Not many students know how to prepare for an OSCE. The Objective Structured Clinical Examination (OSCE) is a type of exam designed to test the clinical skills and professional competencies of future medical professionals, so content revision is not going to be a sufficient study tactic. It is a practical exam that tests abilities beyond your theoretical knowledge. In this blog, you will learn how to prepare for an OSCE, including the exam format, stations’ descriptions, and OSCE study strategies!
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What is the OSCE?
Typically, an OSCE is not a stand-alone examination. It is often incorporated into other medical examinations. For example, the OSCE is used in evaluations such as the National Assessment Collaboration (NAC) Examination, the Medical Council of Canada Qualifying Examination (MCCQE) Part II, and the United States Medical Licensing Examination Step 2 Clinical Skills (USMLE Step 2 CS). OSCEs can also be used in undergraduate, postgraduate, and licensing examinations.
The exam consists of several stations that each candidate has to go through individually. Every participant experiences the same patient problem and is asked to perform the same task within the same timeframe. The stations represent real-life clinical situations and are designed to assess your ability to apply clinical knowledge when meeting a patient, writing an admission or discharge order, conferring with a colleague, etc. You will rotate through a series of timed stations that represent specific clinical scenarios. Each station will examine your ability in one or more areas of clinical competence, for example, history taking, communication, physical examination skills, etc. The stations will be of the same level of difficulty no matter where you take the exam and marked using the same marking scheme.
The OSCE will test your readiness for the practical aspects of the medical profession. The daily responsibilities of a physician include essential skills that cannot be examined using theoretical or written examinations, so this is why practical clinical exams are vital. While written tests assess your theoretical preparedness to become a physician, they cannot assess your readiness for the practical aspects of the profession.
The OSCE helps assess your communication skills, physical examination techniques, professionalism, and abilities for effectively interacting with patients and other healthcare workers. Remember the core competencies outlined by the AAMC when you prepare for your OSCE. If you are trying to become a physician in Canada, you should review the CanMEDS framework which outlines the important roles of a physician in Canada: medical expert, communicator, collaborator, leader, health advocate, scholar, and professional. While all these competencies and roles greatly depend on your theoretical knowledge of the medical sciences, all of them require a practical approach and suitability. Your hard skills are best assessed during a competency-based exam, such as the OSCE.
The OSCE Format
Once you register for the exam, you will be escorted to your exam track. There will be numbers on the station doors throughout the exam track that will help you navigate through the stations. Each station will give you a signal when to enter and when to leave the station. Each OSCE station is timed. There will be several candidates in your exam track, so all of you will rotate through all the stations in the order that is assigned to you. Each candidate is pre-assigned to start at a specific station. For example, if there are 10 stations, you will start at station number 1 and rotate through to number 10. There might be wait stations to accommodate the number of candidates in your track. For example, if there are 10 stations, but 11 participants in the track, one of the participants will sit at the wait station for the duration of one station before moving on to a real station.
Each station is unique. The equipment, setting, and Standardized Patients (SP) will vary based on the purpose of the station. Remember, you will have a copy of the station instructions inside each station for reference. There is no penalty for reviewing the instructions during the course of the station. If the station requires materials, such as a growth chart, lab results, or other relevant information, they will be available in the station and sometimes outside the station as well. However, some stations' props will only be available upon request or if you indicate the need for them, such as information about a patient's vital signs.
At each station, a physician examiner (PE) will be observing, assessing, and recording your performance while you interact with the SP. The OSCE is not an interview, so you do not need to introduce yourself to the PE. While you cannot completely ignore the PE's presence in the station, you should not pay attention to PE's facial expressions or score-keeping. Try to focus your attention on the patient. However, you will need to interact with the PE in some cases, including:
- Confirming your candidate ID number as you enter the station (written on your booklet)
- If you misinterpret the task in the instructions, the PE may redirect you by saying something like “please reread the instructions.”
- In stations where you are asked to verbalize your physical examination maneuvers, the PE may provide the result of a physical examination maneuver as if you had completed it. For example, after indicating that you would perform deep palpation in all four quadrants of the abdomen looking for tenderness, the PE may say “The patient has tenderness in the right adnexal area”, or after saying you would take the patient’s blood pressure the PE may say “the blood pressure is 180/95.” If no information is provided, move on.
Once you finish going through all the OSCE stations, you will return your exam notebook with all pages intact and your candidate badge. Once you are released from the exam, you will be signed out of the examination center, given your personal belongings, and escorted outside.
In what circumstances will you interact with the PE?
You will begin each station in front of the station door, where you will read instructions for that station. Go over them carefully and wait for the signal to enter the station. The instruction located on the door of each station will also be present inside the station and you can reference them at any point without penalty. Once you enter each station, you must present your candidate code to the examiner in the room. The stations are designed to assess these seven competencies:
- History taking
- Data interpretation
- Communication skills
- Physical examination (assessed in a modified format)
- Procedural skills
Procedural skills typically come up in medical school or program-specific OSCEs, rather than in examinations like MCCQE Part I or II. This involves tasks such as inserting an IV, a catheter, or a nasogastric tube on a plastic model and not a standardized patient.
Examples of the OSCE stations may include:
The types of tasks you will face in each station vary. They may include, but not be limited to:
- Taking a patient history
- Conducting a focused physical examination
- Taking a history and doing a focused physical examination (combined tasks)
- Managing/resolving a patient problem
- Assessing and managing an urgent or emergent situation
- Counseling a patient and/or family member(s)
- Answering oral or written questions (short answer written-in or multiple choice)
- Summarizing and presenting findings to an examiner or colleague
- Reading or referencing materials related to the patient’s situation, such as articles, charts, test results, medication lists and summaries
- Interacting with physicians or other health-care professionals
Be aware that some OSCEs include paired stations. This type of station requires you to perform two components sequentially in two separate rooms. Both components will relate to the same clinical scenario. For example, you may be asked to review a patient’s chart in the first component before meeting with the patient in the second component. Or you may meet with a patient in the first component and then answer written questions relating to that patient in the second component.
The SPs you will "examine" will either be healthy persons or persons with chronic stable findings. They have been trained to present a real patient's signs and/or symptoms reliably and consistently. You should interact with SPs as you would with your own patients. In cases where there is a physical examination component, you will be expected to voice, rather than perform, what you would do to the patient. You will be asked to verbalize to the PE what physical examination maneuvers you would perform and what you would be looking for. The PE will verbally provide the findings/results. Interacting with SPs also includes questioning them and responding to their problems. Your interaction with the SP is part of what the PE is assessing.
OSCE Study Strategies
It is important to know that it is not enough to prepare for the OSCE using books and other content materials. Additionally, the AAMC and the Medical Council of Canada (MCC) do not endorse any specific reference books about OSCE stations. Materials that may be helpful should touch on the key principles of doctor-patient interaction, as well as address common ethical and legal issues of the medical profession. They should also be based on a focused approach to presenting problems. When you are looking for study materials, keep in mind that some references may use examples of cases or scoring instruments that are not representative of those used in the examination you’re preparing for. For your reference, the Medical Council of Canada has created a list of reference materials that its test committees have used to validate examination questions and content. You may access the list here. However, remember that the OSCE tests your skills and abilities, so simply reading reference materials is not going to be a sufficient preparation tactic.
Additionally, you should know that there are no approved preparatory courses available for candidates getting ready for the OSCE. Some medical facilities offer programs that may be helpful. There may also be commercial preparatory courses available near you. However, the usefulness of these courses has been debated. While these prep courses give you an opportunity to become familiar with the OSCE format, most of them emphasize the examination-taking skills, rather than your clinical knowledge and judgment. So, if you have weaknesses in your clinical competence, these types of courses are unlikely to help you.
Like with most examinations, your first step should be assessing your baseline. For OSCE, start identifying the objectives that you need to review. Examine what you need to study and focus on common or critical patient presentations. Make sure you're honest in assessing your knowledge and preparedness. When you're going over the objectives, create differential diagnoses, and identify key features that will lead you to establish or confirm your differential diagnoses. Create checklists and identify key orders for investigation and management plans for each one. Write this information in a notebook or a Word file on your computer, so you can access it at any time. If you realize that there is a knowledge gap in a particular area, go back to the basics. Remember, that your study plan must include a detailed outline of the content you'll cover and active review strategies. Recall how you organized your schedule for other exams, such as your MCAT study schedule, and make sure to stick to it as much as possible.
Memorize the Steps of Medical Maneuvers
It is important to know each step of a medical procedure or maneuver that you may be asked to perform in an OSCE. As you study, if you run into a patient problem and are uncertain about the specific steps you need to take to accomplish the task before you, research the specific sequence of actions you need to take to successfully complete the task. Once you write them down in your notes, you will need to practice this sequence until it is drilled into your memory. Once you habituate yourself to follow the correct action sequence when you deal with a specific problem, you will perform the task instinctively. To get good at this, you will need to practice with a group of friends or colleagues.
The most effective study strategy is the practical application of your clinical skills and knowledge. To do this, you should form a study group. Start by identifying which objectives are most important for each group member to review, such as management of chest pain, assessment of vomiting in a child, etc. Make sure that the most competent members of the group do not take on all the responsibility. Every member of the study group needs to be challenged, so make sure everyone gets a fair share of studying and practice. Once everyone discloses the objectives that they find most challenging, you can create a presentation schedule. A member of the group who is confident in a particular objective can create a presentation about this objective. Each member can present common patient situations that they understand well. As each person presents his/her patient problems to the group, they should quiz individuals within the group about how they would assess and manage these problems. Be critical and make sure to challenge each other. Ask questions like "What other diagnoses should you think about in this situation? How would you differentiate between them?", "What investigation are essential? Why?", "What should you assess on your physical examination? What else should you assess?", etc.
Let's go over some key exam-taking strategies that will help you ace your OSCE!
Remember, the OSCE will provide you with one important item that will help you navigate through the stations – your notebook. When you register for the exam, your candidate identification code will be printed on the booklet. You will need to verbally confirm your identification code with the PE upon entering each station. Most importantly, you can also use the booklet to jot down information before and during your stations. Use the notebook when you’re reading the instructions. As you’re reading the task and the patient information, note down the details before you enter the room. You can also note down any questions that come to your mind or any other reflections you have about the patient description. Note what you need to know or do. Don’t forget, the instructions are also available inside the station if you want to check the patient information again.
While you’re practicing for the exam, don’t forget to have back-up strategies in case you find yourself lost about a patient problem. Try falling back on basic clinical interviewing and physical examination skills. Do your best to find out everything you can about the patient's problem. It is a timed exam, but don’t be afraid to take a moment to think about what you want to do next.
You must carefully read, listen to, and follow instructions from the site staff. Make sure to take a mental note of the signal system, the track layout, and other details present in the track or stations. Most importantly, read and follow the instructions provided outside each station. Do not be tempted to do more than what the station instructions indicate. For example, if the instructions say “take a focused history”, then do exactly that. Do not complete a full patient interview covering issues that may not be relevant. Before you enter a station, do not make any assumptions about the purpose of the station. For example, you may rush into thinking a station is designed to assess something but remind yourself to keep an open mind. Remember, the OSCE is designed to assess your active clinical skills; it is important to be guided by the patient’s responses. You should carefully listen to whatever information the patient tells you – these should also be regarded as instructions, as they too will guide whatever you do in the station. Apply your clinical reasoning to the patient’s pertinent positive and negative responses.
Quality communication with the patient is a key component of your performance. The examiners will assess you not only on what you say and ask, but on how well you communicate with the patient. For example, avoid listing off a series of close-ended questions to show off your expertise or because you think they will be on the checklist. Such interrogation will not score highly in the global assessment, which looks at your organization, attitude, and genuine connection with the patient. Instead, demonstrate your ability to apply appropriate questioning approaches, both open and closed questions, as well as other communication skills. Additionally, don’t forget to introduce yourself professionally to the SP, just as you would when you walk into a real patient encounter. A professional and courteous introduction will create a welcoming atmosphere. For example, “Good morning, I am Alice, an internal medicine resident. I’d like to start by asking you a few questions, does that sound alright?” Remember, a good physician must be a good communicator – demonstrate your empathetic and attentive patient approach in the OSCE.
Keep track of time. The OSCE stations are usually only part of what would be a realistic physician-patient encounter, so time management is vital. You will be given a warning signal before the end of each station, but you should keep track of time during the course of your presence in the station. Be especially careful in stations that ask you to perform two tasks, as you will need to divide the allotted time to complete both tasks. For example, if a station instructs you to do a focused history and verbalize your physical examination maneuvers, you must divide your time accordingly.
Remember, if you're having trouble staying within the allotted time slots as you practice, the problem may lie in your patient assessment approach. Each station will give you enough time to complete each task. The tasks have been reviewed by many physicians and deemed appropriate. Don't forget that all candidates face the same challenge. Even if the time limit is challenging, most candidates finish most stations well within the limit. When you practice for the test, make sure your physical examinations are not too generic and thorough relative to the patient problem you're practicing with. Remember not to ask many questions in a disorderly manner. Avoid asking too many close-ended questions, making the patient move around, explaining too much, and missing verbal and physical cues from the patient. You might want to try different assessment approaches to find the correct one. Remember, your patient assessment should be based on the presented clinical problem and its possible causes.
Check out our video for more tips on how to ace your OSCEs:
Some OSCE Don’ts
Do not pay attention to the examiner’s pencil. There are different checklists, and some can only be completed after you leave the station. How often the examiner writes on the checklist during your station is not a reliable indicator of your performance. Concentrate on the patient and do not let the checklist worry you.
Do not ignore the instructions. Make sure you read the task as well as the patient's problem. The instructions will give you a clear task, so make sure to follow it. For example, if you're asked to conduct a focused history, then you will only get scored for taking a history in a clinically appropriate manner. You will not get credit for counseling the patient if the assigned task is to take a history. If the task is "assess and advise" or "discuss" or "counsel", then you will get credit for actions like advising the patient, providing information, and recommending follow-up. If the task is "assess and manage", then you will get credit for assessing the patient (e.g., relevant history and/or describing a physical exam) and for managing the problem, which may include ordering investigations and making immediate treatment decisions.
Do not misinterpret the instructions. Sometimes candidates approach a station by trying to figure out “what is on the test”, rather than basing their actions on a clinically appropriate approach to the patient problem. For example, the patient information describes a belly pain problem and you are asked to verbalize a focused physical examination. Even if a complete basic abdominal exam is verbalized (inspection, auscultation, and palpation of the four quadrants), it is generally not sufficient to achieve a good rating on the station. You may have verbalized some maneuvers that were irrelevant to identifying the most likely diagnosis. The emphasis in a focused physical examination should be making a diagnosis and ruling out differential diagnoses. In the preceding example, an abdominal examination is certainly important but based on the patient information given to you and whatever findings (or lack of findings) you discover, there are other maneuvers and/or systems you will need to assess to rule in or rule out your differential diagnoses.
Do not interrogate the patient. Do not bombard the patient with as many questions as you can, especially if you’re including them in hopes of asking enough questions for the PE’s checklist. Your approach must be coordinated and succinct, preferably organized around a differential diagnosis or around generating a differential diagnosis.
Do not talk too much. Your OSCE is not the time to show off your theoretical knowledge. You are expected to speak to the patient in language that he or she will understand, not to quote textbooks to the examiner. Your manner tells both the patient and the examiner a lot about your attitude to the patient; you do not need to do it all with words. Avoid lecturing and showing off.
Do not ignore what the patient is telling you. SPs often report that OSCE candidates do not listen to them and therefore miss vital information. If a patient’s answer is not clear and the issue is important, then explore further. For example, you ask the patient if he or she has ever had this problem before, and the patient responds with “not like this”. You may want to know what was meant by this statement. If you appear indifferent to their concerns, the patients are expected to react accordingly – you will get less information from them. They are not required to give everyone their whole story. You are expected to elicit their story. And as in clinical practice, patients will be reluctant to confide their underlying fears or embarrassing information if they feel you are indifferent, judgmental, or hostile to them. Remember, even though this is an exam, you are expected to act the way you would with real patients. The quality of your patient interactions will have a huge effect on how you score in the exam.
Do not assume the examiner can read your mind. Be aware that you cannot receive credit for physical examination maneuvers that you would perform unless you indicate to the examiner that you would do such an exam and what findings you would be looking for. In most cases, the examiner is given findings to report to you, but he or she can only do so after you state which examination you would do and what you would be looking for (for ex: “I would assess the patient’s grip strength looking for weakness in the right hand”).
Do not give generic information. As you could see in the station descriptions I outlined above, in some stations, you are expected to provide the patient with information or advice relevant to his or her problem. Some candidates seem to miss the purpose of these stations and only offer very general statements like "There are risks associated with X and you should really do Y." If you are tasked to advise a patient, you are expected to provide him or her with the quality of information that reflects your abilities as a physician, assisting in informed decision-making by the patient and going beyond what is available in the public domain.
OSCE Don'ts to Remember:
1. How is the time assigned for each station? Do most candidates finish on time?
The instructions for each station, including the time given, have been reviewed by many physicians and were deemed appropriate for the time limits. Most candidates finish stations well within the time limit.
2. Is finishing a station early a bad sign?
Finishing early does not necessarily mean that there's a problem. Many stations can be completed in less time than the time assigned. However, if you have done all the important steps in your station and find that you still have lots of time, reflect on what else might help you understand the patient’s problem. If you forgot something, go ahead and do it, even if you have been sitting quietly waiting for the signal to leave.
3. Are there any books that can help me prepare for the OSCE stations?
There are no specific reference books about the OSCE stations that are approved by the MCC. However, the Council has compiled a list of reference books and online resources that have been used to validate the exam’s questions and content. You can find this list in one of the sections in this blog.
4. What is being assessed during the OSCE exam?
This competency-based exam will assess your clinical proficiency in these seven competencies: history taking, diagnosis, data interpretation, investigations, management, communication skills, and physical examination (assessed in a modified format).
5. What kind of score do I get?
No total score will be reported. Only three categories of results will be reported to candidates: pass, fail and pass with superior performance.
6. Why are introductions and goodbyes important when I enter into the station?
Your introductions and goodbyes are of vital importance. Your clinical performance aside, the impression you create with your greeting and the way you exit the station will demonstrate your levels of professionalism and maturity. Appropriate greetings and goodbyes will leave a good impression on the PE and the standardized patient. Remember, you’re also being scored for your ability to be an approachable and empathetic physician.
7. How can I make the best use of time outside the room?
Read the instructions twice and start forming a checklist of items you can sequentially go through in each room.
8. What if I don’t know the material at all?
Focus on the basics of taking a strong history and conducting a good physical examination.
9. What’s the best way to prepare?
Identify the objectives you need to know for each clinical presentation and practice with friends and colleagues. You must be able to practice using the types of scenarios that may come up on the OSCE exam. Tip: any time you encounter a meaningful or educational patient encounter, keep a log of it in a journal or in a Word document. Write down what happened, what you did, and the outcome. Review these with your study group to get a sense of what may come up on test day. Remember, perfect practice makes perfect! You should do realistic, timed simulations and get expert feedback, perhaps from a more senior resident or an attending physician. A lot of residency programs have practice sessions, so do not skip them!
10. What if I fail my OSCE?
Don’t panic. You will most likely be allowed to attempt it again. Find out what went wrong by requesting to see your results, if possible. If not, reflect on the stations and what you did at each one. Seek out expert feedback to rectify the errors you made. Practice intentionally using realistic, timed simulations with feedback prior to your next attempt.
11. Why do I have to say what I am doing out loud?
In order to receive a good score in a station, you must verbalize the physical examination maneuvers that you would perform and what findings you would be looking for. In most cases, the examiner is given findings to report to you, but he or she can only do so after you state which examination you would do. Keep in mind, the examiners cannot read your mind, so in order to receive credit for the station, you must give details of your actions.
12. How far in advance should I begin preparing?
For course-specific OSCEs in medical school, 2-4 weeks of practice and preparation may be sufficient. For more comprehensive undergraduate OSCEs, 3-6 months of preparation may be needed, depending on the amount of content that needs to be covered. For postgraduate and licensing exams, you will need to begin preparing 1 year in advance, due to the amount of content that you must know. Slow, steady study and practice are better than cramming, so set aside time every week to meet with your study group so you stay on track.
13. How do I manage stress before the exam?
Avoid dealing with stress by smoking, drinking, or eating unhealthy food. It is common for students to focus all their time and energy on studying, but do not avoid your family and friends. It is important to take breaks from exam preparation and spend time with your loved ones. During your studies, do not forget to exercise and spend some time outside. The day before your exam, relax, eat healthy meals, and go to bed early. Do not stay up cramming for your exam.
14. Are there any OSCE diagnostic exams, like the MCAT diagnostic test, that can help me figure out my level of knowledge?
Unfortunately, no. However, most residency programs have practice sessions, so make sure to attend them. You can also try searching for preparatory courses in your area. However, keep in mind that most prep courses focus on your exam-taking skills rather than your knowledge.
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