The principle is simple. The examiners first determine what is required of the candidate. A standardized question is given to the candidate (e.g. please examine this 4-year-old boy’s cardiovascular system), and the candidate is observed by the examiner, who ticks off or grades essential elements as they are performed. Further marks are given for general approach, rapport with the child and their parent (or proxy parent), and interpretation of the findings.
OSCE TIP Examples of clinical skills tested in OSCE stations- History-taking
- History presentation and discussion
- Counselling and explaining
- Systems examination, e.g. CVS, respiratory, abdomen, joints, neurology (part), gait, squint, ENT (manikin), newborn hips (manikin)
- Developmental assessment
- Assessment of peak flow or use of asthma devices
- Practical tasks without a patient (dipstick testing of urine)
- Resuscitation (manikin).
A badly written OSCE station will allow you to accumulate marks by a haphazard approach, where you do everything you can possibly think of in a thoughtless and random order. Such stations are now rare. To gain high marks in a good OSCE station, you need to demonstrate a logical approach, good communication and examination skills, and then show that you are able to synthesize and make sense of the clinical information.
28.1.1.1 Communication stations
Here, an actor or member of staff will play the role of a parent. There are two main types of communication station.
History-taking
You may be observed taking a history about a particular presenting symptom. Histories will usually focus on common paediatric presenting symptoms. even if you think you know the diagnosis, it is important to consider differential diagnoses, and to ask relevant questions to help rule those in or out. At the end you may be asked to summarize. Get in the habit of writing and presenting a concise summary for every history you take. This will help you acquire this important clinical skill.
History presentation and discussion
You may have a linked, or stand-alone station, where you present and then discuss a history you have taken or are given. You may need to present this verbally (in person or over the telephone), in note form, or in a letter. The examiner may then ask you questions about the history, or about management.
OSCE TIP Osce history-taking tips- Read the task carefully, and check it part way through to make sure you are doing what has been asked of you.
- Don’t forget to introduce yourself and use the child’s name.
- As with any good history, you need a balance of open questions that allow the parent or child to say what is the matter and how it is affecting them, combined with focused closed or follow-up questions, so that you have the necessary details.
- Spend most time on the history of the presenting complaint, and make sure you know exactly what has been happening, the impact on child and family, any treatments given (including names and doses), and their effect. This aspect is where students lose most marks.
- Use a problem-orientated, logical approach, where you generate your differential diagnosis early based on the presenting complaint, and then repeatedly test and refine this as you gather more information. Avoid blindly asking random questions!
- If you are going to present, summarize or be questioned on the history, try to allow yourself some time to think through the information, and decide on a problem list, differential diagnosis and management plan.
Counselling and explaining
Your task may be to explain a diagnosis, illness or a treatment to a parent or young person, offering the essential facts in a way that is easy to understand, while demonstrating appropriate empathy and good interpersonal skills. The parent may be primed to ask you certain questions. See the example OSCE station at the end of Chapter 2.
OSCE TIP OSCE counselling and explaining tips- You cannot explain well if you don’t have a good understanding yourself. Learn topics that are flagged as important/essential in your syllabus, or that are common and important.
- Read parent information leaflets (and websites), which are usually focused on such topics.
- Listen to consultations in clinics and on wards.
- Be clear about the task: Is any history taking included? – if not, keep to a minimum (although some checking questions can be an appropriate way in).
- Consider drawing a diagram if this helps to explain things more clearly.
- Avoid medical jargon.
- Use the child’s name.
- Consider starting with ‘ICE’ – Ideas, Concerns and Expectations; and finishing with: a summary, asking if any further questions or concerns, and planning follow up (if appropriate).
- Parents will often want the following questions addressed: What is it? What does it mean for my child? What do I do in an acute attack? What do I do to prevent/treat?
- It is quite easy to prepare and practice realistic stations 1 or 2 colleagues. Video yourselves and review – it is easier to spot ways to improve.
28.1.1.2 Clinical examination stations
You may be asked to examine a system in an infant, child or young person. With some thought about your own examination system (particularly venue and number of students), you should be able to work out the sort of things that are unlikely to be examined in this format in real children. For example, children with acute problems are unlikely to be seen in examinations away from clinical areas, or involving large numbers of students. There is increasing use of video or DVD for such cases. Manikins may also be used for testing resuscitation skills, ear examination, hip examination, or auscultation skills. Stations may feature combinations of real patients or well children, manikins, video and audio. For example, you could be asked to peform a cardiovascular examination in a healthy child without a murmur, and then be asked to comment on an audio recording of a ventricular septal defect murmur. Make sure you can do practical tasks such as doing a peak flow measurement, making up a feed, putting on a urine bag or testing urine with a dipstick.
OSCE TIP OSCE Approach- Section, then reportHere you will divide up the task into sections and report back to the examiner after each. This allows you to talk to the child. You can remember HIGHCOST (Section 3.1.2) and use this as a structure (e.g. you could begin with Hello–Introduce yourself–General inspection, and then tell the examiner about this before going on to Health and hands–Centiles–Obvious). In this way you can bank the points as you go through. Finish by mentioning anything that still needs to be done, and summarizing your findings briefly.
- Finish and present Here you will complete the task and the examination and present it to the examiner at the end. This can look very accomplished. It is difficult to do and you will only get the marks that you deserve if you remember to tell the examiner everything that you did or that needs to be done. If time prevents you from presenting, you may get very few marks.
- Running commentary Here you give a continuous account of what you are doing, why and what you find. It interferes with building any rapport with the child. It is also very tedious. It can confuse candidates who need to think as they go through.
Review the OSCE stations and tips at the end of each chapter. These give you examples of typical OSCE stations in undergraduate examinations. Most chapters have a detailed example of a common OSCE station with helpful pointers.
OSCE TIP Osce physical examination tips- Introduce yourself.
- Wash your hands or use alcohol wipes – if you do this outside the station, tell the examiner.
- Examiners may be told to say nothing to you – do not be put off.
- Don’t forget to comment on growth: ‘I would like to assess growth by measuring height and weight, plotting on a centile chart, and comparing to previous measurement plots if available.’
- Do not do anything to a child that could be painful, uncomfortable or embarrassing.
- If you do not do something (for any reason), state that it needs to be done (e.g. ‘I would like to plot Billy on a growth chart’; ‘I would normally check the blood pressure’; ‘Would you like me to check the femoral pulses, only I do not want to embarrass Susan’).
- If you do not do something, and you do not mention it, you will not get the marks for it!
- If you are having a bad OSCE station, stop, think, and then return to task. It is usually possible to recheck the instructions. You may explain to the examiner (e.g. I would have liked to start with gait, so I am going to do it now). Put the station behind you and remember each station is marked independently.
- When reporting your findings, include important negatives (e.g. no acute respiratory distress).
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