Idea of OSCE in obstetrics in brief

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Idea of OSCE in obstetrics in brief
Dr. Manal behery Assistant professor
Zagazig university 2013
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OSCE
O OBJECTIVE S STRUCTURED C
CLINICAL E EXAMINATION
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• Means fair and without bias. Most examination in
  the world are not fair. Use of checklist ensures
  objectivity.
• Rather than subjective, which is where the
  examiners decide whether or not the candidate
  fails based on their subjective assessment of
  their skills.

Objective
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• Refer to the organization of the examination
• The OSCE is carefully structured to include parts
  from all elements of the curriculum as well as a
  wide range of skills.
• Instructions are carefully written to ensure that
  the candidate is given a very specific task to
  complete.

Structured
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• the station are clinical in nature.
• . It is an examination with usually declares
  those who are competent to handle patients.
• the candidate is only asked questions that are on
  the mark sheet and if the candidate is asked any
  others then there will be no marks for them.

Clinical exam
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OSCE ?

• Objective Structured Clinical Examination
• OR
• Over Stimulation and Crying Event
• OR
• Opportunity for Showing your Competence and
  Excellence

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OSCE

• Why OSCE?
• WHAT DOES IT TEST ?
• HOW TO RUN IT?

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WHY OSCE ?

• Increase validity and reliability
• More certain mapping to curriculum
• Better standard setting (pass score)
• More fair?
• More fun?

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Long case

• One hour with the patient
• Full history and exam not observed
• Examiner bias .... unstructured questioning
  little agreement between examiners
• Some easy patients .. some hard ones
• Some co-operative patients some not
• Not a test of communication skills

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With OSCE

• Clinical skill history, exam, procedure
• Marking structured and determined in advance
• Time limit
• Checklist/global rating scale
• Real patient/actor
• Every candidate has the same test

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OSCEs reliable

• Less dependent on examiners foibles (as there
  are lots of examiners)
• Less dependent on patients foibles (as there are
  lots of patients)
• Structured marking
• More stations more reliable
• Wider sampling clinical, communication skills

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OSCEs valid

• Content validity how well sampling of skills
  matches the learning outcomes of the course
• Construct validity people who performed well on
  this test have better skills than those who did
  not perform well
• Length of station should be authentic

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OSCE performance

• Lucky?
• Nervous?
• Confident?
• Uncertain?
• Competent?
• Practised?
• Understood?

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OSCE performance?
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What does it test ?

• 1. History taking.
• Factual knowledge.
• 3. Interpretation of laboratory results and
  clinical data.
• Ability to formulate dd.
• 5. Counseling skills.
• 6. Clinical problem solving.

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OSCEs acceptability

• Perceived fairness examiners and examinees
• Become widespread

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OSCE design - blueprinting

• Map assessment to curriculum
• Adequate sampling
• Feasibility real patients, actors. manikins

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1- Uniform scenarios for all candidates2.
Availability3. Safety, no danger of injury to
patients4. No risk of litigation5. Feedback
from Actors (simulators)6. Allows for Recall7.
Stations can be tailored to level of skills to be
assessed8. Allows for teaching audit9. Allows
for demonstration of emergency skills
Advantage of OSCE
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Disadvantage of OSCE
1- Organizational training 2. The idealized
textbook scenarios may not mimic real-life
situations 3. Expensive
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OSCE Preparations

• See one, do one, teach one ? see many, write
  some, learn some (learn how examiners think)
• Get a template
• Pick a topic from your block guides
• Core clinical presentations?
• Core clinical condition?
• Physical examination skill?
• Procedural or practical skill?
• Medical imaging?

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OSCE Stations

• The OSCE is made up of a series of 10 minute
  stations with short breaks between stations
• The exam is made up of 10 minute couplet stations
  and 10 minute history or physical stations
• Couplet stations consist of a 5 minute clinical
  encounter followed by a 5 minute post-encounter
  probe (PEP)
• The PEP is a written station
• DDx, interpret test results, write orders or
  prescriptons, etc.

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OSCE Stations

• 10 minute stations are usually history taking or
  physical examination stations.
• There is usually a oral question asked by the
  examiner at the 9 minute mark.

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Couplet History Taking

• This is a 5 minute station with 5 minute PEP
• What the candidate reads
• Candidates Instructions
• Mrs. Fatma is 38 weeks pregnant lady complaining
  of headache
• This station is to test your ability to take
  relevant history in the next 5 minutes
• At the next station, you will be asked to answer
  questions about this patient.

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Grade Failure Border line Pass
Marks 0 0.25 0.5
1. Age of patient
2. Duration of symptoms
3. Location of headache
4. Respond to simple analgesics ( pain killers)
5. Nausea or vomiting
6. Blurred vision
7. Swelling of hands, feet and face
8. Pain in upper abdomen ( epigastric)
9. Previous pregnancies (i.e. obstetric history)
10. Relevant Past medical history





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Couplet History Taking

• Examiner asked to judge performance as
  Satisfactory (borderline/good/excellent) or
  Unsatisfactory (borderline/poor/inferior)
• This is a global rating
• If unsatisfactory there are several reasons
• Inadequate medical knowledge
• Could not focus
• Poor communication/interpersonal skills
• Potential harm to patient
• Dangerous act

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Antenatal Labor Postnatal Newborn Gynecology
History Obstetric H/R Diagnosis of labour History of Gynecology
Physical Obstetric Maneuvers Progress in labour Post natal evaluation ( normal and CS) Delivery relevant complications
Tests/investigations/procedures BPP Routine AN tests CTG Instruments Tests in complications Resuscitation of Newborn Instruments Specific investigations
Data interpretation CTG GTT PET Partogram Postnatal tests Rubella. RH HSG Semen test Hormone profile
Communication and education Nutrition Exercise Breast feeding Contraception
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Antenatal Labor Postnatal Newborn Gynecology
History Obstetric H/R Diagnosis of labour History of Gynecology
Physical Obstetric Maneuvers Progress in labour Post natal evaluation ( normal and CS) Delivery relevant complications
Tests/investigations/procedures BPP Routine AN tests CTG Instruments Tests in complications Resuscitation of Newborn Instruments Specific investigations
Data interpretation CTG GTT PET Partogram Postnatal tests Rubella. RH HSG Semen test Hormone profile
Communication and education Nutrition Exercise Breast feeding Contraception
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Antenatal Labor Postnatal Newborn Gynecology
History Obstetric H/R Diagnosis of labour History of Gynecology
Physical Obstetric Maneuvers Progress in labour Post natal evaluation ( normal and CS) Delivery relevant complications
Tests/investigations/procedures BPP Routine AN tests CTG Instruments Tests in complications Resuscitation of Newborn Instruments Specific investigations
Data interpretation CTG GTT PET Partogram Postnatal tests Rubella. RH HSG Semen test Hormone profile
Communication and education Nutrition Exercise Breast feeding Contraception
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Antenatal Labor Postnatal Newborn Gynecology
History Obstetric H/R Diagnosis of labour History of Gynecology
Physical Obstetric Maneuvers Progress in labour Post natal evaluation ( normal and CS) Delivery relevant complications
Tests/investigations/procedures BPP Routine AN tests CTG Instruments Tests in complications Resuscitation of Newborn Instruments Specific investigations
Data interpretation CTG GTT PET Partogram Postnatal tests Rubella. RH HSG Semen test Hormone profile
Communication and education Nutrition Exercise Breast feeding Contraception
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Antenatal Labor Postnatal Newborn Gynecology
History Obstetric H/R Diagnosis of labour History of Gynecology
Physical Obstetric Maneuvers Progress in labour Post natal evaluation ( normal and CS) Delivery relevant complications
Tests/investigations/procedures BPP Routine AN tests CTG Instruments Tests in complications Resuscitation of Newborn Instruments Specific investigations
Data interpretation CTG GTT PET Partogram Postnatal tests Rubella. RH HSG Semen test Hormone profile
Communication and education Nutrition Exercise Breast feeding Contraception
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Couplet Physical Examination

• What the candidate reads
• Candidates InstructionsTM, 31 years old, 33wks
  ,has been brought to your office with a history
  of PROM
• In the next 5 minutes, conduct a focused and
  relevant physical examination.
• As you proceed, explain to the examiner what you
  are doing and describe any findings.At the next
  station, you will be asked to answer questions
  about this patient.

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Couplet Physical Examination

• Did the candidate respond satisfactorily to the
  needs/problem(s) presented by this patient?
• If unsatisfactory, please specify why(For items
  4-6, please explain below)
• Satisfactory - Borderline
• - Good
• - Excellent
• Unsatisfactory - Borderline
• - Poor
• - Inferior
• Inadequate medical knowledge and/or provided
  misinformation
• Could not focus in on this patient's problem
• Demonstrated poor communication and/or
  interpersonal skills
• Actions taken may harm this patient
• Actions taken may be imminently dangerous to this
  patient
• Other

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Data interpretation

• A 38 years old patient, Gravida 8 para 61. Her
  previous delivery ended by cesarean section due
  to failure to progress.
• She is now around 28 weeks
• Her family doctor have ordered a GTT and she
  brought the result for you for advise

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Instruction for the Simulated Patient (Examiner)

• Doctor can you tell me is my GTT result normal or
  not?
• Is there any danger (complications) for me from
  this condition?
• Is there any risk for my baby?

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Item Mark Mark Mark Mark Mark
Well Average Average Average ND
Interpretation of test (Positive for GDM) 2 1 1 1
Risks to the patient Risks to the patient Risks to the patient Risks to the patient Risks to the patient Risks to the patient
Increased risk of high BP (PET) 1 1 ½
Increased rate of infection (urinary/vaginal) 1 1 ½
Risks to the fetus Risks to the fetus Risks to the fetus Risks to the fetus Risks to the fetus Risks to the fetus
Polyhydramnios 1 1 ½
Macrosomia 1 1 ½
Operative / Difficult delivery 1 1 ½
RDS 1 1 ½
Neonatal Jaundice 1 1 ½
Other metabolic disorders 1 1 ½
Total
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Item Mark Mark Mark Mark Mark
Well Average Average Average ND
Interpretation of test (Positive for GDM) 2 1 1 1
Risks to the patient Risks to the patient Risks to the patient Risks to the patient Risks to the patient Risks to the patient
Increased risk of high BP (PET) 1 1 ½
Increased rate of infection (urinary/vaginal) 1 1 ½
Risks to the fetus Risks to the fetus Risks to the fetus Risks to the fetus Risks to the fetus Risks to the fetus
Polyhydramnios 1 1 ½
Macrosomia 1 1 ½
Operative / Difficult delivery 1 1 ½
RDS 1 1 ½
Neonatal Jaundice 1 1 ½
Other metabolic disorders 1 1 ½
Total
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Item Mark Mark Mark Mark Mark
Well Average Average Average ND
Interpretation of test (Positive for GDM) 2 1 1 1
Risks to the patient Risks to the patient Risks to the patient Risks to the patient Risks to the patient Risks to the patient
Increased risk of high BP (PET) 1 1 ½
Increased rate of infection (urinary/vaginal) 1 1 ½
Risks to the fetus Risks to the fetus Risks to the fetus Risks to the fetus Risks to the fetus Risks to the fetus
Polyhydramnios 1 1 ½
Macrosomia 1 1 ½
Operative / Difficult delivery 1 1 ½
RDS 1 1 ½
Neonatal Jaundice 1 1 ½
Other metabolic disorders 1 1 ½
Total
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Data Interpretation

• 28 years old Gravida 10 Para 90, at 13 weeks of
  gestation came to the clinic complaining of
  Palpitation and shortness of breath.
• A complete blood count (CBC) test was performed.
• You are require to interpret the result of the CBC

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Item Mark Mark Mark Mark Mark
Well Average Average Average ND
What does the result of this test shows? (Examiner to show CBC form) What does the result of this test shows? (Examiner to show CBC form) What does the result of this test shows? (Examiner to show CBC form) What does the result of this test shows? (Examiner to show CBC form) What does the result of this test shows? (Examiner to show CBC form) What does the result of this test shows? (Examiner to show CBC form)
Low hemoglobin (anemia) 1 1 1/2
What type of anemia What type of anemia What type of anemia What type of anemia What type of anemia What type of anemia
Hypochromic microcytic 2 2 1
Can it be confused with other type of anemia? Can it be confused with other type of anemia? Can it be confused with other type of anemia? Can it be confused with other type of anemia? Can it be confused with other type of anemia? Can it be confused with other type of anemia?
Thalassanemia and 1 1 1/2
Sickle cell anemia 1 1 1/2
How would you confirm? How would you confirm? How would you confirm? How would you confirm? How would you confirm? How would you confirm?
Hemoglobin electrophoresis 1 1 ½
Sickle cell test 1 1 ½
What do you think of this result? (Examiner to show the result of the electrophoresis) What do you think of this result? (Examiner to show the result of the electrophoresis) What do you think of this result? (Examiner to show the result of the electrophoresis) What do you think of this result? (Examiner to show the result of the electrophoresis) What do you think of this result? (Examiner to show the result of the electrophoresis) What do you think of this result? (Examiner to show the result of the electrophoresis)
Confirm Iron deficiency anemia 3 3 2
Total
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Postnatal Examination

• You are the house officer in the ward and in the
  morning round you came across this patient who
  had delivered 24 hours ago.
• How would you assess her?

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Item Mark Mark Mark
Well Average ND
Initial approach to the patient (introduce him/her self, explain what he/she will be doing) 1 ½
Mode of delivery 1 ½
Delivery outcome (the baby) 1 ½
Lochia / Bleeding 1 ½
Bladder function 1 ½
Perineum/excessive pain (episiotomy) 1 ½
Check vital signs 1 ½
Breast feeding 1 ½
What important investigations you would like to review before discharge What important investigations you would like to review before discharge What important investigations you would like to review before discharge What important investigations you would like to review before discharge
CBC 1/2 1/4
Blood Group (RH factor) 1/2 1/4
Rubella test 1/2 1/4
Hepatitis test 1/2 1/4
Total
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Item Mark Mark Mark
Well Average ND
Initial approach to the patient (introduce him/her self, explain what he/she will be doing) 1 ½
Mode of delivery 1 ½
Delivery outcome (the baby) 1 ½
Lochia / Bleeding 1 ½
Bladder function 1 ½
Perineum/excessive pain (episiotomy) 1 ½
Check vital signs 1 ½
Breast feeding 1 ½
What important investigations you would like to review before discharge What important investigations you would like to review before discharge What important investigations you would like to review before discharge What important investigations you would like to review before discharge
CBC 1/2 1/4
Blood Group (RH factor) 1/2 1/4
Rubella test 1/2 1/4
Hepatitis test 1/2 1/4
Total
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Item Mark Mark Mark
Well Average ND
Initial approach to the patient (introduce him/her self, explain what he/she will be doing) 1 ½
Mode of delivery 1 ½
Delivery outcome (the baby) 1 ½
Lochia / Bleeding 1 ½
Bladder function 1 ½
Perineum/excessive pain (episiotomy) 1 ½
Check vital signs 1 ½
Breast feeding 1 ½
What important investigations you would like to review before discharge What important investigations you would like to review before discharge What important investigations you would like to review before discharge What important investigations you would like to review before discharge
CBC 1/2 1/4
Blood Group (RH factor) 1/2 1/4
Rubella test 1/2 1/4
Hepatitis test 1/2 1/4
Total
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During the morning round you came across a 28
years old who has delivered 24 hours ago.She was
found to run a temperature of 390 c.How would
you approach her

• Mode of Delivery Spontaneous
• Outcome 3 Kg baby Boy
• How is the baby Well in the nursery
• Duration of labour 12 hours
• Any history of SRM Loss of fluid for 3 days
• Symptoms of upper or lower respiratory tract
  infection
• Symptoms of UTI (upper or lower)
• Amount, and nature of Lochia

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You were urgently called to the labour room by
the obstetric nurse. A patient who just had her
episiotomy sutured by your colleague has suddenly
became pale and drowsy with rather heavy vaginal
bleeding

• What is the differential diagnosis of post-partum
  hemorrhage (mention 4)?
• What are the immediate measures that should be
  taken in this case?
• What is the most likely cause of this patient
  collapse?
• How would you confirm This diagnosis

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What is the differential diagnosis of
post-partum hemorrhage (mention 4)

• Uterine Atony
• Lacerations of the Genital tract
• Uterine Inversion
• DIC

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What are the immediate measures that should
be taken in this case?

• (A) Air Way
• (B) Breathing
• (C) Maintain Circulation IV infusion

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What is the most likely cause of this patient
collapse?
Uterine Atony

• How would you confirm This diagnosis?

Abdominal Palpation for Uterine fundal height and
consistency
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An 18 years old primigravida presented to the
emergency room in labour

• What important informations you want to know
  about this case?
• How would you confirm the patient diagnosis?

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What important informations you want to know
about this case?
Yes

• Is she booked or not
• How many weeks is she now ( LMP)
• Is there any known medical problem?

38 weeks
No
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How would you confirm the patient diagnosis?

• Symptoms
• Character of the pain regular in pattern,
  increase in frequency and intensity.
• Signs
• Show.
• Cervical Changes effacement and dilatation
• Loss of fluid per vaginum

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Common Mistakes

• Not reading the question!
• Asking too many unfocused questions (shotgun)
• Not explaining what you are doing during physical
  examination stations
• Rectal, vaginal and inguinal exams not allowed
  BUT you will not be given credit unless you
  indicate that you would do them when appropriate.
• Talking too fast and too much maintain
  professional courtesy
• Trying to guess what the station is about and not
  listening to the patient

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THANK
THANK YOU