All international medical graduates seeking residency placements in Canada must complete and pass the NAC OSCE, or the National Assessment Collaboration Objective Structured Clinical Examination. While OSCE exams are very challenging and stressful to prepare for, we are here to provide you with a comprehensive guide that will outline the NAC OSCE stations, exam expectations, and most importantly, fail-proof prep strategies!


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What is the NAC?

The NAC stands for the National Assessment Collaboration examination. It is a 1-day examination for international medical graduates (IMGs) and DO school graduates from the US applying to Canadian residency programs. It has reduced redundancy and duplication of previous international medical graduate assessments conducted by different programs across Canadian provinces and has standardized the results for all residency program directors.  

Typically, the NAC is an in-person examination, however currently, no physical examinations are conducted with the standardized patient. Applicants will be describing their approach to a physical examination in the stations rather than conducting the physical examination.

The exam is held in multiple cities across Canada and offered in English and French. The option for a French sitting is limited to Montreal.

Eligibility and Application Process

The purpose of this OSCE examination is stated as follows: ”to assess the knowledge, skills and attitudes that are required for entering a postgraduate training program in Canada.” 

The NAC is required for IMGs and DO school graduates from the US applying to Canadian residency programs. If this is your situation, your NAC result must be submitted when you apply to Canadian residencies through CaRMS. To apply for the NAC, use physiciansapply.ca portal. 

When you register for the NAC on physiciansapply.ca, you are asked to choose 3 exam centers in your order of preference. You can choose to select only one or two sites; however, this does not increase the likelihood of writing the NAC at your top location. In fact, providing 3 locations gives you more chances of completing the NAC exam during your chosen time period.

The examination is held twice a year in March and September. If you fail your first attempt, you cannot attempt taking the exam in a consecutive time slot. For example, if you take the NAC in March of a certain year and fail, you are not eligible to re-take the exam until March of the following year. You are only allowed to write the NAC three times irrespective of the outcome. Once you write the NAC, the result is valid indefinitely. And keep in mind that only the most recent result is valid. 

Your result is legitimate across Canada and for this reason, you do not need to write the NAC in the province where you aim to apply for residency. All program directors will accept the result regardless of the location where you completed the exam. 

Just like Canadian graduates, international medical graduates also have to write the Licentiate of the Medical Council of Canada (LMCC) as a component of their CARMS application. The LMCC serves as your official proof of registration in the Canadian Medical Register. The LMCC proofs your academic aptitude and the NAC demonstrates your practical competencies. The NAC is not required to obtain the LMCC, but both are required for your CARMS application.

It is also important to note that just because you pass the NAC does not mean you will secure a residency training position in Canada. There are many components that go into securing a residency training position including the applicant’s residency CV, reference letters, residency personal statements and acing residency interview questions

Check out our tips for acing your residency interview:

What to Expect on the Exam Day

On the day of the exam, you will register at the front desk. At this time, you will have to identify all the items you brought with you and these will be inspected. If you are concerned about privacy, you can ask to have the items examined in a private setting. 

Note that you can bring a small, nut-free and fragrance-free snack in a Ziploc bag and a clear bottle of water into the secure area. 

You must bring a white coat without any university logos, a printed entrance card and a printed and completed copy of the candidate confidentiality agreements from the physiciansapply.ca website. 

There is a list of items that can be brought to the secure area on the official website, including lip balm, eyeglasses, face mask, and medications. Click here for the list of items that are permitted. 

Other items require special permission, such as medical devices that require smartphones to operate. They are listed on the official website as well.

Many items are not allowed in the secure area. These include wallets, keys, coats, watches, bags, and stethoscopes. They recommend limiting how much you bring with you as there is only a small amount of space for storage on site. 

You will be required to wear a mask throughout the interview in all areas. You are allowed to bring your own, otherwise, a non-medical mask will be supplied at the site. 

If you are more than 15 minutes late for registration, you may be denied entry. Once you start the exam, the attempt will count towards the overall number of tries you have to complete the NAC - remember, there's only three. This means that even if you do not finish, you will have used one of your three attempts.

Orientation for the NAC will be provided online. The link is sent to your physiciansapply.ca account. 

Once the exam starts, you are not allowed to talk to other applicants who are completing the exam alongside you. No watches or phones are allowed. If the examiners find a phone on you, your exam may be canceled, and the result may be invalidated. There is also a possibility that you will be unable to retake the exam and may be barred from the MCC - so follow the rules! 

You will be given a candidate identification number that you will read aloud at the start of each station. At registration, you will also be given an identification badge that also identifies at what station you will start your exam. 

You will be provided with one notebook to take notes in during the stations. This notebook will be turned in once you finish the exam. 

What to Expect in the OSCE Stations

The NAC OSCE is comprised of 10 stations, each 11 minutes in length with 2-minute breaks between stations to prepare for the next station. 

A short description will be present on the stations' doors and inside each station outlining the assigned task such as taking a history, or conducting or describing a physical exam. You will have 2 minutes to read the prompt on the door and prepare before you enter the station. A buzzer will signal when you can enter the station.

When the station begins, you will enter the room where a physician examiner (PE) and a standardized patient (SP) will be present. You do not need to pay attention to the physician examiner when you enter the room. Focus all your energy and attention on the standardized patient, whom you will have to examine based on the prompt you read outside the room. You will have 11 minutes to complete each OSCE station. If you finish early, you will wait quietly for the station to finish. However, it is allowable to re-engage with the SP at any time if you think of something else you want to say or do. In some stations, you might be questioned by the examiner, of which you will be notified in the station prompt. A buzzer will signal the time to indicate the transition to examiner questions while you are in the station. Once the physician examiner starts questioning you, you cannot re-engage with the patient even if there’s time remaining. 

As the purpose of the NAC OSCE is to assess your global aptitude and preparation for medical residency in Canada, the scenarios you may encounter at the stations span the spectrum of medical practice. The scenarios come from:

There are many tasks that may be asked in the prompt for you to complete during the station. You may be asked to complete more than one of the following:

  • Take a history 
  • Describe a focused physical exam
  • Manage or resolve a patient problem
  • Counsel a patient or a family member 
  • Answer oral questions 
  • Summarize and present findings
  • Read or reference materials that relate to a patient including their chart, test results or medication lists
  • Interact with physicians or allied health members 

How is the NAC OSCE Scored?

The physician examiner is focused on assessing the qualities and attributes necessary to be a successful resident in a Canadian residency program. In order to best gauge these attributes, the examiner is assessing the questions asked of the SP, the physical exam maneuvers used, the organization and the underlying medical knowledge. 

You are rated on 7 competencies:

The physician examiner scores the station by observing your interaction with the standardized patient. These scores are standardized, as the station includes a checklist and an answer key for the questions to minimize the variation between examiners. Although some stations may seem easier than others, all stations are worth the same in their final score. 

Based on your performance across the competencies, each station is graded on the following scale:

 

You are given a final score of fail, pass, or pass with superior performance based on a pre-set cut score approved by the NAC examination committee. The cut score is not published, and you will not get your total score. 

Do’s and Don’ts of the NAC OSCE

DO

1. Read and follow the instructions. The station instructions are the key to organizing your time. The instructions will provide a framework for what is expected of you. For example, please interview the patient vs. please walk the interviewer through your physical examination. In stations that require a focused interview and physical examination, it will be important to be attentive to the pertinent positives and negatives provided in the prompt and throughout the interview to organize your questions to finish on time. If the prompt states conduct a history, you will not get credit for performing a physical examination. So, pay attention to the instructions and do exactly what is being asked of you.

2. Use your notebook. It is easy to forget some key features provided in the prompt. Use your notebook to highlight pertinent positive and negative features in addition to the requirements of the session. This is key when you move from station to station as it can be easy to confuse stations which can significantly affect your overall performance. When preparing for the prompt, you can use your notebook to write key differentials, important questions, laboratory or management aspects that you may want to refer to later after completing the station requirements and coming up with a preferred diagnosis. 

3. Verbalize your examination. When completing a physical examination, it is crucial to verbalize what you are doing. Depending on the angle, the interviewer may not be able to identify the landmarks you are using or the location at which you are palpating – this is why saying every action you perform is crucial to your success in the stations. In addition, it demonstrates anatomical knowledge and provides the examiner with insight into your thought process. The examiner will provide findings after you verbalize the steps of your physical examination. It is not crucial to explain why you are doing a certain examination, however, you must state it and provide appropriate terminology and organization, both of which are rated on your overall station performance. 

4. Be in the moment. Take it one station at a time. Each station will require you to forget the previous station. Additionally, don’t anticipate upcoming stations. This will allow you to be truly present in the station and attend to the history provided by the patient you are currently working with. Use active listening to attend to the standardized patient as they have key information that will guide your differential and management. 

5. Provide specific information. When you are asked to counsel or advice a patient related to a problem, disease process or medication, it is important to provide specific information tailored to the patient. Do not provide generic advice. When discussing management options including medications, it is important to provide relevant risks and benefits. The aim of counselling stations is to demonstrate your various competencies in medicine including leadership, management, and most importantly in these situations, communication. The aim is to remain unbiased and provide the needed information for your patient to make an informed decision. 

6. Be aware of your verbal and non-verbal communication. Nerves can surface in many ways, including quickened speech, increased hand gestures, and stuttering. At times, it may be difficult to maintain eye contact and rely on your standard approach to questions. This kind of behaviour can come across as judgmental and may not be catered to the responses provided by the standardized patient. When conducting a history, sit outside of the patient’s personal space with open body language, including shoulders squared, feet flat on the ground, and at the same level as the patient. Avoid crossing your arms or legs as it can come across as closed. Take pauses to collect your thoughts and use non-verbal communication including nodding and simple statements to demonstrate to the patient that you are listening. 

NAC OSCE DO's:

DON’T

1. Do not ignore the patient. The standardized patient is the focus of the examination. Oftentimes, standardized patients feel as though the candidates have an agenda and are not truly listening to them. If the SP’s story does not make sense, use probing questions to continue exploring the issue. Pay attention to their statements. If the patient states “it is worse” or “this is different”, probe into what they mean, be inquisitive to discern what they mean by “worse.” Such statements may indicate that the patient has had a similar problem before. Standardized patients are asked to act like real patients. If you are disinterested, the patient will not provide necessary information. However, if you are able to demonstrate empathy, active listening, and collaboration, the patient will be more likely to share embarrassing or fearful information. Your interaction with the patient is key in your overall performance in the examination. 

2. Do not focus on the examiner. It can be easy at times to become fixated on the reaction of the examiner, what they are writing down, or ruminate about what they are thinking. While it is true that the examiner has a checklist and an answer key, the standardized patient is the focus in acquiring the information needed to come up with a differential diagnosis to shape your approach to investigation and management. Some worry that if the examiner is not writing on the checklist, you are not achieving the requirements, but this is not correct. There is vast variation between examiners and how they assess candidates. While some may write everything down, some prefer to sit back, assess your interactions and questions, and simply put a checkmark beside components you ask about. Some may gauge your performance in the station after your interview or physical exam ends. 

3. Do not talk too much. When you are nervous it can be easier to begin the station with a lot of questions as if you are interrogating the patient. This can affect the history the patient is able to supply, especially if you dominate the conversation. In addition, the OSCE is not the place to show off your theoretical knowledge. Rather you are expected to demonstrate your ability to be patient-centered. This means asking question in a manner your patient can understand and respond. Avoid jargon and medical terminology as it can make the patient uncomfortable and embarrassed. When counselling on your management plan, explain the disease process in simple language and provide single step instructions. Provide multiple opportunities for patient questions. This simulates successful clinical encounters and best demonstrates the qualities the PE is assessing in the station. 

Watch our video to get more tips:

How to Prepare for the NAC OSCE 

Create a study plan

Studying for an all-encompassing examination can be daunting and overwhelming. It is important to organize the material into manageable chunks of information to best attend to all the necessary content in a timely and focused manner.

Create learning objectives

As there is a lot of information to cover, it is important to identify key diagnoses. It can be helpful to keep a patient log with the diagnosis or to review organ systems and highlight key diagnoses. Once you have a list of diagnoses, use your time to highlight pertinent history and physical exam findings that contribute to the diagnosis. Ensure to follow up with key investigations and management to have an answer key to review. 

Start early

Setting study priorities for this examination can at times be difficult, especially when the exam is scheduled ahead of time. Many applicants are studying for both the LMCC and NAC examinations simultaneously or consecutively and this can result in burnout. Starting early can allow you the time to study in small increments and avoid cramming. 

Study in groups

Studying with others allows you to remain on track, collaborate on learning objectives, and maximize your retention. Each group member has a different clinical experience and brings about different patient encounters that may alter what they view as critical patient presentations. Individuals have different strengths and weaknesses, so studying in a team can facilitate group skill acquisition through teaching. Teaching others solidifies learning. 

Take study breaks

At times, studying for the NAC OSCE can feel overwhelming. Busy study schedules do not allow for time to focus on other aspects of our lives or our well-being. In order to maintain your physical and mental health, schedule time to refresh and tend to your personal life, hobbies, interests, and other responsibilities. Try to take a day a week to disengage from your NAC studying and reward yourself for hard work. Take a bath, read a book for pleasure, enjoy a movie or spend time with friends. This can provide some relief and allow you to re-energize for another week of studying. 

Practice, practice, practice

The best way to learn is through practice. Develop realistic scenarios and pose the scenarios to your group members. Practicing with new scenarios will replicate the OSCE, allow you to identify your strengths and limitations, and provide opportunities for feedback. Take turns acting as the standardized patient, physician examiner, and applicant. Even when you are not in the role of the applicant, hearing others conduct a history or perform or explain a physical examination will allow you to prepare for the exam. When you feel comfortable with the format, practice with the time limitations. Provide feedback to one another based on the competencies I outlined above. Was the history organized, logical, and complete? Were components of the history missed? Was the physical examination focused and organized? Were the investigations appropriate and were all the investigations needed? Was the communication effective? 

In addition to practicing in groups, take the opportunities you have in clinical situations to get feedback from residents and staff. Implement their feedback into your OSCE practice sessions. Keep a record of scenarios that you have completed and indicate whether or not you feel prepared for such scenarios. As you approach the examination, this log can provide insight into the areas you should focus on towards the end of your preparation period. 

Get professional help

OSCE exams are tremendously challenging. Even study groups cannot always provide all the necessary help you need in preparation for this test. A study group and feedback from fellow residents and staff can keep you on track, but they cannot provide personalized feedback that will let you improve your areas of weakness. A medical school advisor can provide you a clear, objective assessment of how well or poorly you are performing in difference scenarios and stations. Getting personalized feedback will not only improve your professional knowledge but will also allow you to work on your communication skills and positive presentation. 

Check out our tips for acing any OSCE exam:


FAQs

1. How long do I have to complete each station? Do most candidate finish?

You have 11 minutes. The station instructions have been reviewed by many physicians and the tasks are deemed appropriate for the time provided. Most candidates finish the station on time or ahead of time. If you are organized and complete the tasks as asked, there should be enough time to complete the station. 

2. Is finishing a station early a bad sign?

Finishing early does not mean that you did poorly in the station. Most stations can be completed in less time than is provided. Most of the time, if you are organized and complete the required task, you will have time remaining at the end. 

If you have time at the end, reflect on the information you have gathered and determine if there is anything else that may strengthen your differential, rule out acute or life-threatening conditions, or affect your management and investigation strategy. For example, if you think a patient has an infection, it may be helpful to ask if they have any allergies to antibiotics or have any renal impairment as this may affect antibiotic selection or dosing. You can re-engage with the SP if you forgot something even if you had been sitting quietly waiting for the signal for the station to end. However, if you have started the questions, you cannot re-engage.

3. What may help me prepare for the OSCE?

There are no specific prep references for the NAC OSCE provided by the official sources. However, there is a list of reference books available on the MCC website. If you feel weak in a certain area, take the time to review materials related to the topic including books and study notes. Also, try studying in groups or going back over your coursework.

4. How early should I register?

There are only 2 sittings per year. It is important to schedule at least a few months ahead of time, especially since you may require arrangement of accommodations and transportation if you are taking the exam in another city. 

5. What kind of score will I get?

You will get a score of fail, pass, or pass with superior performance. Your numerical score will not be provided, nor will you have details outlining which stations you performed well in. You will also not be given the standardized scoring to indicate a pass or fail score. 

6. Should I introduce myself and say goodbye?

You should provide both introductions and conclusions in each station as it is a sign of professionalism and respect. It can be easiest to introduce yourself when you read out your label. At the buzzer, saying goodbye provides a final positive impression for the SP and the examiner due to the primary and recency effects. They are looking for applicants who are approachable, demonstrate good communication, and are empathetic. 

7. What should I do if I don’t know the topic?

Given the large array of topics, it can be possible to face a station and scenario you are less familiar with. 

In the case of taking a history, ask open ended questions and ask follow-up questions. Take a strong basic history and ask pertinent questions. For example, if the SP is talking about nausea, ask about related symptoms like diarrhea, constipation, emesis, fever, hemoptysis, melena and hematemesis and similar symptoms in close contacts. Despite not necessarily knowing the diagnosis, asking relevant questions can provide some pertinent positives and negatives to rule out or in diagnoses that you are familiar with. 

In the case of a physical exam, conduct a physical examination that is organized. Even if you cannot recall how to do an interview, run through a thorough inspection of redness, swelling, deformity, skin changes. 

8. What happens if I fail my NAC OSCE?

You can ask for a reassessment of your score if you feel like you did better than your result. If you fail, you can re-write the NAC OSCE up to 3 times, but it must be at least 1 year from the previous attempt. Reflect on the stations that you did not feel as comfortable with and allocate time to focus on your areas of weakness. Seek feedback in clinical settings, practice in study groups, and get help of professionals. 

9. When should I start preparing for the NAC OSCE?

Begin preparing for the exam at least 1 year from your anticipated examination. Your time will be split between exam preparation, work or clinical duties, and personal life. Set a schedule that allows you to maintain a sustainable study schedule without experiencing cramming or burnout. 

10. How long is my NAC OSCE score valid?

Your most recent score is valid indefinitely. 

11. How to best use the time outside the room?

Read the instructions, paying attention to the task you have been asked to perform. If key findings or histories are included in the prompt, take note of these and use this information to consider a differential diagnosis. Use this information as an initial differential. You can also use it to base initial questions to rule in or out life threatening and common conditions. Think through the checklists you created for similar situations. For example, approach to nausea. 

12. How can I manage my stress before the exam?

Ensure that you are tending to your own self care and wellness leading to the exam. Exercise regularly, follow a regular sleep schedule and eat well. If stress builds during the exam, tend to your breathing and engage in positive self talk. This can shape your perspective on your own skills. 

13. Do IMGs still have to write MCCQE Part I to be eligible applicants to Canadian residency programs?

IMG have to write the MCCQE Part 1 and complete the NAC examination to be eligible for Canadian residency programs. 

To your success,

Your friends at BeMo

BeMo Academic Consulting

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1 Comments

Ahmad mousavy

Hello Dear experts Ihope you are doing well. My question is does applying for accommodation affect your future, Regards, Ahmad Mousavy

Reply

BeMo Academic Consulting

Hello Ahmad! Thank you so much for writing us! Requesting accommodations will not negatively affect you at all. Please visit this website to learn more about the procedure: https://mcc.ca/examinations/test-accommodations/ Let us know if we can help with anything else!

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