Fellowship

OSCE Preparation

Course Handbook

Version 2 2019

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Introduction

WelcometotheMonashHealthOSCEPreparationCourse.

ThiscourseaimstogiveyouguidanceandpracticeineachoftheOSCEstationtypesand

ultimatelyhelpyoupasstheexam.

YourperformanceintheOSCEshouldbetheculminationofyearsofworkintheED.

Preparationshouldnotinvolvetheacquisitionofnewbookknowledge,butratherhoningthe

skillsyouhavebeendevelopingsinceyoucommencedEDtraining.Ifyouarestillstudying,you

areprobablynotready.

Ourexperiencesofaristhatthisexamisentirelyreasonable(albeitchallenging),andifyou

approachitcorrectlymostAdvancedtraineesshouldhaveaprettydecentchanceatpassing.

Andweareheretohelpgetyouthere!

GoodLuck!

ThismanualwaswrittenbyDrJonDowlingforMonashHealth,2015.Adaptedfromthe

PrincessAlexandriaHospitalOSCEpreparationhandbook(2014)writtenbyDrJonathonIsoardi

andDrDarrenPowrie.UpdatedbyDrJuliaDillon(2019)withpartsadaptedfromtheSunshine

CoastHospitalOSCEHandbookbyDrJuliaHaire(May2017),andtheACEMwebsite.

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Contents

Page

EligibilityCriteria 4

ExamFormat 4

PreparingfortheExam 7

GeneralPerformanceTips 9

Stationtypes 12

Resources 28

MonashOSCEPreparationCourse 30

FellowshipExamEducationGroup 31

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EligibilityCriteria(fromACEM)

Candidatesmustmeetthefollowingeligibilitycriteriabyrelevanteligibilitydeadline:

• BearegisteredtraineeofACEM.

• HavenofinancialdebtstotheCollege.

• HoldcurrentregistrationtopracticemedicineinAustraliaorNewZealand.

• Havecompletedatleast36monthsofthe48monthsofaccreditedAdvancedTraining

timebeforetherelevantexaminationapplicationclosingdate(notincludingany

requiredremediationtime).

• Havesatisfiedthetraineeresearchrequirement.

• HavesuccessfullycompletedtheFellowshipWrittenExam.

ExamFormat

TheObjectiveStructuredClinicalExamination(OSCE)isaclinicaltestheldovertwoconsecutive

days.Theexaminationconsistsofavarietyofclinicalstationsbasedonscenariosthat

candidateswouldexpecttoseeaspartoftheirworkintheEmergencyDepartment–history

taking,physicalexaminations,communication,proceduralskills,simulations,resuscitation,

teaching,managingtheED,teamwork,casesynthesis,creatingmanagementplansand

interpretinginvestigationresults.Simulationorresuscitationstationswillnowbetestedina

single,ratherthanadoublestationasoccurredpreviously.VideoandwrittenexamplesofOSCE

stationsareavailableontheACEMwebsite.

Eachofthe12singleOSCEstationsare11minutes'duration.Thiswillincludefourminutesof

readingtimefollowedbysevenminutesofassessment.Ofthe12stations,therewillbea

minimumofoneofeachofthefollowingtypeofstations:

• Historytaking

• Physicalexamination

• Achallengingcommunicationsituation:patient/relative/staffmember

• TeamBasedSimulation

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• Teaching/advicetojuniorstaff

• StandardisedCase-BasedDiscussion

TheOSCEassessestheapplicationofknowledge,skillsandabilitiesdetailedintheeight

domainsoftheACEMCurriculumFramework,toclinicalscenariosthatcandidateswouldexpect

toseeaspartoftheirwork.

Theeightcurriculumdomainsare:

• MedicalExpertise

• PrioritisationandDecisionMaking

• Communication

• TeamworkandCollaboration

• LeadershipandManagement

• HealthAdvocacy

• ScholarshipandTeaching

• Professionalism

Theexaminationwillincludestationsthatinvolvethecandidateinteractingwithand/ortalking

toactorsorroleplayers,whomayplaytheroleofsimulatedpatients,teamleaders,nurses,

medicalstudents,etc.ortoFACEMConfederatesorexaminers,whomayplaytheroleofjunior

orseniorcolleagues.

TheVenue

Sofar,eachexamhasbeenheldattheAustralianMedicalCouncilNationalTestCentrein

Melbourne.ThisfacilityispurposebuiltformedicalOSCEs.

Therearemultiplesmallroomsthatareaboutthesizeofanoutpatientconsultingroom.They

canbesetupinseveralwaysdependingontherequirementsforaparticularOSCE.Notethe

roomsarequitesmallespeciallycomparedtoaresusbay.

TheroomsareconstructednexttoeachotherinaUshapesothatyouwillgointooneroomfor

astationandthenproceedtotheadjacentroomforthenextstation.

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Readingtime

Readingtimeisoffourminutesduration.Anelectronicscreenwilldisplayinformationabout

thestationandthesituationyoucanexpect,thetasksyouwillbeexpectedtoperformandthe

relativeweightingofthedomainsthatwillbetested.TheremayalsobepropssuchasECGs,

imaging,pathologyresults,observationchartsetc.Thesameinformationwillalsobedisplayed

insidethestation.Youwillnotbeabletotakenotesduringreadingtime.

Don’tbetooconcernedaboutrushing–4minutesisalongtimetoprepare!

Usethereadingtimetoreadthedisplayedquestioncarefullyandtoconsideryourapproachto

thestation.Considerwhatitisyouarerequiredtodoandplanyourapproachbeforeentering

theroom.Examinersreportthatsomecandidateslosemarkswhentheydonotperformallof

thetasksthatwererequired.

WhoisintheOSCEstation?

• TheExaminers-Theremaybe1to3examinersinthecorneroftheroom.They

generallydonotinteractwithyou,exceptfortheSCBD,andphysicalexamination

stations.OccasionallytheymayparticipateinotherOSCEsbutthiswillbeminimal.

• TheRolePlayers-thesemaybetrainedactors,medicalstudents,nursingstaffor

FACEMs.TheyaregivenSPECIFICinstructionsabouttheirroleandwhattheycansayis

limitedsoPAYATTENTIONtowhattheyaresayingandhowtheyaresayingit.Theyare

tryingtohelpyouprogressthroughalloftheOSCE.Theyarehelpfulbutwillshowno

initiative.

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PreparingfortheExam

1. ReadallinformationontheACEMwebsite(FellowshipExamResourcespage)relating

totheOSCE.Ensureyouarefamiliarwithallcollegerequirementsandprocesses,and

theACEMcurriculumframeworkanddomains.LookattheexampleOSCEvideos,the

examinermarkingsheetsandthereleasedOSCEexamfrom2016.1.Understandingthe

OSCEprocessandhowtheyaremarkedwillmakeabigdifferencetohowyouprepare

andyourperformance.

2. Committoanexamandworktowardsthat.From2018onwardsyouwillonlyhave4

chancestopasstheexamandthenyouareoutofthetrainingprogram.Giveyourself

thebestchancetodothisexamonlyonce.AttendallorganisedsessionsoftheOSCE

coursesoyoudonotmissoutonpracticeinanyoneOSCEtype.

3. Joinastudygroup.ThisisESSENTIAL.Youneedtopractisewithotherpeopleso

formingastudygroupof2-4peopleandregularlygettingtogethertopracticeOSCEs

andcritiqueeachotherwillmakeabigdifferencetoyourperformance.Youwillcover

lotsofOSCEsinthiswayandlearnalotfromeachother.

4. BefamiliarwiththeOSCEexaminationformat.Youshouldbewellversedinthe

essentialcomponentsoftheOSCEformatincludingwhatisrequiredduringreadingtime

andwithintheOSCEstations.Considertheroleoftheexaminers,theinteractionsyou

willhavewithothersparticipatingintheOSCE,thetimelimitationsandthevarious

typesofOSCEstation.

5. AimtodevelopyourskillsintheOSCEformat.Thisiswhatwemeanwhenwesayexam

successispartly“learningtoplaythegame”.Practisetheskillsyouwillneedduring

readingtime,suchascomprehension,pickingoutthekeypoints,beingfamiliarwiththe

ACEMCurriculumDomainsanddeterminingthefirstactionyouwillneedtotakeon

enteringthestation.SynthesisingalltheinformationcontainedintheOSCEstem(e.g.

clinicalcontext,yourspecificinstructions(tasks)andthedomainsexamined)isneeded

toallowyoutoplanandanticipateyourapproachduringeachstation.Bepreparedfor

additionalinformationthatisgivenand/orunexpectedissuesthatariseduringtheOSCE

whichwillalsoneedtobeaddressedwithinthetimeframe.Theseskillsneedtobe

practisedovermanyandvariedOSCEstations.

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6. Keepupyourknowledgeandlearnitinadifferentway.Theknowledgethatyouhave

gainedwhilststudyingforthewrittenexamwillnotbeenoughtopassthisexam.This

examteststheapplicationofthatknowledgeinadifferentway,aswellasotherskills

suchascommunication.Whenyouarerevising,dosoinawaythatwillbehelpfulfor

theOSCE.Foreverytopicthinkofhowyouwouldrunaresus,howyouwouldexplain

thatECGandwhatthemanagementofitwouldbe,howyouwouldexplainthatconcept

toajuniororhowyouwouldteachthatprocedureetc.Ingeneral,mostofthebook

studywillhavebeendoneforthewrittenexam.Itisimportant,however,tostay

abreastofanyrecentchangestoworkpractice,asthiswouldbefairgame.Forexample,

ifILCORortheARChasreleasedrecentchangestoresuscitationguidelines,youshould

knowthem!

7. Predictwhatwillbetested.

i) Corecurriculum–common,important,stuffnottestedinthewritten.

ii) Thinkofthechallenging“wetyourpants”momentsinEDandhaveanapproachto

managingthem.

8. Practise,practise,practise.Themoreyoupractise,thebetteryouwillbecomeandthe

morecomfortableyouwillbeontheday.

i) PractiseyourOSCEskillseachdayatwork.GetaFACEMtocritiqueyouwhilstyou

runaresus,takeahistoryorexamineapatient.Practiseyourteachingskills

wheneveraresidentpresentstoyou.WhenyoureceiveanECG/bloodgasorother

investigationfromthenursingstafforjuniormedicalstaff,youshouldpractise

describingandinterpretingittoyourjuniorcolleague.Youshoulduseeverypatient

interactiontopracticeyourcommunicationskills.

ii) Meetandpractisewithyourstudygroupregularly.

iii) TheweeklyOSCEsessionsareonlyonepartofyourpreparation.YouwillneedtodoadditionalpracticewithFACEMs,ideallywiththemanycollegeexaminerswehave

atMonashHealth.ItwillbeyourresponsibilitytoarrangetimewithSMS–mostof

uswillgladlymaketimeforyou,buttheorganizationisuptoyou.Ifyouareunsure

astowhichSMSwillassistyouwithpracticesessions,thelistonpage34ofthis

handbookisastart.

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9. Werecommendthatwhenpreparingforthisexam,youshouldideallybeworkinginone

ofthethreeEmergencyDepartments,asthisisthebestwayofensuringyouareinthe

rightheadspace.ItallowsyoutopracticeyourOSCEskillseverytimeyoucometowork.

10. Areyoureadytosit?Passingthewrittenexaminationshouldnotbeconsideredasan

indicatorofyourreadinesstosittheOSCE,astheOSCEassessesabroaderrangeofskills

andknowledge.Seekobjectivefeedbackfromyourtutors,basedontheirobservationof

yourperformanceinarangeoftrialOSCEstations,todetermineifyouareconsistently

reachingthe‘Above’or‘WellAboveStandard’inmostOSCEs.AttemptingtheOSCE

withoutevidencethatyouaremeetingthisstandardislikelytoresultin

disappointment.ExperiencehasshownthatbeingunsuccessfulintheOSCEcanhavea

significantimpactforyoupersonallyandonyourconfidenceinpreparingfor

subsequentattempts.

GeneralPerformanceTips

• Treatitlikeabigdayatwork.Becomecomfortablewithroleplay,andjustbehaveus

youwouldatwork.

• Readthestemcarefully.Everywordandphraseonthatstemhasbeenworkshopped

manytimes.Itisthereforareasonanditisimportant.Mosttimes,youshouldbeable

topredictwhatwillhappenonceinsidetheroom,basedontheclinicalstem.Whenyou

entertheroom,makesureyoupickuponallcues–theremayberesults,ECGs,x-rays

orotherpropsthatmaybeimportant.However,notallpropswillbeabnormal–be

preparedforanormalx-ray,forinstance,asthismaybethewholepointofthestation.

• Lookatthetasksyouaregiveninthestemandmakesureyouachievethoseinthe

OSCE.TrytoformastructureforeachOSCEinthe4minutesthatyouhaveoutsidethe

room.Thinkofthetask/syouneedtoperformandbreakthemdownintosectionsto

provideastructure.Ifyoucan,outlinethatstructureatthebeginningoftheOSCEasif

youdon’tgettosomethethings,atleasttheexaminerswillknowyouintendedto.

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• Lookatthedomainsbeingtestedandthinkabouthowyoucanconcentrateonthose,

especiallythemainones.Ifitsaysyouarebeingtestedonscholarshipandteaching,

youneedtoteach!Theexaminerswillbeassessingyouoneverydomainthatislistedon

theOSCEstemseparately.Itisnogoodperformingexcellentlyinonedomainwhile

failingatanother.E.g.Thereisnopointspending3minutescounsellingapatientto

stopsmokingifHealthAdvocacyisnotbeingtested.ACEMhaspublishedan“OSCE

DomainCriteria”documentoutliningmanyofthenon-medicalexpertisedomains’

markingcriteriafortheOSCE.Thisdocumentcanhelpyouinyourapproachtothose

domains.

• Betheconsultant!Thisisyourchancetoshowtheexaminersyouarereadytobea

FACEM.Youneedto“own”theOSCEandgivetheimpressionthatyouareincontrolat

alltimesandareunflappable.Takeyourtimewhentalking,pausetothinkandmake

sureyouphrasethingsasiftheyareYOURpractice/planetc.i.e.”MYpracticeisto

..........;MYmanagementplaninthispatientis.....;Ithinkweshould........”Ifthe

problemisdifficult/controversial,sayso-acknowledgesomemaydothingsotherways,

but“mychoiceis…”Examinerswanttoseeacolleagueconsultantwhoissensibleand

safe,notaregistrarwhohasreadalot.

• Prioritiseappropriatelywhenlistingdifferentialsormanagement.Remember,thisisa

consultantlevelexam.E.g.ifapatienthaschestpain,youwouldprioritiseanECGover

anFBE.Mentionearly:Lifethreatening/limbthreatening/mustnotmissdiagnoses,and

mostcommon.

• Staycalmandconfident.Nomatterwhattheroleplayerdoesorwhathappensinthe

scenariokeepgoingandremaincalm.Nevergetangryattheroleplayerorexhibit

frustrationattheprocess.

• Activelylistentotheconfederates/roleplayers.TheexaminationisanINTERACTIVE

processwiththeconfederates/roleplayersandcandidatesexchanginginformation

duringtheencounter.Candidatesareadvisedtolistencarefullytotheroleplayers’

responsesandquestionsandtoact/respondaccordingly.Intheirfeedbackto

unsuccessfulcandidates,examinersfrequentlynotethatthecandidatedidnotanswer

theroleplayer’squestionorignoredaprompt.Questionsandpromptsprovidedbyrole

playersaredesignedtohelpyoutoachievetherequirementsofthestation.

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• Beempatheticwiththepatients.Alwaysshowthatyoucareandbeconsiderate.

• Speakclearlyanddonottalktoofast.Theexaminersneedtobeabletohearand

understandyoutogiveyouthemarks.

• Considergoingtoaperformancepsychologistorspeechcoach.Theymaybeableto

helpyouwithtipsoncontrollingyournerves,slowingspeech,speakingmoreclearly

etc.

• Trytosummariseandthencoverthingsquicklythatyouhavenotgottentointhelast

minute.Summarisingallowstheexaminerstopickuponthingstheymayhavemissed

andgivesyouawaytomakesureyouhavecoveredallyourtasksthatyouneededto

achieveinthatOSCE.

• WhenyouwalkoutoftheOSCE,forgetaboutitcompletelyandfocusonthenextone.

Youdon’twantittonegativelyimpactonyournextstation.

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Stationtypes

Giventheformat,justaboutanythingcanbeaskedinthisexam.Ingeneral,theOSCEstyles

includedare:

1) Historytaking

2) Physicalexamination

3) Communication

4) TeamBasedSimulation

5) ClinicalSynthesis

6) Teaching/advicetojuniorstaff

7) StandardisedCase-BasedDiscussion

8) Procedures

9) Administration

Paediatricscenarioswillcompriseapproximately25%oftheexam,whichmaybeinanyof

theOSCEformats.

1.Historytaking

Inthesestations,youwillbeaskedtotakeafocusedhistoryfromapatient.Youarethenoften

askedtoexplainyourfindingsandyourmanagementplantothepatient(ora

resident/nurse/inpatientconsultantetc.).Ingeneral,youwillnotberequiredtoexaminethe

patient.(Youmayneedtopresentyourfindingsandresultingplantotheexaminer.Ifyoudo

thiswillbeclearlystatedinthestationinstructions/tasklist).

Thedomainsthatarelikelytobetestedinthesestationsare:Medicalexpertise,Prioritisation

andDecisionmaking,Communication,ProfessionalismandHealthAdvocacy.

Youarerequiredtodemonstratethatyoucan‘elicitathorough,relevantandaccuratemedical

history’ina‘focusedandtimelymanner’,‘whileacknowledgingthepatient’sotherexpressed

concerns’(ACEMCurriculumFramework).

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Youshouldbecomfortablewithtakingahistorybutrememberyouwilloftenhavetotakethe

history,explainyourfindingsandexplainyourmanagementplanallin7minutes.

Thismeansthatyoumusttakeafocusedhistorythat:

• Isadetailedhistoryofthepresentingcomplaint

• Exploresadifferentialdiagnosis

• Exploresrelevantpastmedicalhistory;medications;allergies;familyhistory

• Clarifiesyourlikelydiagnosis

• Clarifiestheseverityofthepresentation

• Coversriskstratificationofthepresentation

• Exploresdisposition(socialHx;additionalissues;risks)

Youalsoneedtobeawareofwhattasksyouhavebeengiveninthestemandyouneedto

achieveallthosetasksi.e.ifyoudoagreatandthoroughhistorybutyourunoutoftimeto

explainyourassessmentandyourmanagementyouwillgetgreatpointsforCommunication

andProfessionalismbutverylowmarksforMedicalExpertiseandHealthAdvocacyandmayfail

thatOSCE.

Paycarefulattentiontowhattheroleplayerissaying.Everythingtheysayisrelevantand

importantanddesignedtokeepyouontherighttrack.

LookatthePresentationsListintheCurriculumFrameworkforallthepresentationsyoushould

bepreparedfor.

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Thesearewhatwethinkarethehighyieldhistorytakingtopics:

Cardiorespiratory

Chestpain

Dyspnoea

Palpitations

Cough

Neurological

Dizziness

Vertigo

Headache

Syncope

TIA

Gastrointestinal

Abdominalpain

Diarrhoea(includinginthereturnedtraveller)

Jaundice

Dysphagia

UpperorlowerGIbleeding

Psychiatric

Suicideriskassessment

Mentalstateassessment

Paediatric

BRUE/ALTE

Febrileconvulsion

Limpchild

Fever

Other

Falls

Visualdisturbance

Backpain

Haematuria

Sexualordrughistory

Rash

Weightloss

Hypoglycaemicepisodeinadiabetic

Returnedtravellerwithfever

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TipsfortheHistoryTakingstations(andwhattheexaminersarelookingfor):

• Developandmaintainrapport

• Non-judgemental,empatheticapproach

• Assureconfidentialitywhereappropriate

• Listenactively

• Openendedquestions

• Respondtopatientsverbalandnon-verbalcues

• SUMMARISE

• Verbaliseplan,andreasoninginLAYlanguage

• Givethepatientopportunityforquestions–andaddressthose.

Forexample,thestemmaysay:

“MrSmithisa60yearoldmanwhohaspresentedwithintermittentchestpainsforthelast2

weeks.PleasetakeahistoryfromMrSmith,andcommunicateyourinterimmanagementplan

tohim.”

“So,MrSmith,itsoundslikethispainyou’vebeengettingisreflux,whichwon’trequireyouto

beadmittedtohospital.However,givenyourageandriskfactors,I’dliketodosometests

beforeweletyougo,whichwillincludeanECG,somebloodtestslookingatyourliver,pancreas

andbloodcount.Iftheyareok,thenwewillaskyourLMOtoarrangeanEndoscopy”

2.Physicalexamination

ThisisnotaShortCase.YouarelikelytobeaskedtoperformaFOCUSEDexaminationona

normalpatient.Inmostcasesyouwillbedirectlyobservedby,andexpectedtoexplainyour

examinationto,anexaminer.Youshoulddemonstratetheexaminationtechniqueratherthan

explainit.Youshouldtelltheexaminerwhatyouaredoing,andwhyitisimportantinthe

OSCE’sscenario.Youwillthenbepresentedwiththeexaminationfindingsandwillneedto

explainyourfurthermanagement.Insomecases,yourtaskwillbetoteachanexamination

techniquetoaresident/juniorreg.Inthatcaseyoushouldexplainanddemonstratetothe

confederatetheimportantelementsofarelevantfocusedphysicalexam,aswellasthe

expectedorimportantfindingsyouarelookingforinthatclinicalsituation.

Thereisoftenalottocoverinthesevenminutes.Listencarefullytotheprompts&instructions

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fromthepatient/confederate/examinerastheywillbetryingtohelpyoucoveralltherequired

tasks.

Thedomainsthatarelikelytobetestedinthesestationsare:Medicalexpertise,and

PrioritisationandDecisionmaking.

YouwillstillneedtostudyfromTalleyandO’Connorforthissectionoftheexam.However,the

examinationwillbeafocusedone,soyouneedtoadapttheTalleyandO’Connormethodto

onethatispracticalfortheED.Thiswillmeanyourphysicalexaminationwillcrossdisciplines

e.g.alimbexamthatinvolvesassessmentofneurology,aswellasmusculo-skeletal&vascular

elements.AndyouneedtopractiseyourexaminationsALOTsotheyareslickandyoucando

themonauto-pilotunderstress.Practiseonpatients,eachother,anyoneathome.Aska

FACEMtowatchyouandcritiqueyouwhenyouareatwork.

Youprobablyhavenotdoneaformalclinicalexamforsometime,andprobablyhavesomebad

habits.Youshoulddoatleastafewsessionswithyourstudygroupgoingoverthemainphysical

exams.

Theothermajorskillyouneedtopracticeispresentingyourfindingsinaclearandfocused

method–thisisharderthanyoumightthink.Dependingonthestem,youmaybepresentingto

theexaminerdirectly(whomaybeplayingthepartofacolleague)ortothepatient.The

languageyouneedtousewillclearlyvarydependingonwhomyouarepresentingto.

Donotforgethandhygiene,asepsisorpersonalprotection–anythingyouwoulddoatwork

shouldbedonehere.Ifthepatienthasa(simulated)wound,thenyouareexpectedtowear

gloves.

YoucanbeaskedtodoanyoftheexaminationsthatareinTalleyandO’Connorandyouneed

toprepareforthemall.However,theexaminationsthatwethinkarethehighestyieldare:

• Neuro(cranialnerves,upper/lowerlimb,cerebellar)

• Cardiovascular

• Respiratory

• Abdominal

• LimbsandJoints(e.g.neck,shoulder,hand,back,hip,knee,ankleandfoot)

• Gait

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TipsforthePhysicalExaminationstations(andwhattheexaminersarelookingfor):

• Addresspainanddiscomfort

• Maintaindignityandcomfortofthepatient

• FocusedyetthoroughEDrelevantexam

• Clearinstructionstothepatientwithbriefexplanationsofwhyyouaredoingwhatyou

aredoing

• Summarisefindings

• Discussexaminationfindings,differentialdiagnosesandtreatmentoptionsifaskedin

thestemandprovidepatientinformationaboutprosandconsifthereareafew

options.

• Explainplainlyinlayterms

• Givethepatientanopportunitytoaskquestions-takeanyquestionsorpromptsbythe

patientseriouslyandrespondtothem.

CombinedHxandExam

Youmaybeaskedtotakeahistoryandexamineapatientinthesamestation.Ifthisisthecase

thestemwillclearlystateyouhavetodoboth.Forexample“Apatientpresentswithkneepain.

Takeafocusedhistory,doafocusedexaminationandthenexplainyourfindingsand

managementplantothepatient.”GiventhetimerestraintsintheOSCEthistypeofstationis

unusual.

3.Communicationstations

EveryOSCEinvolvescommunicationbutintheseOSCEs,communicationisthefocusofthe

assessment.

Thedomainsthatarelikelytobetestedinthesestationsare:Medicalexpertise,

Communication,Professionalism,Healthadvocacy.

Itismostimportantwiththesestationsthatyoutakeanempatheticapproach,useappropriate

language,andsuccessfullycommunicatetheimportantinformationtothepatient/relative.

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Someexamplesofcommunicationstationsyoumustpractise:

• Breakingbadnews(diagnosis,complicationofprocedure)

• Obtainingconsentforaprocedure(fromthepatientortheparentofapaediatric

patient)

• Managementofanangryoragitatedpatientorrelative

• Complaintmanagement(maybecombinedwithangrypatient)

• Opendisclosureofanerror

• Dischargeagainstmedicaladvice

• Challenginginteractionwithcolleaguee.g.Difficultreferral,conflictresolution

• Dealingwithanimpairedcolleague

• Talkingtoastrugglingtrainee

• Explainingadiagnosis/result/procedureetc.(includingtoparentsofachild)

• Dischargeadvice

• DiscussingmanagementofafulldepartmentwiththeANUM

Sometemplateswhichyoumayfinduseful:

• Managingacomplaint:

o Empathetic,patientcentredapproach(rememberbodylanguage,

positioningofchairs)

o Developsandmaintainsrapport

o Opendisclosurewithearlyapology

o Non-defensive

o Doesnotblameanyone

o Multi-modalreasonsforerror

o Clearlyoutlinesplansforinvestigations,planforpreventioninthe

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future,andcommunicationofprogresstothepatient

o Addressespatients’concerns

• Impairedcolleague/trainee:

o Introduction,explainreasonformeeting

o Establishrapport

o Non-threatingandnon-judgementalapproach

o Reassurecolleague/traineeofCONFIDENTIALITY

o Activelistening,responsetoverbalandnon-verbalcues

o Allowthetraineetovoicetheirviewsandconcernsandgathernecessary

informationfromthem

o Enquireabouthomesituationandstressors(alcohol,drugs,relationship

issues)

o Facilitatereflection,insight

o Providefeedbackinaconstructivemanner

o Providesupport

o Summariseissuesandplantoaddressthem

o Makeaplan(involveDEMT/Directorasappropriate)

o Organisefollowup

TipsfortheCommunicationOSCEs(whatexaminerslookingfor):

• Introduceyourselfandshakehands

• Establishrapportwithpatient(includinggooduseofbodylanguageandeyecontact)

• Maintainconfidentialityandassurepatientofthis

• Startwithopenendedquestionsandkeepthisapproachforinitialquestioning

• Useappropriatelanguage(e.g.notmedicaljargon)

• Activelylistentopatientandresistinterruptingearly

• Respondtopromptsandnon-verbalcues

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• Conveyunderstandingandempathy

• Logicallyusesecondorderquestioningtofocusonanddifferentiatepresenting

problem/sorconcerns

• Avoidprematureclosure

• Repeatbackpartsofwhatthepatienthassaidtoconfirmlisteningandunderstanding

andtrytouseshareddecisionmaking

• Concludebyaskingforanyfurtherinformationthatthepatientwishestoconvey

ThebestwaytogetgoodattheseOSCEsistopractisethemoverandoveragain.Itisobvious

whichcandidateshavepractised.Practisetheminyourstudygroup,duringyourEDshiftsand

askFACEMstoobserveyouandgiveyoufeedback.Itisusefultohaveyourstudygroupfilmyou

doingthesestations,asyoumayidentifyweaknessesyouarenotawareof.

4.TeamBasedSimulation

Leadingaresuscitationteaminthemanagementofacriticallyunwellpatientisaquintessential

skillofanemergencyphysician,andthesimulationstationassessesthischaracteristic.

Domainsbeingassessedinthesescenariosinclude:Medicalexpertise,Teamworkand

collaboration,PrioritisationandDecision-making,Scholarshipandteaching.

Itislikelyyouwillbetaskedwithleadingaresuscitation,andhaveateamofstaff(e.g.a

registrarandanurse)toassistyou.TheconfederateswillberealEDstaff(notactors),sowill

havesomeexperience.Usuallytheywillhaveinstructionstofollowcommands,andhave

certainpromptstokeepthestationmoving(“Ican’tfeelapulse!”),butwillhavelimitedability

topromptyou.Theywilllikelybeabletoperformcertainproceduresunderyourdirection,such

ascannulation,venepunctureorinsertionofIO.

Mostofthemannequinswillbelowtomediumfidelity,butcanhaveproceduresperformedon

them.Mostofthetimeyou,asteamleader,willbedirectingtheconfederatetodothe

procedure(e.g.talkingaregistrarthroughanintubation).Occasionallytheconfederateswillask

youtoconfirmyourinstructions–thisdoesnotnecessarilymeanyouhavemadeanerror,but

wouldbenormalpracticeinarealresus(e.g.mostnurseswillbeexpectedtocheckadose

beforeitisgiven).

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Youwillbetestedonbothhowyoumanageaclinicalscenarioandhowyouleadateam.Your

communicationandprofessionalismmaybemoreimportanttoyoursuccessthanmedical

knowledge.Itisimportantyoucanplaceyourself“inthemoment”tomakethisscenarioasreal

aspossible,asitwillimproveyourperformance.Itisthereforeextremelyimportantyou

practisethistypeofscenario–westronglyrecommendthatyouareobservedbytheSMSdoing

thesestations,andagainausefulexerciseistofilmyourselfasthiswillidentifyareasof

weaknessthatyouarenotawareof.IdeallyyoushouldhavespenttimeintheSimcentreprior

tothisexam,butrememberthattheSimcentreuseshigherfidelitymannequinsthanthose

usedintherealexam.Youshouldknowandfollowascloselyaspossiblethemostrecentresus

algorithmsforadultsandchildren.

Someofthehigh-yieldtopics,inouropinion,are:

• Advancedlifesupport

o Shockablerhythm

o Non-shockablerhythm

o Specialcircumstances(pregnant,newborn,tox,hypothermia,

trauma)

• Post-resuscitationcare

• Standardintubation–needtobeslickatthis–mayformpartofanysimulation

• DifficultintubationorCan’tIntubate/Can’tVentilatesituation

• Troubleshootingventilationproblemse.g.asthmatic,suddenhypoxaemiainventilated

patient,settingup/modifyingtheventilatorsettings

• CVS/Respemergenciese.g.STEMI-thrombolysis/PCI;cardiogenicshock,massivePE,

tensionpneumothorax,tachyarrhythmias(unstablewideornarrowcomplex);

bradyarrhythmias(includingpacing)

• Haemorrhagicshock(e.g.massiveGIT,PPH)withMassiveTransfusionProtocol

activation

• Anaphylaxis

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• Pre-eclampsiaoreclampsia

• Seizures

• Precipitousbirthordifficultbirthe.g.shoulderdystocia

• Trauma–e.g.severeheadinjury,haemo/pneumothorax,penetratingchestinjury,

severepelvictrauma,abdominaltrauma,spinalinjury/neurogenicshock

• Toxemergenciese.g.TCAoverdose,snakebite

• Paediatricsimulations–e.g.anaphylaxis,asthma,Paediatricadvancedlifesupport,

Chokingchild/Foreignbody,Seizures,Septicshock,SVT,Trauma,Neonatalresuscitation,

Collapsedneonate

5.Clinicalsynthesis

Thisiseverydaypractice.IntheseOSCEsyouareusuallyaskedtointerpretinformation,history

andexaminationfindingsoraninvestigationandthenexplainyourassessmentand

managementplanoroptions.Youareusuallytalkingeithertoajuniordoctororapatient.This

isthemostlikelystationthatwilltestyourknowledgearoundpathology,ECGsandradiology.A

variationtothisstationinvolvesgivingphoneadvicetoanotherhealthprofessional.

Thedomainslikelytobetestedinthesestationsare:MedicalExpertise,Prioritisationand

DecisionMaking,Communication.

SomeexamplesofthesetypesoftheOSCEsare:

• Explanationofaninvestigationanditsimplicationstoajuniordoctor

• Explanationofanyinvestigationresulttoapatient

• Explanationofmanagementoptionstoapatient.E.g.ThrombolysisinSTEMIorstroke,

managementoptionsinspontaneouspneumothorax.

• Referraltoacolleague

Youshouldpractisefocuseddescriptionandinterpretationofcommoninvestigationse.g.ECGs,

X-rays,bloodgases,haematologyandbiochemistryetc.sothatyoucandescribethe

investigationandinterpretitinasuccinctmannertoajuniordoctor.Alsopracticeexplaining

theresultofaninvestigationanditsimplicationsorexplainingmanagementoptionstoa

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patientusinglayterms.Youcanalsocomeupwithtemplatesforreferrals,handoversand

dischargeinstructions.

TheECGOSCEontheACEMwebsiteisagoodexampleofthistypeofstation:ajuniordoctor

presentsapatienttotheseniordoctor(you)andhasanECGforyoutointerpret.Theexpected

responseistotaketheappropriateinfoyouarebeingpresentedwith,formulatewhatyour

workingdiagnosis/problemlistisandcommunicatethatbacktothejunior,alongwitha

managementplan.

Onekeycomponenttothesestationsiseducationofthejuniorstaffmember.Therearemany

waystoteach,butintheexamsettingyoushouldbeveryspecificabouthowyougoaboutit.

Whenpresentedwithasetofresultsbyaconfederate,itisnotacceptabletojustaskthe

confederatewhattheythinkoftheresults(the“wellwhatdoyouthinkofthis”approach)–this

isanexamandyouaretheonebeingtested.Insteadyoushouldtakethe“thisiswhatIthinkof

theseresults,andwhy”approach.

Forexample,whengivenaVBGthatisconsistentwithDKA,don’tasktheconfederatewhether

theyknowhowtocalculatetheaniongap.Instead,calculateityourselfandexplainhowyoudid

it.WhengivenanECG,don’tasktheconfederatewhethertheyknowwhattherhythmis,point

itouttotheconfederate(alongwiththeSTelevation,longQTandwhateverelseisabnormal).

TipsfortheClinicalSynthesisandCommunicationOSCEs(whattheexaminersarelooking

for):

• Summarisekeypointsfromthehistory,physicalexaminationand/orinvestigations

providedtoyou

• Verbaliseinterpretationofinformation,likelydifferential

• Verbaliseriskassessment

• Prioritisetreatmentsandactionsthatneedtobetakenandexplainthereasoning

behindyourprioritisation

• Useappropriatelanguage

• Givethelisteneranopportunitytoaskquestionsandrespondappropriately

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6.TeachingOSCEs

IntheseOSCEsyouareusuallyaskedtoteachajuniordoctorsomeaspectofEmergency

Medicine.However,itusuallyalsoincorporatesinterpretationofclinicalinformationgivento

youandformulatingamanagementplanforapatient.Forexample,ajuniordoctorhasjust

seenapatientwithatrialfibrillationwitharapidventricularresponseandwouldliketoknow

theapproachtopatientswithAFingeneralandwhattodointhispatient.

Thedomainslikelytobetestedinthesestationsare:MedicalExpertise,Prioritisationand

DecisionMaking,Communication,TeachingandScholarship

ThelistoftopicsinEMthatwouldlenditselftothistypeofquestionareinfinitesoagoodway

topracticeforthistypeOSCEistotryandimagineyouareexplainingconceptstoajunior

doctorwhenyouarerevisingyourEMsubjectmaterial.Thebestwaytodothat,whenyouare

revisingasubject,istotrytocreateastructuretoite.g.forexplanationoftheapproachto

patientswithAFyoucandivideitintoheadings-patientscompromisedbyrapidAF,rate

control,rhythmcontrolandanticoagulation.Youalsoneedtopracticeyourteachingand

communicationskillsfortheseOSCEsbydoingthemoverandoveragaintomakesureyou

rememberalltheelementsyouneedtocoverinateachingsessionasoutlinedbelow.

TipsfortheTeachingOSCEs(whattheexaminersarelookingfor):

• Firstestablishthejuniordoctor’sbaselineknowledge

• Outlineaplanfortheteachingsession/topicstobecovered

• Listenandcheckunderstandingthroughout

• Bepatienceandtolerantwiththelearner

• Correctmisconceptions,reinforcecorrectknowledge

• Specificandrelevantdepthandbreadthofknowledgeimparted

• Summariseimportanttakehomepointsattheend

• Answerquestionsthroughout

• AttheendoftheOSCE,thecandidatecouldrecommendthattheRMOreflectonthe

caseandfollowupwithfurtherreading(postexperientialreflection)

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7.StandardisedCase-BasedDiscussion(SCBD)

TheSCBDisaslightlydifferenttypeofstationandwillinvolvethecandidatehavingdirect

interactionwithanexaminer.ThepurposeoftheSCBDstationistoallowenhanceddepthof

assessmentwithinthedomainsofMedicalExpertiseandPrioritisationandDecisionMaking.

Theremaybeuptothreeofthesestationsineachexam.IntheSCBDstations,thecandidate

willbeaskedtooutlinetheirapproachtoassessmentand/ormanagementoftheclinical

situationpresentedandtooutlinetheirreasoningorrationalebehindtheirdecisionmaking,

whereaskedorrequired.Thecandidatewillbeaskedtorespondtofurtherinformationas

additionalinformationisprovided.Thecandidateswillbediscussingandanswering

standardisedquestionsdirectlytoanexaminerabouttheclinicalcasepresentedratherthana

FACEMroleplayer.Thecaseisdesignedtoexploreacandidate’sknowledgeandreasoning

throughdirectquestioning.Thereadingmaterialoutsidethestationwillclearlyindicatewhatis

expectedofthecandidate.

8.Procedures

IntheseOSCEsyouareaskedtoeitherdemonstrateaprocedureorteachaprocedure,usually

toajuniordoctor.AnyoftheproceduresontheProceduresListoftheCurriculumFramework

couldbeusedsopleaserefertothat.Mostprocedureswouldbedonewithaparttasktrainer.

Examplesinclude:LP,centralaccess,intubation,surgicalairway,chestdraininsertionorUS

guidedvenousaccess.ItisfairgametobeaskedtoperformaFASTorAAAscan.

Thedomainslikelytobetestedinthesestationsare:MedicalExpertise,Communication,

TeachingandScholarship.

Ifyouareperformingtheprocedureverbalisewhatyouaredoingthroughouttheprocedurein

astep-by-stepmannersotheexaminersknowwhatyouarethinkingandpreparingfore.g.in

planningforthedifficultairway,explaintoyourairwaynursewhatequipmentyouwant(and

why)andwhatyourplanA,B,Cetc.is.Showthatyouknowindicationsandcontra-indications

totheprocedure.Outlineandprepareforcomplicationsthatmayarise.

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Ifyouareteachingtheprocedurethenthereareextrathingsthatneedtobecoveredsuchas

gaininganunderstandingofthejuniordoctor’spreviousexperiencewiththisprocedure,ensure

thattheyunderstandyourinstructionsetc.

YoushouldpractisetheseOSCEsusingmannequinsandpart-tasktrainers.Foreachprocedure,

youshoulddeconstructthestepsinvolvedandpractiseexplainingittosomeoneelse,sothatit

comesnaturallyintheexam.

Lastly,don’tforgetconsentandpreparationwhereappropriateasafirststep.Andwashyour

hands!

TipsfortheProceduralOSCEs(whattheexaminersarelookingfor):

• Ifteaching,startwithaplanofwhatwillbecoveredduringthe‘session’;ifperforming

theproceduretalkaboutwhen,whereandwithwhomyouwillbedoingtheprocedure

• Obtaininformedconsent

• Ensurecomfortofpatientatalltimes;askpatienthowtheyaredoingthroughoutthe

procedure

• Departmentalawareness–ensurerestofEDokandsafetodoprocedureatthattime

• Rightpersonnelhelpingwithprocedure

• Indications/Contraindications

• Complications

• Equipment

• PPE/Sterility

• Patientpositioning

• Technique

• Howtotroubleshootcommonproblemsandavoidcomplications

• Post-procedurecaree.g.observation,dressings,analgesia

• Disposition

• Givethepatientorthestudentopportunitytoaskquestionsandanswerappropriately

• Ifteaching,ensureunderstandingthroughout

• Ideallyleavetimefortheroleplayertopracticetheskillwithyoursupervisionafteryour

demonstration

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9.Administration

IntheseOSCEsyouareaskedtoperformataskthatismoreadministrativeormanagerial.

TheseareoftendifficultOSCEsastheyaskyoutoperformtasksthatyoudonotdoonadaily

basis.Thismeansthatyouneedtoknowyourtheoryandhaveastructureortemplateinmind

totacklethese.

Thedomainslikelytobetestedinthesestationsare:MedicalExpertise,Communication,

PrioritisationandDecisionMaking,Professionalism,LeadershipandManagement,Teamwork

andCollaboration.

ExamplesoftopicsthatmaybeexaminedintheseOSCEs:

• AddressingflowofpatientsintheEDe.g.youhaveafulldepartmentandyouareabout

toreceive2cat1patients

• Formulatingorenactingadisasterplan

• Formulatingaguideline

• Formulatingaqualityimprovementplan

• AddressingovercrowdingandaccessblockThebiggestmistakethatcandidatesmakein

thesetypesofOSCEsistoconcentratesolelyonwhatcanbedoneintheED.Those

issuesareoftentheonesthatyoucanaddressthemostastheyarewithinyour

departmentbutyoualsoneedtothinkaboutthewiderhospitalandcommunityinyour

discussions.Remembertoescalatetohospitalmanagementwhereappropriate,witha

plane.g.“Contacttheexecutiveoncalltoaskthemtocancelelectivesurgery”

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Resources

RecommendedTexts

Inadditiontothetextsthatyouusedforthewrittenexamthe2othertextsthatyouwillneed

fortheOSCEare:

• TalleyN,O’ConnorS,ExaminationMedicine–aGuidetoPhysicianTraining

• RobertsJR,HedgesJR(eds),ClinicalProceduresinEmergencyMedicineisthegotobook

forprocedures.Whenyoupurchasethisbookyoualsogetaccesstoloadsofvideoson

linedemonstratingtheprocedures.

Web-basedResources

• GCS16–haslotsofpracticeOSCEs

• AdelaideEmergencyPhysicianssite:

http://acemfex.adelaideemergencyphysicians.com/oscehasloadsofpracticeOSCEs

• http://adelaideemergencyphysicians.com/2015/02/tips-on-the-new-acem-fellowship-

clinical-exam/isaniceoverview

• http://geekymedics.com/-meantformedicalstudentsbutthecommunicationskills

sectiongoesthroughstuffthathascomeupinthepreviousexamslikeexplaintothe

parenthowtoadministersalbutamolusingaspacer,Mentalstateexamination,sexual

historytaking.Nicethoroughsummaries.Clinicalexaminationsectionalsogoodfor

summaries,details(forextrabrowniepoints)onjointexamsandexaminationof

particularsystems.

• https://www.youtube.com/user/geekymedics123-goodvideosforclinicalexamination,

allabitlongbutusefulforrevisingtheimportantbitsandthenyouhavetopractice

makingthemshorterandslick.

• http://lifeinthefastlane.com/education/signs/moreexaminationvideos

• http://emcrit.org/podcasts/critical-care-palliation/essentiallisteningforpreparingto

doanyendoflifeconversations.(EMcritPodcast93)

• http://www.gcs16.com/osce-resources.htmlistheMonashsiteandhaslotsofOSCEs

topractice

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• http://topendexam.com/

• http://www.edexam.com.au/

• http://www.edcentral.com.au/

• https://emergencypedia.com/facem-exams-page/

Courses

• TEEMWORKrunsseveralFellowshipExamOSCEcoursesinMelbourne

http://teemwork.com.au/

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MonashFellowshipOSCEPreparationCourse

WewillberunningOSCEpracticesessionseveryWednesdayfrom10amto1pmatMMCfor

thoseregistrarswhohavecommittedtosittingthenextexam.Everyweekwewillfocusona

differenttypeofOSCEstationbutwecanalsoadaptthesessiontotheindividualneedsofthe

candidates,especiallyaswegetclosetotheexam.

WewillrunafulltrialOSCEbeforeyousityourexam.

Thistimetableisaguideonly.ForthemostuptodatetimetablerefertoGCS16.

Week1 IntroductiontoOSCEcourse

Week2 Historytaking

Week3 Casebaseddiscussion

Week4 Procedures

Week5 PhysicalExam

Week6 Communication

Week7 Teaching

Week8 Investigations/Admin

Week9 Simresus

Week10 SkillsDay-practise"TeachingOSCEs"

Week11 MonashTrialOSCE

Week12 Clinicalsynthesisandcommunication

Week13 Casebaseddiscussion

Week14 Revision

Week15 Examweek

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FellowshipEducationGroup

ThiscoursehasbeenarrangedbyDrJuliaDillonandDrDianeFlood.Wesincerelyhopeitis

helpfultoyourexampreparation.

OtherMonashHealthconsultantswhoarewillingtoassistwithOSCEpractice:

ACEMexaminers:

DrSheilaBryan

DrDannyBen-eli

DrAndreVanzyl

DrMichaelComan

DrChristinaFong

Prof.AndisGraudins

OtherFACEMs:

Dr.LisaVallender

DrPreetiRamaswamy

DrShemmaHasanovic

DrSuzanFox

DrParyaFadavi

DrSarahMikhail

Anyproblems,questionsorfeedbackpleasedonothesitatetoemailmeorgivemeacall:

Dr.JuliaDillon

Email:Julia.Dillon@monashhealth.org

Ph:0413276120

GOODLUCK!