Open letter to OSCE candidates

The below is a copy of an open letter sent to all 2016.2 OSCE candidates today. It was written by the RACGP National Assessment Advisor, Dr Guan Yeo. I’m posting it here as it is one of the best OCSE tip summaries I’ve seen, containing many a gem, and will hopefully be helpful to future OSCE candidates also, when they start to prepare for this last FRACGP exam hurdle.

You can find other OSCE related posts here, here and here. My YouTube channel  has links to various physical examination clips and other videos which might also help in OSCE preparation.

Dear candidate,

How are you progressing in your preparation for the Objective Structured Clinical Exam (OSCE)?

By now I expect you have your regular small-group timed roleplay sessions up and running. Improving your performance in the rating areas that apply across multiple OSCE stations is a good way to maximise your chances of success.

Use this quick list to check your performance, eg.:

Rating areas Some features of good performance
Communication and rapport Patient centred? Empathic? Patient expectations? Simple language explanations?
History General and focussed questions? Orderly? Demonstrates safe diagnostic strategy? (Murtagh)?
Physical exam Hand hygiene? Explains and is considerate of patient comfort? Orderly? Gives positive findings and significant negatives?
Investigations Prioritised? Staged – initial and later Investigations? Differentiates between your differential diagnoses?
Management Prioritised? Considered patient supports? What does the patient think/understand? What are the obstacles (eg. to behaviour change)? Safety-netting?
It is time to critically review your clinical experience and familiarity with conditions represented in the ICPC2 groupings, e.g. women’s health, mental health, musculoskeletal, ENT, etc. Study up now on the common presentations in your areas of weaknesses: How do they present? What history or examination do you target? How do you prioritise investigation? How do you manage – short term and longer term, explanations, drugs and non-drugs, again prioritisation.

Finally, hopefully you have already booked in for a trial exam. This is often useful to ‘polish-up’ your preparation.

To use your time effectively during the exam consider the following:

  • In the three minute reading time, do read the instructions line by line. Some nervous candidates miss entire lines as they read. It can be helpful to put your finger against each line as you read – it is simple, may sound silly, but it works. You don’t have to memorise – there is the same set of instructions on the desk inside the station.
  • When in the station, if you are nervous, it is easy to miss visual cues. So if eye contact is not your strong point, train yourself to look regularly at the ‘patient’.
  • Use the time at rest stations wisely. Besides toilet breaks and drinks of water, regroup your thoughts, use short meditative exercises/mindfulness, focus, and regain your composure in readiness for the next station. Avoid dwelling on previous cases as that won’t improve your scores, but rather prepare yourself mentally for the remaining stations.

I hope that you have found this information useful and I wish you well in the OSCE.

Dr Guan Yeo
National Assessment Advisor OSCE

The Life Cycle of an OSCE Case

Where did I come from imageI was asked recently, “So where do OSCE cases come from?  Who writes them and how do they get chosen for use in an exam?”

These are not uncommon questions. For many, the life cycle of an OSCE case seems to be a mysterious process, shrouded in secrecy.

It’s time we had the “Where did I come from?” talk…

It starts with a twinkle in an OSCE case writer’s eye, often during a patient consultation.  “This could be a good OSCE case,” the case writer muses, and from there, a case is conceived. It’s a long and complicated gestation, however, with no guaranteed delivery at the end.

OSCE case writers are neither a special breed nor an elitist group. They are a diverse mix of practising College Fellows from around the country, who are all experienced RACGP OSCE examiners specially trained in how to write OSCE cases, RACGP style.

Cases are based on real patients seen in the case writer’s own practice.  They are not derived from the rare and obscure conditions we all find so interesting, but from common and/or important presentations that competent Australian GPs are expected to be able to manage.

Taking care to de-identify the patient and to ensure that the issues involved are widely applicable to Australian GPs, the case writer creates a first draft using a standard RACGP case writing template.   With support and feedback from OSCE case reviewers, this initial draft may require considerable to-ing and fro-ing.

Once the first draft is complete, it gets formally reviewed by an OCSE medical educator (ME) and then road tested.  Yep, road tested.  Tried out by volunteer GPs who have not previously seen the case to see how it performs – which is not as much fun as taking a new car for a spin, in my opinion.  Essentially, these are people willing to do OSCE cases under exam-like conditions.  Some may call them dedicated, others may say masochistic, but everyone agrees that they are fulfilling an important role and helping make the OSCE better.

After the road test, the case goes through another round of review before moving to Standardisation. This is when a group of experienced OSCE examiners put its eyes on the case and marking scheme, suggests modifications if necessary, and decides on which aspects of the case (“Key Features”) are the most important.  These Key Features are then bolded to assist the OSCE examiners marking the case.

After all that, the case goes into the OSCE pool, vying for selection.  Unlike selection for the Australian Olympic Swimming Team which is, I’m guessing, based largely on swimming very fast in the right races, the selection of cases for the OSCE team is nuanced and complicated.  It is governed by the Exam Blueprint which takes into consideration many factors such as the General Practice curriculum, the frequency a condition is seen in general practice, and the importance of being able to diagnose and manage said condition.  This is why emergency presentations such as myocardial infarction occur more frequently in FRACGP exams than they are seen in a typical general practice.  They are uncommon, but you really need to get the diagnosis and management right when you see them.

The “team” of cases chosen for a particular exam needs to be balanced, so that a sufficiently broad spectrum of knowledge and skills is assessed. It may seem from the outside looking in that in some exams there are very similar cases, but even when the condition is the same, the different cases test different aspects, that is, the assessment tasks are different.

An OSCE case cannot rest on its laurels after selection for a particular exam. There is more scrutiny to come: firstly by an OSCE ME (a “fresh eyes” review) followed by the Assessment Panel Chairs (APCs), then the Quality Assurance (QA) examiners and finally the assigned examiners.  You would think by this stage there would be nothing left to review, but regardless of how many times a case is reviewed there can still be little typos or omissions which have slipped through the net.  Cases requiring last minute adjustments get “green sheets”, on which the changes are outlined for the case’s examiners.  Better to be green sheeted then yellow carded, but still, something to be avoided if possible, and with increased pre-exam reviews green sheet changes are getting fewer in number.

Finally the big day arrives and the OSCE case is role played in upwards of 45 rotations in approximately 15 exam centres around the country.

But it is still not over for an OSCE case.  Post exam, the examiners and QA examiners provide feedback on the case, and the statisticians work their numerical magic to see how it stacked up. If the case fell outside certain statistical parameters (e.g. discrimination index), it goes through a further review process.

After all that, we thank the case for its service by sticking it into quarantine for several exam cycles.

After being brought out of exile, it is updated, reviewed and road tested again before it is considered for use in another OSCE.

OSCE cases, like doctors, diet fads and mobile phones, don’t last forever. At some point, each case will need to come to terms with being pulled out of the pool.  After a bit of rehabilitation, the lucky ones will have a working retirement by being used for examiner training, mock OSCES and the like.  Others disappear, remaining only in the memory of those who tackled them on a long ago OSCE game day….

Such is the life journey of an OSCE case.


(First published in RACGP Queensland’s Examiners’ Newsletter, August 2016)

Ignorance is bliss but not necessarily a good OSCE (exam) strategy

My recollections of sitting my RACGP OSCE (Fellowship clinical exam) are rather hazy, and not just because it was over a decade ago. I do have one bit of advice though – a do-as-I-say-not-do-as-I-did tip – try to avoid traumatic brain injuries in the month leading up to your clinical exam.

Here’s the story of how I came to be doing my RACGP OSCE exams with 6 facial fractures and left temporal lobe contusions….

Saturday, 4th October, 2003.

Photos from old computer 115

I couldn’t close my mouth. That wasn’t a good sign. Many a time I’ve been admonished for having my mouth open more than it’s shut, but on this occasion it had nothing to do with being garrulous. My upper and lower jaw no longer occluded. I sat up – gingerly, to discover that I was completely alone in unfamiliar bushland, with no recollection of how I got there. I lay back down and closed my eyes, inappropriately unperturbed.

Like a slowly developing Polaroid picture, the details appeared in my mind’s eye. The colours were increasingly vibrant yet the focus remained blurry. I remembered studying for my OSCE exams that morning before deciding to take one of horses for a ride in the State forest to clear my head. The rest was a blank; my head had been cleared too well.

Living at Pomona0013It was time to play CSI. The skid marks and saddle imprint in the mud clearly showed where Rondo had shied and fallen (probably on seeing a kangaroo – he was terrified of them), and my face had left a lovely impression at its point of impact. Thankfully, Rondo appeared on cue when called – mud-splattered and jittery but unharmed. It took us several hours to find our way out through the maze of interconnected forest trails, what with my disorientation and his being one of those rare horses with no inclination to make a beeline for home. Unlike many males I’ve known, he was excellent at taking direction but hopeless at finding it.

I remember only one thing clearly about that long ride home: laughter. My laughter – laughter which bubbled up from deep inside, slipping between my maloccluded teeth and spilling out of my bruised mouth. In my concussive haze my situation somehow seemed side-splittingly humorous. The funny side was the only side I could see.

I laughed more in that next month than I’d done in the preceding three years. Although my personal predicament lost its comedic edge fairly quickly (temporal lobe contusions and six facial fractures requiring two maxillofacial surgeries and a six-week liquid diet do tend to be dampeners), the world around me tickled my funny bone in completely new and outrageous ways. I laughed at the news. I laughed when I got stuck in traffic. I laughed over spilt milk. And most surprising of all, I laughed at corny American sitcoms. You know the ones: weak, predictable story lines, groan-worthy one-liners and canned audience laughter. I found them not only funny, but hilarious. I’d laugh so hard that I’d double up on the floor in stitches with tears streaming down my cheeks. I kid you not.

Despite my looming exams, my neurologist prescribed “brain rest” and instructed me not to study. Nothing I read seemed to be retained anyway, so I put my books aside and indulged in my new-found penchant for mindless entertainment. I laughed the days away without a care in the world.

Living at Pomona0020Three weeks after my accident, less than a fortnight after two reconstructive surgeries, and against medical advice, I sat my OSCE exam. In my brain damaged state, I was not at all worried about whether I’d pass or fail, happy to turn up and just “have a go”. I don’t remember much of it, other than wondering why my fellow candidates all looked so worried, receiving stern glances from an exam supervisor as I giggled to myself in a rest station, and having to ask one of the role players about her presenting complaint at least three times (my brain simply refused to retain the information).

I miraculously passed (although it was far from an outstanding performance!). Somewhat unfortunately, over the following weeks my ability to laugh outrageously at the banal also passed, and my sense of humour crept back to the dry and satirical side of the fence. The news of the world was again depressing, traffic congestion got my goat and split milk, although not inducing tears, no longer triggered a giggle.

I’m not sure if my laughter was the illness or the medicine, but it was definitely an integral part of the healing process. Having a traumatic brain injury was for me a far from unpleasant experience. In fact, it seemed to suggest that life is not only more painless for the brainless, but it is also much funnier.

While sitting a major exam in such a state was entirely without stress at the time, I do not recommend it as a technique to reduce performance anxiety. In all seriousness, I was very lucky to have passed, and believe that the only reason I did was that I had spent the previous 18 months preparing. Not by going home and studying every night, but by engaging in deliberate practice each and every day when seeing patients. Good communication skills and examination techniques were so ingrained that they did not require the concentration and higher level thinking that the knock on my head had temporarily disabled. These semi-automated skills alone are not enough to be a safe and competent doctor in the real world of course, but, together with a big helping of luck, were enough to carry me through the OSCE exam on the day, as I smiled and laughed my way through the stations, completely unfazed.