Friday, 13 July 2012

ISCE debrief

In the middle of June I sat my ISCE's (Integrated Structured Clinical Examinations), integrated because we have to do a history, exam and skill all in one. We had six 25 minute stations to do in two groups of three split over two days. We were given 12 scenarios a few days before of which 6 would be our exams and the other 6 would be the re-sits if we failed. Last time I mentioned this, I had a comment from someone saying it wasn't fair if we knew what was coming up. The rumour is we get the scenarios because dyslexics complained a minute outside the station wasn't enough time to read and put them at a disadvantage. It wouldn't be fair to just give them the blurbs and no one else, so we all get them. Find a few friendly dyslexics and persuade them to complain?

Day 1

Gastrointestinal and urine dipstick with documentation
First station and I was pretty nervous because I didn't know what to expect. My examiner was jumping all around the room, peering over my shoulder, getting really close, interrupting me and was completely off putting. I later found out he was the head of ISCE's, so I guess he had a vested interest in making sure I was doing everything right. My patient was a real one with irritable bowel disease I think, which flares when she gets stressed or angry. Luckily for this one I don't have to give a diagnosis or management plan. I took a full history, did a gastrointestinal exam and then I had to do a urine dipstick and document the results. I missed a few bits from the history and the examiner got me flustered closing at the by interrupting me to tell me the things I didn't do when I hadn't actually finished yet. I had to politely tell him I just wanted to close with my patient and then I could answer any of his questions. I had plenty of time left, I think he was just over excited and I was emanating waves of calm. He wasn't supposed to ask questions anyway. He also made me wash my hands for a third time after taking off my gloves because I'd done a urine dipstick so now had uriney hands. I don't think he noticed I actually took my gloves off inside out so that wouldn't happen. He told me off for not taking proper notes, but was happy enough when I said I could write down all the details if he wanted them, they were all in my head. I wasn't being examined on that bit of documentation. All in all it went fine and I finished to time.

Diabetic review with cardiovascular Exam and BP with documentation
This was a weird one. I had an examiner, a real patient and a moderator marking the examiner. The case was a diabetic review which I did fine, taking a BP which also went fine, though I completely forgot how to document it and how to put it on the obs chart. The graph had a space for resp rate and pulse. I'd done pulse but didn't bother with resp rate so I turned round to check it. The patient looked a little expectant, as I was literally just staring at him, so I told him I was checking his breathing rate. I then remembered from class you really aren't supposed to say that as he'd start focussing on his breathing and I wouldn't get a natural result so I thought I'd better distract him. Unfortunately, the first thing I could think to say was "Don't worry, I'm just checking your breathing rate, erm, think about cats!" Cats, really brain? Brilliant. I just hoped my examiners had a sense of humour. I then had to do a cardiovascular exam on him, which was odd, as it didn't really follow from a diabetic review supposedly carried out in a GPs surgery in my opinion. It went fine, I even noticed he had some arthritic nodules on his hands so did some screening questions and got him to agree to go to his Doctor about it. Not sure I was supposed to do that, but hey, I'm thorough at least. I finished with masses of time left, and the two examiners stood in the corner comparing their notes on me and "hmm-ing" to each other which was awful and made me so nervous.

Mental Health with a mini mental exam and mental state exam
This was an actor with early onset Alzheimer's or dementia of some kind I think. She was really forgetful, thought she was in London not Exeter, thought it was a couple of years ago, had big lapses of memory like not being able to remember how to get home from town, couldn't remember her children's birth dates or what her husband had died of and her family were worried about her. This one was going quite well. I got a really good history and remembered all my questions for the mini mental and was writing up under the headings for the mental state exam just in case the examiner wanted me to present back, which luckily she didn't. Then I thought I'd blown it when I was trying to assess if she'd accept help by telling her it wasn't 2009 it was 2012 and she was in Exeter not Devon. She started getting really upset (understandably), but I managed to calm her down and get her consent for help. Again, I finished early, but it went well. I could over hear other people with the same case and could hear them getting really frustrated going round in circles with their actor who was playing at forgetting what they'd just said. All of a sudden they'd switch back to 'who are you, where am I?'. I'm so glad mine didn't.

Day 2

Respiratory with peak flow and documentation
I was much calmer and did a pretty thorough history. I was really pleased with this station. This was a real patient with a history of COPD. They'd also had breast cancer twice, a double mastectomy, stomach cancer, rheumatoid arthritis, ankylosing spondylosis and was a carer for their equally sick husband. She was an amazing woman to talk to. She had all this wrong with her, but she was still so cheery and upbeat about it all. I did a pretty good history but when it came to the exam the examiner was a real pain. She interrupted me and asked if I could talk through what I was doing and what I was looking for. It completely put me off and I lost my train of thought. I started to, but had to stop as thinking of all the differentials and possible signs was really putting me off my flow. She said it was all right if I didn't, just that it helped some people. She then looked really grumpy at me when I asked to do the peak flow on the examiner like we'd been told to and not the patient. I don't think she wanted to get up from her warm corner under a blanket (it was really cold) but I was supposed to explain to the patient and get the examiner to do the peak flow, so, tough basically! I finished this one perfectly on time.

Sexual health history and giving information about Chlamydia with documentation for an MSU request
This was an actor who was worried about a one night stand she'd had following a split from her long term boyfriend. She'd heard the guy she slept with was a bit of a lothario and so wanted to be checked out for Chlamydia. I actually found this one quite difficult. The sexual health history was fine and filling in the form for her to drop a urine sample back later was fine, but I found the giving information bit really hard. She didn't have any questions or concerns, she'd come to get checked out so it wasn't as if I had to convince her. I didn't want to scare her too much because I felt it wasn't necessary. She was smart, she knew already about the fertility problems, so I really didn't have an in. I told her the basics, gave her a leaflet and closed. I could hear other people drawing diagrams so that worried me a bit, but I still don't think it's a good thing to be all doom and gloom and worst case scenario and scare the patient. That was frustrating; I wish she'd had questions to answer. I finished really early.

Ophthalmology with cranial nerve exam and ophthalmoscopy
This was an actor whose history pointed to a pretty standard migraine with aura. I was happy to end on this one, it was nice to have a clear diagnosis. I took a complete history and moved on to the exam and skill section. This is where it all went a bit wrong. Because it was a standard migraine, doing a cranial nerve exam really didn't fit. I forgot papillary reflexes and I forgot to examine the external eye. At the end I went back and did the papillary reflexes when the examiner asked if there was anything else I wanted to do and what hadn't I used yet. Panic! We had to do ophthalmoscopy on a polystyrene head with ping pong balls for eyes. They have blood vessels and clock faces in them and we had to read the times on the clock. Because it was a head held by the patient I completely forgot the whole 'don't look in the light, look at a point on the wall behind me until I tell you', but I did get all the times, even the ones on the clocks that were orientated diagonally. At the end, the patient asked if I'd finished, and though she meant finished all my stations I thought she meant in the exam and was wracking my brain for anything else I missed. External eye exam didn't present in this search. I said I hoped so and she smiled, looked at the markers sheet and mouthed I'd done really well.

All in all, I thought they went alright. They weren't perfect, but I wasn't looking for perfection and we'd been told neither were the examiners. We just had to be safe and polite and competent. I thought I'd done enough to pass. I also needn't have worried, I didn't have any examiners I knew, although I did see their names on the sheet, I didn't have them. Once ISCE's were done, that was it, second year over. I did one more week at the GP surgery and then moved back home and went back to the Pensions Admin company.

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