This article has been written based upon the views and opinions of several past examinees, myself included, and those of various consultants and examiners. It is often said that the MRCEM OSCE examination is ‘just a routine day on the ED shop floor’, but despite this, many excellent practising EM physicians struggle to pass this challenging hurdle.

Data displayed on the RCEM website shows that as few as 25% of non-trainees were able to pass the MRCEM OSCE examination in previous sittings. This, of course, does not mean that the examinees who were unable to pass the exam were incompetent physicians; it simply means that they were unable to adapt their skill set to the requirements of the exam.

In this article, I would like to highlight some of the main reasons that good candidates fail. I have also included some tips from those that have passed and have outlined some easy ways to score points by doing very basic things in every station.

On discussing the exam with past examinees, I found that the most commonly cited reasons for failing to succeed were the following:

  • Anxiety
  • Failing to read the instructions adequately
  • Being unable to decipher the instructions within the pie chart
  • Poor communication skills
  • Ignoring obvious clues within the room or cues from the actor
  • Achieving a poor global score
  • Lack of practice

Below I have attempted to address each of the problems individually.

1. Anxiety

Experiencing anxiety during exams is entirely natural, and the fact that the OSCE stations are only 7 minutes adds to this. The only way to combat exam anxiety is to accept that it is both natural and inevitable. The best way to prepare and suppress the adrenergic surge is practice, practice and more practice. The best way to practice is under exam conditions, and if possible, this should be timed and observed by different examiners.

I am not of the opinion that this practise should be done last minute in the week before the exam; instead, your practice should start long before this point. I personally have utilised the consultants in the ED to observe and comment upon my history taking and examination skills. If you can get into a routine of doing this with 3 to 5 patients per day, you will be able to run through nearly all of the most likely scenarios in only 12 shifts. Another great strategy is to teach OSCEs to the more junior doctors within the department. Teaching can be a powerful learning tool and has helped me immensely with my general revision and also to develop the skills needed for the teaching stations.

2. Failing to read the instructions adequately

It is vitally important to read the instructions very carefully before entering a station. Easy marks are frequently lost by nervous or over-confident candidates that have overlooked vital information or made assumptions by misreading. This is a mistake I have personally made in all parts of the MRCEM exam.

In order to avoid making this mistake yourself, I would recommend utilising the one minute spent outside the station to read the question meticulously and ensure that you fully understand the task(s) assigned. Formulate a plan for the scenario-based upon the pie chart, take two deep breaths and then enter the station with a smile.

3. Being unable to decipher the instructions within the pie chart

There are many vital clues provided in the pie charts that are placed outside each OSCE station in the instructions to the candidate sheet. These pie charts visually break down the marking system for each station. You should carefully inspect the pie chart and make sure you know exactly what is expected of you and where the marks lie.

The example above shows the marking breakdown for a station that requires the candidate to teach ECG interpretation to a medical student. It can be seen that only 25% of the marks are allocated for clinical knowledge, whereas 50% are allocated for teaching skills. Therefore, if most of your time is spent demonstrating your own knowledge of ECG interpretation, rather than actually teaching the skill to the medical student, only a small percentage of the total marks will be available to you.

Similarly, in a station where you are a ‘Resus’ team leader, most of the marks will be allocated for communication and leadership skills. Instead of doing everything yourself, stand back and take charge, assign tasks to the team and run through the algorithm accordingly.

4. Poor communication skills

There has been an increasing emphasis on the assessment of communication skills within medical exams over the past two decades. Good communication skills depend upon far more than the use of language alone, and between 60-70% of our communication is non-verbal. Demonstrating that you have good communication skills whilst stressed in a station that lasts only 7 minutes is no easy task, but some simple things can be done to make this easier. Try to speak loudly and clearly and, if at all possible, sit at the same level as the patient with an open posture. Attempt to make a connection with the patient, maintain good eye contact and give them your undivided attention. Treat actors and mannequins as if they are real patients, interact with them in the same way that you would on the shop floor.

Avoid medical jargon and use language that is easily understood by the patient. Be direct and to the point but deliver any bad news in a sensitive and empathetic manner. Always check whether the patient has understood what you have said and ask if they have any questions. The use of appropriate transitional sentences can be helpful, particularly when trying to elicit sensitive information such as in the sexual history. For example, “I need to ask a few questions related to your sexual health.

Some questions might be embarrassing, but they are really important, and this discussion will be kept confidential. Is this okay with you?” If you are dealing with an angry patient, remember that this may be a coping mechanism that is helping them to deal with a difficult situation, and it is not a personal attack on yourself. Likewise, if you are dealing with a difficult or aggressive colleague, do not be drawn into an argument and remain calm and collected. The examiners will be looking for a doctor that acts in a professional manner.

5. Ignoring obvious clues within the room or cues from the actor

This is an important aspect of the MRCEM OSCE exam that is overlooked by many candidates. Nearly everything that is laid out in a station is there for a reason. There are no tricks, and nothing placed in the station is designed to distract you. For example, the presence of an X-ray in a teaching station will mean that the X-ray should be used. I have heard many stories about obvious props that were not used or missed by candidates. Hand gel is present in every cubicle and should be used. One candidate missed the fact that the lady sitting outside a hip examination station was a chaperone.

Another candidate didn’t realise that the CT scan demonstrating a subdural haematoma with midline shift in a breaking bad news station was meant to be shown to the patient’s relative. If you are not sure how to proceed, be vigilant and carefully look around the room, as there may well be obvious clues to help you.

6. Achieving a poor global score

Many candidates become overly preoccupied with ‘ticking the boxes’ that are necessary to fulfil the set tasks at the expense of the ‘global score’ and ‘patient score’. These scores assess six domains of professional behaviour; communication, rapport and empathy, professional competence, pacing, equal opportunities/discrimination and team skills. Most scenarios will have between 20-25 ‘tick-box’ marks allocated but a further 10 marks allocated for the combined global and patient scores. They, therefore, comprise a significant proportion of the total marks available. A candidate that scores 24 out of 25 but only gets a combined global score mark of 3 or 4 will actually score worse than a candidate that scores 20 out of 25 but was globally exceptional.

7. Lack of practice

I have already mentioned this in the anxiety section, but the importance of practice cannot be overemphasised. Practice in small groups with your friends and colleagues, and take turns to role-play as the candidate, patient and examiner. It is very helpful to get used to being the examiner as you gain a useful insight into the sorts of mistakes that can be easily avoided and see where easy marks can be picked up by monitoring the performance of your colleagues.

Pay careful attention to timekeeping as it is very common for candidates to run out of time, particularly in history taking and communication skills stations. If possible, also try to get experienced senior clinicians, preferably with some experience of marking or invigilating OSCEs, to watch you. Many valuable tips can be picked up in this way.

Learn from the mistakes of others

Hopefully, you can learn from the mistakes that other past examinees and I have made and avoid making the same mistakes yourself. Good luck with your MRCEM OSCE preparation!


Medical Exam Prep would like to thank Dr Sajjad Pathan for contributing this exam tips post.

About Dr Sajjad Pathan: Dr Sajjad Pathan is an Emergency Physician currently working in the UK. He has an active interest in medical education and is involved in teaching candidates preparing for the MRCEM examination. You can learn more about him and follow him on his Emergency Medicine Blog

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