![[Pasted image 20250428133218.png]] The first step once you finish the OSCE is to try and pass whatever tips you have developed during study onto your friends and colleagues while it is still fresh in your mind. In my case, this feels especially relevant due to the fact that I host a website on a domain called "OSCE Pass," although in point of fact, most of the notes herein were for the written exam, and the domain name was simply a leftover from a med school OSCE app I used to host. At the outset of OSCE study I did a lot of online searching and read a few different summaries, the [Monash OSCE Handbook](https://www.monashosce.com/) and [this guide](https://www.alfredemergency.org/post/acing-the-acem-exam-fellowship-osce) are particularly good. I did find it frustrating that there is a general dearth of authoritative information about how to approach the OSCE. For this reason, I highly suggest reading all of the [ACEM content](https://elearning.acem.org.au/course/view.php?id=652) about it, which tremendously de-mystifies the exam, and I will not repeat it here. I mostly included this page in these notes for some degree of posterity; developing a strategy during the 4 month OSCE rush is highly personal. Please take my own synthesis with a grain of salt. There are only a handful of OSCE-specific notes on this website, including [[OSCE Templates and scripts]], [[Neuro - upper limb]], [[Neuro - lower limb]], and [[Paeds history]], and my brief overview below. Another section on this website that may be of particular use during the OSCE study is articles within the "[[Symptoms]]" folder, as pretty much any presenting symptom is an opportunity for an OSCE station. There is a set of flashcards from a Dr. Jack which is a nice overview of topics and templates; I don’t necessarily endorse it per se (i.e. besides looking at a few cards I didn't really use it for my own study), but it is an impressive structured overview of the content: [Dr Jack flashcards](https://bit.ly/m/DrJackNotes). One silver lining to the gauntlet that is OSCE exam prep is that the OSCE is more similar to the written exam than I expected. Although it is a much different exam format, the types of questions are similar, and the challenge of developing efficient and well-structured written exam answers translates well to the "signposting" necessary for good OSCE answers. However, a key to the OSCE is figuring out how to leverage your strengths and developing the style of speaking your answers in a way that feels relatively natural and that examiners reward. *** ## Exam Overview There is a lot of cognitive overhead when you first begin studying in getting a sense of what the exam actually consists of. As I stated above, read ACEM's [published information](https://elearning.acem.org.au/course/view.php?id=652), as it will demystify a great deal of the exam for you. Here is the basic exam format: - All questions are 7 minutes preceded by a 4 minute reading period. No writing during reading period, no watches of course. - The exam occurs over two days. Each day there are 6 OSCE stations. - You have about 30 seconds to walk from station to station that is not included in your reading time. - There may be a pen available in stations for calculations; I never used a pen during the exam, and for calculations I don't like doing (eg I hate calculating [[Blood gas#CO2 compensation met acidosis?|Winter's formula]] under pressure) I just formed a gestalt and said the formula and moved on. - Questions are scored on a 7 point scale for each domain as well as a "global score." - According to ACEM, the global rating does not directly determine a ‘pass’ or ‘fail’ in a station, but is combined with all other candidates’ global ratings to determine a cut score for the station using a method called Borderline Regression. The passing score for the examination is the ‘cut score’ plus one Standard Error of Measurement. - At no point during my study did I ever think too hard about the exact format of the scoring besides trying to form a sense of the difference between a passing and a not-passing score for each domain assessed. One can categorise the spectrum of questions by the *format* of question (i.e. what you are actually doing in the exam station, such as structured case-based discussions or physical exams) or by the types of *domains* they will be assessing you on (see section on [[#Domains]] below for more detail), regardless of the station format. Certain domains lend themselves to certain formats; for example, assessing your communication skills is generally better performed in an exam format that involves an actor, whereas your medical expertise can be examined in either a standardised case-based discussion (SCBD) or with an actor. I strongly advocate that you approach the exam from the perspective of domains being assessed rather than formats, but when you are first learning about the structure of the exam, it is helpful to learn the basic formats of how they can test you so they are familiar and you have a general sense of what you are walking into. There are several "formats" of question ("at least 1" of each type of station according to ACEM) that can be asked. Below is a table noting the approximate format of each type of question (take with a grain of salt). The exam is not beholden to the structure of the formats nearly as much as you might think. For example, in a history taking station, you will likely have to then turn to the examiner at the end when they ask and formulate your differentials and/or your next steps, essentially just like you would in an SCBD station. | Station format | # to expect | Comments | | ------------------------------------------------------------------------ | ----------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | SCBD | ≥ 4 | Essentially the plurality of the questions and resultant majority of your study prep. “Standardised case-based discussion” | | Teaching / advice to junior staff | ≤ 4 | There are several versions of this type of question:<br>- teaching *domain* where you need to demonstrate how to teach the concept<br>- actor asking you questions but teaching is *not* a domain, and essentially it is a permutation of an SCBD but you are talking to a resident. There might be some admin thrown in (eg the resident messed up or you need to check on them or tell them how to get more support, etc) | | History taking | 1 - 2 | Take a history about a [[Symptoms\|symptom]] and then generally either form a synthesis or a plan or list your differentials to the examiner or the management steps. This type of station format may include a difficult discussion domain or a health advocacy domain that you need to prepare for during reading period. | | A challenging communication situation: patient / relative / staff member | 1 | Many of the DEMT practice exams have entire stations like “breaking bad news,” but the real exam may be more nuanced or link it in with a different type of format like history taking or clinical supervision or simply present you with a genuinely difficult situation for which there is no straightforward “right” answer and they want to see how you approach that zone of emergency medicine. | | Physical exam | 1 | Apparently usually only 1. The actor will not have any findings. If you ask a history of them, they will remind you of this. | | Simulation | ≤ 1 | This has changed a bit so read the guideline; there is a recent ACEM OSCE (posted on their practice website) of working with the nurse in charge to organise the department for high acuity that I understand has been asked a few times | | Procedural skills | ? | Maybe something to teach | The sections below are organised more around concepts that I think are important rather than strategies for the above station "formats". ![[Pasted image 20250429160058.png]] ### Domains > Read the ACEM document "[OSCE Domain Criteria March 2022 UPDATED.pdf](https://elearning.acem.org.au/pluginfile.php/195804/mod_folder/content/0/OSCE%20Domain%20Criteria%20March%202022%20UPDATED.pdf?forcedownload=1)" (the most up-to-date document as of this writing in April 2025) More important than the format of question is reading the *domains* being tested, eg education, management, assessment, communication, etc. the classic “gotcha” is where you interact with a resident but aren’t assessed on actually teaching them. - Medical Expertise - Prioritisation and Decision Making - Communication - Teamwork and Collaboration - Leadership and Management - Health Advocacy - Scholarship and Teaching - Professionalism For example, here is a breakdown of the domains assessed for each cohort in the 2025.1 OSCE (from the ACEM exam report): ![[Pasted image 20250516122842.png]] > [!caption] \* Note: Outcomes relevant to teaching may also refer to leadership & management or Communication domains Each question will include at least two domains representing a fraction of your overall score, eg: > Medical Expertise (70%) > Prioritisation and Decision Making (30%) or > Medical Expertise (30%) > Communication (50%) > Health Advocacy (20%) As you read the prompt, take note of the domains and begin preparing what specific issues you may need to address in your answer. - The presence of a "Health Advocacy" domain means you will need to seek this out, because it isn't always straight forward where it will lurk. Is it a parent who doesn't want to [[Unvaccinated risks|vaccinate]] their kids and you need to advocate for this? You may only find this in taking a comprehensive paediatric history and learning this. Is it someone presenting with a benign issue and you learn they are drinking too much and this is an opportunity for [[Alcohol-related disease#ED SBIRT intervention - CAGE|Screening, Brief intervention, and Referral for treatment]] (SBIRT)? - “Scholarship and teaching” domain involves invoking the [[#Stations with actors (teaching, communication, "pseudo-SCBD")|teaching]] pro forma in the “Stations with Actors” section of this document. ### SCBD > The ACEM "[Standardised Case-Based Discussion - Instructions and Example.pdf](https://elearning.acem.org.au/pluginfile.php/195804/mod_folder/content/0/Standardised%20Case-Based%20Discussion%20-%20Instructions%20and%20Example.pdf?forcedownload=1)" is mandatory reading, but this is NOT the best way to develop the optimum strategy for answering SCBDs as it does not explain the "secret curriculum" for how to provide a "good" answer. The plurality if not majority is SCBD (standardised case based discussion), for which there are usually 4 questions within the station, you interact directly with the examiner, and you need to rehearse how you time it. There are many other stations that aren’t formatted like an SCBD but you can invoke the same principles. For example, if you are teaching a resident and they ask you about “assessment,” you can rattle off your approach to history, exam, and investigations for that issue just as you would for an SCBD. The name of the game is “**signposting**:” just like writing a classical 5 paragraph essay, you give a wink and a nod to the examiner upfront that you understand the question by quickly giving a sort-of roadmap for how you are about to answer the question and address the key issues. Signposting is really the key to communicating with examiner about your thinking. The easiest way to do this is with the *LIPS* model: > [!pearl] LIPS for signposting > 1. **Label** the situation > 2. **Issues** to address > 3. **Priorities** > 4. **Summarise** the Stuff you want (space/staff/supplies, etc; this last bit isn't always so important for signposting) I like to teach med students that a referral is not a mystery novel: give away the conclusion up front! A similar principle applies to your approach to OSCE stations; let the examiner know as early and as efficiently as possible what you are thinking about so they can either mark you more easily or guide you if you go astray. **Timing** is critical to the SCBD. Building your summary can help signpost the examiner what you are thinking and where you are going, which can make it easier to mark your points when you get them. It is also important to get in the habit of answering the actual question you have been asked, not the one you wanted them to ask; you will completely waste time if they ask you to "state a list of differentials" and you start discussing investigations you would like to do. > [!pearl] > **Assessment** = history, exam, investigations. Develop a sense for how to frame your answer to a question, succinctly *labelling* the issue ("this is a critically unwell infant with shock and hypoxia"), *summarising* the issues ("there is a broad differential including sepsis, congenital heart disease, metabolic such as hypoglycaemia, and accidental injury"), stating *priorities* aka signposting where you are heading ("my priorities are to optimise breathing and circulation, seek for and treat underlying cause, and arrange for paediatric retrieval for paediatric intensive care"), and then flesh out your *specifics* ("specifically, I will assign medical staff to manage the airway starting with BiPAP, obtain IV access and failing this obtain IO access, provide a fluid bolus of 20mL/kg or 240mL of 0.9% NaCl, review a blood gas looking for hypoglycaemia, hyponatremia, and lactate..." etc). ### Physical exam > Read ACEM "[OSCE Physical Examination Station Guidelines.pdf](https://elearning.acem.org.au/pluginfile.php/195804/mod_folder/content/0/OSCE%20Physical%20Examination%20Station%20Guidelines.pdf?forcedownload=1)" The exam will have one physical exam station. I was always bad at them. I suggest practicing a bit more than I did. Being able to perform a focused exam is high yield; if you see my comments at the top of the [[Neuro - upper limb]] note, the physical exams are not necessarily going to be discrete med student systems eg neuro or ortho but more designed around symptoms. You can check the [[Symptoms]] folder of this website as many of these presenting symptoms may be subject to a physical exam. > Easy points: ask for vitals and temp, utilise some form of structure. Talk out loud while performing exam explaining what you are doing and *why* you are doing it. IMHO, unless you are going for the prize, I wouldn't waste a tremendous amount of time focusing on the physical exam, even though it feels like the quintessential “OSCE” station we remember from med school. In my exam cohort, 58% of candidates "performed satisfactorily" on the physical exam station. I either did or didn't, but fortunately I passed overall. I was most nervous about the physical exam going into the OSCE, and revised a bit of the neuro exam and not much else, but for me the time:value ratio of buffing up the physical exam was simply not worth it for what was likely at most only one station. But get used to actually *examining* a real human being, which I and the rest of my study group did not do and we all felt weak. That being said, the physical exam station for our OSCE was also not a "standard" physical exam, so also trust in yourself that you do physical exams every day and there is a non-zero chance you can get through this station with your pre-existing set of skills. ### Stations with actors (teaching, communication, "pseudo-SCBD") There will also be stations with actors, both communicating with a resident, teaching a resident, taking a history from a patient, breaking bad news, etc. They are often characterised as discrete stations with discrete templates, but in reality the strategy is similar insofar as figuring out how to still signpost key issues when you are talking with an actor. ***Teaching*** Stations with a teaching domain have a certain pro-forma that feels fairly silly. In fact, I went to a practice exam and deliberately did not follow the pro forma to see what would happen. The examiner -- who is a real ACEM examiner -- noted that I had passed everything in the station but I hadn't hit all the check marks for "teaching," and laughed when I explained my reasoning. It really is just checkmarks and you MUST ensure you check them off! It is helpful for "style points" to highlight real world experience in teaching stations. I often invoked describing "my practice" in teaching stations. For example, in teaching an ECG, I will explain my approach, and certain safe heuristics (eg in VT vs SVT with aberrancy, I generally open up with my approach to "safe practice" as assuming VT and then explain some of the ways I differentiate it.) > [!pearl]- Teaching Station pro forma > - Introduce yourself > - Check for prior knowledge (they will always say "I don't know anything") +/- stage of ED training > - briefly state what you will teach them > - Give a specific resource (pro tip, give something genuine, I always stated specific resources I use; if you don't have anything good then just cite a chapter in Dunn or another standard reference. A friend of mine cited a youtube video: "the arrested patient" during a practice station and offered to watch with the resident! I have a major aversion to saying Life in the Fast Lane but some people go with that). Give the resource UP FRONT rather than at the end. > - **SIGNPOST** what the pathology is! Eg if it is an ECG, signpost the high grade block / STEMI / TCA overdose and THEN explain how you got there and what system you use. This is the "Label" of the lips structure > - Check in at some point during the teaching > - ensure you don't miss other domains; eg if there is a domain for health advocacy and the station involves the resident asking about something they missed the day before, ensure you check in around personal / supervision factors as to what may have contributed and point the resident in a direction of support > [!example]- Example Teaching script > These were my notes from practicing with a friend who gave an excellent answer for teaching a resident about approach to collapse on the beach: > > - what stage of training > - checked understanding > - resource: youtube: "the arrested patient", let's watch the video together! > > preparation: > - two issues: > - department > - case itself → enviornmental and medical causes > - staff: trauma call, found on beach, could be trauma > - equipment: IV fluids, warmer, glucose for ↓ glucose, blood products if bleed > - corpuls ready and ventilator > - notify CT and blood blank > - communication preparation: > - brief team about potential events > - high liklihood of differentials > - open communicaiton > - eye contact with anyone you are talking to > - tags on chest for role > - identify everyone by name > - two way and closed loop communication > - DDx: > - lightning strikes > - falls from surf > - aspiration > - octopus or jellyfish stings > - depending on area: snakebites cause neuroparalysis > - medical: > - STEMI/NSTEMI requiring cath lab → inform cardiologists early > - SAH po > - ↓ glucose > - ethanol intoxication > - tox overdose : serotonin or x > - sepsis > - hypothermia > - other equipment: fluids, warmers, antidotes > > note he is hypothermic. what else to plan for? > - classify how hypothermic patient is > - temp 27-32 = moderate > - temp <27 = severe > - target temp >32 > - prepare room: > - bear hugger > - warmed fluids > - blankets > - passive re-warming: remove wet clothes > - active re-warming: interperitoneal or bladder lavage 1-2 deg/h , ICCs. worst case ECMO > - problem: under temp 32, high chance of VF with slight movements. rec is try shock up to 3 times, but after then focus on re-warming > - double amount of time between giving resus drugs > - other issues: > - history, exam, investigation > - hx: > - PMx > - any drugs/medications > - exam: > - lichtenberg signs > > signs of non-salvagable > - pupils fixed and dilated with prlonged CPR > - lactate >7 > - temp <15 > Take special note that ***not every station with a resident actor is a "teaching" station***. for some, the only domains assessed are medical expertise and communication. More on this below. ### Toxicology stations There is no specific "type" of tox station format; it could be an SCBD, teach a resident, scenario, etc. But you are likely to get at least one tox station. Although I generally do not think that there are many [[OSCE Templates and scripts|scripts]] that one needs to use on the OSCE (LIPS, teaching a resident, knowing the key aspects to breaking bad news and investigating a mishap or [[Complaints|complaint]]), I strongly advise you to use **RRSI DEAD** to answer tox questions. Specifically, if you mention your "risk assessment" early, it signposts to the examiner that you are using a structured approach to toxicology. There are two genres of tox station: 1. The toxidrome is diagnosable 2. The toxidrome is purposefully [[Tox Resus#Unknown substance ingestion|ambiguous]] If the toxidrome is diagnosable, then say it up front if you figured it out based on the pre-reading info and then also give your differentials. If the toxidrome is purposefully vague — eg ALOC without a pathognomonic [[Blood gas#HAGMA|VBG]] or [[Classic tox ECGs|ECG]] — then simply resuscitate the patient safely and give appropriate investigations and approach to the undifferentiated patient. A recurring theme is the exam wanting to see what you’ll do if the patient doesn’t respond to your initial resus attempts. Eg if it is a CCB and your adrenaline or [[high dose insulin euglycemia therapy|HIET]] doesn’t fix their shock, what is your escalation? (Eg [[ECMO]]) ### Interpreting tests (VBGs, ECGs, XRs, etc) Again, this is not a type of station, but it is a very common task, often included in your stem. When you interpret the test to the examiner or to the resident, do not bury the lede! Much like writing a medical note, ==this is not a mystery novel==: state upfront what you have observed and THEN explain how you got there. For VBGs in particular, do not lose the forest for the trees. I've seen a practice station with an HHS VBG where candidates spend all this time faffing over the CO2 compensation and A-a gradient and all this useless stuff and miss the two critical issues: the severe hyperglycaemia and [[Blood gas#correct Na for glucose|correcting the Na for glucose]] to find the patient has severe hypernatraemia and commenting on the patient's severe dehydration. ## Overall OSCE advice 1. Start a study group text group on signal/whatsapp/whatever 2. Have a library of past OSCE questions that everyone has access to in some way (I had them on my computer/phone using an app called devonthink, but any local folder or cloud library will work). You can get many from the [Cabrini website](https://www.cabriniemergencyeducation.com), ask your DEMT, etc. Keep track of which you have done using either file tags or a spread sheet. 3. Do as many as you can with your study group. The first few weeks this will require a bit of [ego death](https://en.wikipedia.org/wiki/Ego_death) to get used to the humility of being vulnerable in front of your peers, but it is really important to practice and give and receive honest feedback. 1. At some point, you need to ==ensure you do all the past ACEM questions.== Partially because they might repeat them, but mostly to get a feel of the difference between ACEM questions and past DEMT questions. Like the written, ACEM questions are different from many DEMT questions. ACEM questions LOVE ambiguity that tease out whether you use “safe practice” in the context of difficult or equivocal decisions. It is rare for them to have something straightforward like “manage aortic dissection,” and more common for the issue to be ambiguous and how do you deal with that uncertainty. Which we do all the time in real life. 4. Develop a sense of what a "good answer" is by working with your DEMTs. 1. In the first month of study, don't get too fixated on whether or not your answers are a "pass" or not besides for positive emotional reinforcement during a stressful time. The main goal needs to be just getting comfortable rehearsing and learning the different styles and the secret lexicon of "consultantoid" jargon and focusing on the low-hanging fruit of ways you can improve your answers and scores. 2. You can start being a bit more quantitative as you get more into OSCE study and need to benchmark yourself to see if there are major deficits that need to be addressed. However, I really wouldn't try and put too much energy into determining whether you are getting 4s or 5s or 6s on the questions and more into ensuring that you are mostly hitting the key points on the marking rubric (eventually you will do enough that you start either disagreeing with the marking rubric or finding that some are either unreasonably hard or unrealistically easy) 5. By extension, you will also develop a sense of what a good OSCE question is. Some practice questions are simply unrealistically bad questions; too specific, too many moving parts that are not synthesised into the overall complexity of the case, or require some specialised knowledge that a FACEM wouldn't be expected to possess. 1. For example, I did a practice question about hyperbaric medicine that included far too much detail. Even if [[Diving injuries and Dysbarism|diving injuries]] is fair game for an aspect of the question, ACEM would never design an entire question around hyperbaric medicine. 2. Doing the practice ACEM questions will assist with this so that you don't waste too much energy or time if you perform poorly on a non-ACEM practice question that is very low fidelity for the actual exam. 3. Keep in mind that questions for which the "Medical Expertise" domain represents 70% of the question are likely going to be topics for which the [[ACEM syllabus]] expects you to be an Expert (hyperbaric is only "high knowledge"). 6. At some stage (ideally early in your study), go to the ACEM elearning website and read the [FEx Clinical](https://elearning.acem.org.au/course/view.php?id=652) ACEM content (there are 7 pdfs), which answer a lot of common questions about exam format. 7. Knowing some [[Admin]] is relatively high yield. Nuanced questions about decision making with vulnerable patients (eg under Mental Health act or paediatrics) is a great ACEM-esque way to tease out how you might approach a challenging situation; in these cases, it is less the case that there is one right answer, but they want to see how you've made the difficult decision, and I found it valuable discussing the ethical landscape. 8. Selectively read sections on this website if you identify knowledge gaps during OSCE. The website content was written in terms of the fellowship exam so many pages (sorry, not all) provide the amount of detail that is appropriate for an exam answer.