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.

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