SAHCSSStage1M/OSCEsAdviceandPrep

TheExamination(SetUpInstructions,Marks,Preparation)
AnOSCEexaminationisaseriesoftimedstationsthatstudentsrotatethroughoneafterthe
other.Ateachstation,youwillcarryoutaparticularclinicaltaskandtherewillbeanexaminer
whowillassessyourperformanceusingspecificmarkingcriteria.Therewillusuallyalsobea
patientorpatientactorpresent,dependingonthetask.Youwillmostlikelybegivenaprompt
beforeyouentertheroom,whichwillexplainyourtask.Thetaskwillusuallybequitespecific.
Mostoftenyouwillbeaskedtosummariseandrelayyourfindingstoanexaminer;atothers
timesyoumayberequiredtowriteoutyouranswer.
ThisyearintheSMPtherewillbe6activestationsforStage1.Therecanbeextrareststations.
Thetimeallocatedtoeachstationis8minutes,including1minutetoreadaprompt,6minutesto
carryoutthetask,and1minutetosummariseyourfindingsandansweranyquestionsfromthe
examiner.Seehereforinformationregardingmarkingcriteria.
AtthispointinthecourseOSCEsareusuallyusedtoassessbasicclinicalskills,concentrating
oncorrecttechniqueandappropriatecommunication,ratherthanmorecomplexinterpretationof
symptomsandsigns.Mostpatientswillhaveonlyafewabnormalsigns,ornoneatall,and
simplehistories.
Youshouldbepracticingyourclinicalskillsasoftenaspossible,evenifitisathomeorwith
otherstudents.Itisthebestwaytobecomemorecomfortableandconfidentinanyclinical
situation.Trytogettoapointwheretheyaresecondnature,soyoucomeacrosscomposedand
polished.Youwillbelessnervous,abletothinkmoreclearlyaboutclinicalquestions,andabove
all,morequicklygaintheconfidenceofboththepatientandexaminer.
TypesofStations

Takingahistory
Physicalexamination
Demonstratingaproceduralskill,ortalkinganexaminerthroughone
Datainterpretation
Explainingtheuseofadeviceormedicationtoapatient(eg.correctinhalertechnique)

AbsoluteEssentials
Theseareincrediblyeasymarkstopickup,andaredefinitelossesifyouforgettodothem.
RemembertheacronymWINCER.
1. Washhandsusuallywithalcoholrub,immediatelyasyouentertheroom,andjust
beforeyouleaveeachroom(yes,youwillwashyourhandsmanymanytimes)
2. Introduceyourselfexplainwhoyouaretothepatientandexaminerifappropriate
3. Noticebeobservantofthesurroundings(inparticularlookforinstrumentsoritemsfor
cluese.g.ameasuringtape,inhalerorboxofcigarettes)
4. Consentexplainwhatyouplantodoandaskforconsentfromthepatient
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5. Expose(aftergainingconsent)exposetherelevantpartofthepatientsbodyforan
appropriateexamination
6. Reposition(aftergainingconsent)repositionthepatientintotheappropriatepositionif
necessaryfortheexamination
Regardingexposure,alwaysfirsttellthepatientthatforathoroughexamyouwillneedto
expose(x)partoftheirbodyfor(x)reason(bespecific,e.g.Iwillneedtoexposeyourchest,
boththebackandfront,fromthewaistup,soIcanfeelforandlistentoyourbreathing),and
thenaskifthatisokay.Insomesituationstheexaminerwillstopyouatthispointandtellyou
thatthisisnotnecessary,andtoproceedasthepatientis,orwithanalteration.Thesefrequently
includemusculoskeletalexams,suchasanexaminationofthehip,whereapatientwillleave
shortsortheirunderwearon.Inallinstancesmaintaindignityofthepatientandalwaysrecover
thepatientonceyouhavecompletedtheexamination.
GeneralThingstoRemember

Dontbelate!OSCEsaretimedtotheminutesotheywillabsolutelystartwithoutyou.
Beingearlyalsohelpsyouestablishsomecomposurebeforeyoubegin.
Dressappropriately(clinicalattire).Ensureyourclothingiscomfortable,conservative
andeasytomovearoundin.Avoidloosejewelleryorotheraccessories.
Wearawatch.
WearyourhospitalIDbadge(clippedsomewhere,notdangling).
Ifthereareglovesavailableintheroom(usuallyforallphysicalexamsorprocedures)
putthemon!
Placeyourstethoscopeasideifitisnotneededforastation.Trynottoleaveitdangling
aroundyourneck.Ifyouknowyouareveryforgetfulandmaywalkbackoutoftheroom
withoutit,atleasthooktheendstogetheraroundyourneck.
Avoidannoyinghabits,likeyawning,slouching,tappingyourkneeorchewinggum.
Claspyourhandstogetherifyouknowyoufidgetorfiddle.
Rememberyoursharpssafety.
Alwaysreadtheinstructionscarefully,anddontwastetimeonaspectsthatarenot
relevanttoyourparticularstation(e.g.donotexamineapatientshandsandfaceifyou
havespecificallybeenaskedtoonlyexaminetheirchest).
Ifyouhavetimeleftafterreadingyourprompttrytostartformulatingageneralplan,as
wellasanopeningfewsentences.Beingconfidentinyouropeningremarksmakesa
goodimpression.
Bepoliteandconsideratetoanyoneinvolvedinorganisingorrunningthestations,in
particularpatients,astheycanoftenberealpatientsvolunteeringtheirowntime.Patients
maysometimesbeaskedtheiropinionofyouattheendanditobviouslylooksverybad
ifyouareeverrudeorrough.
Whentalkingtothepatient,trytousesimpleandlaymanterms.Whenaddressingthe
examiner,usemoremedicaljargonifappropriate.
Ifyouwantto,askifitisokaytowritenotesasyouexamineorcollectahistory.Itisa
goodskilltodevelop,andishandywhenpatientshavemorecomplicatedtimelines.It
willalsomakeiteasiertosummarisethecasefortheexamineriftheyaskyouto.There
willbepaperandapensuppliedforyou.

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Tryandmovequicklyandefficiently(youdohavelimitedtime),butdontrushsofast
thateitheryoudistress/annoythepatient,oryouactuallymissvitalsignsoraspectsofa
history.Thisiswherepracticeandconfidenceareimportant.
Treatsimulatedpatients(i.e.otherstafforstudents)asiftheyweregenuine.
Trytodeveloparapportwiththepatient.Treatthemwithrespectandtrytomakethem
feelcomfortable.
Speakclearlyandconfidentlytoboththepatientandexaminer.Trytomaintaineye
contactwhenaddressingeitherparty.
Ifyouareaskedquestionsbytheexaminer,alwaystakeamomenttoconsideryour
answercarefullydontjustblurtoutthefirstthingthatcomestomind.Dontbescared
ofafewsecondsofsilence.Besuccinctandspecificinyouranswers.
Ifyourunoutoftime,orknowthatitisnotfeasiblegiventime/space/equipment,tellthe
examinerwhatelseyouwouldliketoaskorexaminetocompleteyourassessment,eg.a
morethoroughfamilyhistory,bloodpressurereading,oraspecialtestina
musculoskeletalexam.
Thankboththepatientandexaminerwhenyouhavefinished.

HistoryStations
TakingafullycomprehensivepatienthistoryinanOSCEisgenerallynotfeasible.Theprompt
foryourstationwillmostlikelyguideyoutowardappropriatelinesofquestioning.Itisusefulto
followalogicalandrelativelystandardstructure(suchasthatbelow)tokeepyouontrack,but
youdoneedtoacquiretheskillofrecognisingthepertinentquestionstoaskgivenaparticular
historyorpresentingcomplainte.g.enquiringaboutmorningstiffnessinsuspectedrheumatoid
arthritisoranoccupationalhistoryinsomeonewithhaemoptysis.
1. WINCER
2. Patientsnameandage
3. Historyofpresentingcomplaint
Firstaskopenendedquestionsandallowthemtoexplainintheirownwords,thenask
moredetailedquestions
UseSOCRATES,particularlyforanykindofpain
Anyothercomplaintsorconcurrentsymptoms
4. Pastmedicalhistory
Previoussimilarepisodes/symptoms
Previousdiagnoses,illnesses,operations/procedures,hospitaladmissions
Consideraskingspecificallyfor:heartconditions,highbloodpressure,high
cholesterol,diabetes,asthma,COPD,kidneydiseaseorpreviousstrokes
5. Familyhistory
Parentsillnesses,andifappropriate,ageat/causeofdeath
Healthofchildrenandsiblings
Seconddegreerelatives
6. Social/D&Ahistory
Drughistoryprescribed,overthecounterorillicit(alsoconsiderqueryingrouteof
administration,complianceandwhatthepatientisactuallytakingthemfor)
Homeopathic/alternativeremedies
Alcoholconsumption
Smokinghistoryandanyquitattempts
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 Allergies
Impactofillnessonfunctionwork,physical,psychological,spiritual
Livingarrangements
Sexual,travel,vaccinationandoccupationalhistoriesifappropriate
7. Systemsreview(iftime)
Systemicsymptoms(Bsymptoms),musculoskeletal,respiratory,cardiovascular,
neurological,genitourinary,gastrointestinal
8. Finally,askthepatientifthereisanythingelsetheywouldliketotellyou,orthatthey
feelisimportantforyoutoknow.
Forprediagnosedconditionsyoushouldconsiderobtainingfurtherinformation,suchas:

Dateofdiagnosis
Howwasitdiagnosed
o Bywho
o Whatsymptomspromptedthediagnosis
o Investigationresults
Treatmentshowlongforandaretheyhelping
Hospitaladmissionsforcondition
Monitoringeg.bloodwork,peakflows

TipsforHistoryTaking

Keepthelineofquestioningappropriatetoyourtaskanddontgetdistractedeg.ifyour
taskistotakeahistoryofsuspectedosteoarthritis,andapatientrevealstheyhavehada
previousmyocardialinfarction,donotspendhalfofyourremainingtimeenquiringabout
cardiovascularriskfactorsanddisease(unlessyoubelieveitisthatrelevant).
Obviouslytheaboveschemashouldbetweakedasyoulearnmoreaboutthepatient,andnot
followedprecisely.Withlimitedtime,itisimportanttogettothebigquestionsthatarereally
necessaryforaparticularpresentation.Forinstance,itwouldbecriticaltoaskaboutallergies
inalmostanyrespiratoryhistory,thoughperhapsnotasimportantinahistoryoffootpain.
Thatdoesntmeanyoushouldntaskthemifyouhavetimeandremember,justthatyou
shouldkeepinmindthequestionsyoureallywantananswerfor,comparedtojustbeing
thorough.

PhysicalExamination
Liketakingahistory,youshouldknowthespecifictypesofsignsyouneedtolookforinan
examination,whilstatthesametimefollowingageneral,structuredexaminationschema.
GeneralExaminations:Resp,Cardio,Gastroetc.
1.
2.
3.
4.
5.

WINCER
Inspection(generalthenspecific)
Palpation
Percussion
Auscultation

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GeneralMusculoskeletalExaminations
1.
2.
3.
4.
5.

WINCER
Inspection(generalthenspecific)+/screeningtest(look)
Palpation(feel)
Move(activeandpassive)
Specialtests

TipsforPhysicalExams

Alwaysexaminefromthepatientsrighthandside.
Alwaysremembertocomparebetweenleftandright.
Explaintothepatientthatyoumaytalkaboutthemtotheexaminerasyougoalong,and
attheend.
Besuretoguideyourpatientthrougheachstepasyougoalong(brieflyandsimply,
keepinginmindtimeconstraints),astheymayhaveneverbeenexaminedbefore.In
particular,letthepatientknowwhenyouareabouttotouchthemandinwhatway.
Alwaysaskthepatientiftheyarecomfortable,andiftheyareinanypain.Tellthemto
alertyouiftheyeverfeelanypainthroughouttheexamination.Watchtheirfaceforsigns
ofdiscomfort.
Itisagoodideatobrieflywarmyourhandsifyouknowtheygetcold.Thisisalsotrue
foryourstethoscope.
Makeitcleartotheexaminerswhatyouarelookingfor,howeverdontjustsayyoure
lookingforsignswithoutactuallyregisteringiftheyappear.Actuallylookforthemand
remembertocommentonrelevantfindingswhenpresenting.
Whenpalpating,dontjustrandomlyprodaroundintheareayoushouldroughlybein.
Youshouldhaveanappropriateandsystematicpalpationtechnique(generallyusingthe
padsofyourfingersandworkinginonedirectionatatime).Youshouldknowthejoints
andstructuresyoushouldbefeelingforateachpoint.
Ifyouforgetpartofyourexaminationroutine,quietlytryandfititinatthenext
appropriatemoment.Donthighlightthefacttothepatientorexaminers.Yougetthe
marksnomatterwhatorderyougoin.

ProceduralStations

Thesestationsmayincludeanythingfromperformingaprocedureonamannequin(e.g.
cannulainsertionorBLS)toexplainingtheuseofamedicaldevicetoapatientorthe
examiner(e.g.peakflowmeasurementoroxygentherapy)tointerpretingasetofresults
(e.g.chestxrayorbloodfilms).Thesestationscanbeconcludedwithscientific,clinical
orethicalquestionsregardingthingsliketechnique,consent,complicationsoreven
relevantanatomy.
Youshouldfollowtheguidelinesgiventoyouduringyourproceduralskillssessions.
Ifyouaresuppliedwithasetofdata,workthrougheachaspectsequentially,commenting
ontherelevanceasyougo,thencometoaconclusionattheend.Forresultslikexrays,
ABGsandbloodresultsyoushouldestablishaneasytoremembersystemthatyouwork
throughstepbystep.
Rememberforanyemergencysituations:

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o Dangercheckforyourownandthenthepatientssafety(lookforcords,sharps,
fluids,bedlocksetc.andalwaysputongloves!)
o Responseusephysicalandverbalstimuli
o Sendforhelponwardfindthecrashcallbuttonoryellforhelp;inthewildcall
000
o Airwayensurefreeofforeignobjectsorfluids,headtilt
o Breathinglook,listenandfeelfor10seconds
o Circulationcheckforpulse;30:2(rateof100compressionsperminute)
continuinguntilhelparrives
o Defibrillateattachandfollowinstructionsasrequired
ForCPRmakesureyouknowthecorrectrate,depthandtechniqueforcompressionsandwhatto
doifrespiratorysupportdevicesareavailable.Ensurethepatientisinthecorrectpositionandat
anappropriateheight.UsethebeatofNellytheElephantorStayinAlivetoregulateyour
rhythm(Iexpectthe2014revuerstonailthis).
Presenting

Ensureyouhavepracticedpresentingacasetosomeoneelse.Thisisimportantfor
practicingsuccinctness,confidence,andsimplygettingusedtohearingyourownvoice.
Trytobeprecise,e.g.thepatienthaddecreasedbreathsoundsinthelowerleftlobe
ratherthanbreathsoundsseemedliketheymaybealittlequieterontheleftside.
Trytohighlightpositivefindingsandsummarisenegativeones.
Presentfindingsinalogicalorderifunsure,itisusuallyeasiesttosticktotheorderof
yourexamination.
Avoidterminologythatpatientsmayfindoffensiveordistressing,e.g.usehighBMI
ratherthanfat,orneoplasiaratherthancancer.
Donotovercomplicateyourpresentation,oraddininformationthatisntrelevanttoyour
specifictask,i.e.dontcommentonheartsoundsifyouhavespecificallybeenaskedto
examinetherespiratorysystem,anddontbeginmakingdiagnosesorrequesting
investigationsunlesstheexaminerasksyouto.Youwillnotgetextramarksandwillonly
wastetime.

TL;DR
Iknowthatthisisalotofinformation,andalotofitmayseemwaytoodetailedoreventoo
obviousorintuitive.Takefromitwhatyouwillitiscompiledfromavarietyofsourcesand
studentsoverthepastyearorso,andIjustthoughtitmightbehelpfulforsomeofyou.
Themostimportantthingstotakeawayare:

Dontbelate.
Dressappropriately.
WINCER.
Berespectfulandpolitetoeveryoneinvolved.
Followastructuredhistoryandexaminationschema,addinginquestionsortestsyou
knowarerelevantforthatclinicalsituation.

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Ifyoufreakoutthatyouknownothingaboutthestationyouwalkinto,gobacktothe
basicprinciplesofhistoryandexaminationnotonlywillthisalonegetyoumanyofthe
marks,butyouwilllikelyrelaxandsparksomerecall.
o HPC,PMHx,FHx,SHx
o Inspection,Palpation,Percussion,Auscultation
o Look,Feel,Move,SpecialTests
Dowhatyoucaninthetimeallowed.Trytobeefficient,ratherthanjustfast.
Soundsstupid,buttrynottobenervousorintimidated.ParticularlyintheMOSCEs,we
haveallbeenwhereyouarebefore,andhavealmostdefinitelymadesilliermistakes.And
wehaveneverrememberedtodoabsolutelyeverything.

Resources
SMPOSCEAssessmentPagehttp://smp.sydney.edu.au/compass/teachingactivity/view/id/6753
StudentCreatedOSCESchemashttp://www.sydneymedsoc.org.au/resources/osces/

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