My first objective structured clinical examination

After a semester of studying and taking written exams, we had our first OSCE in medical school. An OSCE — or an objective structured clinical examination — is the real deal. Instead of filling out multiple choice boxes, we instead work with a real human being, which for me is a welcome change.

The actor is given a script with their unique condition and story — it’s a simulation of what an actual patient encounter would be like when we attain our credentials in the upcoming years.

For our first OSCE, we weren’t yet assigned the tasks of diagnosing and treating; we were merely running through a patient history and performing a cardio-pulmonology physical exam. These are some of the most essential elements of any encounter a patient has with their physician.

The doctor will introduce themselves and seek to understand what’s wrong with a series of questions ranging from “when did it start” to “describe what the condition is like” before seamlessly transitioning into the physical exam percussing the back and auscultating the heart and lungs. It was a series of maneuvers my pediatrician had performed so many times on me. He seemed so confident, so assured. I trusted that I was in good hands.

This is what medicine was all about to me, and I was nervous but excited to finally be on the opposite end of that doctor-patient dynamic, to be the doctor and not the patient. I had been practicing for the past few days with my classmates, and the learning curve was steeper than I had initially imagined. There were over 25 questions we were expected to ask and over 25 maneuvers we were expected to perform. And because this wasn’t even yet the full comprehensive physical exam, there were still other maneuvers that we didn’t yet have to master (i.e., abdominal, musculoskeletal, head and neck).

When I work with a classmate, I don’t overthink it. I know that they don’t have a real condition. And because we have a sense of familiarity with one another, we know that we will forgive each other for mistakes and actively provide constructive criticism.

On the day of my exam, I walk into the room, and I’m met with a middle-aged lady in visible distress. This is no longer just a practice run through.

I end up overthinking things in trying to make sure I hit every one of the fifty items on my checklist. At the same time, the patient is revealing to me emotions and parts of her story that are deeply intense — the death of a parent, the stresses of her job, her fears of her own death. And then I ask the patient to remove her gown so that I can examine her back and chest, percussing and palpating her skin to ensure normal bodily function.

The entire ordeal is extraordinary. Here I am a 24-year-old, and I’ve just met essentially a stranger who has likely told me more about her personal life than anyone outside of her perhaps closest confidants. This stranger has also allowed me to examine her bare body. All of this has happened in less than 15 minutes upon just meeting her.

The examinations we perform, the questions we ask, are invasive in every sense of the word. Physically and spiritually, such catalyzed intimacy does not exist in any other professional domain.

After the exam, I receive my feedback from the standardized patient and from my preceptor. I had checked off most of the required items for my exam, but that wasn’t what the patient had most appreciated about me. It was my presence she said, my calming voice that made her feel relaxed and safe. I slowed things down and gave her the space to open up in ways she normally might not to a physician.

And it wasn’t the items I missed on the checklist that she was most hurt by in my performance. When the patient expressed to me that she had concerns of having pneumonia, in the subconscious backdrop of making sure I had covered all my bases in the allotted time frame, I had failed to emotionally meet her at her vulnerability.

Instead of moving on to the next question, I should have told her that I heard her fears, I recognized them, and that I would do everything I could with my team to monitor developments. This is a lesson that I will keep with me.

The patient revealed to me that it took courage on her end to share her concerns with me. It’s not something that she would tell anyone. She wouldn’t show her body to anyone.

It’s really only because I wear this white coat and what that represents means she trusts me so much. As a physician and as a human being, it’s my responsibility to meet my fellow brethren when they are at their most helpless, sometimes in the most basic acts of pausing to share a moment of intimacy. It’s something as simple as kindness, as sympathy — that’s what this patient craved the most.

Going through my first OSCE was a lesson in humility. There is still so much for me to learn, so many more repetitions and iterations to go through to make all of these motions and questions feel second nature — to give me the peace of mind to completely give my undivided attention to the patients before me.

My patient had very high expectations of me. As she should. The trust that patients place on me to help them through their ordeal is an honor. I’ll work hard towards meeting these standards.

Johnathan Yao is a medical student.

Image credit: Shutterstock.com

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