The Unintentional How-To: Clinical Exams for Naturopathic Doctor Students

What does being a student at NCNM mean? It means community, collaboration, long hours in the library, chatting with award-winning faculty and – exams! Particular to the ND program students must complete a specific series of clinical exams related to the profession. What do these exams mean, what do they entail? Read below as student James Munro enlightens us with his experience taking the Objective Structured Clinical Examination (OSCE). As we speak current students are gearing up to take the exam in just a matter of days. Exam fever is in the air! But not to worry, James Munro is here to guide us through it.

The following entry is a continuum of the blog series “The Unintentional How-To” by current student, James Munro. The views and opinions expressed here are the author’s own and do not necessarily represent or reflect the views of NCNM.

The Unintentional How-To: OSCE 1

It’s OSCE 1 season! This is your chance to show that you can sort of fumble your way around an exam room enough to start practicing it in real life. I took my OSCE 1 in the spring of 2015 and somehow managed to get a passing grade which means I’m totally qualified to tell you how to do it.

The OSCE (Objective Structured Clinical Examination) is a pretty bizarre exam. It’s a practical exam where we take the patient history and perform a pertinent physical exam on a “standardized patient”, which is really just some dude who gets paid to pretend to have an illness. We then have to discuss our differential diagnosis and potential labs or next steps with a supervising doctor. We have a strictly-timed 45 minutes to complete all of this. Once we pass this exam, we can enter the clinic as secondary interns and start interacting with actual patients. Yeehaw!

I’ll start by describing my study methods prior to the exam in extreme detail. Ok, I didn’t study for the OSCE 1. At all. I didn’t see the point. The exam encompasses everything we’ve learned and wraps it all into one patient in one 45-minute office visit. Going through the list of common conditions and studying everything on there was not going to happen in the middle of the term. My studying was limited to looking at that list and making sure I’ve heard of everything, which of course I had because at that point I’d been at NCNM for almost two years.

I actually advising you to not study??? No, not really. I’m saying you’ve already been studying. Correctly diagnosing the condition isn’t the key to success here. It’s about the thought process. If someone comes in for a cough, you want to listen to their lungs, assess for infection, ask about risk factors, likely etiologies, think about labs, etc.

Your job in this exam is to gather the necessary information to come to a solid conclusion. If you demonstrate that you can do that fairly effectively, it really doesn’t matter if you can’t remember the word “pneumonia.” You are a student. You aren’t supposed to be a world class physician just yet, you’re simply supposed to be on the right path.

You need to know how to perform physical exams (which you already do) and you need to be at least vaguely familiar with how to think through all the conditions on the common conditions list (which you already are). Great. You’re done studying.

Another point worth noting here is that you have two opportunities to take this exam before it’s considered a failing grade. I certainly don’t recommend banking on the prospect of a re-take but allow that fact to take a little pressure off of you. If you walk into the exam room and totally lose your marbles and blow it completely, it’s fine. You just take it again. I think you get charged some exam fee but nothing goes on any permanent record or anything. Take some comfort in knowing that you can go into the exam room, calmly say, “I don’t actually know anything about medicine,” and quietly sit there for the remaining 44.9 minutes and you haven’t yet failed the exam. Ya know, don’t do that. Just know that you can.

My biggest struggle with the exam was that I have no interest in pretending to be a doctor treating a pretend patient. The standardized patient is an actor which forced me to also be an actor. But I want to be a doctor, not an actor. My acting dreams died when I crashed and burned at an audition for a Broadway show in NYC (true story!).

I fully understand the need for this fake experience as an exam but it didn’t stop me from thinking it was stupid. My greatest barrier to success was my attitude. I walked in thinking that I would not be able to truly show what I can do in this silly and artificial environment. I thought of the patient as an actor and I viewed the whole thing as fake and stupid and just this dumb thing I had to do. It didn’t help me.

I recently took the OSCE 2 and had the opposite attitude. I forgot about the exam and viewed the standardized patient as a real patient and did my best to figure out how I could help them. It turned the exam into a fun and rewarding experience. I recommend forgetting that the patient is acting. Be yourself and do your best to help your patient.

Ok, now down to the business end of things. My exam was on a Saturday afternoon, the very last time slot in the exam schedule. I spent most of my Saturday pacing around my apartment with high blood pressure until it was finally time to get myself over to the clinic.

I walked into the clinic’s front door and there was a table where I checked in and signed some form saying I wouldn’t talk about the exam or I’d get expelled or go to jail or something. I was given paper for SOAP notes with the patient’s age, gender and chief complaint on it. I had my medical equipment and a pen with me but realized everyone had a clipboard but me. I found one to use but it added some unnecessary anxiety that I didn’t need. I should’ve brought my own.

I made my way over to the hydrotherapy room for the pre-test orientation. I don’t remember anything from the orientation. I was too busy thinking about differentials for the chief complaint of “abdominal discomfort.” Eventually, the person I wasn’t listening to stopped talking and, one by one, doctors came in and called our names. I heard my name and followed the doctor up the stairs with my mind spinning while she was saying things that probably would’ve been helpful to listen to. We got to our exam room and she said,“I’m going to go into the room. Take a few seconds, then knock on the door, come in and we’ll begin the exam.” Then she walked in, closed the door and I was standing in the hallway by myself. After a super awkward 20 seconds, I knocked on the door and walked in.

I introduced myself and shook the patient’s hand. He was kind of cranky and gave me short, blunt answers. I was impressed by his dedication to his acting role. I think I inappropriately smiled. I began my HPI (history of present illness) and started going through all the questions I could think of. It was a train wreck.

While we’re not required to take notes, I wrote things down in order to buy time because I was constantly running out of things to ask. Instead of staring at him saying, “Uhhhhhhhhhh,” I jotted some notes while desperately trying to come up with pertinent questions. We had to turn in our notes but they weren’t to be graded – I’m thankful for that. I was writing nonsense. At one particularly desperate moment, I actually wrote, “Patient is sitting but I don’t think he’s that tall.”

After a pretty rough interview where I certainly missed multiple pieces of vital information, I was highly suspicious of an appendicitis or some gall bladder or liver issue and I moved on to do some physical exams.

A quick note here: Do not forget to wash your hands before the physical exam! Forgetting is an easy way to lose some major points on the exam.

I took his vitals and told the doctor my actual findings and she corrected with the findings of the fictional case. This is where I really tanked.

The dude sitting in front of me was perfectly healthy so when the doctor told me the abnormal findings, I had a really hard time absorbing the information. I was in a constant state of cognitive dissonance. “His heart rate is 71,” I’d say. The doctor would say, “His heart rate is 95.” I’d think, “What? No it’s not.”

The more physical exams I did, the more lost I became. I had to ask the doctor to repeat herself like 30 times. “I’m sorry, what did you say the findings were for that?” I was sincerely confused by the whole thing.

I listened to his heart with the diaphragm but not the bell; I had long pauses between each physical exam; I kept asking the doctor to repeat the findings. I felt very incompetent.

I finally got to the abdominal exam, which I believed would be the most telling. After light palpation, I said, “He is non-tender to light palpation and I couldn’t feel any masses.” The doctor said, “He is extremely tender to light palpation with significant guarding.”

I said, “Ok, I’m not comfortable continuing with the abdominal exam at this point. I believe he needs an ultrasound.”

She said, “Ok.  Since he’s not actually in pain, I want you to continue the exam as you would if the findings were negative.”

My head nearly exploded. I did deeper palpation and again, the doctor told me that he was in excruciating pain and I was so confused as to how to continue. I eventually said that I didn’t want to perform anymore physical exams.

I came to my conclusion without completing all of the pertinent physical exams. I was right but I realized later that being right wasn’t really the goal. The goal was to show the doctor I knew about McBurney’s, Rovsing’s and Murphy’s points and how to interpret them, how to palpate the liver, assess liver size, palpate the kidneys, etc.

To make sure the exam wasn’t too hard, they provided a very clear case but I jumped to the answer before demonstrating that I would be able to pick up a more subtle presentation of the same disease. (I’m being intentionally vague about the actual diagnosis because I’m scared they’ll expel me or put me in jail if I say too much about my exam. I don’t really know the rules about that…)

I told the patient what I thought was going on and told him about the next steps with his diagnosis. I thanked him, thanked the doctor and went home. I hated the experience. It was confusing and weird and fake and did nothing to boost my confidence.

My diagnosis was right and I suggested the correct labs and imaging so I passed but I didn’t get a great grade because I kind of missed the point of the exam entirely.

Your experience doesn’t need to be like that. The problem was my attitude. The OSCE’s are a super cool opportunity to show off all of the things you know in a non-life threatening situation. No one is actually sick and it’s not possible to hurt anyone. It’s just a chance to show the doctor that you’re on the way to become an amazing doctor. I learned my lesson and my OSCE 2 exam was incredible. It was fun. It boosted my confidence tremendously. I wish I’d had a better attitude for the first one.

If you’ve been showing up to class and studying medicine for the past couple years, you are more than prepared for this exam. Remember, you’re not expected to be the best doctor in the world yet, this is simply your chance to show that you’re on your way.

I wish you all the best of luck and I can’t wait to see you in the clinic with your shiny, new white coats.

If you have any of your own OSCE advice or questions, post them in the comments section below!

 

What would you like to read about next? James will address your questions, topic suggestions or feedback of any kind. Comment here or email James.Munro [at] student.nunm [dot] edu.

  • Please note that this is not a medical column and James is not yet a doctor. Please do not request medical advice here.
  • The views and opinions expressed here are the author’s own and do not necessarily represent or reflect the views of NCNM.

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