Dr Vinu Verghis, Author at Oyamed

23Oct

Situational Awareness in the AMC Clinical Exam: Reading the Simulated Patient

Situational awareness in the AMC Clinical exam means noticing who is in front of you, what state they are in, and what they have been briefed to tell you, hold back, or ask. Every simulated patient walks into the station with a role. If you don’t notice the role, you miss the station.

I watch good doctors lose marks this way all the time. They know the medicine. They have practised the structure. But they are so busy running their own plan that they never look up and see the person in the other chair.

What Is a Simulated Patient Briefed to Do?

A simulated patient is not there to answer your questions in any order you like. They have a brief, just as you have a stem.

The brief tells them who they are, how they feel, what they say first, what they give only if you ask, and very often a question they must put to you at some point. Some are told to be angry until you acknowledge them. Some are told to cry. Some are told to refuse what you offer.

None of this is random. It is written around the marks. So when the simulated patient does something, ask yourself why. That is situational awareness.

Who Is in the Room?

Before you think about the diagnosis, think about the person.

Is this the patient? Or is it a daughter talking about her father’s memory, a mother talking about her baby, or a nurse ringing you about a ward patient at two in the morning? Each of these people has a different agenda, and each needs a different opening.

Take the daughter. Her father has become forgetful. Her role is not only to give you his history. She is tired. She may be the one doing all the caring. She may be asking, without saying it, whether he can stay at home. If you treat her as a messenger and only ask about him, you will miss what she came to say.

Take the nurse on the phone. She knows the observations, the drug chart, and what has happened on the shift. She will tell you exactly what you ask and nothing more. If you never ask for the blood pressure, you will never hear it.

What State Are They In?

Look before you speak.

A man bent forward holding his abdomen does not need ten questions about his bowels first. He needs you to notice he is in pain, and offer him something for it. A woman who has been waiting three hours and is furious will not hear a word of your explanation until you have acknowledged that. A tearful mother needs a moment before she needs information.

The simulated patient has been told to present that way. It is the first thing the examiner is watching for. Content delivered over the top of distress, pain, or anger loses the station, however correct it is.

Who Is the Simulated Patient?

A simulated patient is a trained actor. They can cry on cue forty times in a day. If their script says angry, they will be angry with you, and with the next candidate, and the one after that. It is not personal. It is their job, and they do it very well.

So respect them. Treat them with the same courtesy and kindness you would give a real patient, because that is exactly what the examiner is watching for. Introduce yourself. Use their name. Make sure they are comfortable. Ask before you touch. Thank them at the end.

Don’t roll your eyes at the tears, talk over the anger, or treat them as a prop for your checklist. If you would not do it to a real patient, don’t do it to a simulated one. The way you treat the actor is the way the examiner believes you treat people.

What Are They Telling You?

Listen to the opening line. It is often the whole station in one sentence.

Then listen for the cue. A patient with a cough says, almost in passing, “My dad had a cough like this.” That is not small talk. That is the station. He is frightened it is cancer, and until you pick that up and ask about it, everything else you say will miss him.

And listen for the question. Many simulated patients are told to ask something at a set point: “Is it serious?” “Can I still drive?” “Was it my fault?” That question is a marked moment. Answer it there and then, honestly and simply. If the same question comes back a second time, you did not answer it the first time.

What Are They Not Telling You?

Some information is only given if you ask for it. The simulated patient will not volunteer the alcohol, the new tablet, the missed period, or the fact that they live alone. Silence is not the same as nothing.

And you have to ask for it properly. A broad question gets a broad answer. If a young woman has a headache and you are thinking about the oral contraceptive pill, “Are you on any medications?” is not enough. She may well say no. To her, the pill is not a medication, and the simulated patient has been told to answer exactly what you ask. So ask what you mean: “Are you on the pill, or any other contraception?”

It is the same everywhere. “Do you drink?” gets “Socially.” “How many drinks would you have in a week?” gets a number. “Any problems at home?” gets “No.” “Do you feel safe at home?” may get the truth.

Asking a broad question and hoping for a specific answer does not work. If you know what you are looking for, ask for it by name. And you will only know what you are looking for if you have read the stem and thought about it before you knock.

What Does It Mean When They Push Back?

When a simulated patient says “I don’t understand”, or “That’s a lot to take in”, or simply goes quiet, it is not the patient being difficult. It is a signal. Slow down, say less, and check what they have taken in.

When they refuse what you offer, disagree with you, or ask for something you cannot give, that is in the brief too. The examiner wants to see whether you listen, explain, and negotiate, or whether you repeat yourself louder. Arguing with a simulated patient never earns a mark.

What About the Room Itself?

The room is part of the stem. An inhaler and spacer on the desk. A growth chart. A urine sample. A patient lying flat in a gown. A phone ringing in a ward call. Nothing is put there by accident. If something is on the table, ask yourself why before you begin.

How Do You Stay in the Station?

The simulated patient stays in role, and so should you. Talk to them as a patient, not as an actor. When you need examination findings, ask the examiner, not the patient. Never tell the patient what you think the station is about. Show the examiner you have understood it by what you do.

A Last Word

Every station has two scripts in it. One is in your head. The other belongs to the person in the other chair. The doctors who pass are the ones who notice the second one.

So when you walk in, look up. Who is this? How are they? What are they trying to tell me, and what will they only tell me if I ask properly? Then let the answers decide what you do next.

If you would like help with this in your AMC OSCE preparation, I would be glad to hear from you.

With love,

Dr Vinu

Frequently Asked Questions

What is situational awareness in the AMC Clinical exam?

It is noticing who is in front of you, what state they are in, and what the simulated patient has been briefed to say, hold back, or ask, and letting that guide what you do in the station.

Do simulated patients in the AMC Clinical follow a script?

Yes. Each simulated patient is briefed on who they are, how they feel, what to say first, what to reveal only if asked, and often a question to put to the candidate. Their behaviour is linked to what the examiner is marking.

Why does a simulated patient not tell me important information?

Some information is only given if you ask for it specifically. A broad question such as “Are you on any medications?” may not bring out the oral contraceptive pill. Ask for what you are looking for by name.

What should I do if the simulated patient asks me the same question twice?

Stop and answer it properly. A repeated question usually means it was not answered the first time, and it is often a marked moment in the station.

Is the simulated patient a real patient?

No. A simulated patient is a trained actor playing a role from a script. They can show tears or anger on cue. Treat them with the same respect and kindness you would give a real patient, because that is part of what the examiner is assessing.

Should I ask the simulated patient for examination findings?

No. Examination findings come from the examiner. Speak to the simulated patient as a patient throughout.

09Oct

The Script and the Patient: Why a Lithium Script Won’t Carry You Through the AMC Clinical

If you are in the middle of your AMC OSCE preparation, I want to show you a lithium station, and the way most doctors answer it.

The is one of Oyamed’s AMC clinical mock station

Ms Margaret Hill is 21. She has been on lithium for nine months. She is going to Vietnam for a holiday and has come to the GP practice for travel advice. Her recent blood results are below.

Task: take a focused history and advise Ms Hill.

AMC clinical OSCE lithium station: travel advice stem with a lithium level of 1.4, by Oyamed

The scripted version

This is what I hear, almost word for word, week after week.

“Hello Margaret, thank you for coming. When are you going to Vietnam? Who are you going with? For how long? Are you doing any hiking or bushwalking? Any high-risk sexual activity? Do you have enough tablets for the whole stay?

It will be very hot over there and you will sweat a lot, so please drink plenty of water. Don’t take anti-inflammatories like ibuprofen. If you get shaky hands, vomiting or diarrhoea, or feel confused, see a doctor straight away. Carry a letter with your medicines, and we will check your lithium level when you come home.”

It is a good script. Every word of it is true. The doctor delivers it beautifully, and I can tell they have practised it many, many times.

But read the stem again. What exactly is the station?

What should you be looking for?

What the station was really asking

Look at the blood results. Margaret’s lithium is 1.4 mmol/L. In July it was 0.7. Her level has doubled, it is above the range, and her urea and creatinine have crept up too.

The scripted doctor never looked. They saw the word Vietnam and the script began. They sent a young woman with a high lithium level off to a tropical country, and told her to check her lithium level when she gets back.

The doctor who passes asks one quiet question outside the door: why is the lithium level high? The examiner does not put a lithium level on the page for decoration. The result is the station. Vietnam is the distraction.

So they walk in, and before Vietnam comes up, they find out what has changed. How has she been feeling? Any shaky hands, vomiting, diarrhoea, unsteadiness, muddled thinking? Has she been unwell, or not drinking much? Has anyone started her on something new, an anti-inflammatory, a blood pressure tablet, a water tablet? Has her lithium dose changed? When did she take her last tablet, and when was the blood taken?

Then the plan follows from her answers. If she has any signs of toxicity, she needs to be seen in hospital today. If she is well, the lithium needs reviewing with her prescriber, and the level and kidney function repeated, before she gets on a plane. Either way, the trip waits until her level is safe.

Then they explain it to Margaret in words she can hold on to:

“Margaret, before we talk about Vietnam, I want to go through your blood test with you. Your lithium level has come back higher than it should be, about double what it was in July, and your kidneys are working a little harder than before. I don’t want you travelling to a tropical country with your level like this. Let’s find out why it has gone up, speak to your psychiatrist about your dose, and recheck your bloods. Once your level is safe, we will plan your trip properly.”

Notice something. Almost every fact in the script is still here. Fluids, anti-inflammatories, the warning signs, checking the level. Nothing the doctor learned was wasted. The difference is that this time the knowledge was put to work for the young woman in the room, instead of being recited at her.

The best resources for AMC Clinical will give you the knowledge, so please keep everything you have learned. Just let go of the order/structure/script you learned it in. Read the stem properly, looking at the key informations. Ask yourself why this patient, why these results, and why today. Then let the patient tell you which part of your knowledge she needs.

That is the doctor the examiner is hoping to meet, and it is the habit that helps you pass the AMC Clinical on your first attempt. I believe you already are that doctor. The script just keeps getting in the way.

If you would like to practise this with me, come to Evening OSCE Club on a Friday night, book an AMC clinical mock exam, or talk to me about AMC clinical exam coaching one to one. For the examination stations, join my AMC physical examination face to face workshop in Brisbane. And if you are not already in our Telegram group, please join us. You are not doing this alone.

With love,
Dr Vinu

22Sep

AMC OSCE exam station door — how to open a clinical station, Oyamed guide

How to Open an AMC OSCE Station — and Why “What Brings You In Today?” Can Cost You the Station

My dear doctors, let me tell you about the mistake I corrected more than any other in my years teaching clinical skills at university — and the one I still see most often in candidates preparing for the AMC clinical exam.

It happens in the first ten seconds. Before the history. Before the diagnosis. Before you have shown the examiner a single thing you know.

Not every AMC OSCE station starts at the beginning of the patient’s story.

The scenario every candidate should sit with

Picture this station. A woman in early pregnancy has presented with bleeding. The first doctor has already seen her and arranged an ultrasound. The scan is done. You are the next doctor, and your task is to explain the ultrasound result.

Now imagine walking in and asking, “So, what brings you in today?”

Think about what you have just done. A frightened woman, who may be losing her pregnancy, has already told her story to the triage nurse. Then to the first doctor. Then to the sonographer. And you — the doctor holding her result — have asked her to live through it all again from the beginning, so that you can feel oriented.

We would never accept this in a real hospital. Handover exists precisely so patients don’t have to keep retelling a distressing story. The trauma-informed care literature names this as one of the ways healthcare retraumatises people, and it is why we teach medical students in Australia to pick the story up where it truly is, not where the textbook opening assumes it to be.

The AMC clinical exam is testing whether you practise medicine that way. This is not an etiquette point. It is a safety and communication point, and it is marked.

What the examiner hears in your first sentence

Here is the examiner’s-eye view, because this is the part candidates rarely see.

The station stem told you exactly where this patient is in her story. When you open as though she has just walked in off the street, you have announced — before you’ve even sat down — that you did not really read the station. You are running a memorised script at the patient instead of meeting this patient.

The reverse is also true. A candidate who opens in the right register, at the right point in the story, signals in ten seconds that they read the task, understood the situation, and have worked in a hospital. Examiners feel the difference immediately.

The opening that earns the marks

Introduce yourself and your role, then continue the story rather than restarting it:

“Hello Sarah, I’m Dr X, one of the doctors looking after you today. How are you holding up? I understand you’ve had an ultrasound — can I ask what you’ve been told so far about why you needed it?”

One opening, four jobs done:

You have shown the examiner you read the task.
You have acknowledged what she has already been through — which is where rapport actually comes from, not from a rehearsed pleasantry.
You have discovered what she knows and what she fears, so your explanation starts where she is, not from zero.
You have spared her the retelling.

And for those who like their frameworks: Calgary-Cambridge, the consultation model taught in every Australian medical school, says exactly this — introduce yourself, your role, and the nature of this interview, with an opening question that fits the reason for this consultation. It was never meant to be one fixed line. Candidates memorise the example and skip the principle.

When “what brings you in today?” is exactly right

Let me be fair to the poor sentence — it is completely correct for a fresh, undifferentiated presentation, where you genuinely are the first doctor in the story. The skill is not replacing one script with another. The skill is the question you ask yourself before you knock:

Where is this patient in their story — and which doctor am I in it?

First doctor, fresh presentation: open wide. Second doctor, results in hand: acknowledge, and continue.

Every station type in the AMC clinical has its own front door — the history station, the results station, the parent, the ward call, the distressed patient. Walk through the wrong one and the examiner knows before you’ve spoken your second sentence. Walk through the right one and you have banked your first impression at no cost at all.

That, my dear doctors, is a mark you can earn in ten seconds. There are not many of those in this exam. Take every one.

Dr Vinu Verghis · Oyamed AMC OSCE & RACGP PESCI Coaching · CPD Home Accredited Provider

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Your AMC success starts here!

Author: Dr Vinu Verghis