A go at NAC OSCE

artistic rendition

It’s been a while since the exam session was held in Montreal and I still have a few weeks of waiting before I know whether it was a success or a first attempt. However its being in the past, I can now document my two months of prep (Update: it was a success, hurrah!).

As with many things in my life I have got into express mode prep rather suddenly. The last half year or so have been for want of a better word weird, generally in a good way. We’ve opened up a new map and were looking forward to explore the continent of North America, but reality cut in with the pandemic and all things considered it didn’t go as bad for us as it did for many others, but major changes in plans became inevitable. We were lucky that we managed most of the important stuff before the quarantine measures were rolled out in full in Quebec. Originally I was going to take a 4–5 months or maybe more to do things, but on visiting the website of Medical Council of Canada (MCC) sometime late in May, I found out that the deadline for September’s session was in a less than a week and it was on.

As a prospective candidate, be it an international medical graduate (IMG), or a Canadian graduate, one has to first go the MCC’s website and read through all the information provided there. Overall, I’d say that it has exhaustive content on the exams and related topics, although I still managed to generate a few questions, which however daft or self-explanatory were promptly and thoroughly answered in their online chat. Another essential website to visit is physiciansapply.ca where one has to open an account. Here things are even more straightforward as they have “How to become a practicing physician in Canada” in their menu, which walks you through the process step by step.

Another thing to mention is as an IMG from a country where official language is other than English or French, one has to translate all acceptable medical credentials, which are the diploma, its transcript/addendum (the one with subjects and marks in), any post-graduate certificates. However, the MCC does not accept outside translations of these (though they accept translations of other docs, such as a supplement ID) and once you upload your scanned docs into physiciansapply.ca account, they commission a translation themselves and then each of these translated documents has to be source verified via the same website (see the applicable fees, note though, if my memory does not deceive me, they accept only credit card payments). Once your source verification process has begun, you can apply and take exams, while MCC chugs along checking your docs.

Now, as many connoisseurs in the area of proving one’s medical degree know, NAC is rather similar to USMLE Step 2 CS (which was cancelled this year, glory be et cetera for folks down south). NAC however was not cancelled, but have been modified to reduce the interpersonal contact which mainly came down to verbalizing the physical exam component. Whether it made the test harder or easier, it is hard to tell: on one hand, if you are a proficient talker, it might reduce the stress to some degree, on the other — sometimes showing is much easier than describing. Another change was introduced in scoring— this year it’s either pass, pass with superior performance or fail.

What are they testing? Apart from knowledge, one has to show one’s ability to behave, extract pertinent information, maneuver standard patients (SP) and make clinical decisions. NAC differs from Step 2 CS in that

a) the examiner is in the room with you and SP, and is marking your performance while you interview the patient and

b) in some of the stations they might ask questions related to SP’s condition anywhere from epidemiological aspects to management and treatment,

c) you don’t have to type notes and be scored on them,

d) the length of each encounter is eleven minutes, of which last three might be used for the above mentioned questions.

You’ll have to ignore the examiner until the questions section, which I was able to do without much effort, but presence of three people in hospital room the size of 7–9 square meters, whilst one of them is scratching something and looking at you intently from time to time lends a cozy if not stuffed ambience to the whole affair.

What have I used to prepare?

• First Aid Step 2 CS
• Toronto Notes
• Geeky Medics
• The Book by Hanan Ahmed
• my dauntless spouse who was cast in all sorts of roles from pregnant woman to elderly diabetic
• certain mnemonics to remind of encounter components, here whatever helps you to keep things inside and be orderly and methodical (see the ones I used at the end)

First article on the list is a well organized book of mini an full size clinical cases. You’ll have to adapt it a bit, as the timing is different, but overall it is an excellent source and you’ll be able to utilize almost 100% of it. I’ve made a deck of Anki cards out of mini-cases and was doing them daily, as well as the full sized cases at 3–4 cases per day.

Toronto Notes on the other hand, though a great book (or three books, in newer edition), might be too big in an express prep at over 2000 pages. I mainly used it for local nuance on family practice and emergency medicine, as well as a source of reference on some topics in which I was not sure. It will come useful with the MCCQE1 preparations as well.

Now for the Geeky Medics — these people are amazing and are doing a great service to fellow students and medical residents. Their website is full of information, easy to navigate and most importantly they have a series of videos on objective structured clinical examination or OSCE. Definitely check them out and see if James is still seeing doctors, in spite of being perfectly well, some illness anxiety disorder for sure there ;-)

The Book was written by a fellow IMG as a guide to NAC and MCCQE2. She goes into whats, whys and hows in detail. One must concede some spelling issues and similar trifles like that, as the now doctor had gathered, written down and shared her knowledge to help others. A commendable effort and a very useful source it is. There are a few cases to try out too.

The last is of course of immense importance as not only I rather like my spouse, but also there is no two ways about it — if you want to prepare well, you’ll have to practice with someone. Acting the whole thing and receiving some feedback on it is essential. One might imagine all sort of things in one’s head but actually doing them is a whole new ball game. Your study partner does not have to have medical background, you’d couch them on what’s important, what to look for and how did they feel as a patient of yours. If you’ve been out of practice for a while and have a month or more before the exam, I’d recommend to start by untimed encounters and see how much does it take to build rapport, ask questions and make some decisions. It should bring you better awareness of your natural timing and serve as a baseline to build on.

On the exam day everything was smooth, the staff was very kind, understanding and helpful. Due to distancing we were asked not to bring a stethoscope, but only white lab coat. Our group was through in what seemed like half an hour or less. There was no time to overthink, get anxious and ponder on missteps or unasked questions.

It has been almost ten weeks when I got my result, so take the delay into account, folks, and good luck!

Mnemonics I used:

DOCFAPAA for non painful chief complaint:

• Duration
• Onset
• Constant/intermittent
• Frequency
• Associated symptoms
• Alleviating
• Aggravating

LIQOPRAAA for pain:

• Location
• Intensity
• Quality
• Preceding event
• Radiation
• Associated symptoms
• Alleviating
• Aggravating

SAD CUB FEVERS for pediatric cases:

• Sleep
• Activity
• Dehydration symptoms
• Cough, cold, cry, wheezing
• Urination
• Bowel changes, poor appetite
• Fever, severity, duration
• Ear pulling
• Vomiting
• Ear, eye discharge
• Rash, rhinorrhea
• Seizures, lethargy, sleepiness

PAM HUGS FO SAD SAD for history in adults:

• Previous episode, medical history
• Allergy
• Medications
• Hospitalizations (HITS — Hospitalization, Ill contacts, Trauma, Surgery)
• Urinary symptoms
• GI symptoms
• Family history
• ObGyn history *see next one
• Smoking
• Alcohol
• Drugs
• Sexual history
• Activity
• Diet

LMP RTV CS PAP PSS for ObGyn history:

• Last menstrual period (LMP)
• Menarche (lol, auto correction proposed to change this one to archenemy)
• Period (frequency, how many days), cramps
• Regularity
• Tampons/pads per day
• Vaginal discharge (amount, color, consistency, odor, duration), burning, pain, or pruritus
• Contraception
• Spotting (inter menstrual, post coital)
• Pregnancy (history and complications)
• Abortion/miscarriage
• PAP smear
• Previous episodes
• Sexual history, recent sexual activity, use of douches
• STDs

PAM IF BIG DEAL for pediatric history:

• Previous medical, surgical, prenatal history
• Allergies
• Medications
• Ill contacts
• Family history
• Birth history
• Immunizations
• Growth and development
• Day care
• Eating
• Appetite
• Last checkup (when, was it normal)

THEN FR CS PUB SAW ID for review of systems:

• Trauma, travel
• Headache
• Edema
• Nausea, vomiting (onset, color, frequency, any blood)
• Fever, chills, fatigue, night sweats
• Rash, racing heart
• Chest pain, cough (sputum, color, odor, blood)
• Shortness of breath
• Pain in joints
• Urinary symptoms
• Bowel symptoms
• Sleep problems
• Appetite
• Weight (intentional or not)
• Infection
• Dizziness