Dungeons and Dragons and the OSCE exam

Why the OSCE exam is a cross between a game of “Dungeons and Dragons” and a” Choose your own adventure book”…..
I may be showing my age but I have often thought that performing in an OSCE Exam (and any simulation) seems to utilise all of the skills I developed in my misspent youth playing D and D and reading those literary masterpieces – the choose your own adventure book.
Certainly my knowledge of being the dungeon master has made writing OSCE stations and brainstorming all of the alternatives that candidates may throw at us all that much easier.
It occurs to me that exam candidates may find it helpful to imagine themselves as a D and D character (personally my favourite was the gully dwarf). For those of you naive to the D and D world what this requires is the following.
To start the game your character has strengths and weaknesses. These are set by rolling the dice e.g. 3 for charisma, 6 for strength, 5 for agility, 2 for wisdom – you should probably play a knight whereas 6 for wisdom, 3 for charisma, 1 for strength might be a wizard and so on and so forth.

What the hell has this got to do with the OSCE exam…???

Now while you can’t roll a dice to set your OSCE exam skills you can certainly set them out based on what you or your trusted colleagues know of your own strengths and weaknesses.

As a starting base I would use the Domains and then maybe think about some other special skills. Rate yourself as 1-6 and use this to guide your focus for your study over the coming weeks.

  • Medical Expertise: You should be pretty good at this and all over it by the time you sit the OSCE but if this is a bit weak it will certainly hold you back in having the confidence to shine in the other domains. Big ticket areas rather than the minutiae are the key in the OSCE exam and I really think it is more a confidence thing than a knowledge but my big advice is if there is an area you always shy away from make sure you get on top of it before the exam.
  • Prioritisation and Decision Making: These are the real consultant level skills. Which patients need what and when. Making a call and sticking to it. Having endpoints and decision trees. This is where “The choose your own adventure skills” come in. Which option do I decide and why? Really this is where a confident and decisive fellowship candidate shows they are ready to be a consultant. “I will” not “ I could”. If this is your weak point then practise it on the floor every shift – make a plan with your patients and present it like “you own it”.
  • Communication: The whole exam is really about communication (as is life really…). If this is your weakness now is the time to really practise improving your communication skills. If you are not sure if this is your weakness then drag someone along with you when you talk with patients or do a sim and ASK THEM. Or even better video yourself – you may be surprised at the non-verbal cues you are putting across that you never knew where there. To improve your communication try any of the following:
    1. Practice OSCE stations with your colleagues, your supervisors or at exam courses.
    2. Enrol in a communication course run by experts in this area.
    3. Listen to Podcasts on better listening and communicating in medical interactions.
    4. Find the Online learning tools and checklists like the one below for dealing with difficult situations.effective-comms-checklist
    5. Rehearse with your partner, your patients, your children, your dog or whoever to practice your communication skills – phrases that show you are listening, that you understand and that you want to negotiate an outcome that is good for all.
    6. Talk in front of the mirror or a camera and try modifying your non-verbal clues – open arms, eye contact etc.
    7. Checkout eduAcute future blog posts – watch out for posts on tips on how to communicate clearly at different levels later but I cannot stress enough that this one is a biggy – you need a 5 or 6 roll in communication for this exam.
  • Teamwork and Collaboration: You need to be a good team player. This will mostly come out in your simulation stations so whilst it’s not as high up on the list as communication it is an easy one to master. CRM principles are everywhere. Learn them and channel them. And practise simulation so that you can demonstrate them. If no-one is rating you you can rate yourself with a self-assessment scale such as the elements from the Mayo High performance Teamwork scale https://www.ncbi.nlm.nih.gov/pubmed/19088602.
  • Leadership and Management: You are about to be the leader of your workplace so you need to act like one. Again simulation training can help here but you also need to demonstrate confidence and authority. If you find that you have difficulty commanding your team at work then it may be that you are not coming across as the leader that is inside you. You need to practice this every day. Start by following the following:

eduAcute 6 leadership tips to be the CENTRE of the team:

C ommence with the introduction “Hi, I am the senior doctor”.

E mphasise your role “I am in charge, here to lead the resuscitation, here to address your concerns, here to advise the juniors etc.”.

N egotiate with your team: Check your team understands and is ok with the plan. Being a leader doesn’t necessarily mean you have to do it on your own. The best leader uses everyone’s skills and admits when they need help and accesses it and thanks others for their input.

T ake control. Act like the leader you are – if people are talking over you acknowledge their contribution and confirm that you agree and that the team should go ahead with this. Channel instructions back through you

R eassess and redirect if things change and ensure the team is on board with the new path.

E nsure everything is complete – whether it be debrief, audit or apology the leaders take responsibility for the actions of the team and follow through to improve practice.

  • Scholarship and Teaching: Most of you are very good at teaching – it is what makes us love medicine so much. If this is one of your weaknesses then you need to start incorporating teaching into your every day. Whether it be your patients, your juniors, your nursing staff or each other you can teach every level if you get an approach. Maybe start with some of the following approaches:

SETTUP for procedure teaching (http://lifeinthefastlane.com/teaching-practical-skills-with-sett-up/):

S etting the scene.

E stablish prior experience.

T alk through the procedure (led by the learner).

T ips and tricks (provided by the instructor).

U ndertake procedure (with direct supervision).

P ost-procedure feedback.

SNAPPS for teaching juniors on the floor (https://www.mededcoventry.com/Specialties/Acute/Undergraduate/Snapps.aspx):

S ummarise the case.

N arrow the differential.

A nalyse the differential.

P robe the preceptor.

P lan management.

S elect an issue for self-directed learning.

Now I know that there are two more domains but I reckon if you master the first 6 the last two are less of a challenge (but not less important).

If you roll a 6 in all 6 domains you are amazing and clearly ready to join the consultant ranks….

…..you will also be a welcome and highly skilled addition to any Dungeon’s and Dragon’s consortium.