The National Assessment Collaboration (NAC) Examination is an objective structured clinical examination (OSCE). It consists of a series of stations where you are presented typical clinical scenarios. For a given administration, all candidates rotate through the same series of stations including pilot stations that do not count towards the final score. Each station is 11 minutes long with two minutes between stations.
At each station, a brief written statement introduces a clinical problem and outlines your tasks (e.g., take a history, perform a physical examination, etc.). In each station, there is at least one standardized patient and a physician examiner.
Interacting with a standardized patient
A standardized patient is either a healthy person or a person with chronic stable findings. They have been trained to present a real patient’s signs and/or symptoms in a reliable and consistent manner. You should interact with standardized patients as you would with your own patients. This includes draping a patient appropriately for different elements of a physical examination (regardless of their gender). Most standardized patients that are to be physically examined are already in hospital gowns, but the gowns may be removed as part of the examination.
Interacting with standardized patients also includes questioning them and responding to their problems. Your interaction with the standardized patient is part of what the physician examiner is assessing.
Interacting with the physician examiner
The physician examiner observes the patient encounter. For most stations, the physician examiner will ask you to respond to a series of oral questions after eight minutes with the standardized patient. The candidate instructions (posted on the door and in the room) will indicate whether or not there are oral questions for that station.
While you will generally not interact with the physician examiner, they may intervene in the following circumstances:
- If they believe you have misunderstood the directions (e.g., you are pursuing a history during the physical examination station)
- If they believe there is a problem for the standardized patient
- To provide you with information or results further to an examination manoeuvre on your part. This will save you time and allow you to move on to other sections of the physical examination. For instance, an examiner may be directed to give a blood pressure reading or the results of an ophthalmoscopic examination. They can only do this in certain stations and only if you have initiated the examination maneuver.
- To provide results for some tests. This only occurs at those stations where you are expected to order tests or investigations. Results are not given for all the tests or investigations that are ordered. Please note that ordering a certain laboratory investigation may be a correct procedure, even if no results are forthcoming.
While it is always expected that you will interact directly with the standardized patient, physical examination stations also require that you briefly state what you are doing and report your findings to the physician examiner. A physician examiner cannot give you credit for observing the patient unless you state that you are observing the patient. If there are findings (for example, pallor), then report this to the examiner to indicate that you have noted it. If you observe no positive findings, then you can just report “Normal”. A physician examiner is not allowed to assume, for example, that you are looking for pallor, inflammation, skin rashes, etc. Credit for findings (positive or negative) cannot be given unless you report what you found.
In some administrations and stations, there may be observers or second examiners. These individuals are introduced as part of the quality assurance process and for ongoing assessment.
Focusing on the patient problem
Your performance is assessed based on your ability to focus on the task and the patient problem.
For example, if you are asked to conduct a focused physical examination on a patient with acute onset of shortness of breath, the challenge is to prioritize, organize and conduct a physical examination that is appropriate to the degree of respiratory distress presented by the standardized patient in the time allowed for the station. The ability to decide what is necessary for a patient problem, given limited information and time, is critical to success on the examination.