Case 1: History-taking station
Alan Starks, 46 years old, presents to your office with hematuria.
IN THE NEXT 11 MINUTES:
- OBTAIN A FOCUSED AND RELEVANT HISTORY OF THE PRESENTING PROBLEM.
The 8-minute warning signal will indicate you have 3 minutes remaining with the patient. There are NO examiner oral questions in this station.
GIVE ONE (1) LABEL TO THE EXAMINER.
Candidate voiceover: OK, it says focused and relevant history, so I need to ask pretty specific questions. Hmmm…is it gross or microscopic hematuria? When did he first notice it? Any associated pain? Hmmm…what else? Oh yeah, how about any other systemic symptoms – fever, rash, joint pain? Is he on any meds like NSAIDS or anticoagulants?
Candidate: Hello, I’m Dr. Babak. So, I understand you’ve have had some hematuria.
Patient: What’s that?
Candidate: Sorry…blood in your urine. Is that correct?
Patient: Yeah, yeah…I noticed the blood this morning. It hurts a lot when I pee. And the pain is in my abdomen; it runs down to my groin.
Candidate: Oh, well, let’s have a look at you then. (Candidate gets up and approaches patient)
Examiner: Please reread the instructions.
Candidate voiceover (to himself): Oh, OK, so OK, it’s only a history.
OK. So, when did you first notice the blood and pain in your urine?
Patient: Hmmm…I noticed the pain last night.
A number of things have happened in these first few moments of the station. These are things that you can learn from the video so far:
At the beginning of the station:
- Before the buzzer, the candidate takes some time to organize his thoughts. That’s a great approach.
- The candidate knocks on the door before entering. That isn’t necessary but it is acceptable to do so.
Upon first meeting the patient:
- The candidate offers a label to the examiner, which is important to do.
- Offering to shake hands with the patient is not necessary
- If the patient’s name is on the candidate instructions, you don’t have to ask for their name. Do not address any patient by a first name without asking if that is what they prefer. You may wish to ask how they prefer to be addressed. What is important here is to establish a comfortable, genuine connection with the patient.
- The candidate uses medical terminology (“hematuria”) when talking to the patient. The patient clearly does not understand. In demonstrating patient care, it’s better to use language that is more easily understood by everyone.
While talking to the patient:
- The candidate forgets that the instructions called for a history only, and intends to examine the patient. That would be reasonable to do in a clinical setting, but in an OSCE, each station is designed to focus on specific tasks.
- The examiner prompts the candidate to reread the instructions. An examiner can give this type of prompt only once per station. However, candidates may reread the instructions at any time.
- The candidate asks two questions at once: “When did you first notice the pain and blood in your urine?” The patient gives an answer to the last question only. This will likely be noted in the candidate’s assessment. Asking a patient for two pieces of information at once is unadvised in clinical practice and in OSCEs, as critical patient information could be missed.
Let’s return to the station and continue to watch what happens.
Candidate: Last night, ok, so what did you do last night? Any unusual activity?
Patient: What do you mean? Like what?
Candidate: Like sexual activity?
Once again, the candidate has asked two questions at the same time: “What did you do last night?” and, “Any unusual activity?” The SP replies with “Like what?” This does not mean that the SP doesn’t know the answer. It means that the SP is trained to respond to an open-ended question by asking for a more specific question.
Whether or not sexual activity is on the checklist, the patient has learned a complete story and can respond in a standardized way to any ‘unexpected’ questions.
This brief example demonstrated how organization and interviewing techniques can impact the quality of the candidate’s performance in an OSCE. It can affect the information the candidate elicits from the patient, and will be reflected in the examiner’s assessment.
Next, we’ll consider an example of an OSCE station that focuses on interpretation of instructions and questioning technique.