Yasmin Sultan FRCEM OSCE practice 21918 What well

Yasmin Sultan FRCEM OSCE practice 21/9/18

What we’ll cover �This is probably you at the moment! �I will give you a structure to aid your revision Types of OSCEs you will get How to approach & practice for each How the marks work And then we will practice in groups of 3.

Types of OSCE � 1. Joint examination � 2. History taking � 3. Breaking bad news � 4. Psychiatry � 5. Resus scenarios � 6. Paediatrics � 7. Procedures � 8. Miscellaneous Teaching is incorporated into (some) of these to add an extra element, eg, procedures & examinations

Joints & Histories � 1. Examination -1 per exam Joints, face, hands. Often includes teaching element. Ensure you do some (relevant) special tests. � 2. History taking –about 4 per exam Chest pain, abdo pain, headache, back pain etc You need to be thorough –take a medical student history � with a full Systems Review. Up to 25 marks for questions Include your differential diagnosis, management plan & allow time for questions –about 10 marks! “Difficult” histories: Sexual history (signpost!) travel history, urology Hx, back pain. Maybe Acute confusional state, with MMTS?

BBN & Psychiatry -1 of each � 3. Breaking bad news Easy –find out what they know, let them talk, use silence (once!), summarise, explore their wishes. Then summarise Mx (using any image provided, eg CT) and if asked to, mention organ donation. � 4. Psychiatry Mania (challenging), depression (and screen for domestic violence, suicidal ideation), psychosis, alcohol/drug abuse. Always ask about suicidal ideation, drugs, alcohol Be prepared to summarise in 30 seconds –learn the terms to describe each presentation, eg “evidence of thought withdrawal, thought insertion” “pressure of speech” etc Usually you are asked about management if they want to leave (state no capactity) & what section of MHA you would use.

5. Resus scenarios � 5. Resuscitation Scenarios- 2 per exam, double stations. 17 minutes each. Almost always one APLS. A LOT of content to get through –move fast. May include interpreting a ABG or CT & referral/explanation to family. 1 mark for each. Total marks about 35. You will be team leader for one –prime your team with intros, establish skills, allocate roles. At some point you will need to be hands-on though, eg talk through how you do a chest drain, apply a splint etc. You don’t need to pass them to pass overall though.

6. Paediatrics � No actual kids are used, but paeds forms 25% of exam, so either Resus Sims, or communication skills OSCEs: APLS Neonatal resuscitation ▪ Throws you! Worth having a look at it before your exam. Talking through Mx with parent ▪ Newly diagnosed Addison’s, asthma discharge, D&V, etc Dealing with a missed fracture ▪ Communication, explanation to parent. Suspected Non-accidental injury. Challenging scenario! ▪ Scenario should make it obvious this is NAI. Retake history, then get facts –who has been caring for child, known to Social services, siblings, say need ages, names, schools, etc. ▪ Explain Mx of injury. ▪ Explain that this is suspected NAI & you are legally obliged to investigate, admit, refer to SS & Paeds etc.

7. Procedures -1 per exam � 1. Ones you actually do: Aspiration of pneumothorax, male catheterisation, suturing, pelvic � examination & removal of FB –all of these on mannikin. 2. Ones you just talk through, ie teach (to ENP, student etc) femoral nerve block, digital nerve block, haematoma block, arterial line insertion, use of airway adjuncts. X-ray interpretation, eg C spine. � Options are limited by equipment available at the College, and by the fact that the scene needs to be reset for the next candidate in just 1 minute. � “Teaching” involves adding the following to the basic OSCE: find out what they know, & set objectives for session do the actual procedure, examination etc, in an interactive way Summarise what you’ve told them (if time –ask them to summarise!) Check for questions, answer questions (they always have one) –quickly! Set them some targets for practice /learning, and review later –or can do this at start of OSCE � You need to move fast to get through all this. People who like teaching run out of time � � �

8. Miscellaneous -1 per exam � 1. CDU ward round- ▪ Listen to histories of patients (3) presented by FY 1. Identify any issues with management & give plan to FY 1. Try to avoid saying you will see patient yourself. All will have management pitfalls. ▪ Eg: head injury in alcoholic(? neck CT), eg asthma (as per BTS) eg OD (now wanting to leave), eg Abdo pain young female (? preg test). � 2. Triage of multiple patients ▪ limited departmental resources- talk through how you prioritise & use your limited resources. Supposed to test the sort of skills you need to run the Department. Eg 5 patients in ambulance bay, you give Nurse in charge a plan for each, hampered by an argumentative manager! � 3. Major incident /CRBN – ▪ talk through Mx of department/incident. Requires some knowledge of processes. Refer to your local practice “in my Trust. . . ” Use a framework to think through issues.

The candidate information & pie chart: “clinical reasoning decision making” This means your differential diagnosis, and management plan. � History taking � Communication skills This means asking the patient if they have any questions, & answering them (and in this case, sign-posting SI history and taking history professionally). � You may also see: � Team leadership � Resuscitation skills � Examination skills � Practical skills Try to look at it and memorise what you are expected to do. If your examiner suggests you look at it again, you are off-track.

Any questions so far?

OSCE demo �An 8 minute OSCE with a volunteer �The candidate information and the mark scheme will be available to the audience.

Demo � Candidate information: � The patient has been brought by the police after she tried to climb a lamppost while singing operatic songs in the town centre. She states she is a professional singer.

Demo OSCE � Mark scheme

Tips for Psych OSCEs �Only 5 possible OSCES –practice them all. �Memorise key phrases to describe symptoms of: Mania Psychosis Depression (& ask about DV, alcohol abuse) �Always ask about suicide, PMHx, substance use. �Practice asking the questions while your revision partner tries to be as distracting as possible! �Practice your summary for each condition.

OSCE PRACTICE:

What we are going to do: �Get into groups of 3 � 1 of you is candidate, 1 is actor, 1 is examiner �Actor –read your briefing info. �Candidate instruction -1 minute to read it. �Off you go. . �Examiner please make notes on what goes well & badly –maximum of 3 learning points for the candidate per OSCE. Advise them what they need to practice.

OSCE 1 �Candidate Instruction; �Arthur Johnson is 13 months old. He has been brought to the ED by Jade, his mother, as he is not using his left arm. She denies any history of trauma. �An XR shows a transverse fracture of the humerus which is very suspicious for NAI. �Take a history and determine a management plan

OSCE 1

OSCE 1 Mark

OSCE 2 �Candidate Instruction: You are the only registrar in the ED starting the 8 am day shift. The other Reg is off sick and your Consultant is at a meeting. There are 15 majors patients and 20 minors patients waiting to be seen. You have an Observation ward with an FY 1. Do a board round with the FY 1, giving him a management plan for each patient.

OSCE 2

OSCE 2: Marking scheme

OSCE 3 � � Candidate instruction You are asked to see Mr David Anderson, a 52 year old businessman who is visiting Cambridge today. He tripped on the pavement and injured his ankle and was brought to the ED by ambulance. He has not had analgesia in the ED. � An ENP saw him and has thoroughly examined his ankle as per the Ottawa Ankle Rules. There is no bony tenderness but there is swelling and tenderness over the anterio-talo-fibular ligament, consistent with a sprain. The ENP explained that he does not need an x-ray and offered him crutches & discharged him. You have seen the notes & spoken to the ENP and are satisfied that this injury has been assessed properly. � The patient has told the waiting room nurse that he is not happy and wants to see a doctor. He is reportedly quite angry. � Please talk to him to resolve his issues.

OSCE 3 �¾ communication �¼ clinical reasoning /decision making

OSCE 3

OSCE 4 �Candidate Instruction: �Kate is a 45 year old lady with bleeding in early pregnancy. �Take a history from her and make an appropriate management plan. �¼ history taking �½ communication skills �¼ clinical reasoning /decision making.

OSCE 4

OSCE 5 –candidate instruction �Jo is a trainee ENP in your ED. He/she has seen a patient with a colles fracture of the left wrist. �Teach Jo how to perform a haematoma block to manipulate a colle’s fracture. �Communication: 1/3 �Practical skills: 2/3

OSCE 5

OSCE 6 �Task: Mr Jones has injured his right hand. He has been examined by one of the medical students. Teach the medical student how to examine hands, and discuss further management. 1/2 examination ¼ communication ¼ clinical reasoning /decision making

OSCE 6

OSCE 7 �Task: Harry Peters is a 60 year old man who has dislocated his right shoulder when he fell down some steps today. Explain the injury and how you are going to reduce it (with sedation) and consent him for the procedure. You do not need to examine him.

OSCE 7

OSCE 8 �Candidate instruction: �Miss Harris is a 30 year old woman who has come to the emergency department with abdominal pain. �Take a history from her and discuss further management with her.

OSCE 8

OSCE 8

OSCE 9 � 1/3 history � 1/3 communication � 1/3 clinical reasoning /decision making

OSCE 9

Now you’ve practised. . .

How to revise for the OSCE �Practice in groups of 3 or 4 �Time yourselves and give feedback �If communication skills OSCEs are your worst area, memorise phrases. �For history taking, ask every question you can think of. Test each other on “difficult” histories, eg haematology, urology, vascular, ID. �Make sure you can teach & complete an examination in 6 minutes. �Unless told not to, always take a bit of history and summarise the management.

Where to find OSCEs

Any Questions?

Summary � We have covered: Types of OSCE in the Exam ▪ ▪ ▪ ▪ 1. Joint examination 2. History taking 3. Breaking bad news 4. Psychiatry 5. Resus scenarios 6. Paediatrics 7. Procedures 8. Miscellaneous. . . . &Teaching Practised most of them Tips on how to revise for them Good Luck!

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