen Answer key • Specimen colon shows two polypoidal mass and an ulcerative lesion. The ulcer has irregular and everted margin with a necrotic floor • Multiple colonic polyp and carcinoma colon • Rectal bleeding, change of bowel habit, weight loss, anaemia occurring in a middle or old age. • Colonoscopy and biopsy- histopathology • TNM or Duke’s classification depending on tumour invasion of gut wall and surrounding tissue, nodal involvement and metastasis • Meso-vascular en-block resection of colon with at least 5cm of healthy margin

7. Radiological image • Tests your ability to use this diagnostic tools effectively and rationally • Images could be plain or contrast X-ray, CT or MRI • You need to • Identify what type of image it is • Take some time to appreciate the abnormalities • Find clues from the set questions in script • Answer precisely

8. Example : Imaging Scenario: A 70 year old man presented with recent weight loss and moderate degree of jaundice. As a part of diagnostic workup, an imaging study has been carried out. What kind of image it is? Mention four significant findings in the image. Mention the most probable image based diagnosis and two other differentials Mention two advantages and two limitations of this investigation.

9. Example: Image Answer key • MRCP- Magnetic Resonance Cholangio Pancreatogram • Findings: • Dilated biliary tree up to the terminal end of common bile duct • No filling defect in biliary tree • Gall bladder distended • Pancreatic duct normal • Carcinoma head of the pancreas. • D/D……………….. • Periampullary carcinoma • Cholangio-carcinoma • Impacted calculus at the terminal end of CBD • Advantages………. • Non-invasive investigation • Outlines whole biliary tree and pancreatic duct system for screening • Disadvantage…… • Not always precise in finding pathological changes(compared to ERCP) • Lacks therapeutic intervention

10. Example X-ray SCENARIO : This is the radiological image of chest ( PA view ) of a 50 year old man presented with significant weight loss and anorexia for four months . TASK Please read the radiological image carefully and answer the questions. List four significant findings in the image What is your radiological diagnosis? What organs / systems would you focus on during clinical evaluation of the patient? In absence of obvious clinical clue to have a diagnosis - What biochemical markers will help you? What imaging investigations you will suggest? What is your management strategy for this situation?

11. Example: X-ray Answer key Q 1 List four significant findings in the image. a) Multiple round opacities in both lung fields b) Opacities are different in sizes c) They are peripherally placed d) Cardiac and hilar shadows appears normal e) No pleural effusion Q2 What is your radiological diagnosis ? Multiple pulmonary secondary metastatic tumours Q 3 What organs / systems would you focus on during clinical evaluation of the patient? Thyroid, GI: colon and rectum, Pancreas, Kidneys, Prostate, TestiS, Bone Q 4 In absence of obvious clinical clue to have a diagnosis - (a) What biochemical markers will help you? Tumour Markers: PSA, CEA, βHCG, α Fetoprotein (b) What imaging investigations you will suggest? (i) USG of Abdomen / Scrotum (ii) USG of Thyroid (iii) CT scan of Abdomen. Q 5 What is your management strategy for this situation? a) Diagnosis of the primary lesion b) Treatment of primary disease and systemic treatment (Chemo/Hormone therapy) for pulmonary conditions. c) Palliative care

12. Data analysis • This is to test your ability for rational interpretation of laboratory data in the context of clinical situation • You need to • Take your time reading the whole data mindfully • Read all the questions and the data again • Answer precisely

13. Example page-1 Blood sugar (Random)- 7.1mg/dl Blood Urea 48 mg/dL Serum creatinin 2.8 mg/dL S.Bilirubin- 16 mg/ dl S. AST - 104 unit/ l S. Alkaline phosphatase- 798 unit /l S. Amylase: 50 unit/L Serum Electrolytes Na 125 mEq / dL K 5.3 mEq / dL Cl 94mEq/dL HCO3 23 mEq/dL Prothrombin time - 29 seconds INR: 2.3 HBSAg (screening)- Positive CA 19-9: 69 U/ml A 50Y old man has developed deep jaundice for about two months and having high grade fever and vomiting for a week. His liver was felt enlarged and mildly tender. The following investigators were carried out and the results have been made available for your interpretations. CBC- Hb. 10 gm/dl TLC: 24,000/cmm Polymorph - 81% Lymphocyte - 14% Monocyte - 4% Eosinophil - 1% Questions: What is your interpretation of the patient’s data? Write your initial management plan.

14. Example page-2 S. Alkaline phosphatase- 478 unit /l S. Amylase: 40 unit/L Serum Electrolytes Na 128 mEq / dL K 4.3 mEq / dL Cl 94mEq/dL HCO3 23 mEq/dL Prothrombin time - 21 seconds INR: 2.1 HBSAg (Confirmatory)- Positive After a week of initial management patient had some clinical improvement. Following are the results of review investigations. Give your interpretation. CBC- Hb. 10 gm/dl TLC: 11,000/cmm Polymorph - 75% Lymphocyte - 14% Monocyte - 9% Eosinophil - 2% Blood sugar (Random)- 7.3mg/dl Blood Urea 35 mg/dL Serum creatinin 2.1 mg/dL S.Bilirubin- 9 mg/ dl S. AST - 94 unit/ l Questions: 3. Write your interpretation of the review data. 4. Name further investigations you would suggest.

15. Examplepage-3 Answer key: • Patient is having the following conditions • Obstructive jaundice possibly due to carcinoma of pancreo-biliary origin indicated by raised CA 19-9. • Cholengitis indicated by polymorphonuclearleucocytosis • Renal impairment and electrolyte imbalance • Possible hepatitis-B virus carrier • Initial management • Correction of dehydration and electrolyte imbalance • Broad spectrums antibiotic • Vitamin-K parenteral • Improved blood count and LFT indicating control of cholengitis. Improvement of renal function with electrolyte imbalance correction. • Investigations • Upper GI endoscopy - to inspect the duodenal papilla • MRCP- Non-invasive localisation of biliary obstruction, pancreatic mass detection • CT & guided FNAC -to detect and diagnose the pancreatic ca. • ERCP- Diagnosis of peri-ampullary carcinoma, localisation of biliary obstruction, setting to relieve biliary obstruction.

16. Verbal communications • This is to test your counseling skills in surgical practice • Counseling takes a vital role in surgical managements • You need to • Read the scenario and tasks several times • Organize the core issues in your mind • Write down the points you want to convey • Have natural voice, maintain etiquette all along • Use a single language, avoid medical terms

17. Verbal communication- CounselingExample page-1 Scenario • A 35year old lady, a college teacher and mother of one child, presented with a small lump in her right breast in upper and outer quadrant . It measured 2cm in diameter, appeared mobile, brought no change in nipple and there were no palpable nodes in axilla. FNAC of the lump reported ‘duct cell carcinoma’. You, being the treating surgeon, have to convey the information to the patient in your hospital chamber in order to involve her in the treatment planning.

18. Verbal communication- Counseling Example page-2 Tasks for Examinee: Create an easy atmosphere understanding the mental state of the patient. Inform her about the findings and explain in an understandable language the significance of these findings. Mention your provisional plan that you consider most appropriate, Inform her about the alternate options and briefly discuss those. Answer her queries in order to clarify her confusions. Instructions to Examinee: Presume that you are working in a medical college hospital. A well informed person would play the role of the patient You can use any language convenient to the patient Station observer would assess your performance in verbal communication skills using a structured check-list You may make notes on the paper provided in this station 

19. Verbal communication- Counseling Example page-3 • Check list • Welcomes her, ask her to take seat, asks how she was doing, says some comforting words before serious talks • Explains the reasons of this conversation • States the nature of the disease in easy language • Explains the evidences supporting the diagnosis • Narrates the provisional plan of treatment best for he given the circumstances • Takes questions and allows her to express her desires • Are you going to remove whole breast or part of it? • I do not want to remove my breast. Is it possible? • If the whole breast is not removed, would it cause any harm? • Chemotherapy and radiotherapy cause much problem, can I avoid those? • What are my chances of cure with the treatment you have suggested ? • What are the chances growing the tumour again once removed? • Informs her of the alternate options of treatment with evidence based outcome • Assures her about the overall surgical outcomes • Informs her about the adjuvant treatments and accompanying hazards • Concludes conversation giving her time to think about the whole issues and give response at the earliest

20. Verbal communication: Interactive • This is to test your interactive ability in professional conversations • It occurs between the examinee and a senior surgeon (interviewer) based on a scenario and set questions, but supplementary comes up as conversation goes on • You need to • Listen to the question very carefully: catch the reason • Answer precisely, never say everything • Give a chance to ask the next question that you know • Never say anything but evidence based information • Skip quickly if something is not known to you

21. Verbal communication: Interactive Example page-1 Scenario A one year old girl was brought to the hospital by parents as she had facial defect since birth. Instruction to Interviewer Ask following questions to the examinee with regard to the management of patient’s cleft lip and palate. You are allowed to ask supplementary clarifying questions in response to the answers as and when required. What is the diagnosis?  What is the developmental basis of this abnormality?  What are the present problems of this baby? What would be your advice to the parents regarding feeding and airway? What complications will arise if reconstruction is not done? What would be your management plan? What is the rationale behind the two stage operation? What further managements are required following reconstruction ?

22. Verbal communication: Interactive Example page-2 Answer Key What is the diagnosis? Unilateral complete Cleft lip, alveolus and palate ( left) What is the developmental basis of this abnormality? Failure of the fusion of the fronto-nasal and maxillary process What are the present problems of this baby? Cosmetic, suckling difficulty and nasal regurgitation, impaired speech development. What would be your advice to the parents regarding feeding and airway? Using Soft bottle, modified tits, enlargement of hole of tit, feeding plate and for airway- nursing in prone position(Ref. Bailey & love p-661) What complications will arise if untreated? Facial asymmetry, psycho-social developmental disorder, speech developmental disorder What would be your surgical plan? Reconstruction of lip and soft palate at the age of5-6 months and hard palate and gum pad 15-18 months (Ref. Bailey & love p-661) What is the rationale behind the two stage operation? Two stage closures encourages the physiological narrowing of the hard palate cleft to minimize surgical dissection What further managements are required following surgeries? Hearing and speech therapy, dental care and facial revision surgeries

23. Written communication • This is to test your ability to write surgical documents as surgeons need to write documents in order to communicate with the people • You need to • Read the scenario and the task very carefully • Take your time in planning an outline: header> body: each paragraph for an issue>footer • Never miss a component ( Example: your address, Tel,)

24. Written communication Example Page-1 Task This is a written communication skills station. You are to write a “Death summary” of a patient who has expired 3 -4 hours back, presuming that, it is an important document for ‘Death Review Committee’ of the hospital. Instructions: You shall have to complete the report within 200 words. You will find in patient’s file, chronologically, bridged notes of patient history and physical examination, investigation, treatment, follow up and death confirmation. Please write your code number as you start writing your report Time limit: 10 Minutes

25. Written communication Example Page-2 Check list Incorporates the following in the death summary Patient particulars, admission time and date Admission presentation: Provisional diagnosis and overall condition Immediate treatment on admission Diagnostic workup Diagnosis Intervention: Brief description with time and date Ongoing monitoring and progress of the disease Consultations and specialty opinions Situation before death(deterioration sequence) Time and date of death Cause leading to death

26. Surgical skills • This is for testing your surgical skills that are essentially the standard or recommended techniques you follow while performing a surgical procedure • You need to • Read the scenario and the tasks several times • Go by the written instructions at the station • Stick to standards of surgical skills, not you style • Go slow, but steady; ask for assistance

27. Surgical skills Example page-1 Procedure You will have to perform a basic surgical procedure on a stitching board using available instruments and materials.  Task: Close the incision made on the board by a ‘continuous interlocking’ suture considering it as planned skin incision Put surgeons’ knot at the beginning Put Aberdeen knot at the end Instructions: Introduce yourself with your Code number You don’t need to put on gloves Use 2/0 silk on curved cutting needle Ask for assistance Allotted time: 5 minutes

28. Surgical skills Example page-2 Check list Starting knot • Passes the needle at the end of the incision • Makes first throw with double twist • Makes second throw with single twist to make a reef/squire knot Continuation of suture • Enters the needle into the skin vertically- passes the needle along its long axis- exits at an identical point on opposite side • Keeps distance of entry/exit points from incision margins equal to its depth • Suture interlocks on side of the first knot • Keeps distance between the stitches equal and half that of depth of the incision wound • Maintains adequate tension approximating the wound margin End knot-Aberdeen • Stops the continuous suture at the other end by the final pass close to the just previous one and forms a loop without tightening • Passes several Aberdeen knots and adequately tightens by bedding those down • Makes final pass of thread through loop to end the knot and cuts it General considerations • Holds needle at the tip of needle holder 2/3 away from tip • Holds the wound margin with tooth dissecting forceps or skin hook while passing the needle • Holds the needle holder and forceps properly • Never touches the needle by hand

29. Conclusion • Surgeons need to become skillful in a number of areas in their practice • OSPE represents surgical practice • Stations are constructed from our daily experiences • Mindful observation during training period ensures a best preparation

30. Any question?