Family Medicine Rural Clerkship

OSLE/OSCE

Objective Structured Learning Experience (OSLE)
Objective Structured Clinical Exam (OSCE)
 


In 2003-2004, MUSC Family Medicine introduced an OSLE into the Family Medicine Rural Clerkship to provide students with an OSCE-like learning experience (no grade - purely a learning experience to help prepare students for the OSCE).

OSLE

  • SECOND DAY OF ROTATION

Two or three students enter a Standardized Patient's room with a Family Medicine faculty member.  Students interact with the Standardized Patient based on scenarios listed below.  Students are evaluated on their ability to gather information, perform a physical exam, respond to emotion, and negotiate a mutually agreeable assessment plan with the patient.  MUSC Family Medicine faculty members give students immediate feedback.  Students have expressed great satisfaction with the OSLE and consider it excellent preparation for the OSCE at the end of the rotation.

The Family Medicine Rural Clerkship OSLE currently has 8 stations - click on the following links for a synopsis of each station:

1 Physical Exam station:

                   Patient with shortness of breath/dizziness (Daniel Roberts)

1 Interview station each:         

                  Patient with chronic cough / smoking cessation (Dana Jones)

                 Ongoing care of patient with DM / motivational interviewing (Morgan Sullivan)

                 Patient with hypertension / cultural competency  (Mr. Walker)

1 Simmon-Simulation station:

                 Unstable patient (Mr. Smith)

OSCE - Last Day of Rotation
  • Stations are similar format to teaching OSLE.
  • Details are provided to students when they arrive at the OSCE location.
  • Students are evaluated by standardized patients on both clinical and interpersonal/communication skills.
  • No faculty feedback at OSCE.


OSLE PRESENTING SITUATION and INSTRUCTIONS TO THE STUDENT


Daniel Roberts

Daniel Roberts is a 45 year-old patient who has had shortness of breath, worsening over the past 3 months and dizziness.  The difficulty breathing has been noticeable throughout the day, sometimes worse during activity but occurs at rest too. 

          You are to:

► Perform an appropriate physical exam to address both complaints of shortness of breath AND dizziness.

●  DO NOT take a history from the patient.

●  DO NOT check blood pressure - the nurse has already checked orthostatic vital signs and they are normal.

Checklist
Physical Examination                                                                                                                                                

The student:

Cardiovascular Exam

1.  Inspected.

2.  Palpated for PMI

3.  Listened RUSB, patient leaning forward, full expiration, on skin.

4.  Listened with patient supine, using diaphragm and bell on skin, in all 4 cardiac areas.

5.  Listened in left lateral position over mitral area on skin.

6.  Checked for peripheral edema.

7.  Checked for increased JVD.

8.  Listened to carotid arteries on skin.

9. Checked pulses- carotid plus dorsalis pedis and posterior tibial

Lung Exam

10.  Inspected.

11. Percussed on the skin side to side over 4 intercostal spaces in the back, 1 in the front, and over the right axillary space

12.  Auscultated on the skin side to side over 4 intercostal spaces in the back, 1 in the front, and over the right axillary space

13. Checked for tactile fremitus

14. Checked expansion of the lungs bilaterally

15.  Washed his/her hands.

Communication:                                                                                            

The student:

Introduced him/herself to me.

 


OSLE PRESENTING SITUATION and INSTRUCTIONS TO THE STUDENT

 
Dana Jones

 
Dana Jones is a 52 year-old patient who has had a chief complaint of chronic cough for 3 months.  You and your preceptor have determined that the cause of the cough is bronchitis that is aggravated by smoking.  Your preceptor prescribed an Albuterol inhaler for the patient. Your preceptor has asked you to address smoking cessation with the patient.

You are to:

Discuss smoking cessation counseling with the patient
Use the 5 A's of smoking cessation.
Identify the stage of change that your patient is demonstrating.
Use your motivational interviewing skills to help your patient get to the next stage of change.
          ●  You will NOT have time to conclude your counseling with this patient.
Conclude the session in a timely fashion.
Include plans for your next visit that will occur during the OSCES final in several weeks.

5 A's of Smoking Cessation
  1. Ask the patient if he or she uses
         tobacco
  2. Advise him or her to quit
  3. Assess willingness to make a quit attempt
  4. Assist those willing to quit
  5. Arrange for follow-up contact to prevent  relapse

Students have 15 minutes as a group to perform the above tasks.  It is suggested each student conduct a separate part of the interview within this time period.  (A bell will ring 13 minutes into the encounter and again at the end of the encounter.)

Checklist

 History                                                                       

History

The student asked:

1.  Age of onset smoking.

2.  Number of packs per day.

3.  About attempts to quit.          

4.  Length of abstinence.

5.  Reason relapsed.

 
Communication:                                                                                            

 The student:

 6.    Introduced him/herself to me.

 7.   Advises smoking cessation.

 8.   Assesses willingness to quit.

 9.   Appears to correctly identify stage of change.

 10.  Discusses relevance of smoking cessation to patient's current problem.

 11.  Identifies appropriate risks.

 12.  Asks or discusses rewards of not smoking.

 13.  Asks or discusses roadblocks to quitting.

 14.  Acknowledges difficulty to stop smoking.

 15.  Avoids argument.

 16.  Asks permission to continue discussion on next visit.

 


4 September 2001  |  Volume 135 Issue 35  |  Pages 386-391
MEDICAL WRITINGS   |   To Change or Not to Change:  "Sounds Like You Have a Dilemma"
Wendy Levinson, MD; Marc S. Cohen, MD; Donald Brady, MD; and F. Daniel Duffy, MD

Table Reproduced - Sample words for eachy stage:
 Stage  Patient Verbal Clue Physician Task Sample Words
 Precontemplation“I’m not really interested in quitting. It’s not a problem.”

State your own beliefs clearly, but not as a confrontation or a denial of the patient’s view

“I want to state my opinion clearly.  I think that the most important thing you can do for your health is to quit smoking.”
Try to understand how things look to your patientCould you tell me more about what leads you to feel  this way?”
Build tension between smoking and patient’s goals“Sounds like you enjoy smoking but also you want good health at your age.”
Provide information if patient is willing to receive it“Would you be willing to hear or read some information about the health aspects of smoking?”

 Contemplation

“I know I should quit, but I really do enjoy    smoking.  I’ve got to quit, but with all the stresses of my life right now, I don’t know if I can.”

Empathize with the dilemma

“Sounds like you’re caught in a bind right now.  On one hand, you know that the smoking it bad for  your health and you want to quit.  On the other hand, you enjoy it because it helps with stress.”

Accept the patient's reluctance to change.“I can understand not wanting to quit.”
Ask patients to identify the pros and cons of quitting “Let’s look some more at the things you like  about smoking and the things you don’t like.”  
Build confidence in changing without rushing the patient“I believe you could do this, but I agree that you’re not ready to take that step yet.”

 Determination

“I have to stop and I’m planning how to do that.”

   

Assess patient’s commitment and provide reinforcement

“On a scale of one to ten, how committed are you to quitting?”

Focus on positive features of the problematic behavior and how the patient might replace those features“Let’s look at the good things that smoking does for you.  How will you deal with the absence?”
Develop an action plan“What do you think will work for you?  What problems might arise?  How will you deal with them?

 Action

“I’m doing my best.  It’s tough.”

   

Reinforce positive action

“It’s terrific that you want to quit.  What’s   working for you?"

Anticipate problems and plan“What problems have you had?  How did you solve them?”
Suggest use of self-monitoring (diary), support from friends, follow-up appointmentsRelapse is common.  What will you do   should it start to happen?”

 Maintenance

“I’ve learned a lot through this   process.”

Praise changes and reinforce learning

“What have you learned that helps you   continue to avoid cigarettes?”

“Are there situations in which you are    tempted to smoke?  How do you cope at those times?”

 Relapse

“I blew it.”

Praise the prior success

“I think it’s great that you stopped smoking for a period of time.”

Reframe relapse as learning“What did you learn that might help you to stop next time?”
Assess willingness to change“How do you feel about trying again?”

Top of Page



OSLE PRESENTING SITUATION and INSTRUCTIONS TO THE STUDENT

Morgan Sullivan

Morgan Sullivan is a 40 year-old diabetic patient who has come to the clinic for "burning feet."

 You are to:

  ► Take a relevant history. 
  ► Address healthy lifestyle issues (e.g. diet and exercise).
  ►  Address the need for better glucose control.
  ►  Use your motivational interviewing skills to help your patient achieve these lifestyle changes.

    ● TIP: You may briefly address the “burning feet”, but attempt to focus your effort on the chronic management of his/her diabetes.

Checklist
History                                                                                                           

 The student asked:

 1.  Duration of burning sensation in feet.

 2.  Frequency of sensation.

 3.  What makes the sensation better.    

 4.  What makes the sensation worse.

 5.  If checking blood sugars.

 6.  About diet.

 7.  About exercise.

 
Communication:
                                                                                                                   

 

The student:

8.    Introduced him/herself to me.

9.    Advises diet change.

10.  Advises exercise.

11.  Assesses willingness to change diet and exercise.

12.  Discusses relevance of diet and exercise to patient’s current

       problem.

13.  Asks or discusses rewards of diet change and exercise.

14.  Asks or discusses roadblocks to diet change and exercise.

15.  Assists with suggestions for diet change and exercise.

16.  Negotiates having patient check blood sugar levels more

       frequently.

17.  Acknowledges difficulty of making lifestyle changes.

18.  Suggests involvement with another health care team member

       (i.e., nutritionist, diabetes educator).

19.  Arranges for a follow-up visit to check on progress.


OSLE PRESENTING SITUATION and INSTRUCTIONS TO THE STUDENT

Mr. Walker

Mr. Walker is a 50 year-old patient who was diagnosed with hypertension eight weeks ago.  Since that time, he has had two nurse visits, each with high blood pressure reading (150/102 and 162/108).  During a return visit to the physician a month ago, he was prescribed Atenolol.  He was asked to return a month later to see how his blood pressure was doing with the prescribed medication.

Today his blood pressure reads:  160/100

You are to:

► Conduct a follow-up visit for his hypertension.

► Use the ETHNIC mnemonic to help provide any information to the patient.

       ●  DO NOT take a blood pressure reading

ETHNIC Mnemonic

A framework for culturally competent clinical practice.  Suitable for clinical students since use requires diagnostic and therapeutic skills.

E:

Explanation (How do you explain your illness?)

T:

Treatment (What treatment have you tried?)

H:

Healers (Have you sought any advice from folk healers?)

N:

Negotiate (mutually acceptable options)

I:

(Agree on) Intervention

C:

Collaboration (with patient, family, and healers)

 References:
  Dobbie AE, Medrano M, Tysinger J, Olney C.  The BELIEF instrument: a preclinical teaching tool to elicit patients' health beliefs.  Fam Med 2003; 35 (5): 316-9.
 Levin SJ, Like RC, Gottlieb JD.  ETHNIC: a framework for culturally competent clinical practice.  In: Appendix: Useful clinical interviewing mnemonics.  Patient Care 2000; 34 (9): 188-9.

Checklist

History                                                                                               

 The student asked:

YES

NO

 1.  Any problems taking your medication.

  

 2.  If you have any concerns about taking the medication.

  

 3.  How do you Explain your illness.    

  

 4.  What Treatments have you tried.

  

 5.  If you have seen any other Health care providers.

  

 6.  About diet.

  

 7.  About exercise.

  

Communication:                                                                                            

 The student:

YES

NO

 8.    Introduced him/herself to me.

  

 9.    Affirms use of vinegar and prayer.

  

 10.  Assesses willingness to try medication.

  

 11.  Negotiates options of using vinegar and prayer with the medication.

  

 12.  Sought agreement with me about Intervention.

  

 13.  Collaborates with patient for follow-up with patient if a problem with medication occurs.

  

 

OSLE Instructions to the students:
 
 
 

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