OSCE station: Health Promotion.
OSCE practice: discharge planning
Morning fellow medics,
I am going to breakdown the different concepts behind the “Discharge Planning “ Station. I have witnessed them in many OSCEs, both from a trainee and examiner point of view. This is an important station, as it tests the knowledge of the NHS, fundamentals to minimise unnecessary over crowding of hospital wards along with the awareness we need as doctors of “community care”. So lets set a case and then think about the way we would tackle it:
Example:
You are a FY1 working on an elderly ward. You have been asked to speak to Mrs Smith’s Daughter, Joanne. Mrs Smith was admitted into hospital with a left hip fracture, which has been operated on. She has made a good recovery, and has been seen by the physiotherapist, the occupational therapist and the consultant and subsequently been deemed MFFD (medically fit for discharge). Mrs Smith has capacity and would like to go back home.
The plan is for her to be discharged back to her home today. Joanne would like to discuss her mums discharge as she has a few questions.
This station might go two ways 1) it is a simple station - with no aggravated relative or 2) Joanne is not happy that you are discharging her mum back to her home.
So here are the crucial concepts to think about which will allow this station to flow, look genuine and also help with any conflicts.
1) Build a rapport.
I have said this time and time again- but there is a reason! Firstly you want to show you care and you want to know more about the patient and daughters ideas, concerns and expectations (yes ICE!). Secondly, it helps you get an idea of what the situation is, as sometimes the relative/actor might give you hints to the history or story that you may have missed from looking at the vignette.
So start simple:
“Hello Joanne, I am Dr X, I have been looking after your mum. How can I help you?”.
Allow the relative to speak, to express their concerns and listen to them. Use verbal and non verbal cues to show you hear them and appreciate their concerns.
2) Have you got consent to speak to the relative?
Confidentiality is key to speaking to relatives. In the real world, it might be that you have always spoken to the relative in front of the patient, but has consent ever been sought? This may be documented somewhere on the notes, there may be a code that has to be given when the relatives calls the ward. Whichever way, it is prudent that this is considered. For the sake of the exam, you might need to ask or it may be written down, but as long as you acknowledge that you are aware of this, it shows you work with integrity.
“Before I explain your mothers current treatment, can I just clarify that I have your mothers consent to discuss this with you?”.
This may be followed by the examiner intervening, the relatives agreeing or it may be written down.
3) MDT approach
The general approach to safe discharge planning from hospital care to community is based on a MDT approach. So if Joanne (Mrs Smiths daughter) was not happy that her mum is being discharged but you have all the documentation to make you feel confident this is going to be a safe discharge, then USE this information. Explain that her mother has been seen by the : occupational therapist (OT); the physiotherapist; the pharmacist has put their medications together; the social worker has assessed the house and the consultant is happy from a medical point of view.
4) Think about the social aspect
Discharge planning is more than just a patient being “fixed” in hospital and then being discharged back to the community. As an all round caring compassionate doctor, you need to take the social aspect into consideration. Does Mrs Smith have the correct equipment at home (ie has she been seen by the OT?). If she is moving back in with her daughter, can Joanne cope? Are the family happy to have the patient home? Will it impact on their home life? affect them financially? These are all areas of the “social” history to ask about.
“I can see that the decision to discharge your mum has upset you, and you have spoken about the stress you have at home. Please can I ask about further about these stresses, so I can help you?”
5) If in doubt, ask your seniors.
I have seen in many OSCEs, the trainees get frustrated because they feel they are not seeing “eye to eye” with the relative/patient. But this shouldn’t be the case. The whole point of this OSCE is not to “win”, it is about “communication and management skills”. If you are getting towards the end of the consultation and despite your efforts, the relative is still not happy, do what anyone would do- consult your seniors! This should be part of your management plan. It shows initiative, humility and that you are able to resolve conflict appropriately.
“Joanne, thank you for meeting with me today. I understand that the situation is very frustrating, and you do not feel happy that your mum is being discharged. Would it be possible to arrange a meeting with myself, the consultant and maybe some other team members ie occupational therapy and a social worker"?”
I hope the above has given you some ideas of how to tackle these type of cases. As i always state, it is not about memorising what to say, but about understanding WHY you are saying it (meaning less things to remember!).
Keep practicing and keep that focus on the end goal.
Keep safe :)
OSCE practice: 6 tips to be confident in the OSCE
Hello fellow medics,
I hope we are all keeping well.
Having had lots of OSCE practice by helping students prepare, being an examiner for the OSCE as well as having many exams myself, a common issue I have come across is: “I know the answer but get anxious and freeze up in the OSCE, meaning I can’t communicate my knowledge”.
Nothing is more frustrating than knowing your stuff, but not being able to confidently articulate it in the OSCE. Meaning you can’t showcase all that knowledge you have accumulated over the tiring years of being in medical school.
Below are some tips to help you shine with confidence and SHOWCASE your knowledge!
1) Take a deep breath
Many of times I have had to tell candidates to literally breathe. This can mean physically: yes, stop and take a deep breath but also mentally take a breath. What I mean by this is, literally stop, take a moment, think, re-evaluate your thoughts and continue. Rather than rambling on in a history, or losing your focus on an examination, STOP, BREATHE and CONTINUE. You will not be penalised for taking a moment to put your self back on track. In fact, this can be seen as maturity, as you are showing you have self awareness of going in the wrong direction in the OSCE.
2) Look and feel the part
Dress to impress. This doesn’t mean just to impress the examiner (we are looking for smart attire and that is about it!) but i mean for yourself. You want to wear what you feel confident in. So don’t decide to wear a new pair of uncomfortable shoes, or a new dress that you do not feel happy and confident in. You don’t want to be re-adjusting your dress or trousers throughout the OSCE as it is both distracting to you, the patient/actor and the examiner.
3) Practice - you need to hear your own voice
Practice Practice Practice! This means with colleagues and friends, but also a great way is practicing speaking out loud to yourself. So in the build up to the OSCE, stand in front of the mirror - and talk to yourself. Get to grips with the wording of certain questions, listen to your voice. Practice in the bathroom. This is great way of hearing how you sound, looking at your body language and learning from your mistakes.
4) Act the part - get in the right mindset
Remember the aim of this exam is to pass and then practice as a doctor. So, ACT LIKE A DOCTOR. Have that confidence and self awareness that you deserve to be in that OSCE and deserve to pass and work in the UK. You have passed all the exams needed and are now ready to be part of the NHS in the UK. You need to essentially show the examiner that you have the skills and attributes that THEY need. So get in the mindset that you are an aspiring doctor who is competent, ethical and willing to learn.
5) Don’t critique yourself
In the OSCE, do not critique yourself. Avoid thoughts of: “What does the examiner think about me?” “Why did I say that? I am not competent”. This is not the mindset to have. It will hinder your confidence, block your thinking processes and make you lose focus on the patient in front of you. Remember the OSCE is your chance to show your positive attributes, so if you make a mistake, you acknowledge it (Humility is key) and move on and continue to show your skills.
6) Failure is not an option!
Let your anxieties about this exam drive your ambition and eagerness to learn more and challenge your ideas. Do not enter the OSCE fearing failure- failure is NOT an option! You have to envisage and prepare to PASS this exam. This sounds tough (it won’t be the end of the world if you have to resit) BUT your aim and mindset on entering the exam on the day is to PASS.
I hope these tips and hints worked. It is all about mindset in the OSCE. The knowledge is there (and if it is not - acquire the knowledge). You have to act like you are the confident, hard working, knowledgeable and SAFE doctor that they want caring for the patients.
Stay happy, focused and safe.
Please follow me on instagram, facebook and twitter for more short nuggets of information and inspirational quotes!
You are not alone - speak to friends, family members and myself if you need any guidance.
xx
Examination skills: Dermatology- Skin lesions
Hello my fellow medics,
Dermatology is something that can be easily tested in the Clinical Skills Exam- it might involve showing a photo of a lesion and being asked to describe it and how you would manage it.
I am going to concentrate on a skin lesion i.e. a changing mole. This is an important station as skin cancers are on the rise, and so recognition and educating patients about this is essential.
So without further ado, let’s get on with concepts to consider, questions to ask and how to pass this station (and more importantly, to be a competent doctor!)
Below I use the A to D system to make sure all questions are asked and all red flags symptoms and signs are considered to rule out a melanoma. Before we get started, lets have a think about some concepts in a dermatology station.
Some key tips for OSCE (and real life!)
Ask the patient about the lesion before you look. Some candidates/doctors once confronted with “doctor I have a lesion I am worried about” want to jump straight to examination. You get far more vital information asking the patient the necessary questions before examining rather than during the examination. Multi tasking can be difficult as well as not building on rapport.
Respect the patient. They may need to uncover a part of their body to show you a lesion, so respect that fact. Ask them to uncover when needed and then once you finish the examination, ask them to cover up again. This links with my point above, you don’t want to have a patient exposed unnecessarily as you ask all the questions.
Be systematic in your approach in asking the questions and examination. This will reduce chances of missing vital facts. Use A-D for both history and examination.
Don’t guess the size, measure it with a tape measure/ruler (if in the exam the photo of a lesion has a scale- please don’t ignore!)
Asking about change is so important. So with the A-D questions below, you want to ask about: change to colour, size and shape etc.
“How did you first notice this lesion” - this will tell you if it was painful, itchy, just by chance or a loved one was worried and commented on it. They may have had it for years and now coming for a check up, or it is a new and they are petrified.
Give a Patient Information Leaflet for what to look out for (there is a lot of information to remember) - a good one is on bad.org.uk
A- Asymmetry
Is the lesion symmetrical, meaning the two halves of the lesion are the same.
“How would you describe the shape? is it symmetrical?”
“Are both halves the same?”
B- Border
What is the border of the lesion like, is it blurred, irregular?
“Is the lesions/mole border blurred? Is it regular?”
“What does the edge of the mole look like?”
C- Colour
What is the colour of the lesion, has the colour changed (this is usually the main presenting complaint). If it has changed, find out more about change i.e. Is it darker, lighter?
The colour may be uneven. In a melanoma, the colours may be black, brown or even pink.
“How would you describe the colour of the mole? What colour was it, and what colour is it now?”
D- Diameter
Most melanomas are 6mm or more in diameter. You ask the patient about this before you examine to get their ideas on the size.
“What size is it roughly?”
“Has it grown in size?”
You would then measure it with a ruler.
Additional questions :
“Is the lesion itchy? does it bleed?”
I hope you found this information useful and simple. As I have stated before, my aim is not to teach a topic (you guys are intelligent and resourceful for this) but to give some concepts, ideas and ways of asking the question. This is to get you thinking and practising.
Enjoy your weekend, stay safe and focused :)
5 TIPS for OSCE revision productivity!
Here are 5 tips to keep you productive during these uncertain times. I understand the Clinical Exams for Foundation Programme will be going ahead as planned. It is important to stay focused and keep your knowledge fresh and up to date.
So here are 5 quick tips to help keep you productive:
1) Start early
The earlier you start revising, the less you will have to cram in at the end, which doesn’t benefit anyone. Doing a steady and slow rate of revision i.e. 1 hour every day in a relaxed calm environment, will allow the information to be absorbed. The aim is do little and often bite sized revision chunks.
2) Understand the concepts
If you understand the concept i.e. reasons for heart murmurs, it will make it far easier to remember. No one wants to have to remember facts with no meaning- it takes up too much brain space. You want the examination to be second nature without thinking much!
3) Use different modes of revision
Use different modes of revision to keep your revision fresh. An example being initially reading a chapter from Oxford Clinical Handbook of Foundation Programme on “Abdominal examination” followed by watching a video of the examination ie (Geeky medics) and then practicing yourself. Changing it up makes it exciting and also prevents your brain from getting bored.
4) Listen to information whilst walking/driving.
Now is the perfect time to read and listen (as life has slowed down). So even in those moments when you are driving or taking a walk, you can listen to your revision notes (I know a student in medical school who recorded his own revision notes and then listened back to them - genius)
5) Wake up early
Now you might be thinking “but i enjoy revising at night” so this may not apply to you. IF you are a morning person - Wake up early, own your morning (when you are most productive), get your revision done for the day and then enjoy the rest of the day. Don’t stay in bed, avoiding revision. The anxiety wont go away, it will just stay with you until you get up!
I hope you found these tips useful. I understand this is such a tricky time. We don’t have control over much right now, which is scary and frustrating.
The one thing we do have control over is how we react to the situation and how we prepare for the upcoming months. So look after your mental and physical health, ask for help and speak to friends and family.
Stay safe and positive :)