I like this OSCE module for two reasons:

1. Painful menstrual cramps is a very common symptom, so it is reasonable to test the student’s knowledge and skill in handling this issue.
2. Dysmenorrhea is associated with broad range of gynecologic conditions, allowing the examiner to explore the depth of the student’s knowledge in a short time.

The module follows a basic 15 minute format, and involves a one-on-one interaction with a faculty member, across a desk.

In preparation, the student is given the following information:

Discuss a Case with the Attending

Lois Whitlock is a 35 year old, G-3, P-3 woman with menstrual cramps.

• She’s had trouble with menstrual cramps off and on since age 14, but over the last 5 months, the cramps have gotten much worse.
• The cramps usually start a day before her period and last a day, but more recently they have lasted 4-5 days, and the intensity of the pain is worse.
• Advil makes the pain somewhat better.
• The pain is cramping in nature, with a heavy, dull aching in the pelvis.
• She has no other associated symptoms, such as nausea, vomiting, diarrhea, loss of appetite, or fever.

Menstrual History:·  Menarche age 13 ·  Menses reg., Q26-32 x 4 ·  2nd day is heavy	Pregnancy History·  3 normal Pg’s ·  NSVDs ·  Children ages 7, 9, 11	Contraceptive HistoryOCPs until 2 years ago, when she stopped them because she was not sexually active.
Medical History: NoneSurgical History: None	Meds: NoneAllergies: None	ROS: Negative
Uterine Findings:·  Uterus 10 week size ·  Mobile, Sl. Tender	Adnexal Findings:·  Adnexa NT ·  No Masses	Rectovaginal Exam·  UteroSacral Ligaments NT ·  No nodules

The Resident has already presented this patient to the Attending. But the Attending wants to discuss the patient with you. Go inside and discuss this patient to the Clinic Attending Physician.

——–

So the story is that a 35 year old has a moderately complex history of dysmenorrhea. The history is intentionally non-specific to allow for a range of potential diagnoses.

After sitting down with the faculty to discuss the case, the faculty asks a series of questions:

1. What is your Differential Diagnosis?
2. What additional information would be helpful?
3. The uterus is 10 week size. Does that support any diagnosis?
4. The uterus is mobile and tender. Does that support any diagnosis?
5. The adnexa are non-tender and without masses. Does that support any diagnosis?
6. The Pap and culture are normal. Ultrasound = 10 wk size uterus with multiple small intramural myomas. What is your diagnosis
7. What management plans would be reasonable for her?

The student is then graded, based on a check-off list held by the faculty (below). The checklist has “good points” and “bad points.” The student’s final score is the sum of all the good points, minus the bad points.

Dysmenorrhea Faculty Grading Sheet (pdf)

The faculty also assigns a “gestalt” grade (1-4) that ranks the student independently of the numeric scores.

Faculty are instructed:

• These are not OBGYN oral board exams. Faculty should be pleasant, encouraging, and inspirational. If the student answers incorrectly, give the student the correct answer (in a pleasant way), and move on. This OSCE is 75% educational (“formative”), and 25% evaluation (“summative”).
• This module is a discussion, not a case presentation. If the student were to begin with “This is a 35 year old, G-3, P-3,…” the faculty is instructed to interrupt them and explain, “I’ve already had this patient presented to me by the resident. I just wanted to talk about the patient with you.”

This module has proven to be a reasonably good discriminator of student performance. Broadly, it covers four areas:

1. Differential Diagnosis of Dysmenorrhea
2. Relationship of different aspects of History and Physical Exam to support or exclude different possible diagnoses
3. Evaluation of Dysmenorrhea
4. Long term management of Dysmenorrhea.

Some students do better with some of these elements, and others do not do as well.

The post-exam student evaluations are uniform in their praise of this particular station. They like it because:

• They have the undivided attention of the faculty
• They perceive the module as being mostly educational and not threatening
• They all learn some things they didn’t previously know.
• It seems to be a fair test of their knowledge and ability to apply that knowledge clinically.