FRCEM OSCE APPROACH

1. Yasmin Sultan

3.  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.

4.  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

5.  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 marksfor questions
▪ Include your differential diagnosis, management plan &
allow time for questions –about 10 marks!
 “Difficult” histories:
▪ Sexualhistory (signpost!) travel history, urology Hx, back
pain.
▪ Maybe Acute confusional state, with MMTS?

6.  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.

7.  5. ResuscitationScenarios- 2 per exam, double
stations.
▪ 17 minutes each.Almost always oneAPLS. A LOT of
content to get through –move fast. May include
interpreting aABG orCT & referral/explanationto
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
throughhow you do a chest drain, applya splint etc.
▪ You don’t need to pass them to pass overall though.

8.  No actual kids are used,but paeds forms 25% of exam, so
either Resus Sims, or communication skillsOSCEs:
▪ 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.

9.  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

10.  1. CDU ward round-
▪ Listen to histories of patients (3) presented by FY1. Identify any
issues with management & give plan to FY1.Try to avoid saying you
will see patient yourself.All will have management pitfalls.
▪ Eg: head injury in alcoholic(?neckCT), 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 myTrust...” Use a
framework to think through issues.

11.  “clinical reasoning decisionmaking” -
This meansyour differential diagnosis,
and management plan.
 History taking
 CommunicationskillsThismeans
asking the patient if they have any
questions, & answering them (and in
thiscase, sign-posting SIhistory 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,youare off-track.

13.  An 8 minuteOSCE with a volunteer
 The candidate informationand the mark
scheme will be available to the audience.

14.  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.

15.  Mark scheme

16.  Only 5 possible OSCES –practice them all.
 Memorise key phrases to describe symptoms of:
▪ Mania
▪ Psychosis
▪ Depression (& ask about DV, alcoholabuse)
 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.

19.  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..
 Examinerplease make notes on what goes
well & badly –maximumof 3 learning points
for the candidate per OSCE. Advise them
what they need to practice.

20.  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 whichis very suspicious for NAI.
 Take a history and determine a management
plan

23.  Candidate Instruction:
▪ You are the only registrar in the ED starting the
8am 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 FY1.
▪ Do a board round with the FY1, giving him a
management plan for each patient.

26.  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.

27.  ¾ communication
 ¼ clinical reasoning /decision making

29.  Candidate Instruction:
 Kate is a 45 year old lady with bleeding in
early pregnancy.
 Take a history from her and make an
appropriate managementplan.
 ¼ history taking
 ½ communicationskills
 ¼ clinical reasoning /decision making.

31.  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 haematomablock
to manipulate a colle’s fracture.
 Communication:1/3
 Practical skills: 2/3

33.  Examinerprompt –next page

39.  Candidate instruction:
 Miss Harris is a 30 year old womanwho has
come to the emergency department with
abdominalpain.
 Take a history from her and discuss further
managementwith her.

42.  1/3 history
 1/3 communication
 1/3 clinical reasoning /decision making

44.  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.

46.  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

49.  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.

52.  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!