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Preparing for clinical examinations 

Preparing for clinical examinations
Chapter:
Preparing for clinical examinations
DOI:
10.1093/med/9780199681907.003.0049
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Introducing clinical examinations

Clinical examinations will test your ability to perform effective history taking, communication, physical examinations, and procedural skills. The method employed by most medical schools is the OSCE which consists of a series of short and highly focused ‘stations’. The exact format of clinical examinations is often subtly different between medical schools and even between year groups within the same medical school, and it is important you establish the nature of your clinical examinations. They may utilize actors particularly in history taking stations where the examiners can ensure identical patient responses to each candidate’s questions, in order to ensure an objective and reproducible assessment. While they are often focused on a specific system (see Preparing for clinical examinations Chapter 50) it is important to behave authentically as you would in a clinical setting.

What are they testing?

OSCEs were first introduced to medical schools in 1975 to assess skills not measured by written assessments. These include:

  • observational skills

  • ability to build rapport

  • communication skills

  • problem-solving ability

  • clinical knowledge

  • practical skills.

You will note that some of these skills are generic (i.e. they will apply across all specialties) while others can be specific (i.e. clinical knowledge) (see Table 49.1). The balance of emphasis on these skills will be different in different specialties. For example, communication skills may make up a very small proportion (or may not be marked at all) at an advanced life support station when you are performing CPR on a dummy, while active listening and good communication may be the main component of a psychiatry station. However, both of those are extreme examples and you will find that almost all OSCEs assess manner, communication, and the ubiquitous hand hygiene (communication skills and respect for patient dignity are still marked if you are performing a pelvic exam on a plastic model, for example.)

Table 49.1 Examples of skills

Examples of specific skills

Examples of generic skills

  • Recognition of T-wave inversion on ECG

  • Elicits dull percussion note on chest examination

  • Able to describe maculopapular rash

  • Identification of effusion on chest X-ray

  • Explains procedure to patient and gains consent

  • Good hand hygiene

  • Presents examination findings succinctly

  • Able to form differential diagnoses

You will find it very difficult to pass your OSCEs if you emphasize speedy diagnosis and fact-reciting at the expense of politeness, consideration, and kindness. Ignore these ‘soft skills’ at your peril. They are at the heart of good medical practice.

How do they work?

A typical OSCE consists of a number of stations (usually around 10–15), each comprising a clinical scenario—taking blood, for example, or breaking bad news. Each station typically has one or two examiners. Sometimes there is another person in the room acting as an independent examiner, who will be assessing the way the OSCE is taking place, and not you. Sometimes a layperson is brought in to give a ‘person on the street’ opinion of your manner and communication skills. This is more common in stations where communication is the main skill being assessed, such as a breaking bad news station, or an alcohol counselling station in psychiatry or general practice.

OSCE stations use a variety of methods to illustrate clinical scenarios. These include:

  • models (e.g. a plastic arm for venepuncture, or a torso for CPR)

  • actors (e.g. playing a bereaved partner or angry family member)

  • multimedia (e.g. a photo of a rash or a radiograph)

  • real patient (e.g. with rheumatoid arthritis or a heart murmur).

Most OSCEs will have a mix of these components, but the balance will be different depending on the specialty.

Taking a history

You will be asked to take either a formal history (e.g. for 10–15 min) or a focused history (e.g. for 5–10 min). Even a formal history requires constant refinement of a differential diagnosis throughout the process, asking closed questions to exclude or highlight possible diagnoses. This will take time to develop, but is essential to score well in clinical examinations. One way of achieving this will be to ask about specific risk factors for common presentations (e.g. jaundice, haemoptysis, and melaena)

Examinations

You may have up to 10 min to complete an examination of one particular system (cardiovascular, respiratory, endocrine, etc.) You will be expected to follow the standard procedure of inspection, palpation, percussion, and auscultation (IPPA). In joint exams, you may present your findings as look, feel, and move.

Some students prefer speaking through the examination to report the presence or absence of pertinent clinical signs, while others report their findings at the end.

Practical procedures

You will be given 5–15 min to perform a task in which you will not only be assessed on your practical skills but also how you communicate with the patient through the procedure. Set aside time every week to practise basic practical skills in the skills laboratory. Some common procedures include venesection, ABG, blood cultures, IV cannulation, urinary catheterization, suturing, DRE, vaginal examination, measuring BP, urine dipstick, performing an ECG, measuring peak expiratory flow, and prescribing and administering IV fluids.

Explaining a procedure and gaining consent

You are usually given 10 min to explain a procedure (breast biopsy, colonoscopy, etc.) or gain informed consent. While you will need to have an understanding of the procedure, your assessment will be weighted towards your communication skills. Your task is to explain an invasive procedure, without using medical jargon or complicated terminology. This may also involve explaining the risks of a procedure— knowing the rates of perforation, haemorrhage, infection, failure of procedure, and mortality can be helpful, although precise figures need to be used cautiously if at all. You will need to be able to provide the patient with all the information they require in a way they understand it, and respond to any concerns they may have.

Breaking bad news

This is an important skill to learn but should ideally be done by a senior doctor with a nurse at a scheduled meeting, in an appropriate environment with the patient and their relatives. In the exam situation, you will not be afforded such a luxury, and it will be your task to break bad news alone (e.g. you are on call and have to explain the death of a patient to visiting relatives at night). The following points may be of help:

  • Prior preparation: this is essential for both you and the patient/relatives. Read the patient’s notes beforehand including all the latest results (e.g. blood tests and scans). Mentally rehearse the consultation and the questions you might be asked. Be ready to discuss the significance of results from investigations, and opinions from other specialities and your seniors.

  • Consent: this must be sought from the patient, where possible, in order to divulge information in front of anyone else, including family members. Patients still have the right to their autonomy and you must respect their wishes, even if they prefer not to know about their diagnosis.

  • Introductions: these are necessary so that you know who you are addressing. Also make a note of all those present in the patient’s notes.

  • Establish pre-existing knowledge: this should be asked about at the beginning of the meeting to establish what is already known, and what the patient/family would like to know.

  • Signposting and warning shots: these are effective in psychologically preparing patients to receive some bad news; cryptic and ambiguous language will not help. It is acceptable to say ‘Unfortunately, I have some bad news to share with you’.

  • Time: this is a powerful component in such consultations. After breaking bad news to the patient sensibly, allow adequate time for the information to sink in and do expect emotional reactions such as denial, crying, anger, and shock.

  • Amount of information: this should be given at the patient’s pace, and will need to be judged individually. Everyone can process bad news better if given in manageable chunks. Keep monitoring their responses to the information given, and move forward with the consultation while reconfirming their understanding.

  • Empathy: this will avoid the patient feeling isolated. You may not fully understand what they are feeling but demonstrate that you can relate to them by imagining being in their position. Offer hope but not at the expense of being honest and realistic about treatment and prognosis. Do not commit to a time-frame or make any false promises.

  • Language: must be simple, understandable, and without jargon.

  • ICE: this is a mnemonic (Ideas, Concerns, and Expectations) for you to address the patient’s ideas and concerns about the bad news given and expectations from your team.

  • Summarize: do this at the end because the patient may still be processing the bad news as opposed to all the other matters discussed including management options and counselling. Make sure that the patient is able to understand and repeat the information given back to you at the end of the consultation.

  • Follow-up: by arranging another time to meet with the patient and family members which will give them more time to process the bad news, and provide them with contact details to get in touch if any further questions arise in the meantime.

Use one of the items in Box 49.1 as a model to guide your consultation.

How marks are awarded

OSCE scoring systems differ between medical schools. The two main systems are ‘tick-box’ or ‘global impressions.’ Their main points are summarized in Table 49.2.

Table 49.2 OSCE scoring systems

OSCE type

‘Tick-box’

‘Global impressions’

How it is marked

1 point scored for each action performed. Examples:

  • Handwashing

  • Introduction and consent

  • Ensures patient dignity during examination

  • Palpate for thrill or heave

  • Describes systolic murmur over the mitral area

  • Mentions mitral valve regurgitation in list of differentials

  • Able to describe other pathological findings in association with mitral valve regurgitation, e.g. pulmonary oedema, signs of heart failure (1 point for each)

General impression of student’s approach, courtesy, communication, knowledge of subject, technical skills, and presentation.

Pass mark

Individual stations marked and results totalled

Global pass mark for all stations (i.e. total of 160/200 to be achieved overall), or minimal mark for each station to be attained determined by examiners

Each station judged ‘fail’, ‘borderline’, or ‘pass’

Overall ‘fail’, ‘borderline’, or ‘pass’ given based on analysis of performance in all stations

Pros

  • Good for point-by-point feedback

  • Objective

  • Evidence shows highly correlated with ‘real-life’ clinical performance

  • Used in professional exams

Cons

  • Not how many professional exams are marked

  • Assesses actions but not necessarily quality or confidence—difficult to distinguish between excellent and average candidates

  • More subjective

  • Lacks specific feedback—difficult for student to target areas needing improvement

There are plenty of example OSCE mark sheets for each system in Preparing for clinical examinations Chapter 51.

How examination results are used

Generally speaking, clinical examinations are used in assessment with a written component, but both will have a minimum mark that needs to be exceeded to pass—you cannot fail your OSCE completely then pull yourself up by the written component, or vice versa.

While medical school OSCEs can be left behind you when you graduate, it is worthwhile honing your performance while you can, because OSCEs are here to stay for the rest of your medical training. The GMC is currently running a pilot scheme to incorporate standard OSCEs into specialty interviews from 2017. As well as this official move towards a more standardized grading system, an Preparing for clinical examinationsnumber of specialties are now using OSCE-style stations for interviews, where applicants analyse a paper, break bad news, or describe clinical imaging, in a break from the increasingly old-fashioned ‘Tell me about your greatest achievement’ style of interview. PACES (Practical Assessment of Clinical Examination Skills) and MRCS (Member, Royal College of Anaesthetists) may seem a million years off, but the same skills you are developing as a first-year medical student will pay dividends when you become a registrar.

Finally, and most importantly, think about how you will use your exam results to improve your own practice. Remember that the skills you use to pass OSCEs are those you use every day to communicate to your colleagues, assess patients, and formulate a management plan. They are all part of what will make you an excellent doctor.

Formative vs summative exams

Formative exams are mock exams to prepare you for finals at the end of the academic year. The exam mark may not count towards your degree but it is a strong indication of your progression in medical studies and may be a warning sign for you, your tutor, and the medical school that you are lagging behind. Summative exams are your final exams of an academic year which count towards completing your degree.

Disabilities/extenuating circumstances

Extra time is given to those with a disability in the form of a physical or mental impairment which has a long-term adverse effect on the person’s ability to carry out normal activities according to the Office of Qualifications and Examinations Regulation (Ofqual). Students with dyslexia or other learning difficulties qualify for extra time in exams as well as governmental support to purchase learning aids. If you are experiencing personal difficulties that may affect your ability to perform in exams, it is crucial that you put this in writing after discussing it with your personal tutor, the welfare officer, and the Dean. No one can help you if you report any issues after you have sat exams.

Intercalated degrees

These are marked by weighted averages according to classes as seen in Table 49.3. A degree may be awarded with or without honours. It is worth noting that most institutions expect those pursuing a higher degree afterwards (e.g. a Master’s or PhD) often require at least an upper second in their bachelor’s degree. Percentages traditionally correlate with classes (see Table 49.3).

Table 49.3 Classes of awards for degrees

Class

Average weighted %

First

>70

Upper second

60–69

Lower second

50–59

Third

45–49

Ordinary pass

40–44

Merits and distinctions

These count on your CV, for your portfolio, and job applications. Less than a quarter of your year will graduate with a distinction in a subject which will appear on their degree certificate. Some universities, like the ones in London, hold an annual Gold Medal competition for only the best.

Awards and scholarships

These are awarded to students scoring the highest marks in both written and clinical examinations. These awards tend to be internal and offered by the board of examiners. Prizes vary but usually consist of several hundred pounds as well as formal recognition on your degree.

Curriculum vitae

This will feature any significant grades such as your merits, distinctions, and intercalated degree award classification. Demonstrating a consistent track record of academic achievement is very important to obtain the jobs you want to progress in your career.

Job applications and interviews

Your employers will look for a strong sense of academic merit. Your accolades demonstrate your knowledge, skill, and attitude. You can discuss these in depth at your job interviews which sets you apart from other candidates.

Revision strategies

To succeed at clinical examinations, you need clinical experience. No amount of reading will replace hours spent on the wards, which will consolidate your reading, enhance your practical skills, teach you examination tricks not mentioned in books, and show you how doctors communicate with patients, interpret results, and decide on management plans. Never lose sight of the fact that while the immediate and all-consuming concern may be the looming exam and the need to pass, the ultimate goal is to achieve your full potential as an excellent clinician and to pave the way for a lifetime of learning. See your exams as a tool to hone your clinical skills, to alert you to areas of weakness, and to push you to be the best possible doctor you can be to your patients.

1. Know the curriculum

Dull but true. Start by going through the curriculum. You may find surprising areas of weakness that seems to have been missed out in lectures or by yourself. Start by making a list. These will help direct your clinical learning. A word of warning—while it is important to be familiar with the whole curriculum, in case there are any nasty surprises, do not forget the old medical truism: common things are common. Examiners like horses, not zebras, and their favourite topics will tend to coincide with the important, bread-and-butter sections of clinical medicine. You are very likely to get shown a picture of a fundus with diabetic retinopathy and laser scars—you are unlikely to get a picture with neurosarcoidosis and granulomatous papillitis. Indeed, part of learning to be an excellent doctor is being excellent at recognizing common things, and being excellent at treating them—as well as knowing when to be suspicious that something is out of the ordinary.

2. Develop a system

Tempting as it is to simply open a book and hope the entire contents make their way into your brain so you can repeat it verbatim on demand, it is far better to develop a system for dealing with each condition you come across. Exams are not presented like a textbook, nor will examiners take kindly to you regurgitating a long, meandering list of causes and effects when what they want is a succinct diagnosis, followed by a few pertinent differentials. A system also helps you react to unexpected situations, think through what a surprising examination finding might mean, and try and put the whole thing together into a coherent clinical picture—essential in the stressful environs of an OSCE. Learning in the way exams are presented can be helpful.

For example, you might wish to start learning about lung cancer by beginning with a list of differentials for a radiopaque mass, and go on by considering other ways lung cancer can present, rather than reading through the different types of lung cancer. In terms of presentation, the surgical sieve is a useful start and absolutely priceless if stuck in an OSCE with an examiner demanding to know what could cause this patient to have that weak left arm you have nicely demonstrated. The surgical sieve consists of VITAMIN ABCDEFG:

  • Vascular

  • Infection/inflammatory

  • Trauma

  • Autoimmune

  • Metabolic

  • Idiopathic/iatrogenic

  • Neoplasia

  • Acquired

  • Blood

  • Congenital

  • Drugs/degenerative/developmental

  • Endocrine/environmental

  • Functional

  • Genetic.

There are other systems of presenting and thinking about conditions:

  • Acute vs chronic (e.g. skin changes in allergic eczema, symptoms of heart failure, causes of a pleural effusion).

  • Immediate vs late (e.g. side effects of radiotherapy, complications of surgery, symptoms of organ rejection).

  • Local vs systemic (e.g. symptoms of renal cancer, pulmonary TB).

3. Walk the wards

Armed with a system and a list of target areas, you are ready to hit the wards. Remember, there is no replacement for practical experience. Books are important, and of course there is a balance to be had. However, successful students are overwhelmingly those who have spent more time on the wards. You may know that you have to send off a serum ACTH to diagnose an Addisonian crisis, but only someone who has been on the wards knows the results do not come back for 2 weeks—and that an Addisonian crisis is an urgent clinical diagnosis that needs to be treated without waiting for that blood test. In an OSCE, a few questions can quickly reveal who has put in the time and who has not. More pertinently, that lack of clinical experience will really show when it comes to your first weeks as a nervous doctor. Nevertheless, there are times on the wards when your heart sinks because there is ‘nothing to see and nothing’s happening’. The key is to bring plenty of reading material and other things to do while you wait for an interesting case—and have faith, because there will be one, sooner or later.

4. Attend clinics

Clinics are an excellent way to spend focused clinical time. They play second fiddle to wards in these revision tips, because too much focus on clinics risks missing out a good deal of general inpatient medicine, which will form the bulk of your medical and surgical exam topics. Having said that, clinics can be extremely useful to swot up on areas of weakness, get exposure to rarer conditions, spend a whole morning just looking at knobbly, arthritic joints, identify suspect skin lesions, or peer into ears—many of which are likely to have actual signs. Do your research before going to a clinic.

5. Tutorials

You can learn from anyone more senior than you—whether it is the students in the year above or the consultant about to retire. You just have to ask. If this seems unbearably impertinent, remember that many students and junior doctors are interested in teaching qualifications, CV points, or need teaching feedback for their ARCP (Annual Review of Competence Progression)—so they may be as keen to teach as you are to be taught. The longer you spend on the wards, the more likely you are to get taught. A spare 10 min may crop up unexpectedly and you may get an impromptu bedside tutorial. Also, the longer you spend getting to know a particular team, the more likely it is they will offer to teach you, or respond well to a request for a tutorial. All levels of seniority will be helpful in teaching. Older students will have just been through the process and may have good tips on good consultants to shadow, common exam topics, or good clinics to attend. Junior doctors also remember what it is like to revise for exams. They will have a huge list of patients with good signs and will grill you on your examination technique. Consultants are, of course, the ultimate authority. They may well be setting your exam, and they will be able to clarify any particularly tricky areas you have been wrestling with. Use them all wisely.

6. Multimedia

There are a wide variety of websites out there to help you revise, with useful videos and pictures. These are particularly useful for learning anatomy, practical techniques, and rare and interesting signs, but can be used to complement any facet of your learning, if you find you are a very visual learner. Podcasts are an excellent way to learn while on the move, and for those with short attention spans or who learn particularly well by listening. There are a number of free podcasts available online, and any medical student forum will come up with a long list of possibilities. There are a number of case-based books. These provide easy bite-sized chunks of revision and are a good way of cramming a little bit of revision into a spare 5 min.

7. Practical labs

Your medical school may organize practical labs as catch-up sessions before OSCEs for stations such as cannula insertion, NG tube placement, suturing, and so on. Take advantage of these. You may be able to organize informal sessions by contacting the practical coordinator in your medical school and arranging access out of hours.

8. Mock exams

  • Practise with your medical friends. The first time will be excruciating—the second time will be just a bit awkward—and the next time you will be just eager to tell them exactly what they did wrong. Students are the harshest critics—and it is fairly easy to get a group together, pool your knowledge, and share tips.

  • Practise with your non-medical friends. They will give you hints on communication, manner, and whether you are slipping into medical jargon. They will tell you if your examination leaves them feeling undignified, and if you look convincing when you present, even if they cannot fault you on your knowledge.

  • Practise with doctors. Junior doctors may be willing to run a ‘mock’ OSCE in return for teaching feedback—try suggesting it to some you have been shadowing and see if they are open to taking a 30 min session if you can find a small group.

  • Practise in mock exams. There may be free courses—or very cheap ones—run by other medical students or junior doctors keen for teaching practice. Use these as much as you can—even if they are very informal or not realistic, they are a great way of getting generic feedback and finding your weaknesses.

9. Feedback from previous exams

Feedback from previous OSCEs is an extremely valuable way to inform your exam technique. If you do not automatically get this, try contacting your medical school tutors, who may be able to make this available to you. A helpful way to look at this information is to go through it with a trusted friend or tutor and see if they particularly agree with or can expand on any points made (e.g. if your presentation skills are criticized, might they have noticed you have poor eye contact, or that you tend to repeat yourself?).

10. Take a break!

You cannot study forever. Everyone works more efficiently when they are well rested and energized. So remember to take care of your body as well as your mind. Get enough sleep. Do not burn out just before the exam—an exhausted, demoralized student gives a bad global impression and generally gives a poor performance.

Sources

Clinical examination and skills textbooks

Learn systemic examinations by heart and recognize what signs to look out for in a logical order so that you can perform the examination competently in a timely fashion. Practise your basic clinical skills in the skills laboratory with your colleagues performing the role of the patient. Some popular texts include the following:

Clinical cases books

Many common clinical scenarios have been compiled in books with recommendations on what to specifically look for and how to present these findings to your examiner in order to gain the highest marks. Some popular texts include the following:

Examination videos

Ask your medical school library for any available examination videos. It may be worth watching these videos and then practising each sequential step of the examination with your colleagues. Beware of ‘variations’ or false advice, particularly online; you will need to develop your own examination style which incorporates the techniques needed to elicit important and relevant signs. Some online references:

Group

Revising with your colleagues allows you to assess each other’s performance while gaining the confidence to perform examinations confidently in front of an audience. You can learn from the strengths and weaknesses of others.

Tutor

Request a doctor to act as your group’s tutor so that after practising your clinical examinations and skills for a week, you can then be assessed by your seniors for more guidance and tips to polish off your skills. It is worth obtaining a tutor in general medicine and in general surgery and one tutor within each of the clinical specialties (orthopaedics, rheumatology, obstetrics and gynaecology, neurology, etc.) It is important that you learn from your mistakes during practice sessions as opposed to in the exam.

Speak to senior students

Ask for advice from your predecessors who will have recently passed the clinical examinations. They may be able to offer some helpful tips on effective revision strategies, good revision references, personal insights, and may even offer to tutor you for a few sessions.

Observing doctors

While on clinical placements, ask your doctors if they can demonstrate a model example of examining a patient while talking you through each step and justifying their actions. Doctors will also highlight clinical signs on patients during the ward round. They may also offer to observe your examination technique and give some feedback. Bear in mind that there will be some variation in examination technique between doctors but appreciate that everyone has a fixed system of thoroughly examining which is all that matters. Based on a universally accepted method of inspection, palpation, percussion, and auscultation (or look, feel, and move in joint examinations).

Wards

These are the most valuable sources of real patients with authentic clinical signs. The more time you spend on the ward clerking and examining patients, the more confident and competent you will become. It is only through repetition you will develop clinical judgement, which will be the product of all your previous knowledge and experiences of different signs and clinical presentations.

Courses

There are an abundant number of courses offered by both medical schools and private groups throughout the year. Although not compulsory, some students feel that they benefit from attending courses near exam time. These courses are usually delivered by registrars and consultants who give brief lectures, demonstrate examinations or skills, and observe you practising your technique on volunteer students/patients under exam conditions. Some of the courses may be of use (see Table 49.4).

Table 49.4 Examples of courses

Course

Website

Fee

Days

Location

Q Courses

Preparing for clinical examinations www.qcourses.org

£125

2

London

PME

Preparing for clinical examinations www.professionalmedicaleducation.co.uk

£110

2

Nottingham

Ask Dr Clarke

Preparing for clinical examinations www.askdoctorclarke.com

£69

1

Nationwide

Hammersmith

Preparing for clinical examinations www.hammersmithmedicine.com

£75

2

London

Mentor OSCE

Preparing for clinical examinations www.mentorosce.com

£140

2

London

Doctors Academy

Preparing for clinical examinations www.doctorsacademy.org

£55

1

Manchester

Finalmed

Preparing for clinical examinations www.finalmed.com

£167

2

London

Previous mark sheets

Your tutor may have access to some mark sheets used in previous years which give you a template of what is expected of you during clinical examinations. Generic marks are always given for the following actions:

15 tips for success in clinical examinations

1. Practice, practice, practice …

… makes perfect. Practise with colleagues everyday on and off the wards. It is often helpful to identify good technique while observing others examining and reflecting. Moreover, if you are able to teach a skill, then you are likely to be competent to perform it yourself since it will force you to simplify and justify the relevant steps. If you are having to think hard about the next item on the agenda, you will not have time to put it together. Practice makes you slick, it helps you recognize patterns, and it will make you outstanding.

2. Preparation

This is the best-kept secret for passing clinical examinations. You cannot rely on last-minute cramming since you need to spend a substantial amount of time applying your clinical skills to real patients.

3. Beginning and end matters

Introduce yourself to the examiner and the patient with your name, grade, consent, and duration of exam so that you put the patient and yourself at ease. Be sure to thank the patient at the end of the clinical encounter.

4. Confidence

This is key to convince both examiner and patient that you are reliable and know what you are doing. Project your voice when speaking and presenting. Do not panic if you get stuck since you will be prompted. In examinations, state whether a sign is present or absent but do not use vague words such as ‘I think, it appears, it looks like, it is likely, there could be …’.

5. Non-verbal communication

This is vital in comforting the patient and empowering them to give you the information you seek and demonstrating your competence to the patient and examiner. Focus on keeping your body language, maintain eye contact, nod to empathize with the patient, and do not forget to smile when reassuring the patient.

6. Verbal communication

This is one of the most crucial attributes of a good clinician. Engage with the patient’s ideas, concerns, and expectations while establishing clinical details. Offer signposts to guide the patient when taking a history. Always summarize at the end to make sure no important information has been overlooked. Avoid medical jargon with the patient at all costs; you may use the correct terminology when presenting your findings to the examiner. Present your key findings first, and tell them the story of your diagnosis. Listen to how junior doctors present to their consultants, and use that as a model.

7. Behave professionally

It is important that you adopt a mindset of a doctor and present yourself appropriately, remembering that your attitude and behaviour will also be assessed. Wear a shirt or blouse, tie, and formal trousers or skirt in neutral colours; dress like a doctor. Be mature and respectful towards the patient and address their concerns to the best of your abilities.

8. Think out loud and putting it all together

Doing this during examinations can minimize the risk of missing out significant clinical signs. Otherwise, you may pick up on something significant which you may forget to mention at the end due to stress and time restraints. If someone has a thyroid mass, look at their legs for pretibial myxoedema, and their hands for thyroid acropachy. If someone has a scar on their chest, look at their legs for vein grafts. This shows everyone you are putting everything together and seeing the bigger picture (look for associations, causes, and complications relevant to the signs you identify). If you do not have time to examine for all those things, mention them in your presentation so the examiner knows you have thought about them.

9. Be systematic

And stick to a format you are used to and have practised over and over again. Always go back to basics if you find yourself struggling: IPPA (or look, feel, and move in joint examinations).

10. Courtesy

Be courteous to your patient. They are bored and tired and they have had to sit through the same scenario many times already this morning. Remember to help keep their dignity, to ask for consent, and to make sure they are comfortable before you start presenting. If you do this, your examiners will mark you up, and your patients will like you and help you out—they may give you extra clues in the history, or offer up extra information without you explicitly asking for it. This reflects real life, where putting a patient at their ease is likely to result in better communication all round. Be sure to thank the patient at the end of the clinical encounter. Some OSCEs also leave a few marks to be decided by the patient/actor on how they comfortable they felt to have you as their doctor.

11. The little details count

Make sure everything is right. If you are examining confrontational visual fields, make sure you and the patient are on the same level. If you are looking at the JVP and then palpating the abdomen, make sure the patient really is at 45° to start with, and then take the time to lie them completely flat. These are small details but sloppiness here gives a bad impression. More importantly, failing to get the setting right means you may miss key findings. A sloppy clinician is an unobservant clinician.

12. Think laterally

Contrary to popular expectation, OSCEs are not designed by fiends in human form, itching to catch you out on a technicality. However, bear in mind that a ‘hand examination’ does not always mean musculoskeletal—and can be a catapult to other parts of the examination (e.g. clubbing and yellow nails to the respiratory exam), especially in the ‘endocrine’ or ‘general’ station. Remember that certain things can present in the hands—wasting (so think about a lung apex tumour—and exclude a subtle ptosis), or pigmented palmar creases (so look for signs of Addison’s).

13. Do not see what you expect to see (or hear)

Develop your skills of really looking and really listening. You might be expecting to hear a murmur in the cardiology station, but if the station is all about identifying the central sternotomy scar and talking about cardiovascular risk factors, then presenting a fictional aortic regurgitation is quite frankly embarrassing. Be confident and back yourself if you think you have found something—but do not go convincing yourself you have found something because you think it should be there.

14. Time yourself

Once you have your routine down in memory, it is time to practise to a strict time limit. Find out what the timings are likely to be in the OSCE, and strictly time yourself. There is nothing worse than running out of time in the exam—you are flustered, worried you have missed something, have not put it together, and now you have to present. If you are not disciplined enough, get a friend or a sibling to do it.

15. Let it go

Do not let failure at one station help you fail the next. Just as with a written exam, do not get hung up on a difficult question. This can be hard, as a bad OSCE station has more psychological impact than turning over an exam page, and is harder to forget. But do it. Turn over that blank page in your mind. The next station is a whole new opportunity. The same goes for the next part in the same OSCE. The examiner may not have noticed you started listening to the heart on the wrong side. Carrying on smoothly and correcting your mistakes mean they may never notice. Drawing attention to it or becoming frustrated and letting it affect the rest of your examination means they definitely will.

Medical history

(See Preparing for clinical examinations Chapter 6.)

Presenting complaint

  • In the patient’s own words, why have they come to see you (what changes (symptoms) have they noticed)?

  • Patient’s ideas about the cause of PC.

  • Patient’s concerns.

  • Patient’s expectations of the consultation.

  • Effect/impact of the PC on patient’s life (home and work).

History of presenting complaint

  • When did symptoms start?

  • When were the first changes noticed?

  • What has happened since then?

  • What has the patient done about it?

  • Any over-the-counter medication for PC?

  • Previous episodes and what happened last time.

  • Characterize pain/symptoms (SOCRATES).

  • Investigations and tests.

  • Treatment.

Past medical history

  • Previous illnesses.

  • Previous operations.

  • Previous hospitalizations.

  • Screening questions: MJ THREADS.

Medication/allergies

  • Medication for treatment.

  • DRUGS mnemonic.

  • Allergies.

Family history

  • Parents, siblings, children, partner—quality of relationships with patient.

Social history

  • Age.

  • Place of origin.

  • Marital status/children.

  • Who lives at home?

  • Occupation—nature and satisfaction.

  • Housing—location and type (e.g. house or flat).

Lifestyle

  • Smoking/tobacco:

    • Smoking: 1 pack-year = 20/day/year.

  • Alcohol (CAGE):

    • 1 unit = ½ pint of beer or 1 glass of wine.

  • Recreational drugs.

  • Exercise.

  • Diet.

Additional lifestyle issues

  • Quality of life—effect of illness on daily routine.

    • Activities of daily living: shower, dress, house choirs, shopping.

  • Mobility:

    • Independent, needing assistance, walking aids (stick, crutch, Zimmer frame), wheelchair or bed-bound.

  • Quality of sleep.

  • Sexual history.

  • Recent travel.

  • Significant life events.

Functional enquiry/systems review

  • Systemic/constitutional symptoms:

    • Fever, weight loss, night sweats, lumps, fatigue, loss of appetite.

  • Cardiorespiratory:

    • Palpitations, chest pain, breathlessness, wheezing, cough, sputum, haemoptysis, orthopnoea, peripheral oedema.

  • Gastrointestinal:

    • Abdominal pain, nausea, vomiting, constipation, diarrhoea, weight change, constipation, PR bleed, mucus discharge.

  • Genitourinary:

    • Irritative symptoms (Preparing for clinical examinationsfrequency, haematuria, dysuria, urgency), obstructive symptoms (hesitancy, intermittent stream, straining, terminal dribbling, incomplete bladder emptying), incontinence, discharge, urinary retention; sexual history.

  • Gynaecological:

    • Menstruation, dysmenorrhoea/haemorrhagia; pregnancies.

  • Neurological:

    • Headaches, unilateral weakness, neck stiffness, photophobia, seizures, ataxic, falls, dizziness, vertigo, changes in vision/hearing/balance/speech/taste.

  • Musculoskeletal:

    • Joint/bone pains, joint stiffness, skin changes, deformed joint, fluid, swelling.

  • Psychiatric:

    • Depression, hallucinations, thought (insertion, withdrawal, control), mood.

  • Endocrine/thyroid:

    • Thyrotoxicosis (diarrhoea, weight loss, Grave’s eye signs, insomnia, tachycardia, palpitations, tremor, acropachy, heat intolerance), hypothyroidism (weight gain, proximal myopathy, alopecia, bradycardia, cold intolerance, constipation), goitre.

Communication tips

  • Clarify patient’s terms and understanding.

  • Make transition statements and signposts.

  • Clarify ICE from the patient.

  • Empower patients to ask questions.

  • Provide a summary at the end.

Useful mnemonics in history taking

ICE questionnaire—useful phrases

  • Ideas: what do you know/think/understand about this matter?

  • Concerns: are you concerned or worried about something?

  • Expectations: what do you hope for/expect/anticipate from this?