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Author: Dr Vinu Verghis

09Oct

The Script and the Patient: Why a Lithium Script Won’t Carry You Through the AMC Clinical

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.

AMC clinical OSCE lithium station: travel advice stem with a lithium level of 1.4, by Oyamed

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

22Sep
AMC OSCE exam station door — how to open a clinical station, Oyamed guide

How to Open an AMC OSCE Station — and Why “What Brings You In Today?” Can Cost You the Station

My dear doctors, let me tell you about the mistake I corrected more than any other in my years teaching clinical skills at university — and the one I still see most often in candidates preparing for the AMC clinical exam.

It happens in the first ten seconds. Before the history. Before the diagnosis. Before you have shown the examiner a single thing you know.

Not every AMC OSCE station starts at the beginning of the patient’s story.

The scenario every candidate should sit with

Picture this station. A woman in early pregnancy has presented with bleeding. The first doctor has already seen her and arranged an ultrasound. The scan is done. You are the next doctor, and your task is to explain the ultrasound result.

Now imagine walking in and asking, “So, what brings you in today?”

Think about what you have just done. A frightened woman, who may be losing her pregnancy, has already told her story to the triage nurse. Then to the first doctor. Then to the sonographer. And you — the doctor holding her result — have asked her to live through it all again from the beginning, so that you can feel oriented.

We would never accept this in a real hospital. Handover exists precisely so patients don’t have to keep retelling a distressing story. The trauma-informed care literature names this as one of the ways healthcare retraumatises people, and it is why we teach medical students in Australia to pick the story up where it truly is, not where the textbook opening assumes it to be.

The AMC clinical exam is testing whether you practise medicine that way. This is not an etiquette point. It is a safety and communication point, and it is marked.

What the examiner hears in your first sentence

Here is the examiner’s-eye view, because this is the part candidates rarely see.

The station stem told you exactly where this patient is in her story. When you open as though she has just walked in off the street, you have announced — before you’ve even sat down — that you did not really read the station. You are running a memorised script at the patient instead of meeting this patient.

The reverse is also true. A candidate who opens in the right register, at the right point in the story, signals in ten seconds that they read the task, understood the situation, and have worked in a hospital. Examiners feel the difference immediately.

The opening that earns the marks

Introduce yourself and your role, then continue the story rather than restarting it:

“Hello Sarah, I’m Dr X, one of the doctors looking after you today. How are you holding up? I understand you’ve had an ultrasound — can I ask what you’ve been told so far about why you needed it?”

One opening, four jobs done:

  1. You have shown the examiner you read the task.
  2. You have acknowledged what she has already been through — which is where rapport actually comes from, not from a rehearsed pleasantry.
  3. You have discovered what she knows and what she fears, so your explanation starts where she is, not from zero.
  4. You have spared her the retelling.

And for those who like their frameworks: Calgary-Cambridge, the consultation model taught in every Australian medical school, says exactly this — introduce yourself, your role, and the nature of this interview, with an opening question that fits the reason for this consultation. It was never meant to be one fixed line. Candidates memorise the example and skip the principle.

When “what brings you in today?” is exactly right

Let me be fair to the poor sentence — it is completely correct for a fresh, undifferentiated presentation, where you genuinely are the first doctor in the story. The skill is not replacing one script with another. The skill is the question you ask yourself before you knock:

Where is this patient in their story — and which doctor am I in it?

First doctor, fresh presentation: open wide. Second doctor, results in hand: acknowledge, and continue.

Every station type in the AMC clinical has its own front door — the history station, the results station, the parent, the ward call, the distressed patient. Walk through the wrong one and the examiner knows before you’ve spoken your second sentence. Walk through the right one and you have banked your first impression at no cost at all.

That, my dear doctors, is a mark you can earn in ten seconds. There are not many of those in this exam. Take every one.

Dr Vinu Verghis · Oyamed AMC OSCE & RACGP PESCI Coaching · CPD Home Accredited Provider

08Sep
Oyamed teaching graphic showing an eighteen question budget for a five minute AMC Clinical OSCE history, broken down by section

The 18-Question Rule: How Many Questions You Can Actually Ask in an AMC OSCE History

The short version

  • Five minutes is three hundred seconds.
  • One question and its answer costs about seventeen seconds.
  • That gives you eighteen questions. Not forty. Not thirty. Eighteen.
  • SOCRATES is eight of them — and in a chest pain case, closer to twelve.
  • You are not choosing what to ask. You are choosing what to leave out.

Nobody teaches the second one. It is the whole game.

 

The four-minute moment

You are four minutes in. The patient is still describing the pain. You have not asked about medications, you have not touched family history, and there is a clock behind you that you cannot see.

I have watched this from the examiner’s chair more times than I can count, and I want to be clear about something. The candidate is not lost. She knows the case. She would manage this patient safely on a real ward tomorrow morning.

She is spending money she does not have.

That is what running out of time actually is. Not ignorance. A budgeting problem. And nobody hands candidates the budget, so here it is.

 

How long does one question actually take?

Sit down with a stopwatch and time yourself asking a real patient a real question. Not reading it aloud. Asking it, hearing the answer, taking it in, and moving to the next one.

Three seconds to ask it. Eight to ten for the answer, if the patient is brief. Three or four to register what they said and choose where to go next.

Seventeen seconds.

That is my working figure from coaching, not a laboratory measurement. Time yourself and see how close you land.

And seventeen assumes a cooperative patient. It assumes they do not pause, do not ask you something back, do not tell you about their sister’s operation. The moment a patient says something that matters and you respond to it properly — which you must — that one exchange costs thirty to forty seconds. Two of those and a fifth of your history is gone.

 

Why eighteen is smaller than it sounds

Eighteen sounds generous until you start spending it.

One goes on the opening. Your name, their name, permission to ask some questions.

One goes at the end on is there anything I haven’t asked about that you think I should know. That is the highest-yield question in medicine and you never cut it.

Sixteen left for the actual history.

Now put SOCRATES against that. Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating and relieving factors, Severity. Eight questions. Half of what remains, spent characterising one symptom.

This is not an argument against SOCRATES. It is an argument for knowing what it costs before you reach for it.

 

Where the eighteen go

A working budget for a station whose task is a focused history, then a differential with reasons:

  • 1 — opening and consent
  • 7 — SOCRATES, minus the A
  • 5 — the differential sweep, which is what the A actually costs
  • 2 — risk factors for your leading differential
  • 1 — past history and medications
  • 1 — impact on the patient
  • 1 — the closing catch-all

Eighteen. Nothing spare.

The line that matters is the five. In SOCRATES, “associated symptoms” looks like one question. It is not. It is where your differential lives, and it costs five — one for each thing you are trying to move up or down.

Treat the A as a single question and you have not taken a history. You have characterised a symptom.

Notice what is missing. No systems review. No family history unless it is a risk factor for what you suspect. No occupational history unless the occupation is the point. Those are not forgotten. They are deliberately not asked, because the arithmetic does not allow it.

 

A worked example: Mr Tomás Ferreira, 54, a concreter

Central chest pain, two hours. Take a focused history, then give your differential with reasons.

The stem has already given you his age, his job, and how long this has been going on. Ask any of those again and you have paid seventeen seconds for something that was printed on the door.

The stem has also told you what the examiner wants. A differential. Not a diagnosis.

So this is not a cardiac history.

Positional. Pleuritic. Cardiac. Ribs. Skin.

That is the differential in five words, and it is the discipline this station is testing. Run a cardiac work-up on a fifty-four-year-old with chest pain and you will describe angina beautifully. You will also walk past the pericarditis, the pulmonary embolus, the costochondritis and the shingles.

Here is the spend.

“Good morning Mr Ferreira, my name is Dr ___. Is it alright if I ask you some questions about the pain?”

Then: where exactly is it · when did it start and what were you doing · what does it feel like · does it go anywhere · how bad out of ten · does anything make it better or worse · is it constant or does it come and go.

That is seven. SOCRATES without the A.

Now the A, which is five questions and not one:

  • Positional — is it worse lying flat, and better sitting forward?
  • Pleuritic — does it hurt more when you take a deep breath or cough?
  • Cardiac — are you short of breath, sweaty or nauseated with it?
  • Ribs — is it sore if you press on it, and have you lifted or strained recently?
  • Skin — any rash or blistering over that area, any burning in the skin?

Five questions. Five diagnoses moving up or down. The examiner is watching you build the differential they are about to ask for.

Then: do you smoke, and how much · has anyone in the family had a heart attack young.

Then: any medical conditions, and what are you taking.

Then: how is this affecting you — are you frightened.

Then: is there anything I haven’t asked that you think I should know.

Eighteen questions. Not a cardiac history. A chest pain history, with five causes ruled in or out, and three minutes still in hand for the differential.

SOCRATES cost you twelve of the eighteen, because the A was never one question. Knowing that before you walk in is the difference between finishing and running out.

 

Three ways the budget leaks

The second open question. “Tell me about the pain” is right. “Tell me more about that” thirty seconds later is a second open question, and open questions are expensive — thirty seconds, and the patient decides what you get. One open question. Then close down.

The systems review on autopilot. Bowels, bladder, weight, appetite, sleep, asked of every patient because that is how you learned to clerk on the ward. In a five-minute station that is five questions, more than a quarter of everything you have, and in a chest pain case it buys you nothing.

Re-asking the door. The stem gave you the age, the duration and the complaint. Open with “and how old are you?” and you have paid seventeen seconds for information you already had.

 

When the patient will not stop talking

You will get one. This is where most candidates lose the station, because interrupting feels rude and they were taught not to do it.

Interrupt. Warmly, and with a reason.

“Can I stop you there — that’s helpful, and I want to make sure I ask you a few specific things before we run out of time.”

Five seconds. Buys back forty. And it reads as competent rather than rude, because you gave the patient the reason.

 

Does this apply to every station?

No. And this is where candidates get caught by advice that was true somewhere else.

Five minutes for the history belongs to the eight-minute station whose task is a history plus something else — a differential, a management plan, an explanation. Five for the history, three for the rest.

A psychiatric history station gives seven minutes for the history itself, with the diagnosis and differential asked for afterwards. Seven minutes is about twenty-five questions, and you need all of them, because a psychiatric history has a risk assessment sitting inside it that cannot be cut.

The AMC sets a time guideline per task. It varies by station and it is signalled during the station. Read the door and budget to what that stem gives you.

The arithmetic travels. The number does not.

 

Frequently asked questions

How many questions can you ask in a five-minute OSCE history?

About eighteen. Five minutes is three hundred seconds, and a question with its answer takes roughly seventeen seconds with a cooperative patient. That figure drops fast if the patient gives long answers or tells you something that deserves a proper response.

Is SOCRATES too long for an OSCE station?

No, but it is more expensive than it looks. Eight questions on paper, and closer to twelve in a chest pain case, because “associated symptoms” is not one question — it is the five you need to separate positional, pleuritic, cardiac, rib and skin causes. It is the right tool for pain. It is the wrong tool when the problem is not pain, and reaching for it out of habit is a common way to lose a station.

Should I do a systems review in an OSCE history?

Usually not. A full systems review is five or more questions and in most focused stations it returns nothing you can use. Ask only the systems questions that separate your differentials.

Is it acceptable to interrupt a simulated patient?

Yes, if you give a reason. “Can I stop you there, I want to make sure I ask a few specific things before we run out of time” reads as time management. Letting a patient talk for ninety seconds because interrupting felt impolite reads as a candidate who has lost control of the station.

 

If you want to see this in a real station rather than on a page, the Oyamed Telegram channel carries free teaching cards and worked cases each week, and the Evening OSCE Club runs on Friday evenings with a trained simulated patient who will not slow down to help you. If you want the questions themselves, station by station, the Oyamed case vaults set them out in the order they should be asked.

 

You do not have five minutes.

You have eighteen questions.

Dr Vinu Verghis · MBBS, MSc, MPH, FHEA · Academic Lead, Oyamed · University OSCE examiner · Brisbane.

Oyamed provides one-to-one AMC Clinical OSCE coaching, mock examinations with written feedback, and small-group masterclasses.

Sources: the seventeen-second figure is a coaching estimate drawn from observed practice sessions, not a published measurement. Time guidelines are set per task by the Australian Medical Council and vary between stations, as stated in the Clinical Examination specifications.

Oyamed Pty Ltd is an independent education provider and is not affiliated with, endorsed by or connected to the Australian Medical Council.

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