The MCAI SOE/OSCE (Structured Oral Examinations/Objective Structured Clinical Examination)

 Personal Experience

So for this exam we actually sat them from home again due to Covid (I believe they will be back in person again this year?). For my preparation I really took a haphazard and everchanging approach which is precisely why I am here to hopefully prevent you from making my mistakes. I started 2 months prior using the Dr Podcast book and would plan my study using the contents table (Error no.1 – do not leave the entire curriculum for a two month sprint when you haven’t studied in 5 months. You won’t remember the majority of what you previously studied). About three weeks into this mess, I realised I wasn’t preparing anything for the OSCEs which carry a huge amount of marks and are assessed in a very different way in terms of content. So I then incorporated the MCAI OSCE book and would study a handful of the OSCEs alongside chapters in the Dr Podcast book.

At about week 3, one of our extremely kind Consultants called Deirdre started giving us tutorials for the exam using questions which would be similar to those asked on the day. Straight away it was CRYSTAL clear I was in big trouble. The Dr Podcast book was nowhere near comprehensive enough on any topic. So now I had to 1) complete the OSCEs, 2) Go back on the topics I covered from Dr Podcast and bulk up my notes (was I ever going to get to read these again?) and 3) finish about 1000 more topics (or so it felt). NOT a good situation to find yourself in, five weeks out from a seriously tough exam. Please learn from my mistakes. 

For us (the online exam) there were 15 OSCE questions split into 1.5 hours each. There were two papers to replace the Structured Oral Exams which were also 1.5 hours each. The first paper was split into pharmacology and physics/equipment. The second paper was split into physiology and physics/equipment.

I definitely preferred to sit the exam in the comfort of my own home, dressed in my cosies with a blanket over my lap. So if you are going back into the in-person assessments you have my full sympathy. I can imagine it's very daunting looking two Consultants in the eye if you don't know how to answer what they're asking you. However, my friends and I have talked about it at length and there's definitely the bonus that they can redirect you if you misunderstand the question (I mistook one of my online questions and would have lost several marks if I hadn't gone back to it and realised my mistake in time). They also want to pass you. I know this from experience having spent a year lecturing with RCSI. No-one ever wants to fail somebody and they'll do their best to get you on track if you're struggling in person. So there are pros and cons to both!

Recommendations:

Timeframe: 3 months

(I only gave it just over 2 months and I really regretted it because it was a race from day one. When I realised my study had gone off track and needed complete rejigging it was tremendously stressful because I had no wiggle room in the first place. Also, if you can sit it in close proximity to the last exam ((the MCQ)) definitely do that. There was a five month gap for me as compared to a two month gap for those that went straight on to sit the next sitting. You’ll retain some of your work from the MCQ as compared to me where I really felt I was starting from the beginning again).

 Study Plan:

1. Identify your core texts. Spend time looking at the options available and see which ones suit you best. 

2. Look at the marking scheme and what each topic is weighted - structure your study accordingly. Eg. Pharmacology is worth 1/3 of the SOE versus anatomy which will be 1-2 stations in the OSCE

3. Ensure you are adequately covering both the SOE and OSCE content as both must be passed to pass overall. (See the marking scheme linked in the MCAI overview post).

4. Find a kind Consultant/SpR and start your tutorials early and ideally regularly. This should help guide what depth of study you need to go into.

5. I would recommend starting with a topic you like e.g. pharmacology, and getting your study momentum going before tackling more difficult topics, e.g. physics 

My textbook recommendations are:

1)    1.Dr Podcast
*(I was familiar with this layout from the MCQ so I followed their list of contents for my study. You will need to bulk up your notes from the Primary FRCA in a box. For me I liked the way topics were described in a conversational way. You might prefer a more traditional textbook style, in which case I would suggest the Physics, Pharmacology and Physiology for Anaesthetists by Matthew Cross and Emma Plunkett)

2)   2. Primary FRCA in a box, Second Edition, By Sarah Armstrong Barry

3)   3. Primary FRCA OSCEs in Anaesthesia by Dr William Simpson..

(photos courtesy of amazon.co.uk)

These are the minimum texts you’ll need to get by. I also dipped into Peck and Hill for pharmacology, USMLE First Aid (for biochem/physiology diagrams) and the Essentials of Anaesthetic Equipment by Al Shaikh. These were helpful but I think you could get by using just the three listed above. I am linking the College of Anaesthesiologists in Ireland page for their recommended resources as well.

The NYSORA website was also a great help in learning about the various block techniques. 

This is a link to the MCAI OSCE/SOE curriculum – I glanced at it once or twice but didn’t structure my study according to it as I found it much more overwhelming than to use the textbook contents as a guide.

A few thoughts below:

Look at what each topic is weighted in terms of marks and organise your study according to this. i.e. don’t neglect the OSCEs which have to be passed to pass the exam overall. Is it better to skip one chapter in a core topic to cover more in a different core topic? I skipped the chapters on haemoglobin and immunology during my physiology study as I was running out of time and was greeted with a full question on haemoglobin on the physiology paper which was as you can imagine NOT a pleasant experience. So it’s up to you, but I would still stick to the approach of getting through the majority in each core topic, e.g. it’s better to do 70% of each of pharma/physiology/physics and equipment than 100% of pharma and 20% physics and equipment. In an ideal world you’ll have gone through every chapter at least once or ideally twice/thrice. However, we all live in the real world and sometimes we have to cut the fat in a strategic way, so you make those decisions along your way.

Find yourself some kind Consultant/SpR who likes to teach and see if you can get as MANY tutorials as possible before the exam. Without a doubt, I would not have passed this exam without guidance and having to practice saying my answers aloud. You realise quite quickly how well (or not) your study is going when you have to discuss topics. It will also give you drive for your study when you’re not getting answers right (that was me, quite regularly until the last few weeks – no shame here in not knowing things, that’s what tutorials are for). Another thing that was crucial from these tutorials was that I realised my study was a) completely disorganised and b) the study I had done was inadequate and needed to be further expanded in certain topics I thought I had covered well enough. Learn from the people who contribute to the exams or who have sat them recently. Don’t feel awkward asking for help, it’s essential for passing these exams.

Identify key events/plans you cannot miss in the coming weeks/months and factor that into your study. It’s unlikely you’re going to have free weekends to study for the next three months so you’ll need to compensate for that in your weekly study. I would recommend aiming for at least 16 hours/week. That could be 2 hours per evening during the weekdays (x4) and 4 hours on a Sat and Sun each. Hopefully you’ll be able to power through further on the weekends but always expect to have less time and energy than you’re hoping for. I always took Fridays off (always have done, even since leaving cert) and would recommend having one day per week where you know you will have free time to yourself.

Plan your approach in terms of content. Are you going to start with pharmacology first? Or Physics and Equipment? I started with pharma because I enjoy it the most and it was a gentler way to get into study than starting with physics which for me is a big weak spot. I put physics and equipment in between pharma and physiology which are my stronger suits. For me, starting off with a subject  I struggle with just disheartens me and slows me down. Starting off on a strong foot will give you the momentum to keep going through the rough patch in the middle.

(Photos from my Primary FRCA: OSCEs in Anaesthesia textbook)

*Note – if you feel like some of this content is extremely challenging and difficult, you are not alone. I was particularly exasperated by the electrical equipment for example as I didn’t do physics for leaving cert and I scraped a pass in it during pre-med with my lowest ever score in my lifetime of 56%. So if I can get through it, I assure you so can you.

Weekday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Work	On Call	07:45-17:00	07:45-17:00	07:45-16:00	07:45-16:30	Off	Off
SOE		Inhalational Agents +MAC	Nitrous Oxide	NMBDs + Sux	Off	Anti-convulsants +BZDs	Revise + Propofol and Thio
OSCE	Capnography		CVP, ECG1, ECG2	Humidity, Invasive BP	Off	Resp 1 +Resp2	Revise 8
Exercise			Gym	Gym		Gym
Social		Dinner + Joanne McNally gig			Pizza night w/ Teen
Life admin	Bins		Pay exam fee	Order online food shop			Online food shop delivered
Finance		Dinner 30 euro	Exam fee 800 euro	Food shop 80 euro	Takeaway 30 euro

 

If it's all ahead of you then best of luck!

Questions that came up (March 2022)

Paper 1:

- Drug Receptors (affinity/potency/efficacy)

- Local Anaesthetics (amides versus esters, pKA, addition of adrenaline, EMLA)

- RAAS, Ca+2 Ch blockers (types and examples) Renin angiotensin nephrolysin inhibitors

- Anaesthetic Gases (MAC, blood gas and oil partitions)

- USS (sound waves, wavelength, V/F, how does USS work, components)

- Temperature (thermistor, Stan Boltzmann equation, modes of heat loss and quantitty)

Paper 2

- Hb and oxygen binding, describe the process of Hb changing from oxygenated to de-oxygenated, O2 dissociation curve, the effect of binding one O2 and binding further molecules

- HCL (where is it produced and what, functions, function of the stomach, effect of vagolytic procedure)

- Pressure/force, gas pressure in tanks, different units for measuring pressure, Dalton's law

- Valsalva - stages, definition, uses, how to perform with pt. awake versus ventilated

- Oculocardiac reflex - describe, label diagram + management intra-op, pregnancy physiology for CV system

- Describe components of self-inflating bag valve mask and uses

OSCES

- Communication with anxious patient undergoing GA for TKR, explain analgesia options and regional techniques

- Communication regarding PDPH, explain mechanism, treatment, elicit symptoms, blood patch explanation

- Equipment = Defib, Chest Drain

- Imaging - CTBs

- ECGs - Afib and STEMI

- Anatomy - Ilioinguinal block and cardiac anatomy

- Cardiac exam (technique, describe definitions e.g. thrill, label pictures of pectus excavatum and carinatum)

- Describe RSI (Obs patient, pret-theatre management, intra-op)

- Flow - laminar and turbulent

Anaesthesia OSCE 2021

1. Facilitated diffusion, passive diffusion, transport mechanisms across a cell membrane. Outline different types of transport and identify them on a diagram.

2. Diuretics, which ones work where on the nephron, furosemide MOA and indications, Thiazide S/Es. How to evaluate a pt on diuretics pre-op.

3. Neostigmine MOA, S/Es and effects, sugammadex MOA, effect on OCP and management. Dosing of sugammadex if 1-2 twitches and straight after administration of muscle relaxants.

4. LASER, what does it stand for, 3 features of laser and explain each, explain spontaneous v stimulated emission, safety fx  when using a laser, types of ET tubes to use with laser

5. Anti-emetics - physiology of PONV, S/Es of metoclopramide, risk fx for PONV and methods to address these. Transmitters and receptors involved in PONV and anti-emetic drugs

6. Vaporisers - define vapour, SVP, effect of differing temperature and pressure on vaporisers, TEK 6 vaporiser, label diagram, safety mechanisms in vaporisers, 3 main types of vaporisers used in practice. 

7. Acid-base, buffers, causes of normal anion gap metabolic acidosis, bohr effect and double bohr effect, calculate anion gap and what is a normal anion gap.

8. Oxygen delivery, davenport diagram, dissolved O2 calculation, how RBCs are stored and effect on O2 transport and delivery. How to optimise O2 delivery. 

9. Pituitary, how T3/T4 formed, action of T3 on the body, how thyroid hormones are regulated, post-op complications of thyroidectomy, calcium action in the body, calcitonin effects and MOA, how is vit D metabolised. 

10. Muscle - what is a sarcomere, what is a golgi tendon, explain excitation coupling contraction, explain muscle contraction, explain knee jerk reflex.

11. USS and flows, reynolds number - how to calculate and what different values mean, laminar versus turbulent flow, how USS works, flowmeters - why calibrated differently, why graduations different distances, hypoxic guard, reasons for reduced USS image quality.

12. Electrical safety, microshock, why anaesthetised patients are at increased risk of electrocution, electrical symbols, monopolar v bipolar.

13. Resuscitation - drug overdose, BLS steps, ACLS, doses of drugs and intervals, post resus care of patient, ROSC management, PEA versus VF management.

14. A fib and pacemaker, treatments of AF, pre-op concerns in patients, causes of AF and reasons for pacemaker insertion, concerns pre-cardioversion.

15. Laparoscopic surgery, patient HR 28 on inflation - management and steps, respiratory complications from laparoscopic surg, pressure used in lap surg, other complications from lap surg.

16. Difficult airway - C+L 3, Steps you would take to optimise your view/chances of success on second attempt (x5 things), DAS guidelines, LMA contraindications, who made the LMA.

17. IHD. 3 cardiac conditions which put a patient most at risk for surgery, medications to reduce the risk, intermediate risk surgery for cardiac patient what is the % risk of mortality.

18. Visual acuity, how would you assess, nerves involved in eye movements - names and numbers, 3 diseases which would have signs on fundoscopy, pupillary reflexes.

19. Flowmeters, define flow, why graduations different, effect on bobbin in high and low flow (density v viscosity)

20. Tension PTX, patient desats in theatre steps you would take initially, differentials, how you would rule out certain differentials, initial management of tension PTX, how would you insert a chest drain.

21. Communication - non-fasted patient for hip surgery, explain why unsafe to proceed, patient asks about spinal option, becomes angry and asks to speak to your boss, unhappy and wants to complain - how to manage.

22. Communication - diagnostic laparoscopy in overweight smoker on OCP with previous DVT in pre-op clinic, explain risks, explain measures to reduce risk of DVT this time, things patient can do to reduce their own risk. 

23. PCA, advantages , indications, equipment needed, contraindications, limits on programme.

24. Sickle cell, Hb electrophoresis result in % what type does pt have trait v disease, pre-op concerns for the patient and measures to reduce risks to the pt. SpO2 monitoring frequencies and how it works, what are the frequencies.

25. CXR w/ right upper zone opacification in 78yo smoker w/ fever w/ RR 40 and SpO2 87%, investigations, treatment, diagnosis and differential, identify different parts on CXR

26. Anatomy - identify different parts of larynx and what vertebral level they are at . Brachial plexus, cords, nerves, roots etc 

27. Intrascalene block, complications, persistent nerve injury, investigations and measures you would put in place and how you would manage the patient.

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