Cardiovascular Exam prompt

The thing I said earlier about “using OSCEs”?  This is what I mean.

My cardiovascular exam prompt looks like this:

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Overview of the CVS examination summary

Now, it doesn’t take a genius to work out that this is not going to get you through a post-graduate clinical exam.  I’m not even sure that would have got me through finals.  But it’s a scaffold that I could build information on.

Because for each of those points, I could generate a mind map or another list.

For each of those points, I need to know how to demonstrate that sign; what it signifies; and what clinical conditions it’s associated with.

It’s another example of learning to think backwards.  The MRCPCH starts with the clinical examination.  In order to make sense of the jigsaw, you have to be able to find the pieces (perform the examination), and put the picture together.

For example, one key finding is cyanosis:

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And there’s another list somewhere that links cyanosis with other features (e.g. cyanosis + heart murmur = cyanotic heart disease)

This is why I have so many notebooks.  Because notebooks are how I work.

BTW, my handwriting does not normally look like that.  That’s the neat version because this was at the beginning of the book.  By the end, things looked a little different…

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Slightly psychedelic CVS notebook…
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Using OSCEs

For those that aren’t familiar with them, OSCEs are Objective Structured Clinical Examinations.  I did these at medical school, especially in the first few years.  They were the standard way of checking that you could do basic things like taking blood pressure, or resuscitation.  As an assessment, they’re quite formulaic: the mark-scheme tends to be quite prescriptive ((i.e. one mark for washing your hands, one mark for introducing yourself, one mark for palpating the apex beat…).  It’s a structured (hence the title!) assessment, and I never thought they were particularly useful in “real life”.  (Seriously, you simply cannot follow a structured examination sequence if your patient is running around a playroom, or trying to feed you soggy crisps…And if that’s what you’re trying to do, then you need to start being a paediatrician)

Now, initially, I thought that OSCEs had no place in the MRCPCH clinical.  I mean, these are clinical examinations to be a registrar!  It’s not supposed to be a tick-box exercise: it’s a serious, grown-up exam for “real” doctors who makes decisions and things.  Just going through the motions isn’t good enough.

But then I thought about the time restrictions, and the amount of things that you’re expected to get done, and how much I panic when I’m nervous… And I realised that the OSCE approach could actually be quite useful.  So if you’re like me, and you becoming a quivering tomato in the face of exams (my consultant’s description – thanks Jo!), then this might be useful.

When I revised for my medical school OSCEs, I made myself a tick-list of everything I had to include in my CVS exam.  Then I repeated this for every other system I could think of.  Then I practiced with my friends to make sure I could get all of this done in the time for the station, plus still leave 2 minutes for examiner questions and to go back and check things.  When it came to the clinicals, I did the same thing.  (I also did it for the “other” station – but that’s a whole other topic!).

Now, I am not for one minute suggesting that you treat the clinical stations like an OSCE.  Please, don’t go in there and just go through the motions so that you can get things ticked off a mark sheet (although, please introduce yourself & wash your hands!!)

But sometimes, it’s useful to have a structure, because:

  1. When your mind goes blank, and you have no idea what to do next, then having a routine is a useful thing to fall back on.
  2. It makes sure that you cover the simple, and basic things (like feeling the liver in the CVS exam, or checking for central cyanosis)
  3. The structure is also quite useful to organise your feedback to the examiner (again, if you have a total mind freeze)
  4. It helps with timing: if you know that you can do a structured, and (fairly) complete system examination in 5 minutes, then you know that in the exam you’ll have enough time to do the fancy extras, or to go back and confirm your findings, or spend a bit more time playing with the child and building their confidence, or have a chat about the weather… And you will still have time to answer any questions that the examiner has

Treat the OSCE structure as a template you can build your examination around; make it personal; practice doing it this way at work (on real children): it should become second nature, and then the exam will just feel like everyday… Hopefully. Unless you actually are a quivering wreck, in which case chocolate is useful…