2013  Year  5  OSCE  21st-­‐26th  November  Student  Feedback  

 Students   as   a   cohort   performed   well   in   the   OSCE.   The   pass   rate   was   high.   Of   the  individual  stations,  students  struggled  the  most  with  the  station  on  lithium  toxicity  and  the  station  on  psychosis.    The   following   are   some   specific   feedback   from   examiners   on   nine   stations.   The   other  nine  stations  were  all  performed  well  and  had  no  specific  feedback  from  the  examiners.    The   feedback   below   points   to   a   tendency   for   premature   closure   in   diagnostic  assessment,   areas   of   weakness   in   examination   skills,   weakness   in   recognising   and  assessing  a  presentation  of  psychosis,  and  specific  knowledge  deficits.        Day  1  Station  2:  Lower  limb  examination  Generally,   students   performed   well.   Examiners   recognised   that   a   comprehensive  examination  of  the  lower  limbs  was  not  possible  within  the  limited  time.  Students  who  performed   well   were   able   to   prioritise   the   task   while   still   retaining   a   systematic  approach   (e.g.  not   spend   too   long  on   inspection  and  methodically   looking   for   relevant  signs  in  a  patient  with  diabetes).      Examiners  commented  on  the  following  areas  that  need  attention:  

a) Non-­‐systematic   approach   to   examination,   e.g.   beginning   sensory   examination  with  vibration  sense,  omission  of  testing  for  light  touch.  

b) Poor  examination  technique,  e.g.   incorrect   technique   for  eliciting  reflexes,  poor  technique   for   testing   proprioception,   poor   technique   for   palpating   peripheral  pulses.  

c) Insufficient   knowledge,   e.g.   confusion   between   signs   of   micro-­‐   and   macro-­‐vascular  disease  and  venous  disease.  

d) Failure  to  recognise  signs,  e.g.  Charcot’s  foot,  nail  abnormalities.    Station  3:  Breaking  bad  news  This  station  was  generally  performed  well.  Examiners  commented  on  a  reliance  to  use  stock  standard  statements  to  demonstrate  empathy,  rather  than  engaging  with  the  SP  by  asking  how  he  was  feeling  or  exploring  his  experience  (to  an  extent  feasible  within  the  confines   of   the   station   time).   Examiners   also   noted   that   some   students   had   incorrect  knowledge  about  the  sequence  of  managing  oesophageal  carcinoma.    Station  4:  Lithium  toxicity  This   station  was  generally  poorly  performed.  Examiners  noted   that   a   large  number  of  students  were  not  able  to  identify  the  symptoms  and  signs  of   lithium  toxicity.  Of  those  who   identified   it,   many   did   not   hold   or   cease   lithium,   which   is   an   essential   part   of  management.   Students   should   remember   that   lithium   toxicity   is   a   relatively   common  clinical   presentation,   and   is   a   diagnosis   based   on   clinical   features   rather   than   serum  level,  even  though  serum  level  is  a  useful  aid  to  diagnosis  and  should  be  performed.    Station  6:  Prescribing  (post-­‐operative  analgesia)  The   prescribing   station   was   generally   done   well,   and   most   students   recognised   that  morphine   is   the   drug   of   choice   and   understood   the   need   to   monitor   for   over-­‐sedation.    Some  did  not  complete  the  drug  allergy  panel,  and  a  very  small  number  filled  in   the  panel   as   "none  known"   -­‐   this   is  misleading  and  potentially  dangerous   since   the  

patient  had  a  history  of  penicillin  allergy.    A   few  students  used  oxycodone  rather   than  morphine  –  this  was  acceptable  but  not  ideal.    Day  2  Station  2:  History  of  fatigue  A  number  of  students  did  not  perform  well   in  this  station.  The  main  problem  noted  by  examiners  was   the  premature  diagnosis  by  students,  e.g.   focusing  early  on  malignancy  and  thus  failing  to  adequately  consider  other  differential  diagnoses.    Station  4:  Psychosis  This  station  was  poorly  performed  by  students  as  a  whole.  Examiners  all  commented  on  the   failure   of   many   students   to   identify   psychosis,   despite   SPs   returning   to   their  delusions   on  multiple   occasions   during   the   interview.   Part   of   this   related   to   students  missing  or   ignoring  cues  given  by  SPs,  and  part  of   this  related  to  poor  clinical  skills   in  eliciting  psychotic  features,  e.g.  only  asking  about  auditory  hallucinations  in  assessment  of  psychosis,  asking  for  psychotic  symptoms  in  such  a  way  that  only  insightful  patients  could   answer   (such   as   asking   if   they   had   “thought   withdrawal”   or   if   they   had  experienced  anything  “abnormal”).  Examiners  also  noted  that   few  students  considered  any  aspect  of  risk  to  the  patient  or   infant   in  this  scenario,  which  possibly  reflected  the  failure  to  identify  the  presence  of  psychosis.      Students  should  also  be  aware  that  SPs  are  often  scripted  to  provide  different  verbal  and  non-­‐verbal   responses   depending   on   the   student’s   empathic   engagement   and  questioning  style,  as  patients  do  in  real   life.  Students  therefore  should  not  assume  that  SPs  would  automatically  regurgitate  history  when  probed  –  the  questioning  would  need  to  be  relevant  and  appropriately  skilled  in  order  for  history  to  be  elicited.    Day  3  Station  1:  Cardiac  examination  This   station   was   generally   performed   well.   Examiners   commented   on   the   need   for  greater  competence  in  examination  technique,  in  particular  relating  to  the  manoeuvres  for  auscultating  cardiac  murmurs.    Station  2:  Pre-­‐operative  bleeding  This   station   was   generally   performed   well.   Examiners   commented   that   few   students  demonstrated  open  questioning  in  their  history  taking,  instead  relying  on  rapidly  firing  questions   at   the   SPs.   Examiners   also   identified   premature   closure   in   diagnostic  consideration,  with  a  rapid   focus  on  one  diagnosis  at   the  expense  of  considering  other  differential  diagnoses.    Station  5:  Skin  lesion  This   station   was   generally   performed   well.   Examiners   commented   that   the   area  requiring  the  most  improvement  was  description  of  the  lesion,  and  there  was  a  need  for  greater   familiarity   with   descriptive   terms.   Some   students   also   showed   an   incorrect  knowledge  of  the  margin  for  excisional  biopsy.