OSCEs I: Format, history taking, communication and data interpretation stations

🩺 OSCEs I: format, history taking, communication and data interpretation stations. The Objective Structured Clinical Examination (OSCE) tests what you can do, not just what you know. In the UK, final-year students sit the UKMLA Clinical and Professional Skills Assessment (CPSA), set by their medical school against the GMC's requirements; international graduates sit PLAB 2; and physicians sit MRCP(UK) PACES. This chapter explains the format and marking, then covers the stations that make up most of the exam: history taking, explanation and communication (including breaking bad news, consent and difficult conversations), and data interpretation. Examination stations are covered in the Clinical Examination chapters, and procedures, prescribing and emergencies in OSCEs II.
Your four questions entering any station: What exactly is the task (read the instructions twice)? Who am I talking to, and what do they want from this encounter? What is the minimum safe content I must cover? How will I close - summary, safety-netting and a clear plan?

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Format of UK OSCEs - CPSA, PLAB 2 and PACES

• UKMLA (from 2024–25 graduates): two parts - the Applied Knowledge Test (AKT) (set by the GMC, sat at medical school) and the Clinical and Professional Skills Assessment (CPSA) - each school's own OSCE, which must meet GMC requirements and cover the MLA content map (conditions, presentations, professional knowledge) and the practical skills and procedures list. Passing both is required for full GMC registration for UK graduates.
• PLAB 2 - for international medical graduates; currently 16 scenarios of 8 minutes each (with 1.5 minutes reading time), set in a mock clinical environment with simulated patients and mannequins.
• MRCP(UK) PACES - for physicians in training: five stations rotating around a carousel (respiratory and abdominal; history taking; cardiovascular and neurological; communication skills and ethics; brief clinical consultations), assessed across seven skills (physical examination, identifying physical signs, clinical communication, differential diagnosis, clinical judgement, managing patient concerns, maintaining patient welfare). (Format was revised in 2023–24 - check the current MRCP(UK) website.)
• Station types: history taking; clinical examination; communication (explanation, breaking bad news, consent, difficult conversations, ethics); practical procedures; data interpretation (ECG, ABG, CXR, bloods); prescribing; acute care (ABCDE simulation); teaching; handover.
• Timing - typically 8–10 minutes per station plus 1–2 minutes reading; a warning bell before the end.

How Stations Are Marked

• Checklists (specific items - "asks about haemoptysis") and global rating scales (overall impression - clear pass, borderline, fail) are combined; borderline regression is commonly used to set the pass mark.
• Domains typically assessed - information gathering, clinical reasoning (differential diagnosis, plan), communication (rapport, structure, clarity, empathy, checking understanding), technical skill, patient safety (infection control, identity checks, allergy, escalation) and professionalism.
• Patient safety errors can fail a station outright - e.g. not checking allergies before prescribing, giving a contraindicated drug, not identifying a red flag, breaching confidentiality, unsafe procedure.
• Simulated patients often give a mark for "would you like to see this doctor again?" - rapport counts.
• Conjunctive standards - many exams require passing a minimum number of stations as well as the overall mark.

Exam Technique

• Read the instructions carefully - task, setting, who the patient is, and what you are asked to do (e.g. "take a history and explain the likely diagnosis" - two tasks).
• Plan during reading time - a mental template of the key questions and red flags; the likely differential; what to say at the end.
• Introduce, identify, consent - in every station.
• Signpost - "I'd like to ask some questions about your general health now"; "I'm going to explain what we think is happening".
• Time management - leave the last 1–2 minutes for summarising, answering questions and safety-netting; if asked questions by the examiner at the end, answer concisely and structured.
• Do not argue with the simulated patient; respond to cues (emotional and verbal) - they are often scripted triggers for marks.
• Reset between stations - a bad station does not mean failure; each station is independent.
• Practise aloud in groups with a timer and a mark scheme; record yourself.

The Structure of a History

• Introduction - name, role, patient name and DOB, purpose, consent.
• Presenting complaint - in the patient's words; open question first ("What brought you in today?"), then let them talk (golden minute).
• History of presenting complaint - SOCRATES for pain (Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating and relieving factors, Severity); progression, previous episodes, red flags, relevant systemic enquiry for that system.
• ICE - Ideas (what do you think is causing it?), Concerns (what worries you most?), Expectations (what were you hoping we could do today?) - plus impact on life.
• Past medical and surgical history - including mnemonic MJTHREADS (MI, jaundice, TB, hypertension, rheumatic fever, epilepsy, asthma, diabetes, stroke).
• Drug history - prescribed, over-the-counter, herbal, recreational; adherence; allergies and the nature of the reaction.
• Family history - relevant conditions, ages, causes of death; genogram if relevant.
• Social history - occupation (and exposures), living situation and support, function (ADLs, mobility, stairs, carers), smoking (pack-years), alcohol (units/week; AUDIT-C), recreational drugs, driving (DVLA implications), travel, sexual history if relevant, diet and exercise.
• Systems review - brief screen of other systems.
• Summarise and check - "Let me check I've understood..." - then answer questions, explain next steps and safety-net.

Focused Histories - What Not to Miss

Presentation	Red flags and must-ask questions
Chest pain	Character, radiation to arm/jaw, exertional, associated sweating/breathlessness/syncope; PE risk factors (immobility, surgery, malignancy, pregnancy, COCP, previous VTE); tearing pain to back (dissection); cardiac risk factors; cocaine
Breathlessness	Onset (sudden - PE, pneumothorax), orthopnoea and PND (heart failure), wheeze, cough and sputum, haemoptysis, weight loss, smoking, occupational exposure, exercise tolerance, pets
Headache	Thunderclap (SAH), fever and neck stiffness (meningitis), new headache over 50 with jaw claudication or scalp tenderness (GCA), worse lying or on coughing with vomiting (raised ICP), focal neurology, papilloedema, pregnancy (pre-eclampsia, venous sinus thrombosis), immunosuppression, cancer history
Abdominal pain	Peritonism, GI bleeding, change in bowel habit, weight loss, jaundice, vomiting, LMP and pregnancy possibility (ectopic), urinary symptoms, AAA risk (older male smoker with back pain and collapse)
Change in bowel habit / rectal bleeding	Age, weight loss, anaemia, iron deficiency, abdominal mass, family history of bowel cancer (FIT test - NICE DG56/NG12)
Back pain	Cauda equina (saddle anaesthesia, sphincter disturbance, bilateral sciatica), cancer history, weight loss, fever, IV drug use, trauma, osteoporosis, age >50, night pain
Collapse / syncope	Before (prodrome, exertion, palpitations, posture), during (witness - jerking, colour, duration, tongue biting, incontinence), after (confusion - seizure; rapid recovery - syncope); family history of sudden death; driving advice
Weight loss	Appetite, intake, diarrhoea, thyroid symptoms, diabetes symptoms, night sweats and fever (lymphoma, TB), cancer red flags, mood, social circumstances
Low mood	Suicide risk (thoughts, plans, intent, previous attempts, protective factors, access to means), psychotic symptoms, substance use, safeguarding (dependants)
Headache, fever, rash in a child	Non-blanching rash, drowsiness, irritability, poor feeding, NICE traffic-light features

• Sexual history - privacy and confidentiality explained; symptoms, last sexual contact, partner(s) (gender, regular or casual, country), types of sex, condom use, previous STIs, contraception and LMP, HIV and hepatitis risk factors, PrEP, consent and safeguarding (age, coercion).
• Paediatric history - from parent and child; birth history, development, immunisations, feeding, growth, family and social circumstances, safeguarding.

Communication Frameworks

• Calgary–Cambridge model - initiating the session → gathering information → providing structure → building the relationship (throughout) → explanation and planning → closing.
• Skills: open then closed questions, active listening, silence, summarising, signposting, picking up and responding to cues, empathy ("That sounds really difficult"), avoiding jargon, chunk and check (small pieces of information, check understanding after each), teach-back ("Can you tell me in your own words what we've discussed?"), shared decision-making (options, risks and benefits, what matters to the patient).
• Non-verbal - eye contact, open posture, sitting at the same level, appropriate pace and tone.
• Interpreters - use professional interpreters (not family, especially children) for clinical conversations; speak to the patient directly.

Breaking Bad News

• SPIKES framework:
  • S - Setting - private room, sit down, mobile off, tissues, allow time, offer a relative or friend to be present, involve a specialist nurse.
  • P - Perception - find out what the patient already knows or suspects ("What have you been told so far?").
  • I - Invitation - ask how much they want to know ("Would it be helpful if I explained the results in detail?").
  • K - Knowledge - give a warning shot ("I'm afraid the results are not what we had hoped for"), then deliver the news clearly in plain language, without euphemisms ("The biopsy shows a cancer"), in small chunks; pause and allow silence.
  • E - Emotions/Empathy - acknowledge and respond to emotions ("I can see this is a shock"); allow time.
  • S - Strategy and Summary - outline the next steps (further tests, MDT, specialist), offer written information and contact details (specialist nurse), arrange follow-up, check support at home; summarise.
• Avoid - false reassurance, giving prognosis figures you are unsure of, overwhelming detail, rushing, leaving without a plan.
• If asked "How long have I got?" - explore why they are asking, be honest about uncertainty, give ranges if appropriate (weeks to months, months to years), and offer to discuss further with the specialist.

Explaining a Diagnosis or Treatment

• Structure: introduce and establish what they know → explain the condition (what it is, why it happens, how common) → investigations → treatment options (benefits, risks, alternatives including no treatment) → self-management and lifestyle → follow-up → safety-netting → check understanding (teach-back) → written information.
• Common explanation stations: new diagnosis (type 2 diabetes, asthma, hypertension, epilepsy - driving rules, IBS, heart failure), new medication (inhaler technique, warfarin or DOAC (bleeding, interactions, missed doses, alert card), methotrexate (weekly dose, folic acid on a different day, blood monitoring, avoid trimethoprim, infections), lithium, insulin, steroids (sick day rules, steroid card, do not stop suddenly), bisphosphonates (take on empty stomach with water, upright for 30 minutes), combined pill (missed pill rules, VTE risk), SGLT2 inhibitors (sick day rules - DKA), opioids (constipation, driving)), procedures (endoscopy, colonoscopy and bowel prep, lumbar puncture), results (abnormal smear, raised PSA).
• Use analogies and diagrams; avoid numbers without context - use natural frequencies ("out of 100 people like you, about 5 would...") and absolute rather than relative risk.

Consent and Capacity Stations

• Valid consent requires that the patient: has capacity, is informed (nature and purpose of the procedure, material risks - those a reasonable person in the patient's position would consider significant, and what this patient would want to know (Montgomery v Lanarkshire 2015), benefits, alternatives including doing nothing), and is giving consent voluntarily (free from coercion). Consent can be withdrawn at any time.
• Assessing capacity (Mental Capacity Act 2005) - presume capacity; capacity is decision- and time-specific. Two-stage test: is there an impairment of, or disturbance in, the functioning of the mind or brain? If so, does it mean the person cannot understand the information, retain it long enough, use or weigh it, or communicate a decision? Unwise decisions do not by themselves indicate lack of capacity. Take all practicable steps to support decision-making.
• If the patient lacks capacity - act in their best interests (consider their past and present wishes, beliefs and values; consult family, carers and any LPA for health and welfare or court-appointed deputy; consider a valid and applicable advance decision to refuse treatment; the least restrictive option); appoint an IMCA if there is no one to consult for serious decisions.
• Children - those 16–17 are presumed to have capacity; under 16 - Gillick competence (sufficient maturity and understanding); Fraser guidelines for contraception; a competent young person's refusal of life-saving treatment may in some circumstances be overridden by the court.
• Consent station structure - introduce → check what they know → explain the procedure (what, why, how, preparation, anaesthesia/sedation) → benefits → risks (common and serious, with numbers) → alternatives (including no treatment) → after the procedure → questions → check understanding → confirm decision and that they can change their mind → document (Consent Form 1).

Difficult Conversations - Anger, Errors and Ethics

• The angry patient or relative - stay calm, let them speak without interruption, acknowledge their feelings ("I can see you're very upset, and I want to understand what has happened"), apologise for their experience, find out the specific concerns, explain what you know and what you will do, don't blame colleagues, offer to escalate (senior, PALS, complaints process); ensure your safety (leave the door accessible).
• Duty of candour - when something goes wrong and causes (or could cause) harm, be open and honest: tell the patient, apologise (an apology is not an admission of liability), explain what happened and the likely effects, put things right where possible, explain what will happen next (incident report - Datix; learning), and offer support (GMC/NMC joint guidance; statutory duty for organisations - notifiable safety incidents).
• Common ethics stations:
  • Confidentiality - a relative asks about a patient (do not disclose without consent; listen to their concerns); DVLA (patient with epilepsy who continues to drive - advise them to stop and inform DVLA; if they refuse, tell them you will inform DVLA, then do so, and tell them in writing - GMC guidance); disclosure in the public interest (serious crime, risk of serious harm), safeguarding, notifiable diseases.
  • A colleague who smells of alcohol or is unsafe - patient safety first: ensure patients are safe, speak to the colleague privately if appropriate, and escalate to a senior/clinical supervisor; follow raising concerns guidance.
  • Refusal of treatment by a capacitous patient (e.g. a Jehovah's Witness refusing blood) - respect it, explore reasons and alternatives (cell salvage, iron, EPO, tranexamic acid), document; check advance decision.
  • Request for a second opinion, request to see records, a patient wanting antibiotics for a cold, a patient asking for euthanasia (currently illegal in the UK - explore concerns, address symptoms and fears, involve palliative care; legislation on assisted dying has been before Parliament since 2024, so check the current legal position).
  • DNACPR and ReSPECT discussions - CPR is a treatment decision; discuss sensitively, explain what CPR involves and likely outcome; families cannot demand CPR but should be informed and consulted (Tracey judgment 2014).

Data Interpretation Stations

• ECG - systematic: patient details, date, calibration; rate; rhythm; axis; P waves; PR interval (0.12–0.20 s); QRS duration (<0.12 s) and morphology; ST segments; T waves; QT/QTc (men <450 ms, women <460 ms). Classic stations - STEMI (territory), AF, atrial flutter, heart blocks (first degree, Mobitz I and II, complete), bundle branch blocks, hyperkalaemia (tall tented T, wide QRS, sine wave), VT, SVT, WPW, pericarditis (saddle ST, PR depression), long QT, LVH, PE (sinus tachycardia, S1Q3T3, RV strain).
• Arterial blood gas - (1) oxygenation (PaO₂ relative to FiO₂ - type 1 vs type 2 respiratory failure); (2) pH - acidaemia or alkalaemia; (3) PaCO₂ - respiratory component; (4) HCO₃⁻/base excess - metabolic component; (5) compensation; (6) anion gap (Na⁺ − (Cl⁻ + HCO₃⁻), normal about 8–12; raised - lactate, ketones, renal failure, toxins - methanol, ethylene glycol, salicylate); (7) lactate, glucose, electrolytes.
• Chest X-ray - ABCDE: patient details and projection (PA or AP), quality (RIPE - rotation, inspiration, projection, exposure); Airway (trachea), Breathing (lung fields, zones, pleura, costophrenic angles), Circulation (heart size - CTR <0.5 on PA, mediastinum, hila), Disability (bones), Everything else (diaphragm - free air under it, soft tissues, lines and tubes - NG tube position, ET tube, central lines). Classic stations - consolidation, effusion, pneumothorax (tension), collapse (lobar patterns), pulmonary oedema (bat-wing, Kerley B lines, upper lobe diversion, effusions), mass, hilar lymphadenopathy, pneumoperitoneum, misplaced NG tube.
• Blood results - FBC (anaemia classification by MCV), U&E (AKI, hyperkalaemia, hyponatraemia), LFTs (pattern), bone profile, TFTs, coagulation, CSF, ascitic and pleural fluid (Light's criteria), urine dipstick and ACR.
• Approach in the station - state what the test is, patient details and date, then a systematic description, then the diagnosis and immediate management - examiners want you to act on dangerous results (e.g. "K⁺ 7.1 with ECG changes - I would give IV calcium gluconate, insulin–dextrose and salbutamol nebulisers, and seek senior help").

SBAR, Handover and Referral

• SBAR:
  • S - Situation - who you are, where you are calling from, who the patient is, and why you are calling ("I'm calling about Mrs Jones, 74, on Ward 6, who has a NEWS2 of 7 and I'm concerned she has sepsis").
  • B - Background - reason for admission, relevant history, medications, recent events.
  • A - Assessment - your ABCDE findings, observations, results, what you think is going on, what you have done.
  • R - Recommendation/Request - what you want ("I'd like you to review her within 30 minutes"; "Should I start antibiotics now?"), and agree a timescale; read back and document.
• Telephone referral stations - be prepared, have notes and results to hand, be concise, state the question clearly, and document the conversation (name, time, advice).
• Handover - structured (e.g. SBAR or local tools), prioritising sick patients and outstanding tasks, with clear ownership and escalation plans.

At a Glance

Station	Framework
History	PC → HPC (SOCRATES) → ICE → PMH → DH (allergies) → FH → SH → ROS → summary
Breaking bad news	SPIKES - warning shot, plain words, silence, empathy, plan
Explanation	Chunk and check; teach-back; natural frequencies
Consent	Capacity, information (Montgomery), voluntariness
Capacity	Understand, retain, weigh, communicate
Error	Duty of candour - be honest, apologise, explain, report
ABG	Oxygenation, pH, CO₂, HCO₃⁻, compensation, anion gap
CXR	RIPE then ABCDE
Referral	SBAR - say what you want

Worked Example Stations

• History - "A 55-year-old man with chest pain." Key questions: SOCRATES, exertional, rest pain, radiation, autonomic features, breathlessness, palpitations, syncope; risk factors (smoking, diabetes, hypertension, lipids, family history), PE and dissection risk factors, cocaine; ICE. Differential: ACS, stable angina, PE, dissection, pericarditis, GORD, musculoskeletal. Plan: ECG within 10 minutes, troponin, aspirin if ACS suspected, senior review.
• Communication - "Explain to Mrs Patel that her chest X-ray shows a mass." SPIKES; check what she knows ("You had the chest X-ray because of your cough..."); warning shot; "The X-ray shows a shadow on the right lung. We call it a mass. It may be a cancer, but we need more tests to be sure." Pause; respond to emotion; explain next steps (CT scan, referral to the lung cancer team within 2 weeks, specialist nurse); check support; safety-net (haemoptysis, breathlessness); written information.
• Data - "Interpret this ABG: pH 7.28, PaCO₂ 8.9 kPa, PaO₂ 7.8 kPa on air, HCO₃⁻ 31 mmol/L." Type 2 respiratory failure with respiratory acidosis and partial metabolic compensation (raised bicarbonate suggests chronic CO₂ retention with an acute-on-chronic exacerbation) - e.g. COPD exacerbation. Management: controlled oxygen (target 88–92%), nebulised bronchodilators, steroids, treat infection, consider NIV (pH <7.35 and PaCO₂ >6.5 despite optimal medical therapy).

Exam-style Scenarios

• Scenario. In a station, a woman with epilepsy who had a seizure last week says she will keep driving because she needs to get to work. What do you do?
  Answer: Explain that she must not drive and must inform the DVLA (usually no driving for 6 months after a first unprovoked seizure, or 12 months for epilepsy, depending on circumstances); explore her concerns (work, transport) and offer support; document. If she continues to drive, GMC guidance allows you to inform the DVLA after telling her you intend to do so, and then to write to her confirming this.
• Scenario. During a consent station for colonoscopy, the patient asks, "Do I really need to know all these risks?"
  Answer: Explain why you discuss risks (to help them make an informed decision), and ask what they would like to know; respect a wish not to know detail but give basic information needed for valid consent (what the procedure involves and serious or common risks such as perforation and bleeding), document their wishes, and offer to provide more information later (GMC Decision making and consent 2020).
• Scenario. A simulated patient becomes tearful when you mention the word "tumour". What should you do?
  Answer: Stop giving information, allow silence, acknowledge the emotion ("I can see this is very upsetting"), offer tissues, ask what is going through their mind, and continue only when they are ready - responding to cues is assessed and essential.

Key Points

• Read the task twice; plan in reading time; leave time to close.
• Patient safety and professionalism errors can fail a station outright.
• Use a consistent history template, always with ICE and red flags.
• SPIKES for bad news; chunk and check; teach-back.
• Consent: capacity, information (Montgomery), voluntariness; know the MCA test.
• Data stations: systematic description, diagnosis, then immediate action.
• SBAR for referrals - finish with a clear request.

Guidelines and Further Reading

• GMC: Medical Licensing Assessment - MLA content map and CPSA requirements
• GMC: Good medical practice (2024); Decision making and consent (2020); Confidentiality (2017)
• GMC/NMC: Openness and honesty when things go wrong - the professional duty of candour
• Mental Capacity Act 2005 Code of Practice
• MRCP(UK): PACES format and marking; GMC: PLAB 2 guidance
• Baile WF et al. SPIKES - a six-step protocol for delivering bad news. The Oncologist 2000