The Insiders Guide to Passing Medical Finals at

Univ. of Nottingham 2010

By Rohit Gohil
1. When are Finals and what is the format?
The examinations that I sat in 2010 were spread out over a two-week period in
the latter half of March. The first week was concerned with the OSCE and OSLER
skills examinations. They were sat on different days, but always at the same
centre. I was allocated to sit these exams in Derby, but colleagues were sent as
far away as Mansfield or Lincoln. The site where you are allocated to is totally
random and it is ensured that there is no difference in the quality of assessors
across the different sites. The OSCE consists of twelve stations, each being six
minutes long. A range of skills is assessed, from clinical examinations, to an acute
care scenario and an ethics station. The OSLER is an assessment of your history
taking skills. Here, you clerk a patient with a chronic illness, and afterwards two
assessors listen to your presentation and ask specific questions in a viva-type
examination.
The written knowledge papers were then sat in the second week. There are two
in total. It was speculated that one of the papers was harder than the other, with
that paper being for the honours students. In reality, both my colleagues and I
scored similar marks for both papers, and as I recall the difficulty of questions
was similar between both papers. Both knowledge papers are completed on
computers with a time limit of two hours to complete each one.
2. Finals Written Exam Format: question type and how the marks are
allocated for each paper (i.e. what percentage of the marks are allocated to
medicine, surgery, ethics, epidemiology, pharmacology, etc.)
The written papers cover a vast number of subjects. They are broadly divided
according to the rotations that you will cover in your 5th year MDD, Medicine,
Surgery, and a bit of primary care. Allocation of marks between these subjects is
more or less equally divided from the total paper mark.

The papers employ a number of different question types to fully assess you. They
range from simple MCQs, where you pick the most appropriate response, to
extended matching questions and drag and drop responses. The electronic
format of the papers allows you to interact with illustrations in some cases to
deliver your answers especially when identifying radiographs.

3. When should you start revising?

Once you have looked through the entirety of the red integrated guide, that
contains all the objectives for finals, you will realise that there is a lot of expected
knowledge for you to have covered in your time at medical school. The key is to
start assimilating knowledge sooner rather than later. I started writing my notes
for the knowledge component of finals during the second half of my first
rotation. Whereas I started preparing for the skills exams at a slightly later date
initially getting my practise on the wards. In the few months leading up to finals, I
started practising at home, with housemates and friends.
4. How did you plan your Finals revision over such a long period of time?
As mentioned earlier, the key is not to leave revision to the last minute. My first
rotation in fifth year was MDD, therefore I started by covering the
musculoskeletal objectives to begin with, and no less because I hadnt got to
grips with anything like this in the previous years of medical school. Thereafter, I
proceeded to cover the objectives in much the same order as they were in the
guide. I didnt confine myself to doing purely surgical notes during my surgical
rotations, nor medical notes for medicine, as there was a lot of overlap in the
objectives.
As expected over the subsequent months I was able to cover the entire syllabus.
The main idea is to try and work consistently over the year because it really does
help towards the end when it comes to revising.
With respect to the skills exams, it really does depend on you and how you best
learn practical skills such as clinical examinations. I started by getting a list of the
potential OSCE stations off the NLE website. I especially studied the examinations

that I was less familiar with, such as the MDD examinations and some
neurological examinations.
On the wards, I would try to practise these examinations under the guidance of
the F1 doctor, getting ample feedback and tailoring my examination style
accordingly. Scheduled bedside teaching sessions were another source of much
needed guidance in perfecting my technique.
Once my colleagues and I felt that we had sufficiently learnt these skills, we
started practising at home, initially performing single examinations on each
other. In the months before the exams, we started organising mock OSCEs,
where we would be timed and assessed by peers. This may seem like a lot of
effort and requiring a lot of organisation, but it really does help in getting you to
grips with the fast pace of a twelve station OSCE, but in the rather nonthreatening setting of your home!
As the OSLER was an exercise of history taking ability, I purely practised this in
the ward setting, timing myself to take a full history and examination in thirty
minutes. I would then try and take about five minutes to organise my notes and
then present back to the F1 or other doctor on the ward. This practise was
invaluable in increasing my confidence in doing such a lot in rather a short
amount of time.
5. Describe your OSCE experience and how the examiners treated you.
As mentioned before, the OSCE consists of twelve stations, each being six
minutes long with a minute to travel between stations. The examiners that I had
were varied in the way they assessed me, but on the whole they were very
forthcoming and friendly. They realised that students would be nervous and
somewhat flustered with the fast pace of the exam, and accordingly they tried
their best to put us all at ease. It is notable to mention that one or two
consultant assessors were not as friendly as Ive just mentioned, but that should
in no way affect your performance.
An issue that my colleagues and I found was that if we felt we had not done so
well in a particular station, then they would be flustered for the following
stations. It is important to try and put those thoughts to the back of your mind
and try your best to attend to the task at hand. It is worth remembering that

your performance at one station has no bearing on your assessment at any other
station they are all marked exclusively from each other.
6a. What OSCE cases were you given?
Here is a list of the OSCE stations that I was assessed on, I have given a little extra
information on each station, with the aim of giving you an insight into the depth
of detail that the assessors expected me to go into:
a. Acute care: This station required me to attend to an acutely ill patient
(mannequin) who had had an anaphylactic reaction to antibiotics he had
recently been prescribed. I had to go through the ABCDE algorithm and
comment on my findings as I went along. My assessor also questioned me as I
went along as to which fluids and airway adjuncts that I would use.
b. Communication: This was a reasonably straightforward station where I had
to explain a suspicious chest X-ray result to a patient, including follow-up.
Here a lot of emphasis was placed on exploring the patients concerns as it
arose that their close relative had died of lung cancer.
c/d. Ethics: Ethics was split between two stations. Initially I was presented with a
written ethical scenario that I had to comment on and find the key ethical
issues therein and come up with a plan to resolve them. I had six minutes to
write down my thoughts before progressing to the next station where I had
another six minutes to discuss the case with my assessor.
e. MDD (spine): This station threw me a little because they asked me to
perform only a few components of the whole examination. It is therefore
expected of students to have such an implicit knowledge of the examination
that they can move straight to the middle of the examination if asked. The
case itself was a rather straightforward one of a patient with ankylosing
spondylitis.
f. MDD (foot): The foot examination was assessed in much the same way as the
spinal examination, where I was asked to perform only a few select parts of
the entire examination and report my findings. This case was slightly more
difficult with a patient with rheumatoid arthritis and bilateral ankle
arthrodesis.

g. Respiratory: I was asked to perform the entire respiratory examination on a

patient who had clubbing and inspiratory crackles, suggestive of a chronic
fibrosing lung pathology.
h. Cardiovascular: This was again another straightforward station where I was
asked to perform the entire examination on the patient. In this case the
patient had numerous peripheral signs (such as visible neck vein pulsation
and corneal arcus) and an easily audible pansystolic murmur, suggestive of a
regurgitant mitral valve.
i.

Vascular: In this station, I was only required to palpate the patients leg
pulses and perform an ABPI, rather than complete either the arterial or
venous leg examinations that I had learnt. Once I had given my ABPI value, I
was briefly questioned about normal and abnormal values.

j.

Abdominal: This station was another reasonably straightforward case of

performing the entire examination. In this case, the patient had a
characteristic scar for past peritoneal dialysis, as well as a palpable
transplanted kidney in his left iliac fossa.

k. Head and Neck: The head and neck station is one that I found to be quite hit
and miss amongst my colleagues. I was asked to perform the entire
examination, but the assessor asked me questions throughout. The patient in
this case had a stone in his submandibular gland duct, causing a slight fullness
under his jaw.
l.

Neurological: In my case, I was asked to perform the entire cerebellar

examination on a patient who had bilateral signs as well as numerous
findings upon inspection alone.

6b. What OSCE cases were others in your year given?

There was a massive variety in what cases my colleagues where given, both
between different examination sites, but also within. During my run patients
were being swapped over as we moved from station to station.
The only information that we had to go by prior to the examination was a list of
potential stations that would come up on the day. This was released on the NLE a

week before the exam and was useful in that it mentioned that we had two
separate MDD stations, but nothing more specific than that.
Between my colleagues, and myself, we were assessed on all of the potential
stations that could come up, with most variety occurring at the MDD and
neurology stations. Upper and lower limb peripheral nervous system
examinations seemed to be a very popular choice for the neurology station.

7. Any additional advice/information youd like to give the year below including how to pace themselves/ using revision groups/ how to juggle
going in to attachments and revising simultaneously, etc.
Getting through your final year of medical school is quite a feat to get your head
around, but with good planning and a fairly consistent work ethic, it shouldnt be
too taxing. There are numerous online resources out there that can help you
along as well as courses covering a range of subjects. Some clinicians also take
time out during the evenings to hold lectures at the medical school for finals
orientated teaching sessions. This is obviously a personal preference, and if you
feel it helps towards a better understanding of the work that is required of you,
then they should be pursued.
Another issue is juggling all of your commitments during your rotations, along
with your personal study. It is initially difficult to maintain a strong work ethic,
whilst going into hospital consistently. I personally took the route of making a
goal to work towards in a given amount of time therefore I could take an
evening off, as long as I caught up with the work on another day. This seemed to
work for me, but explore different strategies for yourself until you find one that
suits you.

How to pass medical finals at the

University of Nottingham 2008
Raghav Murali-Ganesh
Karan Malhotra
Emma McLaren
Kishan Ubayasiri

Exam information regarding the question type and how the marks are allocated for each
paper (i.e. what percentage of the marks are allocated to medicine/ surgery/ ethics/
epidemiology/ pharmacology etc.)
In the Nottingham finals there are two written papers, an OSCE and an OSLER.
Written Paper:
The written papers cover medicine, surgery and musculoskeletal disorders and disability
(MDD) in roughly equal proportions. There are a few pharmacology questions but these are
clinically based and are not extensive. You should also expect to see questions based on
acute care and resuscitation.
There are a mixture of question types including Multiple Choice Questions (MCQ's)
and Extended Matching Questions (EMQ's). Each paper includes questions from each topic
i.e. the exams are not divided into one on medicine and one on surgery.
OSCE:
The OSCE has 12 stations of 6 minutes each with a 1 minute gap between each station. You
are told a few weeks before the exam which stations will be included in the exam. The bank
of stations includes cardiovascular, respiratory, abdomen, groin, neurology, breast, head and
neck, acute care and resuscitation, communication, ethics, rehabilitation, radiology, vascular
and 2 musculoskeletal.
In 2007/08 the abdominal and groin stations were combined into one station. Students can
pass despite failing up to 2 stations providing their overall percentage is high enough.
Yellow cards may be issued by the examiners for significant mistakes.
OSLER:
In the OSLER you spend 40 minutes taking a history from and examining a patient. You then
spend 20 minutes with the examiners during which time you present your patient and
answer questions. In this exam you should be prepared to see a patient with any condition.
The patients you encounter vary from those with only one or two simple conditions to
others with many co-existing or rare conditions.
The focus of this part of the examination is less on what you know about a given pathology
and more on your interaction with your patient and your understanding of how their illness
impacts upon their life. You will be given a mark scheme for the OSLER a few weeks before
the exam and it is worthwhile having a good look at this and practising presenting patients
along the lines they expect.

Mark allocation:
You are given an overall mark for your written papers (50%), in which the two papers are
weighted equally. You are given a separate mark for clinical skills (50%), in which the OSCE
counts for 2/3 and the OSLER for 1/3.
When you should start revising to achieve:
a) Pass
b) Honours

Nottingham Medical School awards one of 2 grades upon successful completion of the finals:
pass or honours.
Finals are of two types: written papers and clinical skills (OSCE / OSLER). Each of these exam
types demands slightly different types of preparation. Written papers focus more on
application of knowledge and attention to detail. OSCEs on the other hand incorporate
communication skills and require you to demonstrate logical patterns of thinking and safe
practice. Although the last-minute preparation for these papers may differ slightly the long
term study plan should remain the same.
When you start revising depends hugely on your learning style and your approach to
assimilating information throughout the course. You must identify how you learn best in
order to make the most of the time you spend working.
Passing with honours ideally requires that you have not frittered away your prior years at
medical school since there is not enough time in the final semester to learn all of medicine!
That said, the difference between pass and honours is time spent learning from your team in
hospital and seeing lots of patients.
Aiming for a pass is generally not a good idea. Although one may often get a lower mark
than they expected, they will seldom get a higher mark than what they worked for.
From experience the best way to revise is to do it throughout the year and at a steady pace.
Having laid the foundations in this way you will then have to decide when to start your final
consolidation (cramming!). It may be wise to note that there is however too much to cover
in a very short period of time so budget accordingly and target this to key points to help you
reinforce what you have learnt throughout the year.

How do you plan your revision over such a long period of time?
It is difficult to revise whilst still on clinical attachment. Clinical attachments also run right up
until the exams, further increasing time pressure. In these circumstances planning your
revision is essential to ensure you make the most of your precious time!
It is important to make this plan early in the year. The type of plan you make depends on the
type of person you are. Are you someone who works best with a daily or weekly plan of
what you need to cover? Are you someone who wants to go over everything once before
the exam? Or do you prefer to focus on things you find difficult?
It is also useful to identify how you learn. Although everyone has a preferred method of
learning, largely we fall into 3 categories: those who learn best by listening, those who learn
best by seeing and those who learn best by doing. You must try to identify (if you havent
already) which your strength is and tailor your study accordingly.
Having identified the above you will then want to know what you actually need to know. At
the beginning of the ACE course handbook, there is a list of all the skills and conditions you
should have knowledge of from GP, MDD (musculoskeletal disorders and disability), surgery
and medicine. Use this list as a framework and identify areas of weakness which you would
like to concentrate on more; it can be tempting to go over familiar ground but you need to
work on areas where you would otherwise be losing marks. Use this to formulate a revision
timetable. It is far easier to maintain direction if your objectives for a particular revision
session are clear. Try and break larger topics into smaller bite-sized more manageable
chunks. Focus on the basics - it is easy to get bogged down in detail but most of the marks
come from core information.
Revision can be broken down broadly into 3 types: reading from books, practice questions
and clinical practice. A good idea is to combine these in your revision. Whilst on attachment
spend your first few days going over the basics of anatomy, physiology, pharmacology etc. to
refresh your memory. Subsequently you may prefer to do more of book reading in the
beginning of the placements and more of practice questions to test your knowledge towards
the end. Alternatively you may choose to use revision questions at the beginning /
throughout your study to identify gaps in knowledge and assess progress. Practice questions
give you a good idea of the level of detail needed and they can also break up the monotony
of text books and notes. These are a good way to revise in general for the written papers.
In order to revise for the practical exams you need to focus on your practical skills. Revision
for the OSLER is best achieved by taking a history and then examining a previously unknown
patient in 40 minutes. Present your findings to a senior member of your team, and ask them
to question you. Revision for the OSCE is best achieved by forming a group to practice with.
List all the possible OSCEs and systematically practice on each other.

Ensure each examination is completed within the allotted time of 4 minutes. Once you have
reached a degree of proficiency, locate suitable patients for short cases from the wards, and
if possible practice with your group in front of a consultant or registrar.
You may also find it very useful to write out checklists for each station based on a model
answer. For history taking stations write on a piece of paper all the questions you would
need to ask for a particular case and commit this to memory. Once in the exam it is then a
matter of simply identifying early on what the case pertains to and then following the
familiar pattern. This will allow you to relax a little and concentrate on maintaining good
rapport.
Finally, if you do make a formal plan, make sure you review it as you go along and make
changes if you are falling behind.

What books/material should you use for each exam and why did you find these useful?
The selection of books is once again up to you as an individual, some prefer to learn from
textbooks which provide detailed written explanations of conditions whilst others prefer
diagrammatic books with lots of pictures and annotations. Find one that suits your style of
learning.
Using books that contain a lot of detail such as Kumar & Clark and Davidsons textbooks of
medicine are best reserved for early revision rather than using them right up until the
exams. They include a lot of detail and the chapters can take a while to get through so it is
best to be selective when using these. Davidsons is recommended to use especially for the
chapter on MDD as it is written by Prof Doherty and tends to contain questions that appear
in the MDD sections of the written papers.
Small and concise books such as the Oxford Handbook of Clinical Medicine (OHCM) and
Medicine at a Glance are very useful books to have during clinic hours for use in the small
pockets of time that can be spared during the day. The OHCM is brilliant as it summarises all
the key points on a topic without unnecessary detail and includes basic surgery and acute
care. These books are also very valuable for the final revision period before exams as they
are short, digestible and not too daunting for the final few weeks. They also help you re-visit
topics mid-year so that hopefully, come finals, you will have touched on the key topics at
least 3 times over the space of 5th year.
A resource often neglected is lecture notes. These are really a very valuable source of
information, not least because lecturers also tend to be question setters.

Use as many OSCE and OSLER case books and MCQ books/websites as you can find. These
present information in a different way to traditional books. The more varied the sources
from which information is gleaned, the more likely it is to stick. Make sure that any MCQ
books you use include not only the answers but also explanations.

Are there any books that you would perhaps advise to avoid and why?
There arent any specific books to avoid but try to stay away from too many revision books.
Have a good look through and pick one which you think suits your needs and stick with it.
For the rest, use practice questions.
Look to avoid heavy, reference textbooks, whilst these may be useful in preceding years or
the early part of 5th year, at a late stage of revision this will only hinder you, slowing you
down.
Again, the most important thing in selecting your books is to look for a style that suits you
and content that covers your main priorities. You dont want to be struggling with a style
you find laborious or difficult to digest.

Your thoughts/ feelings after each exam:

Here are a selection of thoughts and feelings from some of our authors after their exams,
Written:
Emma: To be honest, I did find the written exams difficult. I felt that often I did not know
enough detail and at other points was cross with myself for lacking some basics. Again
though, the results do tend to be better than you imagine, so try not to torture yourself too
much with memories of a point lost here or there.
Karan: About the written papers there's not much to be said. There are some questions I got
perhaps needlessly confused on but as part of my strategy I made a quick decision and
moved on. I do not tend to go back to questions even if I have time unless they are very
tricky ones.
Kishan: The written exams on the whole have questions that are expected. There are,
however, always a couple of real sidewinders in each paper, the content of which you have
probably never even heard of. These are designed to separate good candidates from
excellent ones.

OSLER:
Emma: When I first came out of the OSLER I felt like it had gone reasonably well. Then came
the memories of all the questions I couldn't answer and the conversations with other people
and I soon felt like it had been a disaster. I would suggest not discussing the details of any of
your exams with other people until after the results. Sometimes people make this very
difficult for you but it is honestly worth it, for your sanity and theirs.
Karan: Prior to my exams I felt that my preparation had gone well. As always there was
always more that could have been done but I felt prepared and calm. By far the worst part
was waiting for the OSLER to start with my colleagues who were all nervous, crying and
joking about failing as part of their coping strategy. Once we started however all nerves got
pushed aside as I fell into a familiar system that I had long practiced. This allowed me
enough time and ensured I did well in the time allotted. After coming out of the OSLER I was
pleased with how it went and didnt dwell on it too much.
Kishan: After the OSLER I felt a bit off-centre feeling that I could have presented my history
more sequentially and could have answered the questions regarding heart failure somewhat
more adroitly.
OSCE:
Emma: My OSCE felt like a constant 100 metre sprint, I was always behind time. I
had practised a lot for this exam and felt frustrated that this had not come across in the real
thing.
It's easier said than done, but do try to put each exam behind you as they happen, the result
will probably be better than you expect. Most people I know were slightly haunted by the
OSCE for a while afterwards, it is a tough exam. See it as an opportunity to showcase the fact
that you have seen lots of patients and are confident in examining.
Karan: During my OSCE some spot diagnosis stations were perplexing and I hadn't a clue
what was going on. I took a moment to step back, clear my mind, and describe what I saw,
linking observations as I went along and eventually came to the correct diagnosis. After
completing the exam I realised it was actually not as difficult as I had envisioned it to be.
Kishan: After each station in the OSCE it is key not to lose focus and to not allow a previous
poor station to linger on the mind. Each station only lasts six minutes, and you must be
battle ready for each one.
Inevitably after all exams there is that feeling of anticlimax and emptiness. This slowly fades
on the days after the exams only to be replaced by panic in the run up to results! True relief
is only felt upon passing finals.

Describe your OSCE experience/ how the examiners treated you and what cases you were
given
The OSCEs consist of 12 stations, 10 of which must be passed. The pass mark for each station
is again 50%. Each station lasts 6 minutes, 4 minutes of which you spend examining, 1
minute presenting and 1 minute fielding questions.
Below are two experiences of the Nottingham 2007/08 finals OSCEs.

Kishan:
Station 1: Cardiovascular
I examined the patient, and was not interrupted. I did not finish my routine, running out of
time, and could not honestly find anything abnormal! A thin veil of panic descended, but I
reported that I could find no abnormality. From the questions I was asked, I am guessing
that the patient had aortic regurgitation. However, I was able to make out no such murmur
and did not feel a collapsing pulse. Do not make up signs, this will only lead to heartache, it
is always best to be honest.
Station 2: Ethics
You have 6 minutes of preparation prior to this one. My case was of a young Asian woman
who had been prescribed a drug with which you were not familiar. She now presents to you
as her GP asking for another prescription. What do you do? I was not entirely sure the point
of this one. One of the questions the examiner asked me was what law this scenario related
to. To this day I do not know!

Station 3: Communication skills

I had to counsel a patient actor about her terminally ill husband who was in the final stages
of life due to his cancer.
Station 4: Knee
Examination of the knee, watched gait, straightforward osteoarthritis of the knee.
Station 5: Hand
Again straightforward, carpal tunnel syndrome, although there was also hypothenar muscle
wasting due to some co morbidity. Make sure you know which nerves are sensory and
motor to all parts of the hand and the major muscles and there functions.

Station 6: Vascular
Examination of the arterial then venous system of the lower limbs. I was allowed to conduct
my entire routine uninterrupted. Make sure you know how to do
tourniquet/Trendelenburgs test, tap test and Buergers test. Actually practice doing a
tourniquet test on a patient. Although I was not asked to do this, you may look silly if you
cannot complete this slickly. Patient had previous angioplasties to both lower limbs.
Station 7: Rehabilitation
Picture of a gentleman in a wheelchair. I was asked various questions regarding the
neurology of his condition and the level at which the lesion might lie. Asked about the
grading of pressure sores.

Station 8: Anaesthetics/Resuscitation
You know the drill. ABC DE. A case of cardiogenic shock, although the aetiology of the shock
only dawned on me at the end. Be safe and know how to read the patients observations
chart. Know what the Portsmouth sign is and that it is not good!
Station 9: Radiology
Chest radiograph showing signs of heart failure
Abdominal radiograph showing small bowel obstruction
KUB showing renal calculi.

Station 10: Abdominal

Had to examine a woman with a colostomy. Know the differences between colostomies and
iliostomies. She also had a stomal hernia. You could only see this when she flexed her
abdominal muscle. Think this may have been a bonus point! Examiner kept interrupting my
flow, commanding me to jump to various points in my routine most irritating. Be familiar
with the examination of an inguinal hernia. Make sure you go to day case during your
surgery attachment and examine a few hernias prior to their surgery.
Station 11: Respiratory
COPD, although she seemed to be more at the chronic bronchitis end of the spectrum. She
was cyanosed, had course crackles and was breathless on minimal exertion.
Station 12: Neurology
Neurological examination of the lower limbs. Patient suffered bilateral lower motor neuron
lesions. She also had deformities of both lower extremities. She, thus, probably suffered
from a genetic disorder.

Emma:
As I mentioned above, my OSCE was a constant rush. Despite lots of timed practice, 6
minutes felt very short every time.
Some of the cases I was given in the clinical examinations were more complex than
expected. My cardiovascular station involved a patient with multiple pathologies who had
had several cardiac operations. There was a lot to find in her examination but the examiner
was happy to coach you through the questions. My respiratory patient had bronchiectasis,
an OSCE classic and my neurology patient had a mixture of signs that would most likely be
explained by MS, another condition commonly seen in the OSCE. However, the focus in my
neurology station was on eliciting the signs and putting them together to localise the lesion,
rather than identify a specific pathology.
In my vascular station the patient had obvious venous disease but I was asked to examine
the arterial and venous systems, which threw me slightly. My musculoskeletal cases were
Dupytren's contracture and a knee soft tissue injury.
My acute care station was a patient in cardiogenic shock. In the communication station I
was asked to explain to a patient's relative that the patient was very unwell and likely to
pass away in the near future. There was no preparation time for this station so it was a little
difficult to decide exactly what to say on the spot but the important thing seemed to be to
stick to a structure. My ethics station was not what I expected and it was actually quite
tricky to pick out exactly what the key ethical issues were in the scenario. It involved
a patient who attended her GP with a letter from a hospital consultant asking her to
prescribe a medication she had never heard of before. There was 6 minutes of preparation
time for this station. None of the classical ethical debates seemed directly relevant and it
was a bit frustrating not to be able to demonstrate my knowledge of the core debates. In
this station my examiner seemed to be very fed up with people churning out the ethical
principles so, whilst these are useful for structuring your own thoughts, make sure you have
more to say than this. My rehabilitation station was around pressure sores, a fairly
predictable topic, but again I was slightly frustrated as the examiners questions were quite
specific and it is not always possible to show all your knowledge of the topic. Again, there
was no preparation time for this station. In radiology I was given one chest xray, one
abdominal film, an IVU and a wrist xray (Colles' fracture). The expected structure for
presenting the films was as follows - describe the type of study, describe the film, give a
most likely and a differential diagnosis, tell the examiner what you would do next ie.
emergency interventions, further radiological studies etc depending on the case.
The examiners all took slightly different approaches. On the whole they were friendly but
could seem a little abrupt when trying to get you to make the most of your 6 minutes. It is
important to listen carefully to the exact instruction you are given on entering the room, you
may not be asked to do the examinations in full. Each station tells you what it is on the door,
use any spare moments spent standing outside the room to focus your mind on that topic.

Try to see each station as a fresh start, remember that each examiner does not know how
brilliantly or badly you have done in the previous station. In reality there is little time for
dwelling on your performance between stations, that all comes after the exam is over!

Any additional advice/ information youd like to give the year below- including how to
pace themselves/ using revision groups/ how to juggle going in to attachments and
revising simultaneously etc.
To conclude, some tips to tide you through your revision:
1. Written papers require attention to detail. For multiple choice questions read the
question. Most incorrect responses are due to not reading the question correctly.
Questions which say always, never, should, and must are usually false.
Conversely those which say sometimes or can are usually true.

2. The best way to learn is to teach. Make it a point to teach another person certain
topics that you find hard to understand and make sure they understand it.

3. If you ever have a doubt as to what a term means, look it up. The most annoying
thing in a multiple choice question is to be caught out simply because you forgot the
exact meaning of a word. For example it might be easy to confuse dysphasia and
dysarthria as they are similar in meaning but have different pathologies altogether.

4. On history taking stations and indeed in all patient centred stations, remember ICE
patient Ideas, Concerns and Expectations. Address these and youre well on your
way to a good mark.

5. Revise and practice in groups but try not to let other peoples stress affect you.
Being around other medics at finals time can be a great thing and a terrible thing.
Find the balance that suits you, but make sure you do have a chance to practice
OSCEs with others. It is useful to be a part of a group that meets once a week for
about 2 months before the exams. Having a regular slot with people outside the
house is something to look forward to and a good way of socialising despite the
exams.

6. In OSCEs remember to project confidence even if you dont feel it! Make eye
contact. Good preparation will help and involves having a system. Knowledge is
important but will get you few marks if you come across as disorganised and under
confident. With all history and examinations have a system, one which works for you
and one you have practiced with a friend!

7. Most importantly, always remember to be courteous to the patient. The examiners

ask the patients what they thought of you after you have left and if they could see
you as being their future doctor. These are easy marks, which do not necessitate any
actual knowledge!

8. Final tip for OSCEs it is generally not a good idea to blurt out a word / condition
you know little about just to make yourself sound clever. Chances are youll be asked
about that and may end up looking rather silly!

9. Keep doing things you enjoy. To do well in finals you don't have to give up
everything else. On the contrary, a happier, more relaxed you will come across
better in the practical exams and cope better with the pressure of the exam week.
Do take time off. Finals are totally achievable without going mad. The actual week of
the exams is rather unpleasant but they need not spoil your whole year!

10. The day before the exam do not cram, take it easy, relax and use the time to
consolidate rather than try to learn something new. Make sure you get at least 8
hours of sleep the day before an exam, it will do you much more good than
cramming remember, by that stage you probably have all the knowledge, sleep
will help your mind relax and make it easier to access what you know on exam day!

Short station OSCEs (i.e. past OSCEs- communication skills/ short history taking stations/
explaining procedures etc- we thought it would be very useful to write "model answers"
for all the most common short station OSCE stations repeated at your university excluding
physical examinations and clinical skills.)
Communication skills stations:
These stations are all about developing a rapport with your patient, earning their trust and
defusing potentially explosive situations. They often take the format of one of the following:
1. Breaking bad news
2. Dealing with a concerned patient / relative/ parent
3. Handling a complaint
4. Explaining a procedure / test / result
A good way to fail these stations is simply to reveal the news that has to be given, not show
empathy, not let the patient talk, be defensive or use lots of jargon. We all know this but yet
it is easy to fall into these traps when we are nervous. The emphasis in these stations is on
the process of delivering the information rather than the content of what you have to say.
The approach to this is to have a structure or framework. Two commonly used methods the
Calgary-Cambridge method and the SPIKES framework for breaking bad news. These systems
are both intended to deliver information to patients. The communication station also
requires you to elicit information from patients, for this the ICE (Ideas, Concerns and
Expectations) model is useful.
A combination of one of the aforementioned methods to deliver information combined with
the ICE model to elicit information is the best way to tackle this station.

Model answer:
Here is a useful algorithm that incorporates the SPIKES and Calgary-Cambridge
communication. SPIKES is an acronym that stands for Setting, Perception, Invitation,
Knowledge, Empathy and Summary.
Introduce yourself, SMILE, make eye contact.

1. Setting: Having an appropriate setting is paramount, you cannot be on a noisy ward

nor have nosey onlookers about. Mention that you would use a suitably private
setting. Take a nurse in with you if appropriate, set plenty of time aside.

Ask if they have anybody with them or if they would like to have anybody present.
2. Perception: Clarify the purpose of the conversation, check the listener agrees.
Decide on a structure for the discussion

'first I'll let you know the results of the test, then we can go through what this means,
then I'll answer all your questions and then we'll make a plan for what we'll do next.
Does that sound okay to you? Is there anything else you wanted to cover today?' Ask
them how much they like to know eg 'Are you the kind of person who likes to know
everything or would you prefer me just to tell you the bare minimum?'
Ask them what they understand of the situation. This will not only help you set the
scene but also gauge how much they want to know to tailor what you will say next.
Assess their Ideas, Concerns and Expectations.
3. Invitation: Having established rapport, check with the patient that is okay to
proceed. If its breaking bad news, issue a warning shot,

eg. 'I'm afraid the results aren't quite what we hoped', 'I'm afraid we've got some
more work to do on things'
4. Knowledge & Empathy: Tell the person the news. Knowledge and Empathy (E) go
hand in hand. If you have established the rapport then you will be able to tell them
directly and sensitively.

'As you know your husband has been quite unwell recently. Unfortunately this recent
infection has been quite difficult for him and he has become more unwell. Recently
his condition has deteriorated even further and he has begun to show signs that
he might not recover.'
Make sure you use plenty of pauses and allow the patient to express emotion and
ask questions. Encourage the patient or relative to express their feelings. Give them
the information they ask for if you know it but don't be afraid to say you don't know
and will find out for them. Clarify the patient's understanding. In some scenarios you

could ask them if they would like to go over what they are going to tell a relative
about their diagnosis, in others it might be more appropriate simply to ask if what
you have said is clear and ask them what they have understood from what you've
said.
5. Summarise: ask the parent or relative if there is anything else you would like to
discuss, ask them if they have any questions and NEVER forget to make a plan. Make
sure the patient is involved in these decisions and that they agree with the
plan. Make sure the plan is clearly communicated to them and that they know
exactly what will happen next.

6. To finish: Offer written information or telephone numbers. Thank the patient and
make explicit arrangements about when you will see them again.

Rehabilitation station:
Make use of the Rehabilitation Handbook you will be given at the start of the
musculoskeletal block, it contains a lot of useful tips for the rehabilitation station. Here is a
short example of one kind of question you could be asked in this station. Other topics that
are very likely to come up are stroke, head injury and spinal cord injury.
Pressure sores:
In this station you might be shown a picture of a pressure sore and asked questions such as
these:
1. Describe what you see.
Introduce your description with a phrase such as 'This picture shows a break in the skin on
the patient's sacral area which is consistent with a pressure sore'. You should then describe
the size, depth and edge of the sore as well as the surrounding skin
1. What grade do you think this pressure sore is?
You should then grade the pressure sore according to a scale such as this one:
Grade 1 - non-blanching erythema
Grade 2 - partial thickness skin loss involving epidermis / dermis (an abrasion or ulcer)
Grade 3 - full thickness skin loss extending into subcutaneous tissue but not the
underlying fascia

Grade 4 - full thickness skin loss with extensive damage to and necrosis of underlying tissue
(Resource - http://www.judy-waterlow.co.uk/pressure-sore-symptoms.htm)
3. What advice might you give to the patient and their carers about preventing pressure
sores?
Try to structure your answer to questions like this by dividing your response into 3 parts eg.
education, prevention and detection. Some examples of interventions you might give are as
follows.
Prevention:
Education about the aetiology of pressure sores
Avoid immobility where possible
Pressure relieving devices eg. cushion for chair, matress for bed
Careful positioning
Frequent moving - including manual turning
Prevention of incontinence
Ensure there are no wrinkles in clothes and bed linen

Adequate nutrition and hydration

Good management of diabetes and cardiovascular disease
Detection:
Education about the appearance of pressure sores
Frequent examination of at-risk sites
Early detection - erythematous areas
Early involvement of GP and district nurses

4. Apply ICF framework

You should also be prepared to apply the International Classification of Functioning to any
scenario you are given in the rehabilitation station. This could involve giving an example of a
kind of activity or participation a person may have difficulty with and an intervention which
would help them.

Ethics:
The key to these stations is:
Knowing your ethics! There is no substitute for this. You need to know what the legal
position is on things such as:
a) Doctor-Patient Confidentiality
b) DVLA regulations
c) Mental Health Act
d) Mental Capacity Act
e) Treating children under The Lord Fraser ruling
f)

Refusal and Consent to treatment

g) Euthanasia

For situations not governed by legal positions such as these there is really no right or wrong
answer.
These situations include:
a) Finding out your colleague does drugs
b) Finding out your colleague likes a patient
c) Finding out your colleague does some other wrongful practice

For the latter situations the examiner will likely ask you what you would do in a given
situation. It is then less of a communication station and you would essentially have to show
that you would handle to situation tactfully instead of directly ratting him out. It is more a
case of how you approach the situation and in general it is good practice to approach him
first but demonstrate that you understand this is unacceptable behaviour and if need be you
must indeed take the matter to a higher authority. Just be sure to say that youd tell him
that you would do this. The same applies to known epileptics who are still driving after being
advised to stop.

Most ethics stations can be a discussion with the examiner and they expect you to be able to
demonstrate knowledge of the law and sensitive handling of the situation.
To make things difficult they may combine an ethics station with a communication station
for example, a relative who is demanding information about a sick patient. This may lead to
an angry-relative scenario as well and must be handled using ICE. It will be necessary in this
situation to explain the law to the patient in an empathic manner. It is very useful to
establish how much the relative knows in this situation and work with that rather than point
blank refusing to give out information. The latter will most likely create a confrontation
which will cause you to run out of time and lose marks.
Above all do not break the law and do not lie, you may feel under pressure in these
situations and remember that it is *always* appropriate and acceptable to call for help from
a senior or at least to suggest it. In fact in most situations, failure to do so will result in a loss
of marks.
Here is a basic framework for approaching your ethical scenario, your examiner is likely to
ask you similar questions to these so it is useful to bear them in mind during your
preparation time:

What factors impact upon this scenario?

Consider your scenario from a range of perspectives. As mentioned above, for last years
station none of the 4 ethical principles seemed directly relevant so it is important to look at
it from different perspectives rather than just churning out the 4 ethical principles.
- philosophical - the ethical principles
- consent and confidentiality
- legal - any laws or test cases that apply
- political priorities and local policy
- family
- society
- professional conduct
- clinical evidence - that supports or refutes an intervention
What are the pros and cons of the intervention?
- weigh up the perspectives that you have outlines above
What compromise exists?
- what possible solutions can you imagine?

What would you do next?

- asking for help from colleagues and professional bodies such as MPS or MDU
- your next practical steps to reach a solution
How would the various parties feel in this situation?
- remember to include how this scenario makes you feel, as well as the other parties
involved

Authors and Editors:

Raghav Murali-Ganesh- Author and Editor
Karan Malhotra- Author
Emma McLaren- Author
Kishan Ubayasiri - Author