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).

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:

Two examinations are presented in the OSLE, and the others are presented in an Academic Day Workshop.

Straight Leg Raise (SLR) = pt lying on his/her back, and examiner lifts leg fully extended at the knee. The Art and Science of Bedside Diagnosis and Bates both agree that a positive test is defined as pain radiating at least to the buttock at an angle of 30 to 60 degrees.

Synopsis of Musculoskeletal Physical Examinations in an Academic Day Workshop each rotation (if not covered in OSLE) - presented by MUSC faculty member:

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. The dizziness is mostly a spinning sensation and is made worse by sudden movement of his head or turning of his head.

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

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

Students have 15 minutes as a group to perform the above tasks. It is suggested each student conducts the physical exam by him/herself. (A bell will ring 13 minutes into the encounter and again at the end of the encounter.)

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.

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.)

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 patient	“Could 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 appointments	“Relapse 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?”

Beth Henson is a 30 year-old patient who was asked to return today because her cervical test showed gonorrhea. She was seen by one of your preceptor's partners two days ago for pelvic pain and vaginal discharge, the chart states. Physical exam showed cervical motion tenderness and cervical discharge. She was diagnosed with Pelvic Inflammatory Disease, and received a shot of Rocephin in addition to a prescription for Doxycycline. You asked her to return to discuss the lab results. The entire family is enrolled in your practice.

Students have 15 minutes to perform these tasks. (A bell will ring 13 minutes into the encounter and again at the end of the encounter.)

Teaching Checklist

History

The student asked:	YES	NO
1. If pain improved.
2. If sexually active.
3. If husband is symptomatic.
4. How is marriage.
5. If there are other partners.
6. If partner(s) have an infection.
7. Previous history of sexually transmitted diseases.

Communication:

The student:	YES	NO
8. Introduced him/herself to me.
9. Informed patient of likely sexual transmission
10. Assessed patient's reaction to info about STD.
11. Assessed patient's next step with this information.
12. Discussed treatment of sexual partner.
13. Offered HIV, syphilis, and hepatitis testing.
14. Offered assistance in breaking news with spouse.

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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.

Students have 15 minutes to perform these tasks as a group. 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.)

Teaching Checklist

History

The student asked:	YES	NO
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:	YES	NO
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.

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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.

Students have 15 minutes as a group to perform these tasks. It is suggested each student conducts 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.)

Teaching 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.

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