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Category: AMC Clinical Coaching

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

04Jul
How to Pass AMC Clinical First Attempt | Success Story

How one of my students passed the AMC Clinical with 13 out of 14 on her first attempt

Inside an AMC Clinical Exam Preparation Success Story

A few weeks ago, one of my students sat her AMC Clinical exam for the first time. She scored 13 out of 14. I am not going to spend this whole post talking about that number because numbers are the easy part. What I want to talk about is her amc clinical exam preparation in the weeks before. There was nothing magical about it. She did what a lot of my students do, but she just did it consistently.

For context, she is an International Medical Graduate. Having passed AMC Part 1, she came to me for guidance. She has a young family and had about twelve weeks to prepare. At the time, she was terrified. This was not the polite kind of nervous most candidates say they are on the intake form. It was actual, up-at-night, second-guessing-her-decision-to-sit-this-exam terrified. This is the mindset most of my students walk in with.

The thing about the AMC Clinical exam is that it does not test what you know. It tests whether you can show what you know inside eight minutes in front of a stranger with a stopwatch. This is tough when your brain decides this is a life-or-death moment. Knowledge is roughly twenty per cent of the mark. Delivery, verbalisation and safety-netting are the other eighty per cent. Nobody tells you this until it is too late. She and I spent the first session talking about none of that. Instead, we talked about what she was actually scared of.

She learned the method before she learned the cases.

This is the biggest thing I keep repeating to candidates, and the biggest thing that gets ignored. Every good AMC candidate I have coached knew the method before they touched a single case card. The method is the scaffolding, while cases are the paint. If you paint without scaffolding, you fall off.

Most doctors sitting the AMC follow a structure. They use a different structure for each type of case. Chest pain has its own template, headache has another one, and so does the abdomen. It feels reassuring in the beginning. However, it stops working in the actual exam. The moment the station does not fit the template, you freeze while trying to decide which structure to run.

A method does not have that failure mode. A method is one way of thinking that fits every case, even the ones you have not practised before. Her method was four tools:

  • SOCRATES for every presenting complaint, not just pain.

  • VINDICATE for differentials.

  • PACE for physical examinations (Prepare, Approach, Complete, Explain).

  • Read, Name, Pivot for presenting findings.

Four tools were all she needed. She drilled them until she could run them in her sleep. When you can run the method in your sleep, the case-specific knowledge slots in without effort. When you cannot, every station feels completely new.

She practised out loud, not in her head.

This one hurts to write because it is so simple and so many candidates skip it. She read cases out loud. She presented findings to her bedroom wall. Additionally, she recorded herself on her phone and made herself watch it back the same day.

Watching yourself back is horrible. I absolutely hate watching my own recording because I sound so terrible. Even now, when students ask me to share my masterclass recordings, I sit on them for weeks. Apparently, some of the world’s best actors refuse to watch their own films. I am claiming membership in that club and refusing to be examined further.

But you cannot know what your presentation sounds like until you have heard it from outside your own head. Only when you watch yourself do you realise how many times you actually say “um” in five minutes of history-taking. In one of my own practice videos, I counted myself saying it eight times in just 5 minutes. Once I heard it, I stopped doing it. Imagine the examiner having to hear an “um” before and after every sentence. If you have not recorded yourself presenting at least once, you do not yet know what the examiner is going to hear.

She trusted the eight-minute clock more than she trusted her instincts.

Every AMC Clinical station is eight minutes. It is not seven or nine minutes; it is exactly eight. During those eight minutes, closing your case with a clear diagnosis and management plan earns more than an extra history question. Most candidates spend so long asking history that they never get to the summary. This usually happens because their structure has too many questions. Consequently, they feel uneasy stopping until they have asked all of them.

We built the timer into every practice. We allowed thirty seconds for introduction and consent, and three to four minutes for history or examination. Next, we took one minute for investigations and the completion statement, leaving ninety seconds to present. The last ninety seconds is where the diagnosis marks live. If you do not get there, you cannot score them. This holds true no matter how good the first six minutes were. By the time she sat the exam, the clock was completely in her body.

Two weeks before the exam.

We actually did fewer cases in the last two weeks. Our goal was to be mindful about stress and anxiety. After all, even the best prepared doctor can fail if they cannot manage their anxiety during the exam. Most doctors undergo this temptation, especially in the last two weeks, to read as many resources as possible. They download every PDF, guideline, and note they can find to blast through them.

The last few weeks are strictly for revision. You do not learn new content in the final stretch. Instead, you revise and consolidate what you already have. Two cases done three times is six real practice runs. Conversely, twenty cases skimmed once is twenty superficial impressions. Which one do you think shows up on exam day? It is the one you have drilled six times, every single time. That is how muscle memory works.

She stopped memorising and started integrating.

There is a moment somewhere around the sixth week of prep where the good candidates stop trying to remember things and start understanding them. She hit that moment in week five, which was earlier than I usually see it.

The moment goes something like this: “If the patient takes lisinopril and ibuprofen and now has an AKI, I do not need to memorise a list. I just need to think about what those three things do together.”

That is integration, and that is what the exam catches. It is what candidates who are stuck in memorisation mode never quite reach. I could see it happen in our sessions as her questions changed. Instead of asking what to say for symptom X, she asked why the examiner put that detail in the stem. She was thinking one level above the case.

What surprised me as her coach

There were no surprises. All I did was waiting and hoping that she would score more than me. In all the years I have coached the exam, no one had ever done that. Most of my students top out at 12 out of 14, but she got 13. As a teacher, there is nothing more rewarding than to see someone actually show up.

What this means if you are reading this and preparing

I am not writing this to say she was lucky, or that her cases were easier. That is not why she passed. She passed because she used every minute of the twelve weeks she had, and she was focused. She flew all the way down from Mackay to sit in the room for the Oyamed Physical Examination Masterclass. That is the kind of focus and determination this exam asks for, and she possessed both.

If I could give one message to every candidate starting their prep this week, it is this: do less, more properly. Learn the method before you learn any cases. Record yourself doing a case every week, and make yourself watch it. Trust the clock.

In the last stretch, drill sixteen cases daily. Your brain needs to experience sixteen consecutive cases before the real thing. Finally, ask yourself in week five whether you are still memorising or whether you have started integrating.

That is the whole plan. It is not complicated, but it does require you to trust it long enough for it to work. If any of that lands, you may want the actual tools I use with my students. I provide the method, the phrase bank, practice stations, and marking sheets. Most of what I mentioned is on my Payhip and Telegram, and much of it is free. Grab it, use it, and let me know when your score comes back.

– Vinu

P.S. You know you are loved when a student flies 960 kilometres to say thank you in person. She even brought purple flowers because she remembered my favourite colour!

As a touching show of gratitude, the student presented me with a beautiful bouquet of purple flowers.
As a touching show of gratitude, the student presented me with a beautiful bouquet of purple flowers.
29May
AMC OSCE preparation

A 7-Day AMC OSCE Rescue Plan: Structured Revision When You’re Running Out of Time

It’s Sunday night in Brisbane. The exam is next Saturday. You have eighteen tabs open across two browsers. Three textbooks balance on your knee. Also, you have two PDFs you’ve been “about to read” for a month. Your kitchen table has more notes on it than dinner. Somewhere underneath all of that is a study plan you stopped following in week three.

If this is you, close the tabs. Stop reading the textbooks. The week before your AMC OSCE is not the week for more content. Instead, it is the week for structure.

I’m Dr Vinu Verghis. I am a University OSCE Examiner who provides AMC OSCE preparation from a small clinic in Brisbane. I have examined hundreds of clinical stations and coached hundreds of candidates. The pattern in the last week before the exam is always the same. Candidates who are already content-heavy keep trying to add more content. However, they fail for another reason. They cannot retrieve, structure, and present what they already know in the eight-minute station limit.

Consequently, this is the rescue plan I give every candidate who arrives at my door at day six.

The myth about last-minute AMC preparation

Almost every candidate I see at one week out is doing the same thing: cramming. They want more cases. Some seek more differentials. Others read more guidelines and flashcards.

I understand the impulse. The exam feels enormous. Meanwhile, content feels like the thing you can control. If you just learn one more management plan, surely you have covered the gap.

Unfortunately, it does not work. I will tell you why, because this might be the most important thing you read this week.

Your brain at one week out cannot absorb new information quickly. You are sleep-deprived, and your cortisol is up. Furthermore, the very stress you use to push yourself harder functionally impairs your hippocampus. This is the part of your brain that consolidates new memory. Therefore, the content you read tonight will not be there on Saturday in any reliable form.

But there is one thing your brain CAN do well now. It can rehearse the application of what it already knows. You need the frameworks. Moreover, you require the structures and the retrieval scaffolding.

Consequently, that is what this week is for.

Why frameworks beat content (when time is running out)

At every AMC OSCE station you sit, the examiner has a specific goal. They are not testing whether you know the seventeen causes of chest pain. Instead, they test your ability to take a structured chest pain history. You must present it in a way that demonstrates clinical reasoning. The content is the easier half. The structure is what most candidates lose marks on.

If you have studied for six months, you already have the content. What you are missing is the scaffolding. This framework lets you apply the content under pressure to a stranger in eight minutes.

A framework is not a script. It is a structure. For example, use SOCRATES for pain and ICE for opening. Apply ABCDE for the deteriorating patient and PEACE for counselling. Each one is a five- or seven-letter scaffold. It lets you cover the right ground without thinking about what comes next.

When you walk into a station with a framework in your hand, you stop stressing. You do not try to remember everything you know. You let the scaffold do that work. Subsequently, your attention goes to the patient.

This is what passes the AMC OSCE. It is not content, but structure.

The 7-day rescue plan: Early Week Prep

Here is the plan I give my candidates who arrive at day seven in a panic. They have everything already in their head but no way to access it. This structured AMC OSCE preparation method works.

On Day 1 (Sunday), you will conduct an audit. Spend two hours making a list of the five AMC OSCE disciplines. These are Medicine, Surgery, Obstetrics & Gynaecology, Paediatrics, and Psychiatry. Under each one, write down the five most likely station types. You will find you can do this from memory because you already know what is likely.

Moving to Day 2 (Monday), focus entirely on history frameworks. Dedicate two hours to rehearsing SOCRATES (pain), ICE (ideas, concerns, expectations), and the systems-review structure. Do this out loud, three times each. It must be out loud because the mouth muscles need rehearsal as much as the brain does.

Next, Day 3 (Tuesday) involves examination frameworks. Spend two hours walking through the CVS, respiratory, abdominal, and neuro examination sequences. Put your hand on a chest and pretend you are at the bedside. Do not just read about how to do it—do it.

The 7-day rescue plan: Late Week Execution

Then comes Day 4 (Wednesday), which shifts to counselling. Take two hours to pick two counselling stations like breaking bad news or contraception. After that, rehearse them with anyone who will sit with you. Be sure to use the PEACE framework: Prepare, Explain, Acknowledge, Choices, End plan.

When Day 5 (Thursday) arrives, start your time management drill. Allocate two hours and set an eight-minute timer. Take a case you know cold. Practise your opening, structured history, brief examination, three-line summary, and plan. Do this five times. The eight-minute clock is the real opponent here, so you must befriend it.

For Day 6 (Friday), you must simulate mock conditions. Spend one hour, no more, running one full mock station from start to finish. Do this under exam conditions with a study buddy, and then stop. The night before the exam is not for revision because it is strictly for rest.

Finally, on Day 7 (Saturday), follow your rest and arrival ritual. Sleep in if you can and eat a real breakfast. Arrive at the exam centre with thirty minutes to spare. Do not open a textbook on the morning of the exam. Instead, listen to music, walk around, and breathe.

The one thing to do every single day

After every block of practice, spend five minutes on retrieval. Close all your notes. Take a blank piece of paper. Write down what you just rehearsed from memory. Note the framework letters. Record the opener you used. List the three things you would say first to a patient with chest pain.

This is the single most powerful tool in cognitive science for retention. It makes the difference between reading something and summoning it under pressure. Five minutes a day will save you marks.

The morning of the exam

Eat protein. Also, drink water. Wear something you have worn before. Your nervous system does not need new clothes on top of new stress.

The bell rings at each station. As you stand at the door reading the candidate stem, act strategically. Do three things in order. First, read the stem twice. Decide your opener. This is the first sentence you will say when entering. Finally, take three slow breaths, and then walk in.

The first thirty seconds of any station decide the rest of it. PREPARE is the most underrated of the OSCE frameworks. It happens entirely outside the room.

A short story about Priya

Last year I had a candidate I will call Priya. She came to me at day five in tears, convinced she would fail. She had read everything. For ten months, she had studied intensely. She knew the content of three medical schools’ worth of clinical material. However, she could not deliver it in eight minutes to save her life.

I told her to put her textbooks away. We spent four hours over two evenings on nothing but frameworks. We did SOCRATES out loud. We used PEACE for counselling. We practiced three-line summaries with an eight-minute timer. We did not open a single textbook.

She passed. In fact, she achieved marks above her own expectations on counselling and history-taking. She told me afterward that the relief of having a structure helped her. It was what let the content come back. She had always known it. She just couldn’t access it under pressure.

Ultimately, this is what frameworks do.

If you want the full 7-day plan with worked examples

This article is the skeleton. The full version sits in the Top 50 Cases Vault. It contains worked examples for all twenty frameworks and fifty cases across the five disciplines. Additionally, it offers a structured timetable that you can easily follow to the day.

It is a 125-page PDF I built for exactly this candidate. The guide is for those who are content-heavy, time-poor, and panicking in the last week. The price is A$79 at launch, rising to A$99 in 30 days. This is a one-time purchase. It comes personally watermarked and delivered within 24 hours.

https://buy.stripe.com/aFa8wQeWM7RJ3QI9TFenS03

If you have one week and want a structured way through it, this is the book.

— Dr Vinu Verghis

University OSCE Examiner who coaches AMC candidates. Brisbane. Director of Oyamed AMC OSCE Coaching.

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