For the first time in a long time, I felt doubtful of myself. Doubtful of whether or not I should continue as a medical student. Unsure if I really had what it took to continue. Embarrassed, almost, at how I could ever be deemed worthy to have the ‘medical student’ title. I felt almost as rubbish as I did when I was admit in a psychiatric unit last year.
What had caused this to happen a couple of days ago?
Two words: The OSPE. I’m not sure if many people, medical student or otherwise, have heard of this word. Essentially, to explain and keep it simple, we had a formative exam a few days ago that was meant to give us an idea of what a real OSCE feels like. It was more tailored towards our anatomy teaching rather than clinical teaching. The medical students, nurses or other healthcare professionals will be (I hope!) nodding their heads slowly when I mention the word ‘OSCE’.
For the sake of people who’ve never heard of what an OSCE is, it stands for Objective Structured Clinical Examination. It is essentially an examination in which the medical student is in a cubicle, there is a ‘patient’ (usually an actor) and an examination and the medical student is asked to perform several physical examinations on the ‘patient’. I found out just how thoroughly difficult it is a few days ago – and it was only formative for me!
Let me explain what happened.
The very first station I had was the cardiovascular station. I started reading the brief outside the cubicle, and it said:
“You are required to perform aspects of a cardiovascular examination on [name]. You are NOT expected to take a full history.”
Then, before I could calm down, a whistle sounded. This was our cue to enter the cubicle. I slowly did and saw – to my relief – that the ‘patient’ was male. I hope I don’t come across as sexist here and apologise profusely if I do, but I was desperately nervous of getting a female patient. This was because some of the important landmarks of a female are found under the breast, and I’ve always been way too shy to examine that area. The vast majority of our practice physical anatomy sessions were done on each other and, completely understandably, not many of our female colleagues were willing for us to examine them in that area.
I looked at my ‘patient’, smiled, introduced myself and…almost forgot to use the alcohol hand sanitizer. Funny what pressure can do.
“You’re a bloody doctor – well, doctor to-be. Come on!”
Being told off by an examiner in person because you’ve not answered a question properly is definitely not ideal. Fast forward to my cranial nerve station.
Before the exam, this was the station that I was most confident about. I had revised cranial nerve functions to a standard that I was happy with, and was comfortable that I could easily work out how to test for a function. I had not revised the anatomy of cranial nerves yet, however, and so was not particularly comfortable with their paths. No matter, I thought, I doubt they’ll ask hard questions like that.
Guess what they ended up asking?
“So tell me,” the examiner said. “Where in the cranium does the parasympathetic branch of the facial nerve exit from?”
“Erm,” I replied. The examiner stared at me. “Well…erm…the parasympathetic branch of the facial nerve is the Greater Petrosal nerve so erm…”
“Where does it exit from?” the examiner probed.
“Erm…” I said.
10 seconds later, the examiner went: “OK, you don’t know, next question then.”
Most of my answers for that station were “I don’t know.”
At the end, the examiner pulled out an X-Ray of the skull. “What type of image is this?” he asked me.
“MRI!” I said confidently.
The examiner looked at me as though I had just asked him for his liver. That is where he said the whole: “Come on!” thing.
Finding the Ulnar Pulse
They’ll never ask me to find the ulnar pulse, I thought to myself before the exam. Radial pulse, maybe (the one in the wrist most doctors use). Brachial pulse, maybe (one at the level of the elbow). If they were being really mean, they could ask me to find the posterior tibial pulse (in the foot) but an ulnar pulse? Ha, fat chance!
Imagine my horror when in the exam, the examiner went: “Please locate the subject’s ulnar pulse.”
I felt like shouting: “WHAT?!” The ulnar pulse is bloody difficult to find. It’s essentially on the other side of the wrist to where people feel for the radial pulse (the one your doctor looks for if they’ve ever asked to measure your pulse). To make sure we’re not making it up, the examiner finds another pulse of the patient, measure it themselves and then ask us to tell them the heart rate of the patient. If our answer matches what the examiner worked out, then we’ve got it right. If not – well, it’s more likely that we’ve made a mistake rather than the examiner.
“Sure,” I said to the examiner, calmer than I felt. I went to the patient’s arm, palpated the approximate area where the pulse was meant to be and then started panicking internally. I couldn’t feel a thing. Right, I thought to myself as I pretended to be counting. We’ll be measuring for 15 seconds. Therefore, the pulse rate has to be a multiple of 4 as we’ll multiple whatever we get by 4 to work out the rate per minute. This patient was a healthy patient too, for he was also a medical student, so therefore his pulse rate had to be between 60 and 100.
So what number is a multiple of 4 and is between 60 and 100? 68 should do nicely, I thought. Just as I thought of that, the 15 seconds had elapsed.
“What was the heart rate?” the examiner asked.
“I got 68 beats per minute,” I said, pretending to sound confident.
I have only skimmed the surface of what happened in that exam. It was a completely and utter disaster. But having spoken to many doctors, they’ve all told me many stories of their own OSCEs and their mistakes. Looks like I’m not the only one who find them difficult! If you have any OSCE stories too, I’d love to hear them. As always, send me comments either on here or on Twitter.