MRCEM Part C: 125 OSCE Stations Nitin Jain, Kiran Somani
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1MRCEM Part C: 125 OSCE Stations Second Edition2
3MRCEM Part C: 125 OSCE Stations Second Edition
Kiran Somani BA (Hons) MBBS MRCP DTM&H FRCEM Locum Consultant in Emergency Medicine University Hospital Southampton, UK Nitin Jain MBBS MS Orth MRCS Eng FRCEM FACEM Staff Specialist at Liverpool Hospital Liverpool, NSW, Australia
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5Foreword to First Edition
Any book that helps candidates to pass an exam has to be welcomed. But this one does more than that. Not only does it prepare candidates for the MRCEM Part C OSCEs by describing their structure and logic and by providing multiple examples, it also explains why the subject matter is important to the practice of emergency medicine and how this knowledge will make the candidate a better emergency physician. The sections on common presentations, communication, physical examination, psychiatry, practical procedures and resuscitation all contain important information that will be valuable to all candidates for their practice as well as for the examination. All the content is helpfully mapped to the Royal College of Emergency Medicine curriculum which is the basis of training. This book, combined with a thorough knowledge of the curriculum and the College's own guidance for the exams, should prepare the candidate well.
Dr Mike Clancy
Consultant in Emergency Medicine
University Hospital Southampton NHS Foundation Trust, UK
6Dedication
This book is dedicated to Dr Nandkishor and Pramila Somani with love, gratitude and pride.
Kiran Somani
Acknowledgements
The authors would like to thank the following individuals for their help with providing material for this book: Dr David Connor, Dr Yulia Novytska, Dr Ka Mei Lo, Dr Elizabeth Forbes, Ross Brown and Rich Lister.7
8Preface to Second Edition
Completion of the Membership Examination of the Royal College of Emergency Medicine (MRCEM) is seen as a ticket to the senior tier of our specialty. It is a badge of competency which can be worn proudly. This book has been written to assist candidates with their revision for the OSCE component of the exam.
Success in any OSCE-style exam requires the candidate to have acquired the necessary knowledge and to have practised the skills which will be assessed until a proficient routine is established. It will also benefit candidates to have considered as many scenarios as possible prior to the exam. Only through this level of meticulous preparation will a candidate convey the level of competence necessary to be successful.
Though there are various revision courses and individual OSCE mark sheets that some candidates acquire during their revision, there are few resources accessible to all candidates sitting the OSCE exam. Our intention when writing this book was to combine our knowledge and experience of OSCEs into a format that allows all candidates to access a high quality OSCE revision aid.
Using this book, candidates can test themselves with scenarios that reflect those used in the real exam. Furthermore we hope that candidates who read this book will be prepared for the OSCEs that commonly arise in the exam; will understand what they are being tested on and how the necessary marks in each OSCE are scored; and lastly, will be able to anticipate which scenarios are likely to arise, to avoid surprises.
In this second edition we have added 16 new OSCE scenarios. We hope that by encouraging a wider breadth of revision, candidates will be better prepared for the variety of scenarios that may arise in their exam. To ensure our material remains current we have updated the text using the latest versions of all the national guidelines cited.
We recommend using the MRCEM curriculum to guide revision. With this in mind each OSCE in this book lists the MRCEM curriculum codes relevant to each scenario. We urge candidates to refer to the curriculum to ensure there are no gaps in their revision. Also, we strongly recommend that candidates check the latest exam information on the Royal College of Emergency Medicine's website.
Congratulations on choosing the most exciting and rewarding career in medicine. We wish you every success with your exams and future career!
Kiran Somani
Nitin Jain
November 20159
10How to use this book
The most effective way to use this book is to work though each station under exam conditions. Ideally this requires each one to be timed, allowing 1 minute to read the instructions followed by 7 minutes to complete the task. In the real exam, the stress caused by time constraints, the scrutiny of the examiner and a fear of failure can all lead to candidates performing poorly. Practising as many stations as possible in an exam-like environment is by far the best preparation.
You will find it invaluable to practise in groups of two or three, with each person taking turns to play the role of candidate, actor (if needed) and examiner (the latter two can be the same person if a third person is not available). Afterwards, time should be spent reflecting on the mark sheet, assessing the candidate's performance and identifying areas for further study.
If you are working alone, it is still possible to work though the practice stations. However we encourage you to arrange to be observed by, and receive feedback from, your senior colleagues and peers on at least a few occasions prior to the exam.
Using this approach, you will be well prepared on the day of the exam.
Format
The majority of the stations in this book include the following information:
  • Introductory text – this provides relevant background information on the topic being assessed
  • Scenario – this presents the exam question or task to be completed
  • Pie chart – this illustrates which areas of competence are being tested
  • Mark sheet – this lists specific actions which the candidate is expected to perform. The candidate will be successful if enough of these are carried out. In most cases it is acceptable for the order of the actions to vary; however this may have an impact on the global score (see p.xiii)
  • Additional guidance/observations/information – where included, these indicate important events that occur during the course of each scenario. These are particularly relevant in the resuscitation scenarios
  • Instructions for actor(s) – these are intended to help candidates anticipate the different ways in which the patient or the actor may behave. These are generally included in the history, communication and teaching scenarios. However, these instructions are not provided in the examination and practical skills scenarios, as the behaviour of the actor or patient is not likely to influence the candidate's actions to the same degree
11Introduction to the MRCEM Part C: OSCE examination
Aims of the examination
The Membership Examination of the Royal College of Emergency Medicine (MRCEM) is intended to assess the knowledge, skills and behaviours necessary for a doctor to be able to practise emergency medicine in the UK and Ireland, at the level required to be a senior decision maker. This means it is the hurdle which must be successfully negotiated prior to entry into higher specialist training.
Part C of the MRCEM exam uses objective structured clinical examination (OSCE) stations to assess a broad range of the competences required for the evaluation and immediate management of common clinical conditions seen in the emergency department (ED) in adults and children.
The expectation is that candidates must demonstrate that they have achieved a competent standard to supervise foundation and core trainees and to provide senior clinical decision making during some out of hours periods. Candidates should understand and reflect on the fact that during the examination the examiners ask themselves: ‘if this doctor were working in my department would they be able to manage this case (and the department) competently?’ It is still not uncommon to hear the exam referred to as the ‘registrar test’, and success in the MRCEM often results in doctors being thought of as a ‘safe pair of hands’.
Content of the exam (the curriculum)
The exam is based on the major and acute presentations listed in the curriculum (which is available from the Royal College of Emergency Medicine website). The College has clearly stated that presentations not included in the acute care common stem (ACCS) curriculum will not be assessed in the exam.
Obviously this means the value of the curriculum as a reference during revision must not be underestimated and for many it provides a clear framework for focusing revision. Rest assured it has also provided the framework for constructing this book. To make it easier for candidates to ensure the curriculum is covered, each OSCE in this text begins by stating the curriculum codes for the areas of the curriculum that the authors feel are relevant. This may be a ‘Common Competence’, ‘Presentation’, or ‘Procedure’ from the curriculum.
Format of the exam
The exam consists of 18 OSCE stations which candidates rotate through over a period of approximately two and a half hours. Areas to be assessed include clinical knowledge, psycho-motor ability, interpersonal skills (including communication and conflict resolution), professional behaviour and clinical decision-making skills.
Incorporated in the 18 stations there are normally two ‘resuscitation-style’ stations which require the candidate to manage an acute presentation. These are normally twice as long as the other stations and therefore carry twice as many marks.
In addition there are usually two rest stations. During these, candidates may sometimes be given information relevant to the following station and offered the opportunity to prepare themselves.
12Each OSCE station poses a scenario where specific competences are tested and the candidate's performance is observed and scored against a pre-prepared mark sheet. When rotating through the 18 stations, one minute is allowed outside each station to read the relevant instructions. In addition to the instruction, a pie chart is often present which shows the general areas over which the marks for this station are distributed.
The pass mark for each station is decided for each sitting before the examination diet commences. Following the sitting, examiners are invited to confirm the pass mark after marking the exam, and further adjustment may be made in the light of the cohort performance on particular questions or stations.
Candidates must pass 14 of the 18 stations to pass the whole exam.
Competences tested
In each OSCE the competences being assessed are placed on a pie chart with the scenario. Candidates must be aware of where the marks lie. Without reflecting on the pie chart a candidate may mistakenly spend the majority of an OSCE performing a procedure when the marks are mainly for teaching, or spend a whole OSCE talking to a patient when the marks are for examination skills.
Each OSCE in this book contains a scenario and with it a pie chart to help candidates prepare for the exam. The competences that may be tested are:
  • Clinical reasoning/decision making
  • Communication skills
  • Examination skills
  • History taking
  • Dealing with conflict
  • Organisation skills
  • Practical skills
  • Resuscitation skills
  • Teaching skills
  • Team leadership
How to prepare for the exam
It is vital that candidates prepare adequately for MRCEM Part C. Reviewing the curriculum and the expected competences, gaining familiarity with the exam format, practising OSCE scenarios and seeking feedback on clinical skills are all necessary for success. Already in this introduction, reference has twice been made to ‘performance’. This is deliberate. The only way for the examiner to assess a candidate is based on what the candidate says and does in that OSCE station. Nothing can be assumed or inferred. In this way, an OSCE is very similar to a driving test – it is performance on the day that counts. Examiners are not looking for clever tricks, and minor faults are allowed. Candidates should remember that it is their performance which is being assessed, rather than simply their knowledge. With this in mind, many candidates find it helpful to prepare in groups. This allows them the opportunity to have their actions observed repeatedly, and to practise the same scenario repeatedly so that their performance improves. It also has the added benefit that there are enough people to play the roles of candidate, actor and examiner in each scenario.13
Candidates are also strongly advised to request feedback on their clinical performance from senior colleagues within their departments and to undertake appropriate workplace-based assessments to allow them to focus their preparation for the examination.
Global scores
Each OSCE mark sheet includes a global score from the examiner and (if applicable) the actor in the station. The matrix below provides indicative examples in generic domains of professional behaviour. It should be used by the examiners and the role player where appropriate to determine the global score. Not every domain will be applicable to every skill station. As a rough rule:
  • 5 = mostly exemplary
  • 4 = mix of exemplary and acceptable
  • 3 = mostly acceptable
  • 2 = mix of acceptable and unacceptable
  • 1 = mostly unacceptable
Domain
Examples of unacceptable behaviour
Examples of acceptable behaviour
Examples of exemplary behaviour
Communication
No introduction, and no information about what the station is about
Closed questions
Not listening to the answer
Gives the answer themselves
Doesn't warn patient of actions
Uses jargon without explanation
Attempts to introduce themselves and to inform what about to do
Some open questions
Invites questions
Occasionally interrupts inappropriately
Attempts to explain what is doing
Uses jargon but then explains
Introduces and informs what the task is about
Open and closed questions used appropriately
Good use of silence
Invites questions from patient and answers well in plain English
Keeps patient involved and informed constantly
Rapport and empathy
No attempt to establish rapport
No response to body language or patient distress
Hurts or embarrasses patient
Adequate rapport
Responds to distress but obviously uncomfortable, no eye contact
Didn't offend but not always mindful of patient privacy or comfort
Excellent rapport
Empathic, good eye contact
Appropriate body language
Ensures patient comfort
Professional competence
Appears novice
No structure to task
Steps in wrong order
Appears over/under confident
Becomes uncomfortable or irritated
Logical structure but halting and stilted
Has to pause to think
Appears under confident
Clearly anxious but able to control
Logical sequence
Looks polished
Confident
Appears calm and professional
Pacing
Does not complete task
Appears hurried but completes task
Completes task within time and looks comfortable
Equal opportunities/
discrimination
Appears biased – exhibits racism, sexism or ageism
Stereotypes patients in questions and answers
Rude or patronising
No apparent prejudice
Non-judgemental, actively accepting of patient's cultural or behavioural differences
Team skills
No involvement of helper
Doesn't listen to examiners or team
Some involvement with team/helper but works autonomously
No interaction with examiner
Involves team/helper, maintains cohesive working environment
Interacts well with examiner, accepting given cues
14
Practicalities
Candidates should make sure they arrive in plenty of time. Arriving in a rush or panic will prevent a confident, calm performance (and arriving too late may mean a candidate is not permitted to sit the exam). This may mean travelling the night before to some venues, so make sure that practical arrangements are made well in advance to reduce stress on the day of the exam. Candidates wear a variety of clothes. It is important to look professional, but there will inevitably be practical skills to be performed during the exam. Consequently, many people choose to wear ‘scrubs’. Candidates who choose to wear their own clothes are advised to ensure their arms are bare below the elbows. Facilities will be provided for storage of personal belongings during the exam. It is recommended that candidates bring their own stethoscope which they are familiar with. All other equipment needed will be provided at the individual OSCE station. There will be plenty of people on hand to make sure that candidates go to the correct station at the correct time, and there should be water at the rest stations.
Candidates are usually free to leave as soon as the examination is over. Results are published online a few weeks after the exam – as a list of candidate numbers with the result for each one. Success will be confirmed by a letter from the College shortly afterwards. Those candidates who are unsuccessful will receive feedback about which stations they did well in and which stations they failed. Candidates are advised to discuss this feedback with their educational supervisor early in the process of planning a subsequent attempt.