1. Don’t panic. Be philosophical about your exams. Put them into perspective. And remember that as long as you do your bit, you are statistically very unlikely to fail. Book a holiday to a sunny Greek island starting on the day after your exams to help focus your attention.
  2. Read the instructions carefully and stick to them. Sometimes it’s just possible to have revised so much that you no longer ‘see’ the instructions and just fire out the bullet points like an automatic gun. If you forget the instructions or the actor looks at you like Caliban in the mirror, ask to read the instructions again. A related point is this: pay careful attention to the facial expression of the actor or examiner. Just as an ECG monitor provides live indirect feedback on the heart’s performance, so the actor or examiner’s facial expression provides live indirect feedback on your performance, the only difference being – I’m sure you’ll agree – that facial expressions are far easier to read than ECG monitors.
  3. Quickly survey the cubicle for the equipment and materials provided. You can be sure that items such as hand disinfectant, a tendon hammer, a sharps bin, or a box of tissues are not just random objects that the examiner later plans to take home.
  4. First impressions count. You never get a second chance to make a good first impression. As much of your future career depends on it, make sure that you get off to an early start. And who knows? You might even fool yourself.
  5. Prefer breadth to depth. Marks are normally distributed across a number of relevant domains, such that you score more marks for touching upon a large number of domains than for exploring any one domain in great depth. Do this only if you have time, if it seems particularly relevant, or if you are specifically asked. Perhaps ironically, touching upon a large number of domains makes you look more focused, and thereby safer and more competent.
  6. Don’t let the examiners put you off or hold you back. If they are being difficult, that’s their problem, not yours. Or at least, it’s everyone’s problem, not yours. And remember that all that is gold does not glitter; a difficult examiner may be a hidden gem.
  7. Be genuine. This is easier said than done, but then even actors are people. By convincing yourself that the OSCE stations are real situations, you are much more likely to score highly with the actors, if only by ‘remembering’ to treat them like real patients. This may hand you a merit over a pass and, in borderline situations, a pass over a fail. Although they never seem to think so, students usually fail OSCEs through poor communication skills and lack of empathy, not through lack of studying and poor memory.
  8. Enjoy yourself. After all, you did choose to be there, and you probably chose wisely. If you do badly in one station, try to put it behind you. It’s not for nothing that psychiatrists refer to ‘repression’ as a ‘defence mechanism’, and a selectively bad memory will do you no end of good.
  9. Keep to time but do not appear rushed. If you don’t finish by the first bell, simply tell the examiner what else needs to be said or done, or tell him or her indirectly by telling the patient, for example, “Can we make another appointment to give us more time to go through your treatment options?” Then summarise and conclude. Students often think that tight protocols impress examiners, but looking slick and natural and handing over some control to the patient is often far more impressive. And probably easier.
  10. Be nice to the patient. Have I already said this? Introduce yourself, shake hands, smile, even joke if it seems appropriate – it makes life easier for everyone, including yourself. Remember to explain everything to the patient as you go along, to ask them about pain before you touch them, and to thank them on the second bell. The patient holds the key to the station, and they may hand it to you on a silver platter if you seem deserving enough. That having been said, if you reach the end of the station and feel that something is amiss, there’s no harm in gently reminding them, for example, “Is there anything else that you feel is important but that we haven’t had time to talk about?” Nudge-nudge.
  11. Take a step back to jump further. Last minute cramming is not going to magically turn you into a good doctor, so spend the day before the exam relaxing and sharpening your mind. Go to the country, play some sports, stream a film. And make sure that you are tired enough to fall asleep by a reasonable hour.
  12. Finally, remember to practise, practise, and practise. Look at the bright side of things: at least you’re not going to be alone, and there are going to be plenty of opportunities for good conversations, good laughs, and good meals. You might even make lifelong friends in the process. And then go off to that Greek island.

Adapted from the new sixth edition of Clinical Skills for OSCEs.

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Dies iræ! dies illa
Solvet sæclum in favilla:
Teste David cum Sibylla!

Recordare, Iesu pie,
Quod sum causa tuæ viæ:
Ne me perdas illa die.
———
The day of wrath, that day
Will dissolve the world in ashes
As foretold by David and the sibyl!

Remember, merciful Jesus,
That I am the cause of thy way:
Lest thou lose me in that day.

—Mass for the Dead, sequence by Thomas of Celano (c. 1200-1260)

Prosecco, Lambrusco, Sekt, and Asti

The long ageing, autolytic character, and expense associated with the traditional method is not best suited to all grape varieties. The other main method of making sparkling wine is the tank method, also known as cuve close or Charmat. Sugar and yeast are added to the base wine in a large pressurized tank, which may be fitted with rousing paddles to increase yeast contact. Once the second fermentation has taken place, the wine is cooled, clarified by centrifugation and filtration, and given a dosage. The method is cheap and consistent and has the notable advantage of preserving freshness and varietal character. On the other hand, it calls upon a large upfront investment, requires a skilled operator to prevent any loss of pressure, and lacks the charm and cachet of the traditional method. It is also unsuited to small-scale production.

Prosecco, most lambrusco, and most Sekt, amongst others, are made using the tank method. Prosecco is made in the area of Treviso in northeast Italy, where the cool and continental climate is perfectly suited to the late-ripening prosecco (Glera) grape. The DOCG delimited area covers 4,100 hectares running into the pre-Alps and Dolomites in the north. Most prosecco is made in the Conegliano and Valdobbiadene area. Prosecco from the hill of Cartizze, a vineyard of 107 hectares, is particularly rich and creamy and highly rated. The bulk of the prosecco production (around 20 million bottles) is spumante, most of the rest is frizzante (lightly sparkling), and a small amount is still. Prosecco should be drunk young. It is light, fresh, and intensely aromatic with primary fruit flavours, a modest alcohol of around 11%, and a signature slightly bitter finish. The traditional style is off dry with a sugar content of 16-17g/l that nicely fills out the wine. Today, much of exported prosecco is brut in style so as to suit modern tastes and best compete with champagne.

Lambrusco is, in the main, a red frizzante wine that is made from the eponymous lambrusco grape, a black grape that encompasses several varietals and that has been in cultivation since Roman and even Etruscan times. For a period in the 1970s and 1980s, it was the biggest selling import wine in the United States. The grapes and the wine originate from four areas of Emilia-Romagna and one area of Lombardy. The climate is Mediterranean and the soils are fertile, and yields can be fairly high. Most lambrusco is made by the tank method in co-operatives, and is of rather ordinary quality. Of the five Lambrusco DOCs, Lambrusco di Sorbara is the most highly regarded, with the best examples being made by the traditional method. Lambrusco is characterized by a flavour of sour cherries, high acidity, and a dry or off-dry style.

About 90% of Germany’s Sekt is made from inexpensive base wine sourced from outside Germany — mainly Italy, France, and Spain. The remainder is Deutscher Sekt, that is, Sekt made from German grapes. The vast majority of Sekt and Deutscher Sekt is made by the tank method and sold under the label of a large and inexpensive brand. The small amount of Deutscher Sekt that is made by the traditional method tends to consist of riesling, chardonnay, or the pinot varieties. The very best are likely to state the vineyard name and the vintage on the label. Sekt is big business in Germany, so much so that three of the world’s five biggest producers of sparkling wine are German.

Asti (formerly asti spumante, a name that had acquired a noxious reputation) is made from moscato bianco, that is, muscat blanc à petits grains, from a delimited region in southeast Piedmont, Italy. The DOCG limited areas are centred on the towns of Asti and Alba. Here the climate is continental and the land calcareous and gently sloping. The grapes are harvested by a large number of growers and sold off to négociants. The method of vinfication is the Asti method or single tank fermentation method. The must is transferred into large tanks and chilled to almost 0°C to inhibit fermentation. The tanks are sealed and pressurized and the temperature is raised to 16-18°C for a single fermentation to 7-7.5% alcohol and a pressure of around 5 atmospheres. The wine is then cooled to 0°C to halt fermentation and membrane filtered to remove the yeast and yeast nutrients. Finally, it is bottled under pressure using cool sterile bottling. Asti can also be made by double fermentation, with a second fermentation from 6% to 7.5% taking place in a sealed tank to build up pressure. The wine is fresh and intensely fruity and floral with dominant aromas of peach and musk and enough acidity to balance out the 3-5% residual sugar. Asti should not be confused with Moscato d’Asti, which is made from the same grape in the same region, but which is frizzante and with even lower alcohol. The Asti DOCG has the largest production of all Italian appellations, with an annual output of almost 90 millions bottles.