OSPE Guideline

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OSPE Guideline

• Prof. A.H.M.Shamsul Alam

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OSPE

• Objective Responses are measurable
• Structured Responses are in uniform format
• Practical Practical aspects of Surgery
• This examination format focuses on testing the
  practical skills of examinee while using
  diagnostic tools, laboratory data , procedural
  techniques and communication modes

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OSPE fields of evaluation

• Surgical pathology
• Specimen
• Illustration of pathological lesions
• Diagnostic tools
• Images
• X-ray
• CT scan/MRI
• Data interpretation
• Communication skills
• Verbal counseling
• Written
• Verbal Interactive( with colleagues)
• Surgical skills (procedures)

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Surgical pathology

• This is to test your pathological background
  while you manage a surgical problem
• Usually, a surgically removed specimen containing
  a pathological lesion is displayed
• You need to
• Identifying the organ see all around and look
  evidences of surgery and read all the questions
  in the script- you will find the clues
• Take your time and observe the morphology
• Describe methodically organgt nature of lesiongt
  involved areagt characteristics of lesiongt
  surrounding tissue

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Example Specimen

1. Find three significant features in this
   pathological specimen
2. What is your gross pathological diagnosis?
3. What could be the possible presentation with such
   a lesion?
4. Mention diagnostic investigations for such a
   disease.
5. How do you stage this disease?
6. What are the principles of treating this disease?

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Example specimen Answer key

1. Specimen colon shows two polypoidal mass and an
   ulcerative lesion. The ulcer has irregular and
   everted margin with a necrotic floor
2. Multiple colonic polyp and carcinoma colon
3. Rectal bleeding, change of bowel habit, weight
   loss, anaemia occurring in a middle or old age.
4. Colonoscopy and biopsy- histopathology
5. TNM or Dukes classification depending on tumour
   invasion of gut wall and surrounding tissue,
   nodal involvement and metastasis
6. Meso-vascular en-block resection of colon with at
   least 5cm of healthy margin

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Radiological image

• Tests your ability to use this diagnostic tools
  effectively and rationally
• Images could be plain or contrast X-ray, CT or
  MRI
• You need to
• Identify what type of image it is
• Take some time to appreciate the abnormalities
• Find clues from the set questions in script
• Answer precisely

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Example Imaging

• Scenario
• A 70 year old man presented with recent weight
  loss and moderate degree of jaundice. As a part
  of diagnostic workup, an imaging study has been
  carried out.
•  
• What kind of image it is?
• Mention four significant findings in the image.
•  
• Mention the most probable image based diagnosis
  and two other differentials
• Mention two advantages and two limitations of
  this investigation.

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Example Image Answer key

1. MRCP- Magnetic Resonance Cholangio
   Pancreatogram
2. Findings
3. Dilated biliary tree up to the terminal end of
   common bile duct
4. No filling defect in biliary tree
5. Gall bladder distended
6. Pancreatic duct normal
7. Carcinoma head of the pancreas.
8. D/D..
9. Periampullary carcinoma
10. Cholangio-carcinoma
11. Impacted calculus at the terminal end of CBD
12. Advantages.
13. Non-invasive investigation
14. Outlines whole biliary tree and pancreatic duct
    system for screening
15. Disadvantage
16. Not always precise in finding pathological
    changes(compared to ERCP)
17. Lacks therapeutic intervention

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Example X-ray

• SCENARIO This is the radiological image of
  chest ( PA view ) of a 50 year old man presented
  with significant weight loss and anorexia for
  four months .
• TASK Please read the radiological image
  carefully and answer the questions.
• List four significant findings in the image
• What is your radiological diagnosis?
• What organs / systems would you focus on during
  clinical evaluation of the patient?
• In absence of obvious clinical clue to have a
  diagnosis -
• What biochemical markers will help you?
• What imaging investigations you will suggest?
• What is your management strategy for this
  situation?

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Example X-ray Answer key
Q 1 List four significant findings in the image.
a) Multiple round opacities in both lung
fields b) Opacities are different in
sizes c) They are peripherally placed d)
Cardiac and hilar shadows appears normal e)
No pleural effusion Q2 What is your radiological
diagnosis ? Multiple pulmonary secondary
metastatic tumours Q 3 What organs / systems
would you focus on during clinical evaluation of
the patient? Thyroid, GI colon and rectum,
Pancreas, Kidneys, Prostate, TestiS, Bone Q 4 In
absence of obvious clinical clue to have a
diagnosis - (a) What biochemical markers will
help you? Tumour Markers PSA, CEA, ßHCG, a
Fetoprotein (b) What imaging investigations you
will suggest? (i) USG of Abdomen / Scrotum
(ii) USG of Thyroid (iii) CT scan of
Abdomen. Q 5 What is your management strategy
for this situation? a) Diagnosis of the
primary lesion b) Treatment of primary
disease and systemic treatment (Chemo/Hormone
therapy) for pulmonary conditions. c)
Palliative care
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Data analysis

• This is to test your ability for rational
  interpretation of laboratory data in the context
  of clinical situation
• You need to
• Take your time reading the whole data mindfully
• Read all the questions and the data again
• Answer precisely

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Example page-1

• A 50Y old man has developed deep jaundice for
  about two months and having high grade fever and
  vomiting for a week. His liver was felt enlarged
  and mildly tender. The following investigators
  were carried out and the results have been made
  available for your interpretations.
• CBC-
• Hb. 10 gm/dl
• TLC 24,000/cmm
• Polymorph - 81
• Lymphocyte - 14
• Monocyte - 4
• Eosinophil - 1
•  

Blood sugar (Random)- 7.1mg/dl Blood Urea 48
mg/dL Serum creatinin 2.8
mg/dL S.Bilirubin- 16 mg/ dl S. AST - 104
unit/ l S. Alkaline phosphatase- 798 unit /l S.
Amylase 50 unit/L Serum Electrolytes Na 125
mEq / dL K 5.3 mEq / dL Cl 94mEq/dL
HCO3 23 mEq/dL Prothrombin time - 29
seconds INR 2.3 HBSAg (screening)- Positive CA
19-9 69 U/ml

• Questions
• What is your interpretation of the patients
  data?
• Write your initial management plan.

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Example page-2

• After a week of initial management patient had
  some clinical improvement. Following are the
  results of review investigations. Give your
  interpretation.
•  
• CBC-
• Hb. 10 gm/dl
• TLC 11,000/cmm
• Polymorph - 75
• Lymphocyte - 14
• Monocyte - 9
• Eosinophil - 2
• Blood sugar (Random)- 7.3mg/dl
• Blood Urea 35 mg/dL
• Serum creatinin 2.1 mg/dL
• S.Bilirubin- 9 mg/ dl
• S. AST - 94 unit/ l
•  
•  
•  
•  

S. Alkaline phosphatase- 478 unit /l S. Amylase
40 unit/L Serum Electrolytes Na 128 mEq /
dL K 4.3 mEq / dL Cl 94mEq/dL
HCO3 23 mEq/dL Prothrombin time - 21
seconds INR 2.1 HBSAg (Confirmatory)- Positive
Questions 3. Write your interpretation of the
review data. 4. Name further investigations you
would suggest.
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Example page-3

• Answer key
• Patient is having the following conditions
• Obstructive jaundice possibly due to carcinoma
  of pancreo-biliary origin indicated by raised CA
  19-9.
• Cholengitis indicated by polymorphonuclear
  leucocytosis
• Renal impairment and electrolyte imbalance
• Possible hepatitis-B virus carrier
• Initial management
• Correction of dehydration and electrolyte
  imbalance
• Broad spectrums antibiotic
• Vitamin-K parenteral
• Improved blood count and LFT indicating control
  of cholengitis. Improvement of renal function
  with electrolyte imbalance correction.
• Investigations
• Upper GI endoscopy - to inspect the duodenal
  papilla
• MRCP- Non-invasive localisation of biliary
  obstruction, pancreatic mass detection
• CT guided FNAC -to detect and diagnose the
  pancreatic ca.
• ERCP- Diagnosis of peri-ampullary carcinoma,
  localisation of biliary obstruction, setting to
  relieve biliary obstruction.

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Verbal communications

• This is to test your counseling skills in
  surgical practice
• Counseling takes a vital role in surgical
  managements
• You need to
• Read the scenario and tasks several times
• Organize the core issues in your mind
• Write down the points you want to convey
• Have natural voice, maintain etiquette all along
  
• Use a single language, avoid medical terms

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Verbal communication- CounselingExample
page-1

• Scenario
• A 35year old lady, a college teacher and mother
  of one child, presented with a small lump in her
  right breast in upper and outer quadrant . It
  measured 2cm in diameter, appeared mobile,
  brought no change in nipple and there were no
  palpable nodes in axilla. FNAC of the lump
  reported duct cell carcinoma. You, being the
  treating surgeon, have to convey the
  information to the patient in your hospital
  chamber in order to involve her in the treatment
  planning.

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Verbal communication- Counseling Example page-2

• Tasks for Examinee
• Create an easy atmosphere understanding the
  mental state of the patient.
• Inform her about the findings and explain in an
  understandable language the significance of these
  findings.
• Mention your provisional plan that you consider
  most appropriate,
• Inform her about the alternate options and
  briefly discuss those.
• Answer her queries in order to clarify her
  confusions.
• Instructions to Examinee
• Presume that you are working in a medical
  college hospital.
• A well informed person would play the role of the
  patient
• You can use any language convenient to the
  patient
• Station observer would assess your performance
  in verbal communication skills using a structured
  check-list
• You may make notes on the paper provided in this
  station 

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Verbal communication- Counseling Example page-3

• Check list
• Welcomes her, ask her to take seat, asks how she
  was doing, says some comforting words before
  serious talks
• Explains the reasons of this conversation
• States the nature of the disease in easy language
• Explains the evidences supporting the diagnosis
• Narrates the provisional plan of treatment best
  for he given the circumstances
• Takes questions and allows her to express her
  desires
• Are you going to remove whole breast or part of
  it?
• I do not want to remove my breast. Is it
  possible?
• If the whole breast is not removed, would it
  cause any harm?
• Chemotherapy and radiotherapy cause much problem,
  can I avoid those?
• What are my chances of cure with the treatment
  you have suggested ?
• What are the chances growing the tumour again
  once removed?
• Informs her of the alternate options of treatment
  with evidence based outcome
• Assures her about the overall surgical outcomes
• Informs her about the adjuvant treatments and
  accompanying hazards
• Concludes conversation giving her time to think
  about the whole issues and give response at the
  earliest

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Verbal communication Interactive

• This is to test your interactive ability in
  professional conversations
• It occurs between the examinee and a senior
  surgeon (interviewer) based on a scenario and set
  questions, but supplementary comes up as
  conversation goes on
• You need to
• Listen to the question very carefully catch the
  reason
• Answer precisely, never say everything
• Give a chance to ask the next question that you
  know
• Never say anything but evidence based information
• Skip quickly if something is not known to you

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Verbal communication Interactive Example
page-1

• Scenario
• A one year old girl was brought to the hospital
  by parents as she had facial defect since birth.
•  
• Instruction to Interviewer
• Ask following questions to the examinee with
  regard to the management of patients cleft lip
  and palate. You are allowed to ask supplementary
  clarifying questions in response to the answers
  as and when required.
•  
• What is the diagnosis?
•  What is the developmental basis of this
  abnormality?
•  What are the present problems of this baby?
• What would be your advice to the parents
  regarding feeding and airway?
• What complications will arise if reconstruction
  is not done?
• What would be your management plan?
• What is the rationale behind the two stage
  operation?
• What further managements are required following
  reconstruction ?

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Verbal communication Interactive Example
page-2
Answer Key What is the diagnosis? Unilateral
complete Cleft lip, alveolus and palate ( left)
What is the developmental basis of this
abnormality? Failure of the fusion of the
fronto-nasal and maxillary process What are the
present problems of this baby? Cosmetic, suckling
difficulty and nasal regurgitation, impaired
speech development. What would be your advice to
the parents regarding feeding and airway? Using
Soft bottle, modified tits, enlargement of hole
of tit, feeding plate and for airway- nursing in
prone position(Ref. Bailey love p-661) What
complications will arise if untreated? Facial
asymmetry, psycho-social developmental disorder,
speech developmental disorder What would be
your surgical plan? Reconstruction of lip and
soft palate at the age of5-6 months and hard
palate and gum pad 15-18 months (Ref. Bailey
love p-661) What is the rationale behind the two
stage operation? Two stage closures encourages
the physiological narrowing of the hard palate
cleft to minimize surgical dissection What
further managements are required following
surgeries? Hearing and speech therapy, dental
care and facial revision surgeries
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Written communication

• This is to test your ability to write surgical
  documents as surgeons need to write documents in
  order to communicate with the people
• You need to
• Read the scenario and the task very carefully
• Take your time in planning an outline headergt
  body each paragraph for an issuegtfooter
• Never miss a component ( Example your address,
  Tel,)

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Written communication Example Page-1
Task This is a written communication skills
station. You are to write a Death summary of a
patient who has expired 3 -4 hours back,
presuming that, it is an important document for
Death Review Committee of the
hospital.   Instructions You shall have to
complete the report within 200 words. You will
find in patients file, chronologically, bridged
notes of patient history and physical
examination, investigation, treatment, follow up
and death confirmation. Please write your code
number as you start writing your report   Time
limit 10 Minutes
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Written communication Example Page-2

• Check list
• Incorporates the following in the death summary
• Patient particulars, admission time and date
• Admission presentation Provisional diagnosis and
  overall condition
• Immediate treatment on admission
• Diagnostic workup
• Diagnosis
• Intervention Brief description with time and
  date
• Ongoing monitoring and progress of the disease
• Consultations and specialty opinions
• Situation before death(deterioration sequence)
• Time and date of death
• Cause leading to death

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Surgical skills

• This is for testing your surgical skills that are
  essentially the standard or recommended
  techniques you follow while performing a surgical
  procedure
• You need to
• Read the scenario and the tasks several times
• Go by the written instructions at the station
• Stick to standards of surgical skills, not you
  style
• Go slow, but steady ask for assistance

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Surgical skills Example page-1

• Procedure
• You will have to perform a basic surgical
  procedure on a stitching board using available
  instruments and materials. 
• Task
• Close the incision made on the board by a
  continuous interlocking suture considering it
  as planned skin incision
• Put surgeons knot at the beginning
• Put Aberdeen knot at the end
•  
• Instructions
• Introduce yourself with your Code number
• You dont need to put on gloves
• Use 2/0 silk on curved cutting needle
• Ask for assistance
• Allotted time 5 minutes

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Surgical skills Example page-2

• Check list
• Starting knot
• Passes the needle at the end of the incision
• Makes first throw with double twist
• Makes second throw with single twist to make a
  reef/squire knot
• Continuation of suture
• Enters the needle into the skin vertically-
  passes the needle along its long axis- exits at
  an identical point on opposite side
• Keeps distance of entry/exit points from incision
  margins equal to its depth
• Suture interlocks on side of the first knot
• Keeps distance between the stitches equal and
  half that of depth of the incision wound
• Maintains adequate tension approximating the
  wound margin
• End knot-Aberdeen
• Stops the continuous suture at the other end by
  the final pass close to the just previous one and
  forms a loop without tightening
• Passes several Aberdeen knots and adequately
  tightens by bedding those down
• Makes final pass of thread through loop to end
  the knot and cuts it
• General considerations
• Holds needle at the tip of needle holder 2/3 away
  from tip
• Holds the wound margin with tooth dissecting
  forceps or skin hook while passing the needle
• Holds the needle holder and forceps properly

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Conclusion

• Surgeons need to become skillful in a number of
  areas in their practice
• OSPE represents surgical practice
• Stations are constructed from our daily
  experiences
• Mindful observation during training period
  ensures a best preparation

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Any question?
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