idea of osce in obstetrics in breif

Idea of “OSCE” in obstetrics in brief

Dr. Manal behery Assistant professor Zagazig university

2013

OSCE

O : OBJECTIVE

S : STRUCTURED

C : CLINICAL

E : EXAMINATION

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

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

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

Objective Structured Clinical Examination

OR

Over Stimulation and Crying EventOR

Opportunity for Showing your Competence and Excellence

OSCE ?

Why OSCE?

WHAT DOES IT TEST ?

HOW TO RUN IT?

OSCE

Increase validity and reliability

More certain mapping to curriculum

Better standard setting (pass score)

More fair?

More fun?

WHY OSCE ?

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

Long case

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

With OSCE

OSCEs – reliable Less dependent on examiner’s foibles (as there are lots of examiners)

Less dependent on patient’s foibles (as there are lots of patients)

Structured marking

More stations … more reliable

Wider sampling – clinical, communication skills

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”

13

OSCE performance

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

OSCE performance?

What does it test ?1. History taking.

2. Factual knowledge.

3. Interpretation of laboratory results and clinical data.

4. Ability to formulate dd.

5. Counseling skills.

6. Clinical problem solving.

OSCEs – acceptability

Perceived fairness – examiners and examinees

Become widespread

OSCE design - blueprinting

Map assessment to curriculum

Adequate sampling

Feasibility – real patients, actors. manikins

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

1- Organizational training

2. The idealized ‘textbook’ scenarios may not mimic real-life situations

3. Expensive

Disadvantage of OSCE

OSCE PreparationsSee 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?

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.

OSCE Stations10 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.

Couplet History Taking

This is a 5 minute station with 5 minute PEP

What the candidate readsCandidate’s 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.

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

Couplet History TakingExaminer 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

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

BPPRoutine AN tests

CTGInstruments

Tests in complications

Resuscitation of Newborn

Instruments Specific investigations

Data interpretation

CTGGTTPET

Partogram Postnatal tests: Rubella. RH

HSGSemen testHormone profile

Communication and education

NutritionExercise

Breast feeding Contraception

Couplet Physical Examination

What the candidate readsCandidate’s InstructionsTM, 31 years old, 33wks ,has been brought to your office with a history of PROMIn 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.

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

Data interpretation

A 38 years old patient, Gravida 8 para 6+1. 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

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?

Item Mark

Well Average ND

Interpretation of test (Positive for GDM) 2 1

Risks to the patient

Increased risk of high BP (PET) 1 ½

Increased rate of infection (urinary/vaginal) 1 ½

Risks to the fetus

Polyhydramnios 1 ½

Macrosomia 1 ½

Operative / Difficult delivery 1 ½

RDS 1 ½

Neonatal Jaundice 1 ½

Other metabolic disorders 1 ½

Total

Data Interpretation

28 years old Gravida 10 Para 9+0, 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

Item Mark

Well Average ND

What does the result of this test shows? (Examiner to show CBC form)

Low hemoglobin (anemia) 1 1/2

What type of anemia

Hypochromic microcytic 2 1

Can it be confused with other type of anemia?

Thalassanemia and 1 1/2

Sickle cell anemia 1 1/2

How would you confirm?

Hemoglobin electrophoresis 1 ½

Sickle cell test 1 ½

What do you think of this result? (Examiner to show the result of the electrophoresis)

Confirm Iron deficiency anemia 3 2

Total

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?

Item 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

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:

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: SpontaneousOutcome: 3 Kg baby BoyHow is the baby: Well in the nurseryDuration of labour: 12 hoursAny history of SRM: Loss of fluid for 3 daysSymptoms of upper or lower respiratory tract infectionSymptoms of UTI (upper or lower)Amount, and nature of Lochia

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

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

Uterine AtonyLacerations of the Genital tractUterine InversionDIC

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

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

What is the most likely cause of this patient collapse?

How would you confirm This diagnosis?

Uterine Atony

Abdominal Palpation for Uterine fundal height and consistency

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?

What important informations you want to know about this case?

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

Yes38 weeks

No

How would you confirm the patient diagnosis?

Symptoms:o Character of the pain: regular in pattern,

increase in frequency and intensity.Signs:

o Show.o Cervical Changes: effacement and

dilatationo Loss of fluid per vaginum

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 courtesyTrying to guess what the station is about and not listening to the patient

THANK

THANK YOU

THANK YOU

idea of osce in obstetrics in breif

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