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"Measure Results, Not Effort" - My First OSCE Experience

Posted Feb 03 2011 8:04pm
The first time I saw that quote was in a fellow classmate's email signature a year and a half ago. At the time, I had a very strong, negative, visceral reaction to it. I always thought it was about the effort, the hard work that led to the reward. But then I had my first OSCE experience, and I now understand that quote...

Objective Structured Clinical Examination, or OSCE, is where medical students draw upon the clincial knowledge they've acquired over the last two years and utilize it in a timed, videotaped, physician-proctored exam with an actor/patient. It's a sneak peek of what's to come in third year when we find ourselves in an actual hospital room on the first day of our clinical rotations ordered to do a complete history (by an actual resident or attending) of an actual patient. OSCEs serve as a transition from "let's pretend my healthy, albeit stressed out and sleep deprived, classmate is an 87 year old man with rheumatoid arthritis and prostate cancer and a glass eye" to "Oh no, I forgot to ask my patient if she travelled recently - she might have some obscure infectious disease that I missed because I forgot to ask that one question about her social history and now she might die and I will have killed my first patient because I have no idea what I'm doing." Yes, OSCEs serve as a nice bridge from second year to third year.

I was scheduled for this week, a comprehensive history of a new patient. I had some time to prepare and I definitely made use of it. I practiced with people, I wrote out all of the questions and committed them to heart. I felt prepared, and I had managed to get everything done in the alloted 20 minute time frame. So when the day finally arrived and I was standing outside of the door in my Ann Taylor navy pinstriped pants, tan heels, and a slightly stiff kind-of-itchy short white coat, I felt okay about it. Sure, my hands were shaking and the thought hurling passed my mind, but I grabbed my actor/patient's chart and went into the exam room. In my head I thought it was going well. I had a good rapport with my actor/patient, I was writing everything down for the SOAP note I would have to write later, and I was midway through the review of systems when all of a sudden someone in the hall belted out, "TIME!"

What? Time already? But I'm not done. No, this can't be. I didn't finish.

All that practice, all that preparation for nothing. I guess it's true - "Measure results, not effort."

When I returned a few hours later for my faculty review session, I asked my physician proctor if 20 minutes is an average allotment of time with a patient. "Oh sure, I would have done the history and physical in 15 minutes." How is it humanly possible to ask all of those questions plus a complete physical in only 15 minutes? I was really enjoying getting to know my "patient" and hearing her story. I wanted her to talk freely, but I should have kept it to quick yes/no questions. I have to admit, I feel frustrated by the fact that I only get such a short amount of time to do everything, do it with quality, and do it correctly. But I guess that's the real world experience of a physician - too much paperwork and not enough patient time, dealing with insurance companies and overbooked patient appointments. I feel the rose-colored glasses slipping off.

I know I should be happy with my actor/patient's critique. This was my first clinical encounter and she said she would have wanted me as her doctor. I'm only a second year and she said I made her feel comfortable. But all I can think about is that I didn't finish, which correlates to a grade that reflects that I didn't finish. My professors won't see all of the effort I put into preparing for this first OSCE or that I know what questions to ask, they'll just see what I missed because I ran out of time. And residency programs won't see that my actor/patient thought I was caring and competent or that my physician proctor thought I had good interviewing skills; they'll see the grade that reflects that I didn't finish in time.

I've been pretty down about it. I know I should move on, focus on studying for the Boards, prepare for the next OSCE assignment - that's what a rational, sensible person would do. Not me! I play it over and over again in my head, letting the frustration stew in my head until it gets me into a bummed out mood. And at the end of a very long day and my brain couldn't handle to eight hours of class and self-punishment, I headed home to wallow in my "why can't I do this?" mood and a box of cookies. And on my way out I held the door open for the security guard who walks throughout the building monitoring the rooms and takes notes on his clipboard. I see him throughout the day, sometimes at too late/too early hours of the day, and I always wave or say hello. But today, when I held the door open for him as I was simultaneously balancing a heavy backpack with one hand and fishing my gloves out of my coat pocket with the other hand he said, "You're always in a nice mood. There are some folks around here that aren't, they always have a frown on their face. But you, you always smile. You have a nice aura."

It was so unexpected. I thought about what he had just said, and I felt my perspective re-shuffle itself. As I walked home I thought to myself, "You know what, that actor/patient said she would have wanted you as her doctor. She felt comfortable and cared for, and isn't that more important? Isn't that the only thing that's important?" I get so bogged down in grades and numbers and scores that sometimes the big picture escapes me. The results will always be measured, but I still believe that the effort is just as important too.
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