Re: ACEM OSCE 2019:1 ‘Refugee‘ Station
Emergency Department
Back of Bourke Base Hospital
NSW 2121
Australia
April the 1st 2019
(not in jest)
Dear Dr Jeff Cott,
Cultural competence is a central part of Emergency Medicine practice, especially in 2019 in an Australasian setting. I was glad to hear that ACEM are considering increasing their summative assessments of cultural competency. Further, I note this now applies to both for trainees and FACEMs. The ACEM college should be congratulated on addressing this important issue in-line with RACS and ANZCA.
Early this week (on the 1st of April; but not in jest) we were informed (having not been present at the 2019:1 OSCE examination) that one of the stations aimed to test cultural competencies and communcation skills in an extraordinary way. Paraphrasing, it’s apparent that one of the OSCE stations used the case of a ‘refugee‘; ‘muslim‘; ‘female‘; ‘quiet‘; ‘refusing to speak‘; ‘distressed‘ patient who had multiple somatoform complaints. Clichéd? appropriate? offensive? necessary? – are all words I have heard to describe the station from various quarters…
Needless to say, this particular OSCE station has caused a wee bit of a stir. Was it based on a real case? Was it in an exam blueprint or was it just made up? I am sure it has been included with best of intentions and it is important to test the topic of cultural competence.
As a perpetual ACEM trainee what is my opinion? Well, while clichéd grey cases in medical exams are less than ideal, they always have been common place… These types of questions have been an integral part of the assessment process for many years especially in MCQ exams….
These grey cases with a ‘touch of stereotype‘ are a classic form of question, but should these pattern recognition cases be kept of the OSCE exam? The rationale would be that the professional ‘live actor’ may play their OSCE role neither safely nor consistently. Additionally, who can really judge objectively what ‘cultural competency’ looks like from a particular minority’s perspective in a stressful OSCE setting? What if the observers (examiners) are not in fact from the minority group concerned?
On the other hand, in a written exam the wording can be precisely workshopped leaving no doubt to either the reader or examiner of what exactly is being tested. Furthermore general rules can be tested and specific documents recommended for reading in the curriculum list.
For example, describing ‘a 22-year-old middle eastern patient with recurrent acute abdominal pain and peritonism‘ would make me think (the exam answer) of Familial Mediterranean Fever. This would be a classic case that I think you need to ‘classic descriptions for’ to make the ‘spot diagnosis’. This kind of thing should be tested – but in a written format. Likewise you could test the “refugee patient” case in a written exam somewhat effectively, albeit at a lower level of application on Miller’s Pyramid (Fig. 1):
I think what caused such a stir in this case wasn’t the idea of testing Cultural Competency per se, but rather the issue was putting this, otherwise appropriate case in a high-stakes OSCE setting.
This has upset many in minority groups who feel that the case is perpetuating stereotypes. They are especially concerned because of the perception that the exam has been stacked against individuals from minority groups and non-english speaking backgrounds.
Yours Sincerely
Dr Ed Reje
ACEM Trainee (Perpetual Maintenance Pathway)
EmergencyPedia 
Assessing cultural competence ,which is an integral part of ACEM core curriculum is appropriate.
The problem arises when it is done in an insensitive manner. Why is it always a muslim woman from a middle eastern background? Why do we have to give her an origin? Is there something specific that you want trainees to know about refugees from Middle East?
Why can’t it be done for people from other races, religion or groups? Because that would be inappropriate.?.. why is it appropriate always to stigmatise this one group always
Why do people think Middle Eastern women cannot talk to men?
I think I have asked too many questions without any answers.
The station is a great reflection of the superficial stereotypical understanding of other cultures, coupled with the naïve belief that cultural competence can be attained by viewing three modules onthe ACEM portal. Within this belief system is the subconsciously entrenched notion of Anglo-Saxon cultural supremacy that supports the biased world view. We have not learned our lessons, the first fleet arrived in 1788, 2019 we still do not understand the cultural beliefs and value systems of the people who lived on this land for thousands of years and fail to remember that no foreign power could impose democracy in Afghanistan.
The station is a condescending stereotype that again trivializes the training process making a mockery of specialist assessment. Seven minutes to teach a JMO about cultural competence, refugee health, social safety. If a JMO feels confident after this, then I fell very concerned for my patients.
However let’s focus on the exam. Naveed this is not a difficult station to pass, if you know what the examiners think is the “standard”, I can see you will struggle in the station and most likely fail, because you may be knowledgably the 17 countries of the middle east with 100’s of linguistic, religious and cultural groups within the region and may have actually worked in the region or have family ties there. You are not here to teach what you know, you are here to play a game to be certified a specialist. Just play the game.
Let me reinforce, remember the aim is to plan the seven minute game and get certified as “experts”. That is it.
Let me “teach” you my approach to this station: Need tick boxes in each of the following.
This is what you do / tell the JMO confederate:
1. Check prior understanding. (Please don’t tell me you know, this is scripted you just play along).
2. Say to the JMO “use non-threatening approach” sit at patients level make eye contact. (Imagine doing this is in real life, this will be considered completely inappropriate in many cultures, but the examiners don’t know that, so play along).
3. Offer a lady doctor / nurse: imagine a well-meaning locally trained doctor walks in, tries to shake hands and says “its ok darling, you are safe, love, we will look after you”. This locally trained doctor will smash the station 9/7 very well above standard. I am sure you are smiling to yourself imaging this in real life. This would be so inappropriate.
4. Display empathy: sit forward and active listening. Active listening, repeat at least one thing the patient said and you are done.
5. Please check understanding, or loose a point.
6. The rest is stock standard, get interpreter, involve family, contact refugee health liaison, and involve social worker. Make sure she’s safe, check domestic violence, very important (Middle Eastern women are oppressed).
7. Medically: very simple: isolation, CXR, quantiferon gold, bloods for everything possible rain bow tubes. You name the infectious disease she can have it, she’s likely from a third world middle east country, it must be like Naru unfit for human living. You will not be wrong if you name any infectious disease.
You are done. Now it is up to the discretion of the examiners where they mark you on the standards scale 1- 7. I would guess that you have an accent and “non Anglo” body posture; I would guess you will get a 4.0 for each domain and just at standard. This unfortunately you should accept.
The most concerning aspect of the OSCE process is certifying competence based on a 7 minute performance. The above is a good example of how this mechanism is putting patient safety at risk and trainee welfare in jeopardy.
@John – you forgot hand hygiene for two further points….
@ Andrew that is “FACEM” level ! Thanks a lot.
One more thing to add is that Naveed even if you do your best as pointed out by @John and you get 4 in each domain i.e at standard, yet you would never pass this OSCE because the examiners wouldn’t mark you more than that.
Even after tick boxes are checked the marking will be very stingy, the reasons are firstly based on your country of primary medical degree and secondly because you have an accent.
They call it communication problem.
HAVING an ACCENT tantamount to SUBSTANDARD COMMUNICATION BY DEFAULT.
And this is not considered discriminatory conduct of the assessor.
Furthermore talking about stereotyping middle eastern women and framing OSCE questions to assess DV and assuming middle eastern women not talking to men, this is not evidence based and in fact reflects lack of knowledge of the ACEM examiners who makes this kind of question and their biased based no media rhetoric undermining Muslims a.k.a Middle Eastern Cultural and Religious practices.
I have worked in Middle East in the Ultra Conservative Saudi Arabia where women did not have any problem speaking to male doctors and in fact most women preferred to see a male Obstetrician and Gynaecologist.
And I have not come across a single case of DV.
Australian statistics about DV are well known to every one so why when it comes to DV it is always migrants from Middle East.
This is appalling to see that ACEM being the highest training body for Emergency Medicine lacks fairness and accuracy when it comes to testing cultural competency and health advocacy of the trainees with regards to patients from culturally and linguistically diverse groups.
Hey Andrew
Not sure whose purpose this discussion serves.
You( I doubt)
Website( maybe)
Or
People like me- (clearly not.)
Personally I don’t find anything offensive in this station But I must admit I don’t have first hand knowledge of the whole scenario.
Anyhow ACEM has made much bigger f..k ups then this but Dr Reje decided not to rake up those issues.
I still remember his first blog in 2015 after the written exam in 2015 but we never heard from him again. Probably because after getting the fellowship and half a million a year contract he decided bagging the college is no longer useful.
Therefore i wonder why this sudden empathy towards minorities and Non English speaking trainees/BTW we are not non English speaking- as we do have to pass IELTS to get into this country.
I somehow have a feeling that this blog isn’t what it portrays to be.
I hope I am wrong.
Regards
Sumit
First of all on behalf of ACEM my sincere apologies to anyone who’s feeling may have been hurt by the recent OSCE on Refugee health. I assure you we will learn from our mistakes and make this better next time. The college accepts no liability but we are really sorry if you fail this OSCE. Our heart goes out to you Naveed, the good intentions of ACEM has been misunderstood. All we were trying was to ensure that we could somehow deal with this lady in 7 minutes so that she can be out of the department in 4 hours. KPI s are important you see! We understand that you may be very stressed at this time. Our thoughts and prayers are with you. So that you won’t leak this to press like some disgruntled trainees in 2016, ACEM will offer you a free course. We can even provide you with excellent training by Prof Jill Kein on resilience. This will be our way of thank you for bringing this error to our notice. If you have any questions please feel free to contact the college. We are here to support you. The EAP program is available 24 * 7. we pay for it but trainees don’t seem to use it much. That was my lame attempt to poopoo ACEMs response )
Now the serious issue.
Cultural competence is a very loaded word – it’s learned over a lifetime. If anyone in ACEM thought we can teach and test Cultural competency in 7 minutes is foolhardy. It not like learning CPR, we as emergency physicians like to simplify everything as ABCDEFG but unfortunately, that is not the way the world really works.
If ACEMs new emphasis is to show that they are doing something to “tick ” the cultural competency box in some govt document then it’s great! We can expect a 32-year gay man with HIV and 45-year-old intoxicated Indigenous Australian man ( maybe even woman ) in the next OSCE. No stereotyping here, just making sure that future FACEMs are culturally competent.
Fair enough Sumit. It did say non English speaking “backgrounds”
The use of a character isn’t to make light of the situation but to bring some humour, so apologies if you feel pardody is bad taste – it’s a serious issue
The station is new to the OSCE exam, and I reflected a lot on the content and construct of the station, especially in the light of the events in Christchurch and the incredible leadership demonstrated by the Prime Minister of New Zealand. The particular station was one in where the candidate was to teach a JMO about the assessment of a middle – eastern refugee women. “Refugee middle – eastern women, not talking, looking at the wall”. Sounded like “African gangs”, Veiled Muslim lady”, not to forget Winston Churchill’s “half-naked fakir” comment about Mahatma Gandhi.
The station was a condescending, stereotypical oversimplification of an important topic on which “specialist” competency is assessed in seven minutes.
The OSCE exam, in general, unfortunately, lacks cultural competency. The very fact that the exam is based on the premise that multiple attributes including “empathy, leadership and collaboration and teamwork” are measurable and are uniformly expressed across cultures, this reflects the mentality that demands uniformity of culture, the so-called assimilation. Moreover, this is not in any way different from the imagery of the Murdoch press or the rhetoric of “one nation”. The exam is measuring abstract qualities appropriated to a stereotypical Anglo – Saxon understanding. Body language, word descriptors of empathy, leadership style and keywords all of which are interpreted to the standard of an “Australian” stereotype (inappropriate word, explanation bellow). The seven minute OSCE wonder is trivialization of every aspect of patient care. Of course EQ does not matter, its a tick box game.
The subjectivity of the marking scheme is putting people from NSEB backgrounds at a disadvantage and patient safety at risk. It is not rocket science, and the examiners gut feeling determines the outcome for the candidate. “I did not feel your empathy”, Your leadership did not come through in the simulation station”, “you did not seem engaged with the patient”. The exam is now unfortunately a power game, that’s putting both patients and trainees in harms way. the statements tell the story.
We do serve a multicultural clientele; the exam is designed to test, the Anglo – Saxon understanding (inappropriate word, explanation bellow). To give a few examples. A man from South- Asian origin, will, in general, be offended and not interact with anyone who asks him about suicidality. Once the question is posed any further interaction from there off is off the table, because suicide is against many religious beliefs, cultures and considered a selfish act. However this would be a pass-fail tick box in the exam, I can understand some who are “culturally aware” would never ask anyone the question as a matter of routine, and yet develop rapport, elicit information and keep the patient safe in real life but will fail the exam. The same way some of us know, we cannot ask an unmarried lady from certain cultural backgrounds, if she is sexually active or pregnant without spending considerable time on multiple occasions to gain the rapport. The question will be grossly inappropriate, traumatising and offensive. We know if we don’t tick the box in the OCSE, we will fail. In real life, patient safety is compromised.
Cultural competency is not three modules, and it’s a daily process, a conversation that’s ongoing and continuous. No amount of doing modules while cooking, cleaning or doing a shift in ED to achieve a tick box will help to promote cross-cultural understanding and respect. On the contrary this simplistic exercise defeats the purpose giving the participant a false sense of competence.
If we want to walk the talk on diversity and inclusion and to develop intercultural understanding, let’s start with conversations. Tweets about equality versus equity, closing the gap, empowerment etc., sound very good, and are in tune with the current political discourse. We should hope to make them a reality on the ground.
We need to walk the talk. We are not doing it !
(The use of the word Anglo – Saxon is inappropriate, however the word “Australian” is too board. 29 % of Australian population is born overseas, the college may not be aware of the client profile, immigration treads and global population growth or the fact that one in every 3 people on the planet is of “Indian or Chinese” heritage and 25 million people live on our Island – continent – country. That’s ok. Even after two centuries, we still do not understand the values of the people who lived on this land for thousands of years, we should give the college a century to catch up.)
I understand the refugee station was not the only issue the 2019.1 OSCE suffered.
After resisting the temptation of recording the OSCE’s for 3 years, ACEM finally started recording the exam. It may be of interest to the reader to know, that the venue for the OSCE exam is fully equipped to record the proceedings, it’s curious that the college decided to brazen it out for so long. It begs a question, what was the reason for the resisting the option to record the exam and open up the process to scrutiny? The answer is obvious.
The advent of recording resulted in the chaos of day one of the OSCE. A station was changed halfway through the exam and there were multiple issues with the five remaining stations on day one and the rest of the days.
It is clear that the college was not prepared for initiation of recording and the scrutiny that would follow.
The basic questions:
1. How is it OK that station a high stakes exam is modified mid-way through the exam?
2. The stations are designed by “scholars, teachers, leaders, medical experts” and other adjectives which go with the “fellow” tag. And we are told are work-shopped for two hours prior to the exam (a candidate gets 84 minutes for the entire examination to prove “expertise”). Yet clearly many stations are poorly designed, by the ACEM’s own admission of changing station domains. If the organizers can’t get the stations right, how can candidates performing in a high pressure situation be expected to put up “masterly performance?”
3. The so called experts failed to deliver, why do the candidates have to pay the price?
4. If a station is thought to be substandard, the college gets to remove some components halfway through, if the trainee’s performance is considered substandard, the trainee is removed. Is it at all logical?
A substandard system is certifying expert level competence !
What’s up with the shoulder?
Both the shoulder examination station in cohort 1 was confusing. One was changed halfway through the OSCE – even after changing it, it was presented differently to different candidates. Some had examiner interaction ( yes there was interaction with the examiner). OSCEs except SCBDs are not meant to have examiner interaction. There is something terribly wrong here – Even ” THE EXPERTs” couldn’t get it right after workshopping for 2 hours then changing it halfway through the OSCE.
Then the other shoulder station – were lady had a dislocation for 6 months – it was missed by GP and a few others – the poor FACEM ( candidate) had to do the Open disclosure for which many candidates struggled – the conference himself could not get his head around what was going on – I wonder how the examiners marked this ?
Four years into the aftermath and we ask ourselves, “what really happened??”, as nothing much so far has ever been acknowledged by anyone. A so called independent investigation that claimed unintentional, little, benign whatever happened. Then, ‘they’ were simply just nondescriptly “sorry” for something that vaguely happened, now, long time ago.
Are we about to call ourselves the forgotten people??
The smoke may have dissipated away, but the scars of tragedy are clearly visible. The scars ARE ACCUMULATING and we DO NOT claim here that we are the ones that scratched our own faces!
We are not going to disappear or go into hiding like the board engineers who keep refusing to put up a single portrait of themselves on their profile pages. In this era of mobiles and selfies, why not just show your faces and your innocence, if that’s what your conscience is niggling you away with?
The strongly audible Melbourne heartbeats we hear, makes their low profiles not absolvable!
For the trainees, our low profile so far is in NO WAY defeat!
The final path to our victory lies in our coordination. Trainees in each state, nominate a Legal Rep for your home state. Amongst the Legal Reps, nominate the National Legal Rep………………….. You know what I mean 😉
In this path, the first step to your achievements has to be YOUR DEMONSTRATION that YOU ALL CAN obtain YOUR LOCAL STATS as to how many of you passed. Don’t be shy. Don’t be frightened. Cooperate and coordinate! Build your fortress to victory!
It’s the power of ONE! If each and everyone of you make your small contribution, your united immensity will be there to be feared.
Let’s wait for the results first!
Freedom Fighter