If you’re studying for the RACGP OSCE, you’ve already done the hard yards in passing the written exams. You have the “Knows” and “Knows How” of Miller’s Pyramid, so now it’s time for the does.
But don’t forget that Miller’s pyramid can also be seen as a prism, incorporating knowledge, skills and attitudes – and it’s the latter two components that the OSCE will look to test.
In an ideal world, the best way to assess a doctor’s competence is for them to be observed in ‘real practice’, over multiple occasions, by multiple different assessors. But logistics and pragmatics make this method of ‘Does’ assessment unachievable, so the OSCE uses 8 and 19 minute ‘snapshots’ of consultations instead. In no way is the exam encouraging of ‘quick medicine’. This ‘snippit of a consult’ concept is critical in understanding how to approach the OSCE exam. So let’s get SMART about approaching the OSCE.
Many of you will have seen the SMART acronym when goal-setting or planning learning, but let’s look at it in terms of OSCE preparation.
S – Specific
M – Measurable
A – Achievable
R – Realistic
T – Time-focused
Start by using your reading time effectively. Use an OSCE proforma to ensure that you have a plan to refer back to when that bell rings and the nerves kick in. We shouldn’t see a patient without reviewing their record first, nor should we dive into an OSCE station unprepared. If you don’t have an OSCE profroma, you can download one from our website after activating a free GP Study System Bronze Subscription. Then check that your proforma and technique is SMART.
SPECIFIC
- Be specific in your history-taking – remember to ask questions that reflect equally the diagnosis you are suspecting and the ones you should rule out. Don’t spend time re-asking information that you are already given.
- Be specific in your examinations – complete focused and relevant examinations demonstrating that you are looking for the key positive and negative findings. A traditional ‘top to toe’ Talley examination whilst thorough, does not reflect realistic practice, nor your interpretation of the relevant history whilst examining the patient.
- Be specific in your investigations – do not ask for investigations that you would not normally do in practice or will not change your diagnostic or therapeutic reasoning.
- Be specific in your management advice – list the management aspects that require consideration then address each one systematically and in order of importance.
- Be specific in your demonstration of the non-clinical domains of practice – how will you demonstration the art of communication skills, population health and context, professional and ethical domains, and organisational and legal aspects of practice. Even though we practice the non-clinical domains routinely in practice, we often haven’t thought of how we make these obvious to another who is observing.
Measurable
- Consider how a borderline candidate might perform in the case in question (this is much easier to do when you are practising cases). What are the pitfalls and key concepts that are likely to be missed?
- Demonstrate Evidence-based Medicine – these are the measured and research-based facts that demonstrate clear knowledge of guidelines.
- Ensure that there are measurable outcomes and goals for management – clear articulation of red flags and safety-netting, and the timing and importance of follow-up.
Achievable
- Are the investigations and management you are suggesting achievable in the context of this patient, this context and this setting? Consider ethnicity, literacy, rurality, rational investigations and therapeutics in the case at hand.
- Are your investigations and management aligned and achievable with the agenda of the patient, their family and their community?
- What can you reasonably achieve in each segment of the consultation in this brief clinical ‘snippit’ – choose the components that demonstrate the domains of practice and your knowledge, skills and attitudes the best.
Realistic
- Keep it real, and don’t do or say anything you wouldn’t normally do in practice.
- Proceed confidently and appear as if you have done that consultation, that examination etc hundreds of times (and you should have by know if you are working in mainstream General Practice).
- If the case/station doesn’t go as planned, don’t be hard on yourself as everyone else is probably finding that case difficult too. Put the case behind you when that bell rings and give your full attention to the next case as we should do in clinical practice. Use the next station for a toilet and drink break to recharge for the remaining stations. A bad consult in a day of practice doesn’t necessarily mean that you haven’t performed well for the rest of the day.
Time-focused
- This is perhaps the hardest goal and can only be attained by practice. Without a stopwatch it is difficult to know what 3, 8 and 19 minutes feels like. So practice, practice, practice with a colleague. After you finish a consultation, consider that if it were an OSCE station, what could you reasonable demonstrate in the time given. What are the likely components the examiners would be looking for to demonstrate safety?
- Use summarising, sign-posting, and the bells in a long case to define your time.
- If you are spending too long on one component of a consultation, it is likely that you have lost your way. Take the time to review the task list, consider your notes and chart a new course in the consultation.
SMART STUDY
It can be hard to motivate yourself for this last stretch towards Fellowship. This is an exam that allows you to ‘show’ what you do – so try approaching in a more active way!
- As a colleague to observe your practice as if it was an OSCE case and give you feedback.
- Practice with a friend in a beautiful outdoor space.
- Watch videos and podcasts of consultations, particularly to appreciate the non-clinical domains, but also to refine your examination skills.
- Consider sitting in with colleagues who see different patients than you, e.g. a women’s health GP, the local physiotherapist for MSK tips.
- If you a resitting the exam, taking the same approach is likely to result in the same outcome – so change it!
- Ask yourself how SMART your approach is each time you practice a case.