The formative

So this year, as we are joined by the cohort from St. Andrews we are given a formative OSCE. This is basically a "mock" type thing, so doesn't affect any overall grade and consists of half the number of stations of the real thing. It's to give everyone an idea of how it's going to go in March.

I had done a fair amount of preparation for this formative. We know that 2 out of 4 examinations are going to come up (Abdo, neuro, cardio, resp) so we could nail those in our own time, we know there will be 2 history taking stations [and they'll probably be one of the 4 above] so we could really nail those and the rest would be a bit of a free for all. 1 data interpretation, 2 sharing information, 1 prescribing. The real thing will be about double all that.

So reflecting on the formative like I have done every exam so far let's go:

Station 1 : Abdominal Examination
I was confident I wouldn't do too badly in this station. WIPE, strong approach, bit thrown as the first thing that threw me was that this was an actual patient. She had a colostomy bag. I was scared to palpate around that area. I mean overall, I was very happy with how I did that station, but the examiner in this station really pissed me off.

Firstly, when I was doing light palpation of the 9 sections of the abdomen he suddenly went - "is that your dominant hand?" - er, why does it matter. Who fucking cares if it is or isn't?? Why does it matter if I'm left or right handed? Anyway, i'm actually right handed but have always palpated using my left because its a softer touch so I shrugged and switched hands. I didn't think he could just interrupt me like that, it really threw me, I felt embarrassed and confused.

By the time I was doing deep palpation, he wasn't watching me at all. He literally had his back to me and was playing with the curtain. It was so fucking bizarre. Anyway, the end of the station rolled round, I felt happy that I had enough time to do everything and said what I would do to complete the station.

Feedback time came (in the formative we always get 2 minutes for feedback) and my feedback was:
1. Didn't check patients face to see if they were in any pain as I did palpation.
2. Didn't check for abdominal signs on the back of the patient.

1. fair enough. 2. er, say whaaaaat? I have literally never heard of this before in my life. Upon further research, apparently you hit the kidneys looking for pyelonephritis?

Station 2: Explain COPD
Right, so I started off well in this. WIPE'd, asked her why she had come in today, "oh blowing tests?" what where they like, do you know what they were for?

Great. Introduced myself, laid out my structure, asked if there was anything else she wanted to discuss and started asking about why she had come in or why she had taken these tests. Lovely.

Next; and this is where the confusion was. I'm a third year medical student - I am in no position to be telling a patient what their test results are and what they mean; or so I thought. In actual fact, that was exactly what I was meant to do. SO - COPD. This is Chronic Obstructive Pulmonary Disorder. Do you know what that means? Nothing? Ok. So your lungs. *draws a really shitty diagram* they're obstructed, giving way to the symptoms you have been having recently like getting more breathless. Why do you have it? Well, it could be many reasons. Oh you smoke? Ok so that has a high corre...well it's found more commonly in smokers so yes it could be it. Lots of people who don't smoke also get COPD though-  wrong. 

At this point I really needed to be saying you're a smoker, this is why you have COPD, you need to stop smoking to stop it getting any worse.

Instead I got so lost in trying not to offend the patient, or outright tell her it's all of her fault that I skirted around the issue not saying anything at all.

I had completely lost where I was in my structure by this point. My initial structure was: we'll talk about what the results show, what they mean and what we can do to combat them. I had gotten lost in explaining that she had COPD. Anyway, I sort of managed to pick it up again and wrapped it up towards the end. Christ. Next.

Station 3: Prescribing
I basically just had to prescribe so IV antibiotics and some medication from enlarged prostate. Firstly, hands up, fine, I've only ever picked up the BNF like twice before. I really need to get a spare book and look over what the hell is happening. Anyway, filled out the majority of it right, did the IV bit, great.
Next I had to prescribe a branded drug. I found it in the index, page 711, good. Looking at page 711, I couldn't find the brand name anywhere. I scoured it over and over. The actual drug names x hydrochloride or whatever where clearly headed. Buzzer for 2 minutes remaining went. Fuck.
I shrugged my shoulders. My examiner said, look, it's definitely on that page. Me in my head: yes, i fucking know, I can't see it!! Eventually, with seconds remaining, I got it. Great. 400 micrograms. Got it, scribble scribble scribble.
Feedback: I wrote the second routine medication in the Antibiotics section. Well bloody done. The stress of finding the drug just completely threw me. 

  • When writing the medication on the correct side, remember to fill in the details at the top of the page like normal
  • When putting in the antibiotic, remember if it’s twice a day, you’ll need to circle the times at least 12 hours apart
  • Check how long you have to review common medications for e.g. Antibiotics, 48 hours review

Station 4: Cardio History
Presenting complaint: chest pain
Angina on exertion. Came on as she walked up a steep hill. Stopped if she stopped for a few minutes. Started two weeks ago. 
Went through SOCRATES. Forgot a little a bit about the order of doing past medical history, occupational history, drug history, family history and got a bit scatty.

  • Must remember to write down the order of taking any history. Not usually a problem, but clearly just forgot to find the will to live by this point.
  • Good patient rapport.
  • Was OK

Station 5: Respiratory exam
So this guy had a massive fuck off scar underneath his left arm - for some reason, i said this was a chest drain. Of course it wasn’t you idiot, which chest drain goes that far along your body? 

- Forgot to do respiratory rate the same time as doing the pulse. No surprise there as I always forget to do it even when practising. 
  • Did not inspect the back for more scars of which there were many. Need to review all the different scars and what they mean.
  • I didn’t spot the lobectomy. Also couldn’t hear a fucking thing through my stethoscope. I began to believe it was broken.

Station 6; HF history
  • Right so my history taking was OK. Asked all the relevant questions. Completely forgot about family history to the very end. 
  • Didn’t ask when his parents died of cancer.
  • Didn’t get to his real concern of being scared of dying of cancer.
  • Also for some bizarre reason could’t put heart failure and orthopnoea together!!!! for crying out loud man. Need to write down which symptoms = which disease. makes me v sad and frustrated.

Station 7: Data interpretation
Joke station. So this was really and truly fucking difficult to understand what I had to do. I had 5 minutes to read through what this patient was going through, aka get the clinical picture. 45 year old caucasian male, diagnosed with type 2 diabetes 3 months ago. BP 150/90. Plan 3 months ago was to start an education course, restrict calories, exercise more. He comes in today and his diabetes is even worse. His BP is just as high. The question is: what are you going to do about his diabetes…?
I started rambling on about his diet. No no, what i needed to say at this point was we need to prescribe metformin. And for some reason all the NICE guidelines literally evaporated from my mind and I decided I would prescribe this man a beta-blocker for his blood pressure. A beta blocker is like a third line drug. Come on man!!!!

Station 8: Hyperthyroid
Right, so this woman comes in, i’ve got to tell her i’ve got the results of her thyroid function tests and they show she’s hyperthyroid. I need to go through the treatment options and side effects.

Completely forgot about carbimazole. Was like, “well, i don’t actually know what one would normally prescribe you for hyperthyroid but I can tell you surgery and radio-iodine are both options too." I don't know how much this affected my mark over all but I mean, it won't be very high well it.

  • Must review the treatment options for the major disease
  • Recognise common drugs to be used
  • Review common drugs that need to be explained

Other OSCE stations that came up for other people:

  1. Explain a statin
  2. Explain anaemia