In most medical schools today, history taking and
physical examination are examined using the OSCE
(although long- and short-case testing may also be
used). This comprises a series of stations (e.g. 10 minutes
each) where particular history or physical examination
skills are tested in front of one or two examiners.
Students rotate through all of the stations and each
station has different examiners. At each station, after
a stem or introduction has been provided (e.g. patient’s
name, age and presenting symptom), the task to be
completed is highly specific (e.g. ‘Please take the blood
pressure’). The questions are standardised and preset,
and the scoring is predetermined, as is (usually) the
pass mark. You gain a mark for each necessary step
properly completed (e.g. introducing yourself: 1 mark;
washing your hands: 1 mark). This means that you
must have a system for examination in the OSCE setting
and practise it until it becomes second nature.
At the end of most chapters of this text a list of
sample OSCE cases and questions is provided to help
with revision and as a preparation guide. Look up the
answers in the chapter and use this as a way of revising.
At OSCE stations, candidates may be asked to take
a specific history (e.g. the social history) or examine
a particular body system or part (e.g. the praecordium
for heart murmurs or the posterior chest for lung signs).
Other stations, depending on the stude
nts’ seniority,
may test clinical skills such as prescription writing.
Each medical school conducts these exams slightly
differently, but there are certain general principles all
students should understand (if they wish to pass).
Remember, the ‘patient’ in the exam may be an
actor trained to answer questions in a certain way.
Actors are also used for the physical examination to test
that students complete their techniques properly. The
idea of using trained actors is that answers to student
questions will be standardised. The actor patients often
come from local theatrical schools and there is a small
risk that they will be tempted to overact (e.g. bursting
into tears when asked their age; see Fig. 3.20). The
good news is that all candidates will experience the
same conditions.
There are a number of key points to keep in mind
during this ordeal:
1. The examiners know how difficult it is to
perform while being watched.
2. Their expectations are much lower for students
in their first few years of the course.
3. You will be given a spoken or written
introduction, or both. This will tell you what the
examiners expect you to do, so don’t do
something different. For example, if the request
is to examine the upper limbs of a patient with
weakness in the arms, don’t begin by testing
sensation. Time is limited and the examiners will
have directed you to where the abnormal signswill be (if there are any, which often there are not
in this type of exam).
4. As important to the examiners as a good
technical approach is your attitude to the patient.
You can expect to fail if you are rude and
inconsiderate.
5. It is important to develop a routine when you
practise for these exams. This includes
introducing yourself and explaining at the start,
and then with each step, what you are going to
do. For example, if asked to examine the patient’s
abdomen, having introduced yourself, say
something like ‘I have been asked to examine
your abdomen. I will need you to lie flat for me
with just one pillow. Will you be comfortable like
that? I will need to pull your underpants down a
little lower. Is that all right? Are you sore
anywhere? I’m sorry my hands are a little cold.
Please let me know if this is at all uncomfortable
for you.’ Make it clear during the examination
that you are watching the patient’s face for any
sign that the examination is painful. This type of
approach to patients is really only normal
politeness and should be routine (i.e. not just
used during exams).
6. Remember to wash your hands before and after
for an easy mark (and in practice you should
always do this to protect the patient and you).
Video-recorded OSCE examinations are provided
with this edition to help guide you further. They are
marked with this reference guide from the appropriate
chapter. There is more help online; for example, search
for Wikiversity’s OSCE review or Instamedic. There
are also useful phone apps available.
References
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