Down the Rabbit Hole (... mid OSCE station)

The Rabbit Hole

You are mid OSCE station and you’ve hit a roadblock.  Not sure what to ask next, where to go, where you have gone wrong? You have no idea what the diagnosis is and are getting poker faces from the examiners.  What do you do next?

This situation is everyone’s worst fear. So, what is the best way to address a fear? Prepare a contingency plan. Here’s one you can try.

Contingency plan…

  1. Excuse yourself: What do you do in a consultation when you have no idea (other than send the patient to collect a urine specimen)? You take some time out to write some notes.   Here are some OSCE equivalents:
    • Summarise: ‘You’ve given me lots of useful information here, I’m just going to summarise it back to you’. Reflecting the information may jog your memory to consider other questions, or give the patient an opportunity to correct information or add more.  It also shows the patient (and the examiner) that you’ve listened.
    • Collect your thoughts: ‘I have lots of information to think about, I’m just going to collect my thoughts for a moment’. Take some time to look over your history notes or reading time notes.
    • Go back to the very beginning: Start the history again.   Yes, this will take time but may make an enormous difference in the case outcome.
  2. Look back at your reading time plan (see previous post on 5 Steps in 3-minute reading time).
    • Read the question again: Is it what you thought it would be about?
    • Review the key features.
    • Consider your differentials – most likely, an alternative diagnosis and one not to miss. Use a surgical sieve (e.g. VINDICATE).
    • Think about Murtagh’s masquerades.
  3. Cues: Have I missed something?   Does the patient understand?   Are they telling me the same information over and over?  (I’m missing something obviously)
  4. TASK LIST: Read it again.
  5. Leave:   If you’re sure you’re done, leave the room.   Often staying will mean that you ‘dig yourself a hole’ and make comments that are unnecessary or inappropriate whilst searching for the answer.   Use the leftover time seated outside to recharge for the next station.

When the station doesn’t go well…

If the station/case didn’t go so well then remind yourself:

  • There are always one or two stations that are there to discriminate the excellent from the good candidates. This may have been one of them.
  • You can perform not so well in one station and still pass.
  • You can still pass a station without getting the diagnosis – you don’t know how the various components of the station are rated.
  • All of you have completed the AKT and KFP, to get to this point. Core knowledge is rarely an issue in the OSCE but the non-clinical domains are so important – that’s why you need to regroup before the next station to optimise your communication, contextual, organisational and professional skills.

Please note:  This post was originally published on the Medcast exam preparation blog.


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