Objective structured clinical examinations

Paul Tomlins looks back on his finals and gives his suggestions to all of you about to sit finals...

Objective structured clinical examinations (OSCEs) are a terrifying experience. The frantic last minute cramming ends abruptly, and as you hear the first bell you instantly forget anything you have learnt in the past few weeks. But like anything else, a few hints, tips, and tricks can make all the difference on the big day. Here are just a few that I have found useful.

Before any exam there are always plenty of rumours: you should believe none of them. The perennial favourite is that “you won't get (insert disease/examination) in the OSCE.” Don't believe a word of it. Whatever it is, it will turn up if you haven't prepared for it.

Examiners have favourites. There are two types of patients in clinical exams. First are outpatients bought into hospital especially for the exams. These patients will have stable chronic conditions with dependable signs. They often come back year after year and a few questions to those who took the exam last year at the same hospital can dig up some surprisingly accurate intelligence. These patients are often dab hands at being examined and so may give you the occasional cue, proudly sticking out the relevant part of anatomy you would have otherwise forgotten to examine.

Knowing who is organising the exam may provide a few hints on who is coming in. For example, a chest doctor will bring in a higher proportion of patients with chest signs. A more underhand method is to beg, persuade, coerce, or extort the relevant house officer, as he or she may have valuable inside knowledge on any patient being bought in for the exams (please note that the studentBMJ does not condone this).

The second source of patients is the wards. For obvious reasons, these patients have to be fairly healthy, and so some of their signs might have faded by the time they are stable. So be on the lookout for “soft” signs.

There are certain traditional OSCE short cases, some of which are so common that turning up without being able to recognise them is suicide. The advantage of this is that any of these cases is an absolute gift and you should be able to score quite highly on them if you turn up prepared. It is virtually a certainty that there will be a few heart murmurs kicking around. Other favourite exam questions include big livers or spleens, pleural effusions, and rheumatoid hands. A few salient facts about these are priceless.

There are only a certain number of signs in medicine, and for each sign, there are only a certain number of possible causes. So for each sign you could be expected to elicit, you should be able to rattle off the commonest causes parrot fashion. Remember that it is vital that you don't miss out any important causes. Remember that mitotic lesions—not cancer, never say “cancer” in front of a patient in the exam—and infection are a cause for pretty much anything. Also useful is the “surgical sieve” method—for example, vitamin D: vascular, infection, trauma, autoimmune, metabolic, inflammation, neoplasia, degeneration) which can point you in the right direction when otherwise you would be left staring blankly at the examiner.

The other reason parrots would pass OSCEs is that parrots do not stop talking. As long as you are not talking gibberish, it is best to keep talking, for the simple fact that if you are talking then they cannot ask you any questions.

OSCEs don't just fall out of the sky. You generally get plenty of warning, so you should use your time on the wards as practice. OSCEs are a performance, and nobody in their right mind would appear on stage without a rehearsal or two. Watch each other examine and, most importantly, criticise each other. Examine partners, family members, housemates, pets, furniture, anything you can get your hands on and repeat ad nauseum. The more times you practice, the slicker and more professional you will appear on the day.

Friendly doctors can be persuaded to act as impromptu practice examiners. Especially useful are senior house officers who are practising for postgraduate exams, as they will also know where all the good signs are hiding on the wards.

Clinical exams have been around for a long time and there are plenty of good books on the subject. As well as books written for medical students, Member of the Royal College of Physicians (MRCP) books can provide helpful tips. Examiners will either have examined for or been examined by the MRCP and so will use similar (albeit much lower) benchmarks.

There are plenty of ways to make the exams that little bit easier. Remember that a little bit of confidence goes a long way. So, whatever you do, make sure that you have done whatever you can to instil some confidence for the exams and the best way is through practice. If you have seen and elicited the sign before then you will recognise it in the exam and when you present your findings you will be able to do it with confidence.

Nearly all candidates will pass the clinic finals, so the odds are in your favour. Remember, it is a performance, so rehearse often and, as they say, break a leg.