Hector Thomson, Nathan Hunter and Josh Monester
There are a number of excellent guides to the OSCE floating around from different health services. These are our thoughts on having sat the 2023.2 Fellowship OSCE.
My written knowledge was excellent, surely translating this into the OSCE will be easy?
We were shocked at how wrong this is. Yes, having good medical expertise is crucial to passing this exam, but the OSCE is about so much more, all packaged into a “thinking on your feet” format, mixed in with your analytical and communication skills. It requires a huge amount of OSCE-specific study and preparation, and lots and lots of practice. Performing for the OSCE did not come naturally to us, but at some stage you’ll find that it “clicks” and it even becomes enjoyable.
What is the OSCE all about?
The OSCE is about showing the examiners you are a safe, capable colleague who they would happily let manage their resus area. In the beginning we were desperate for people to give us templates. To go into each station and give a prepared TED talk on hyponatraemia but sadly this is not how you score points.
Whenever anyone asked if specific words meant we had to do something in a particular way (screen for domestic violence/check for drug use/safety net) we inevitably realised that “It depends.” Rather than developing templates, be present, actively listen and just perform the tasks the stem asks of you.
Should I power through after the written exam?
If you sit the OSCE immediately after the written there is approximately four months between exams, so some people choose to sit at the next sitting and some the subsequent one (10 months between exams).
Some arguments for power through to the next sitting:
You’ll remember your fine-grained written knowledge more easily
This minimises the total time you are studying
You can continue on as a study group
You can get the whole exam process over
Some arguments to defer to a subsequent sitting:
If you feel you need more time to understand the OSCE format and exam to adequately prepare
If you are burnt out
Major life events
We chose to continue straight through. We started our OSCE campaign two weeks after we sat the written. Keep in mind you will not have your results yet! While it can be hard to motivate yourself, you need to start. If you wait 6 weeks for your written result there is not enough time.
What was your timeline to prepare?
0-2 weeks post written: Rest and Recovery
We took time off and took a deep breath. Booked Airbnbs in various parts of the state and enjoyed a drink.
2 weeks post written: Planning
We sat down and marked out dates along with an overall approach to preparation.
3 months out: Exposure
Tried to do as many OSCEs as we could. We filmed our stations and reviewed them. Initially we stayed within our group then gradually started doing more with FACEMs.
2 months out: Style
We did private coaching sessions to work on our weak points. We developed the phrases that worked for us that we could use in different stations.
1-2 months out: Stamina
We sat mock OSCEs and started to do 6 OSCE in a row.
1 month out: Polish
Went to an OSCE preparation course in Sydney which included a full 2 day OSCE
1-2 week out: Confidence
We only did stations with people who would give us good feedback. We did stations we liked and felt good about.
Do I keep doing my ankis/flashcards?
You still need to keep up your “medical expertise” to do well at the OSCE. Thankfully the focus shifts from small facts to approaches and key treatments. We developed a list of core topics and thought about what would be important from an assessment (history/exam/investigations) and management (resus/specific/supportive/disposition) perspective.
That being said there are some facts that are useful to have to hand to explain things to patients and to sound clever in an SCBD, (e.g. 25% of women have bleeding in early pregnancy and 50% will go on to have a normal pregnancy. These can be useful additions to your anki deck should you continue using it, or form a separate deck of ‘OSCE nuggets’
What do the domains mean?
You need to read everything in the “Fellowship Examination Resources” page. Similarly to the written you need to figure out what you are being examined on and ANSWER THE F***ING QUESTION. Read the Glossary of Terms a few times. You need to know how assessment and management questions differ.
The focus of the written exam is almost entirely on Medical Expertise, as this is far easier to mark in written format. However, the OSCE focuses not only on Medical Expertise, but multiple other domains. The key document here is the OSCE Domain Criteria on the ACEM exam resources page.
The bottom of each OSCE stem lists the domains and relative percentages upon which the station is marked. This is so important because it tells you where to focus your time. For example, if there is a station where you are advising a Junior Registrar, if there is 40% Scholarship and Teaching, you will need to spend significant time ticking off the relevant points under this domain. If the domains are 100% Medical Expertise, do not waste any time with teaching points including checking level and understanding, feel free to steamroll the roleplayer with your amazing knowledge.
How should I practise?
Unlike the written where you can do practice papers on your own, the OSCE is a team sport. You need a study group to meet with regularly. We aimed for at least one station a day. There’s real benefit from repetition and a quick Zoom call after or before a shift to go through one station each still felt very worthwhile. We had a study group of three and tried to organise longer sessions when we were all off.
We did a mix of online and in-person (thanks Erin for letting us use your living room.) The in-person sessions are so much more useful however with ED shift work sometimes you can’t find time. Obviously examination stations are much more useful when done in person!
(The authors, elated at discovering the “Under the sea” filter on zoom!)
It’s important to recognise that OSCE study is a different beast to written study. Being on the spot, practising stations, receiving critical feedback, and rehearsing stations over and over will tire you out mentally much quicker. We found that even our in-person longer study sessions rarely lasted more than a few hours before we had to stop doing stations for the day, or at least take a very extended lunch break. We would then generally use the rest of the day to do things such as read through and brainstorm past exam reports, filter through our anki decks (suspending any no-longer useful cards), or identify and prepare summaries for key OSCE topics or station styles.
As much as it is painful to hear your own voice, filming these sessions is useful. We spent more time debriefing and going over the station than actually performing then for the first month. We would do a station with one person being the candidate, one asking the question and one marking. We would listen to the recording and then talk about the station. Sometimes we would get the candidate to repeat a section if we had collectively come up with a better approach. This was really helpful if you felt you bombed a section (or whole station), allowing you to get it clear in your head, practice hearing the right words come out of your mouth, and importantly, keep your confidence up.
Make sure you are practising to time. Set up a timer on your phone with reading time and then a 6 minute and 7 minute buzzer. We used a shorter reading time to allow for moving between rooms.
Outside of your study group you need to hassle all the FACEMs you can (even ones you are scared of) to do stations with. If you have examiners in your ED get in contact with them early. They know how the whole process works and will point out your bad habits early. Everyone has a different approach to this exam so try to get a variety of opinions.
Examination reports - Hidden gold
One resource that a lot of people only skim is the examination reports. (Thanks Gavin for suggesting this!) There is a surprisingly large amount of information released in these reports that can allow you to extrapolate a station. It also gives a good idea of what mistakes people consistently make. Once you start trying to write some OSCE stations you will realise what a difficult task it is to write one. As such there are common stations that will come up time and time again. If a station works well as a discriminator it may be simply reworked. We read through the reports and then generated possible questions and answers.
Where do I get OSCEs?
There are generally shared folders of hospital’s practice OSCEs floating around. Ask the group who just sat. Generally the further back you go towards 2015 the worse the quality. The Monash OSCE website is excellent.
We formed an excel spreadsheet to keep track of which stations we each had done. For each we tried to take away key learning points and traps. This was useful when we were still figuring out what the stations meant but dropped off towards the end, however did come in useful when trying to find a particular station that we’d practised and wanted to re-visit.
How do I read a stem?
This is a crucial skill that must be developed. There are many ways to read a stem. We recommend top down then back up taking it all in. Then being deliberate.
Label the station to give yourself a framework - “Life-threatening paediatric asthma”
Analyse every word - It is all there for a reason. (Rural ED for example means you will need to think about retrieval). These stations are picked apart during their creation process and they do not add in red herrings.
Figure out the domains and their weighting - This will guide how much time you need to spend on each part to maximise your marks
Read the tasks - You must perform these to score points.
For every patient outside the room consider:
This patient
This place
This time
A 25-year-old in a major trauma centre at 10 am is a very different patient to a 90-year-old in a rural urgent care centre at 2 am. You must frame your answers in this response.
You also have a copy of the stem in the room. Placing the stem in the same place in every station can be useful. If it’s under your right hand every time if you get lost or forget what you need to do you can look down.
Is there a framework for answering SCBD questions?
We were taught the LISA system (Thanks Chris Roubal) and while we could talk about different structures for different stations this is the most useful. This is a handy way to frame your clinical answers and provides a nice structure to answering questions in a SCBD.
Label: This patient has a life-threatening anaphylaxis with upper airway obstruction
Issues: The key issues will be treating anaphylaxis and securing a definitive airway. There is a high risk of this patient needing a surgical airway given their significant angioedema.
Show the examiner you know what is going on and what is going to harm the patient
This is where you show your prioritisation and decision making!
Send for help: “I would urgently call for assistance from anaesthetics/ENT/ICU…”
This was put in as a reminder to always use key available resources.
Remember to always REFER FOR A REASON. Do not simply push the clinical problem onto another specialty. Take ownership as the FACEM but recognise when you need help from other teams.
Actions: Clearly list out your steps in ORDER OF CLINICAL PRIORITY
Adrenaline: 0.5mg IM into anterolateral thigh with 2nd dose at 5 minutes while starting and adrenaline infusion at….
Oxygen: 15L via hudson mask while…..
As with the written, be very clear in your treatments giving a dose, route and a clinical endpoint you are aiming for.
What about areas of clinical controversy?
This is where you get to show off you’re ready to be a consultant! Avoid sitting on the fence and saying “Well I could do this and I could do this…” Just as at work, there will be areas of grey. Make a decision and explain your thinking e.g. “I recognise the competing priorities however I would use… and then change my plan if….”
How do I deal with all the feedback?
This is the most concentrated period of negative feedback you will have received in your life. You will get feedback from your bosses and peers and it is hard to not take it to heart. Especially people who you work with daily and respect. Remember that the OSCE is an intensely personal exercise and everyone has a different approach, so there will always be something you could have done better.
Take on board the feedback but be careful not to let it hurt your confidence. You need both cheerleaders and critics. As you learn the process, harsh critics are useful to point out mistakes. As the date approaches you need to shift to cheerleaders who will make you feel good about yourself. Do not underestimate how much confidence plays a part in performing on the day.
Do I do the courses?
We chose to do the Teemwork course. It was useful to do a full exam run-through over two days. While your hospital will hopefully run a mock this is usually 6 stations. The full two-day experience is invaluable.
How do I handle the stress?
The mindset we tried to cultivate was that we had done the hard work preparing for the written and this was our chance to show off everything we had learned. It may sound absurd but if you can try and enjoy the day it will set everyone in the exam room at ease.
One of us used a lot of self-talk. The mantra of “Calm Clear Confident: I am the consultant” repeated over and over proved useful.
What do I do on the day?
Do what you can to minimise any possible additional stressors. Some things that we’ve found helpful or seen help other candidates are:
Planning or even pre-preparing your meals before and in between the exams.
Booking into a hotel near the examination centre. This was even helpful for some candidates living in the same city as their examination centre, if there was a reason their sleep may be significantly disrupted at home, or if transport was particularly unreliable.
Make a plan A, B, and C for how you will get there should you miss your bus/train or your Uber cancels 4 times in a row.
If you are a caffeine drinker, consider planning the timing of your pre-exam beverage to optimise mental clarity and minimise palpitations. The exam cannot pause to allow you a toilet break.
Lastly, pay attention to how your performance changes throughout the day in your practice sessions. Especially later on when you may be practising 3-6 stations in a row. If, like most of us, it sometimes takes you a station or two to warm up and get into the right mindset, it might be worth calling in a favour from a study buddy or willing FACEM. Ask them to run one or two stations (at most, don’t exhaust yourself) for you an hour or so before you attend the exam. It is critical that you pick stations you are very comfortable with, and know you will completely walk through to help keep your confidence at peak level!
What do I do once I’m in the room?
When the sound goes you need to hit the ground running. Walk straight in confidently and introduce yourself. Actively engage with the station.
It can help to have your first sentence or two prepared and briefly rehearsed, to avoid it coming out in a jumble as you close the door and try to sit on a chair with your adrenaline through the roof.
If you feel yourself losing direction, always remember to return to the tasks. Keep the provided copy of the stem in front of you, and don’t be afraid to pause for a second to re-read the list of tasks during the station and make sure you’re not going off-piste. On this note, the examiners and confederates really want you to pass. They will help guide you as much as they are allowed to within the strict limits of the station and general OSCE protocol. If they interrupt you or repeat a question, you can safely take it as a clear sign that you need to immediately wrap up what you’re currently talking about.
Even if what you are saying is 100% factually correct and clinically genius, if you’ve strayed away from the tasks, or have already ticked everything on their mark sheet for that section then you are gaining no points and only wasting precious time.
What do I do if the station is going to shit?
It’s ok to ask for a second to gather your thoughts. Take a couple of slow breaths and re-check the stem provided in the room to make sure you haven’t missed something. If you don’t want to leave too big of a silent space, you can ask the examiner or confederate to please repeat their question, to give you a few extra seconds.
Examiners are limited in the questions they can ask, which are mostly scripted, and they can’t prompt you to talk about a specific topic you’ve missed. They can however circle back to something you’ve already mentioned and ask you to expand on this. For this reason, briefly and clearly listing/signposting the topics or areas you’re about to talk about in your answer permits them to give you a nudge to go back and expand on that area and squeeze out a few more points. If you keep your planned answer structure secret in your head and then forget one section, they can’t help.
Despite all the practice in the world, it’s still really common to have “bombed” a station, or at least feel like you’ve done so. Practise during your mock OSCE to have a technique that works for you. We were taught to physically close the door to the station room with purpose, allowing a clear break mentally. Take a deep breath or have a sip of water and move straight on to the next station.
What do I do after day 1?
Debrief if you have to. Beware those who sat on the same day. Just because they said something doesn’t mean that was the right answer! Writing down the stations and then putting it away worked to let it go. Exercise heavily so you will go to sleep then eat something comforting. Lean on your support people and get into a good headspace. You are so close!
Conclusion/Top tips
You will trauma bond with your study group - lean into these. Baked goods and cocktails certainly made our experience a lot less painful!
This will be the most concentrated period of negative/constructive feedback you’ve likely ever received. Feedback tends to focus on ways to improve, not pats on the back for your good work. Keep your performance in perspective, use the feedback to improve but try not to get bogged down in it.
Be kind to yourself. Preparing for this exam will take its toll, so make sure you’re prioritising keeping your body well-fed, exercised, and rested.
Accept support from those close to you. Whether this is in the form of meals, transport, entertainment, or anything else. You will have plenty of opportunity to return the favours once you are on the other side!
On this note, as much as some friends or relatives may offer their assistance, try and keep your practice of OSCE content limited to those in your study group or FACEMs/registrars on the other side of the exam. A well-meaning model may offer a limb for you to practise a neuro exam on, but they won’t help you iron out bad habits or offer you what may be useful but potentially uncomfortable critique.
HECTOR THOMSON
Emergency Registrar
Hector is a post-fellowship exams ED trainee currently working at Adult Retrieval Victoria. He enjoys shoulder dislocations, trauma, rugby union, fresh pasta and good gin. He doesn’t like vague allergies or cats.
NATHAN HUNTER
Emergency Registrar
Nathan is an advanced trainee at The Alfred. At work (and increasingly on his days off) he can generally be found running a sim of some variety, which he has been heard to describe as ‘basically Dungeons and Dragons but with a defibrillator’. He enjoys getting his ultrasound images to balance by the rule of thirds, and sculpting aesthetically satisfying POP casts. He misses drawing little doodles of patient’s ailing body parts in paper-based notes and is still to this day searching for a clinical use for glitter.
JOSH MONESTER
Emergency Registrar
Josh is a senior emergency medicine registrar with Alfred Health, having crash-landed back in Victoria after a protracted “working lap” of the country, dodging sharks in WA and chasing waterholes in the NT. He works to fuel his ice cream habit, but is driven by his love of trauma, ultrasound and medical education.
