The Ultimate Guide to Acing the NAC OSCE

April 18, 2021

April 18^th, 2021

The Ultimate Guide to Acing the NAC OSCE

The NAC OSCE exam is one of the essential standardized examinations that international medical graduates (IMGs) seeking residency in Canada must complete. Previously this exam was scored, where students would receive an actual mark. Since COVID, however, the exam has moved to a pass or fail scoring scheme. However, exceptional students may receive a pass with superior performance, indicating that they were in the top tier of test-takers. While the primary source of stress for many candidates, this exam is one of the best opportunities for you to demonstrate your clinical acumen.

This ultimate NAC OSCE guide, put together by our medical team, seasoned NAC OSCE proctors, is intended to help support the many questions many have about the NAC OSCE. These instructors have been teaching our course for years. With a 99.9% pass rate amongst our NAC OSCE students, MedApplications has been a leader in NAC OSCE preparation since its inception.

Here, we will outline standard stations that one may encounter on the NAC OSCE, tips and tricks about the exam, and preparations strategies on how to ACE this critical exam.

What is the NAC OSCE?

Starting with some basics… The national assessment collaboration exam (NAC EXAM) is a one-day examination intended for international medical graduates and DO graduates from the United States interested in applying to Canadian medical residency programs. Some may ask why is this necessary? The primary focus of this exam is for students graduating from non-Canadian medical programs is one of clinical safety. The exam’s purpose is to ensure that individuals who trained outside of Canada maintain the same clinical standards as graduating Canadian medical students, regardless of prior experience.

Canadian medical residency programs use this exam of clinical ability, which is equated to the fourth-year Canadian medical graduate level. The NAC OSCE was primarily an in-person examination, with a combination of history and physical exam stations. However, since the COVID pandemic, the exam has shifted to an utterly history-oriented examination, with follow-up questions assessing basic medical knowledge. At present, no physical examinations are required. Instead, candidates outline their approach to the physical exam rather than conducting the physical exam itself. The exams are offered throughout Canada in English and French.

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Can I take the NAC OSCE? How to Apply and Who is Eligible?

As we began discussing in the introduction, the purpose of this clinical exam is to assess the knowledge, skills and attitudes that are required for entering a postgraduate medical residency training program in Canada. As a result, IMGs and DO school graduates from the United States, are eligible to take this exam. It is necessary in order to apply to the Canadian medical residency match known as CaRMS.

The process to register for the NAC OSCE is quite simple. The first step is to go to www.physiciansapply.ca, where you are asked to select the location of your exam. Often you can make your top 3 choices. In addition to location, you can also select your time period. The examination is offered 2 times per year in March and September. If you are not successful at passing the exam , you cannot take it in the consecutive time slot. You need to wait a full year until the next cycle. This is different than other standardized exams. Only your most recent result is valid. Your only required to take the exam once, and it is valid for the entire Canadian medical residency system. All residency programs will accept the results, regardless of where you physically took the exam. For example, if you took the exam in Ontario, it will be valid in Alberta, British Columbia, Saskatchewan etc…

In addition, in the same structure as a Canadian medical school graduate, international medical school graduates are also requiring to write the LMCC exam as part of their application for a Canadian medical residency position. More information about the Licentiate of the Medical Council of Canada can be found at https://mcc.ca/about/lmcc/. The reason why the LMC C is required, is it demonstrates proof of your registration with the Canadian medical registry. Please note that you can write the LMCC without doing the NAC OSCE as a prerequisite. However, both exams are necessary for your CaRMS application. It is also important to note that just because you pass one exam, does not mean you pass the other, and passing both exams, does not guarantee you a position in a medical residency program in Canada. There are many factors that got into deciding whether some of the successful in matching to a Canadian medical residency program. Some of these factors include your CV, reference letters, personal statements, interviewed performance, and rotation evaluations to name a few.

What happens during the NAC OSCE Exam?

So now that we have gone through a bit of background related to why candidates are required to sit the exam. Now we will talk a little bit about what occurs on the day of the exam. This is changed a lot over the last year as a result of a COVID.

On the day of the exam, you will register at the front desk with your photo identification. You will not be allowed to keep your smart phone or any preparation materials. You can bring a small allergy friendly snack with you and a clear bottle of water.

You must bring a white coat without any university logos, a printed entrance card and a printed and completed copy of the candidate confidentiality agreements from the physiciansapply.ca website. Please do not forget this. You do not want to add any additional stress to exam day by forgetting any of these items.

In addition to the above, you are allowed eye glasses, a face mask, medications, etc… Anything else, such as medical devices that use smart phones are required to have special permission. Please contact the NAC OSCE exam board early if you are unsure.

You are not allowed to bring” wallets, keys, coats, watches, bags, and stethoscopes. They recommend limiting how much you bring with you as there is only a small amount of space for storage on site. Due to the COVID-19 pandemic, you will be required to wear a mask throughout the interview in all areas. You are allowed to bring your own, otherwise, a non-medical mask will be supplied at the site.  You must come within 15 minutes of your registration time or you may not be allowed to sit the exam.

Orientation for the NAC will be provided online- please check your Physician Apply account regularly in the days and weeks leading up to the exam. Remember as for any other exam, you are not allowed to communicate with colleagues, refer to any materials, access any digital devices. Do not risk losing the ability to sit the exam or any other exams due to breaching any of the above rules. If you are unsure, please clarify with onsite instructors immediately.

You will be given a candidate identification number that you will read aloud at the start of each station for tracking purposes. At registration, you will also be given an identification badge that also identifies at what station you will start your exam. You will be provided with one notebook to take notes in during the stations. This notebook will be turned in once you finish the exam. No materials can be removed from the NAC OSCE.

What to expect in the OSCE Stations: How to prepare for the NAC EXAM

The NAC OSCE is comprised of 10 stations, each 11 minutes in length with 2-minute breaks between stations to prepare for the next station. These rest periods are essential to gather your thoughts and breathe.

A short description will be present on the stations’ doors and inside each station outlining the assigned task such as taking a history, or conducting or describing a physical exam. This is very similar to an MMI format, where a prompt is provided giving you instructions. Like most bell ringer style exams, you will have 2 minutes to read the prompt on the door and prepare before you enter the station. A buzzer will signal when you can enter the station. Exam coordinators will be present every step of the way to guide you from station to station. If you lose track of where you should be, as a proctor immediately to avoid wasted time.

When a station begins, you will enter the room where a physician examiner (PE) and a standardized patient (SP) will be present. This is when the evaluation process starts. Do not pay attention to the examiner. They are simply there to score you. They do not interact with you. You must focus exclusively on the SP.

You will have roughly 11 minutes to complete each OSCE station. If you finish early, you will wait quietly for the station to finish. However, it is allowable to re-engage with the SP at any time if you think of something else you want to say or do. You may lose marks for general structure and organization, but if you have prudent questions that you forgot to ask, now is the time. In some stations, you might be questioned by the examiner, of which you will be notified in the station prompt. You will always know when to expect questions at the end. There will be no surprises. A buzzer will signal the time to indicate the transition to examiner questions while you are in the station. Once the physician examiner starts questioning you, you cannot re-engage with the patient even if there’s time remaining. This part of the station is strictly intended for you to answer the clinical content questions. Questions might vary from clinical knowledge to suggested next steps and management.

Remember that the purpose of the NAC OSCE is to assess your global aptitude and preparation for medical residency in Canada. This is not like the USMLE.  The scenarios you may encounter at the stations span the spectrum of medical practice and can touch on all specialties and topics.  

CORE NAC OSCE STATION TOPICS:

1. Internal Medicine
2. Surgery
3. Pediatrics
4. Obstetrics Gynecology
5. Psychiatry & Counselling
6. Emergency Medicine & Trauma
7. Primary Care

There are many tasks that may be asked in the prompt for you to complete during the station. You may be asked to complete more than one of the following:

• Take a history 
• Describe a focused physical exam
• Manage or resolve a patient problem
• Counsel a patient or a family member 
• Answer oral questions 
• Summarize and present findings
• Read or reference materials that relate to a patient including their chart, test results or medication lists
• Interact with physicians or allied health members 

How is the NAC OSCE Scored?

The physician examiner of the NAC EXAM is focused on assessing the qualities and attributes necessary to be a successful resident in a Canadian residency program. Think of yourself as demonstrating the requirements of a 4^th year Canadian medical school graduate.

The examiner is assessing the questions asked of the SP, the physical exam maneuvers used (or described), the organization and the underlying medical knowledge. It is as much about your overall performance, as it is about any one individual component.

The 7 competencies assessed in the NAC OSCE EXAM

• Quality of History Taking
  1. The NAC OSCE physician examiner is assessing for a chronological and organized, medically logical description of the main concern. This includes basic history taking including the onset, location and duration, character and severity when it is appropriate. Some label this PQRST or Sacred 7.

• Diagnosis
  • The NAC OSCE physician examiner is assessing the applicant’s ability to sift through important and less important details to identify the differential diagnosis and primary diagnosis. Be obvious about this when interacting with the SP. Don’t make it difficult for the examiner to infer what diagnoses you are thinking about.

• Management
  • The NAC OSCE physician examiner is assessing the applicant’s knowledge of a management plan. Remember this is at the level of a 4th-year Canadian medical graduate, NOT at the level of the Royal College Exam. A basic plan may include non-pharmacologic treatment, pharmacologic treatment, follow-up, referrals/consultations etc… When recommending a medication, you can mention the medication class, education required pertaining to expected results/adverse effects. Education around a proposed treatment or intervention is more important than the intervention itself. Remember, the patient is at the centre. A review of risks, benefits and alternatives is crucial when discussing management with the patient. Think of a basic management plan for hypertension, what would you tell the patient?

• Communication Skills
  • The NAC OSCE physician examiner is assessing the applicant’s ability to quickly develop a trustworthy rapport with the standardized patient. It becomes a fine balance of listening and questioning asking. They are also assessing the way that applicants communicate with the patients, including their tone and body language. Please avoid the use of medical jargon. Ask a combination of open and closed questions. If you are too vague, you will not trigger the appropriate SP’s responses. If you are too closed, you may miss key historical features. 

• Physical Examination
  • The NAC OSCE physician examiner is assessing the applicant’s ability to walk through their intended physical exam and organization. Note physical exams are not conducted during COVID-19.

• Investigations
  • The NAC OSCE physician examiner is assessing the applicant’s ability to order relevant investigations. These include labs, imaging, biopsies etc…. This is usually best assessed in the post-encounter questions. When choosing laboratory and diagnostic imaging tests, ensure you focus on the key investigations that will confirm the diagnosis, assess for complications, and may be needed for treatment. For example, you may wish to order blood work for to monitor adverse effects of a particular medication. You may wish to order an ECG to monitor the patients QTc. You may wish to trend a patient’s INR when evaluating for liver failure.r

• Data Interpretation
  • At times, physician examiners may provide investigations that the applicant is to interpret. This could take the form of an ECG, a diagnostic image or laboratory investigations. They are assessing the applicant’s ability to identify abnormal results. It is critical that you start from the basics. Identify the type of study, confirm patient ID, outline pertinent positives and pertinent negatives. If you are not sure what the data is showing, staying organized will help score some points while you figure out the answer.

The way you are score for the NAC OSCE is as follows:

1. Unacceptable
2. Borderline Unacceptable
3. Borderline Acceptable
4. Acceptable
5. Above Expectations

You are given a final score of fail, pass, or pass with superior performance based on a pre-set cut score approved by the NAC examination committee. The cut score is not published, and you will not get your total score. 

How to Prepare for the NAC OSCE: What we have learned at MedApplications

Start Planning and Plan Smart

Studying for an exam like the NAC OSCE can be challenging in scope. It is important to organize the material into manageable chunks of information to best attend to all the necessary content in a timely and focused manner. Create a study plan and stick to it. Students often find studying by topic the most effective way to start.

Staying Accountable

The NAC OSCE requires coverage of a ton of information. Remember this is NOT a content exam. The NAC OSCE is a clinical exam, emphasizing communication, organization and overall medical knowledge. Being accountable to your schedule, meeting preparation milestones and practicing is key. This is not an exam to leave to the last minute. It can be helpful to keep a patient log with the diagnosis or to review organ systems and highlight key diagnoses. Once you have a list of diagnoses, use your time to highlight pertinent history and physical exam findings that contribute to the diagnosis. Some students make charts or grids to help check off topics they feel comfortable with. Ensure to follow up with key investigations and management to have an answer key to review. 

Start your preparation early

Preparing for the NAC OSCE amidst other clinical commitments can be tough. However, setting study priorities on a weekly basis will help you sail through the NAC EXAM. Many applicants are studying for both the LMCC and NAC examinations simultaneously or consecutively and this can result in burnout. Plan at least 1 year in advance and go slow. Starting early can allow you the time to study in small increments and avoid cramming which often leads to stress and poor results. 

Group studying

Studying with others allows you to remain on track, collaborate on learning objectives, and maximize your retention. At MedApplications, we connect you with other students within our ecosystem of learning to practice in parallel to our courses. Each group member has a different clinical experience and brings about different patient encounters that may alter what they view as critical patient presentations. Likely when one person has a question, others do to. Individuals have different strengths and weaknesses, so take advantage of that!

Practice, practice, practice

The best way to learn is through practice. Develop realistic scenarios and pose the scenarios to your group members. Leverage prior experiences, think through scenarios and commit to your action plan.

In addition to practicing in groups, take the opportunities you have in clinical situations to get feedback from residents and staff. Implement their feedback into your OSCE practice sessions. Keep a record of scenarios that you have completed and indicate whether or not you feel prepared for such scenarios. If you are doing a NAC OSCE course, cover the topics in parallel to your instructors so you can ask them about scenarios you have questions about.

Get professional help: It really makes a difference

OSCE exams are tremendously challenging and our NAC OSCE advisors at MedApplications are the first to admit it. Our advisors, IMGs and CMGs, have been teaching our courses for years and have heard the trials and tribulations of IMGs. Even with study groups, there are often gaps, and the feedback sometimes is not on point. Independent advisors can act to make your preparation more efficient and target while providing objective feedback as former proctors themselves. It is critical to think about how an unbiased evaluator would evaluate your performance. Often a little guidance goes a long way!