Prof. A.H.M.Shamsul Alam
 Objective: Responses are measurable
 Structured: Responses are in uniform format
 Practical: Practical aspects of Surgery
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This examination format focuses on testing
the practical skills of examinee while using
diagnostic tools, laboratory data , procedural
techniques and communication modes
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Surgical pathology
 Specimen
 Illustration of pathological lesions
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Diagnostic tools
 Images
▪ X-ray
▪ CT scan/MRI
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Data interpretation
Communication skills
 Verbal counseling
 Written
 Verbal Interactive( with colleagues)
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Surgical skills (procedures)
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This is to test your pathological background while you
manage a surgical problem
Usually, a surgically removed specimen containing
a pathological lesion is displayed
 You need to

 Identifying the organ: see all around and look evidences
of surgery and read all the questions in the script- you will
find the clues
 Take your time and observe the morphology
 Describe methodically: organ> nature of lesion> involved
area> characteristics of lesion> surrounding tissue
Example:
Specimen
1.
2.
3.
4.
5.
6.
Find three significant
features in this
pathological specimen
What is your gross
pathological diagnosis?
What could be the
possible presentation with
such a lesion?
Mention diagnostic
investigations for such a
disease.
How do you stage this
disease?
What are the principles of
treating this disease?
1.
2.
3.
4.
5.
6.
Specimen colon shows two polypoidal mass and an
ulcerative lesion. The ulcer has irregular and everted margin
with a necrotic floor
Multiple colonic polyp and carcinoma colon
Rectal bleeding, change of bowel habit, weight loss,
anaemia occurring in a middle or old age.
Colonoscopy and biopsy- histopathology
TNM or Duke’s classification depending on tumour invasion
of gut wall and surrounding tissue, nodal involvement and
metastasis
Meso-vascular en-block resection of colon with at least 5cm
of healthy margin
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Tests your ability to use this diagnostic tools
effectively and rationally
Images could be plain or contrast X-ray, CT or
MRI
You need to
 Identify what type of image it is
 Take some time to appreciate the abnormalities
 Find clues from the set questions in script
 Answer precisely
Example :
Imaging
Scenario:
A 70 year old man presented with
recent weight loss and moderate
degree of jaundice. As a part of
diagnostic workup, an imaging
study has been carried out.
What kind of image it is?
Mention four significant findings in
the image.
Mention the most probable image
based diagnosis and two other
differentials
Mention two advantages and two
limitations of this investigation.
1.
2.
3.
4.
5.
6.
MRCP- Magnetic Resonance Cholangio Pancreatogram
Findings:
1. Dilated biliary tree up to the terminal end of common bile duct
2. No filling defect in biliary tree
3. Gall bladder distended
4. Pancreatic duct normal
Carcinoma head of the pancreas.
D/D………………..
1. Periampullary carcinoma
2. Cholangio-carcinoma
3. Impacted calculus at the terminal end of CBD
Advantages……….
1. Non-invasive investigation
2. Outlines whole biliary tree and pancreatic duct system for screening
Disadvantage……
1. Not always precise in finding pathological changes(compared to ERCP)
2. Lacks therapeutic intervention
Example
X-ray
SCENARIO : This is the radiological image
of chest ( PA view ) of a 50 year old man
presented with significant weight loss and
anorexia for four months .
TASK
Please read the radiological image
carefully and answer the questions.
1. List four significant findings in the image
2. What is your radiological diagnosis?
3. What organs / systems would you focus
on during clinical evaluation of the
patient?
4. In absence of obvious clinical clue to
have a diagnosis 5. What biochemical markers will help you?
6. What imaging investigations you will
suggest?
7. What is your management strategy for
this situation?
Example: X-ray
Answer key
Q 1 List four significant findings in the image.
a) Multiple round opacities in both lung fields
b) Opacities are different in sizes
c) They are peripherally placed
d) Cardiac and hilar shadows appears normal
e) No pleural effusion
Q2 What is your radiological diagnosis ?
Multiple pulmonary secondary metastatic tumours
Q 3 What organs / systems would you focus on during clinical evaluation of the patient?
Thyroid, GI: colon and rectum, Pancreas, Kidneys, Prostate, TestiS, Bone
Q 4 In absence of obvious clinical clue to have a diagnosis (a) What biochemical markers will help you?
Tumour Markers: PSA, CEA, βHCG, α Fetoprotein
(b) What imaging investigations you will suggest?
(i) USG of Abdomen / Scrotum
(ii) USG of Thyroid
(iii) CT scan of Abdomen.
Q 5 What is your management strategy for this situation?
a) Diagnosis of the primary lesion
b) Treatment of primary disease and systemic treatment (Chemo/Hormone therapy)
for pulmonary conditions.
c) Palliative care
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
This is to test your ability for rational
interpretation of laboratory data in the
context of clinical situation
You need to
 Take your time reading the whole data mindfully
 Read all the questions and the data again
 Answer precisely
A 50Y old man has developed deep
jaundice for about two months and
having high grade fever and vomiting
for a week. His liver was felt enlarged
and mildly tender. The following
investigators were carried out and the
results have been made available for
your interpretations.
CBCHb. 10 gm/dl
TLC: 24,000/cmm
Polymorph - 81%
Lymphocyte - 14%
Monocyte - 4%
Eosinophil - 1%
Blood sugar (Random)7.1mg/dl
Blood Urea
48 mg/dL
Serum creatinin
2.8 mg/dL
S.Bilirubin16 mg/ dl
S. AST 104 unit/ l
S. Alkaline phosphatase- 798 unit /l
S. Amylase: 50 unit/L
Serum Electrolytes
Na
125 mEq / dL
K
5.3 mEq / dL
Cl
94mEq/dL
HCO3 23 mEq/dL
Prothrombin time - 29 seconds
INR: 2.3
HBSAg (screening)- Positive
CA 19-9: 69 U/ml
Questions:
1. What is your interpretation of the patient’s data?
2. Write your initial management plan.
After a week of initial management patient
had some clinical improvement. Following are
the results of review investigations. Give your
interpretation.
CBCHb. 10 gm/dl
TLC: 11,000/cmm
Polymorph - 75%
Lymphocyte - 14%
Monocyte - 9%
Eosinophil - 2%
Blood sugar (Random)- 7.3mg/dl
Blood Urea
35 mg/dL
Serum creatinin
2.1 mg/dL
S.Bilirubin9 mg/ dl
S. AST 94 unit/ l
S. Alkaline phosphatase- 478 unit /l
S. Amylase: 40 unit/L
Serum Electrolytes
Na
128 mEq / dL
K
4.3 mEq / dL
Cl
94mEq/dL
HCO3
23 mEq/dL
Prothrombin time - 21 seconds
INR: 2.1
HBSAg (Confirmatory)- Positive
Questions:
3. Write your interpretation of the review data.
4. Name further investigations you would suggest.
Answer key:
1. Patient is having the following conditions
1. Obstructive jaundice possibly due to carcinoma of pancreo-biliary origin
indicated by raised CA 19-9.
2. Cholengitis indicated by polymorphonuclear leucocytosis
3. Renal impairment and electrolyte imbalance
4. Possible hepatitis-B virus carrier
2.
Initial management
1. Correction of dehydration and electrolyte imbalance
2. Broad spectrums antibiotic
3. Vitamin-K parenteral
3.
4.
Improved blood count and LFT indicating control of cholengitis.
Improvement of renal function with electrolyte imbalance correction.
Investigations
1.
2.
3.
4.
Upper GI endoscopy - to inspect the duodenal papilla
MRCP- Non-invasive localisation of biliary obstruction, pancreatic mass detection
CT & guided FNAC -to detect and diagnose the pancreatic ca.
ERCP- Diagnosis of peri-ampullary carcinoma, localisation of biliary obstruction, setting
to relieve biliary obstruction.
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This is to test your counseling skills in surgical
practice
Counseling takes a vital role in surgical
managements
You need to
 Read the scenario and tasks several times
 Organize the core issues in your mind
 Write down the points you want to convey
 Have natural voice, maintain etiquette all along
 Use a single language, avoid medical terms
Scenario
 A 35year old lady, a college teacher and mother
of one child, presented with a small lump in her
right breast in upper and outer quadrant . It
measured 2cm in diameter, appeared mobile,
brought no change in nipple and there were no
palpable nodes in axilla. FNAC of the lump
reported ‘duct cell carcinoma’. You, being the
treating surgeon, have to convey the
information to the patient in your hospital
chamber in order to involve her in the treatment
planning.
Verbal communication- Counseling
Example page-2
Tasks for Examinee:
1. Create an easy atmosphere understanding the mental state of the
patient.
2. Inform her about the findings and explain in an understandable
language the significance of these findings.
3. Mention your provisional plan that you consider most appropriate,
4. Inform her about the alternate options and briefly discuss those.
5. Answer her queries in order to clarify her confusions.
Instructions to Examinee:
1. Presume that you are working in a medical college hospital.
2. A well informed person would play the role of the patient
3. You can use any language convenient to the patient
4. Station observer would assess your performance in verbal
communication skills using a structured check-list
5. You may make notes on the paper provided in this station
Verbal communication- Counseling
Example page-3
Check list
1. Welcomes her, ask her to take seat, asks how she was doing, says some
comforting words before serious talks
2. Explains the reasons of this conversation
3. States the nature of the disease in easy language
4. Explains the evidences supporting the diagnosis
5. Narrates the provisional plan of treatment best for he given the circumstances
6. Takes questions and allows her to express her desires
1.
2.
3.
4.
5.
6.
Are you going to remove whole breast or part of it?
I do not want to remove my breast. Is it possible?
If the whole breast is not removed, would it cause any harm?
Chemotherapy and radiotherapy cause much problem, can I avoid those?
What are my chances of cure with the treatment you have suggested ?
What are the chances growing the tumour again once removed?
7. Informs her of the alternate options of treatment with evidence based outcome
8. Assures her about the overall surgical outcomes
9. Informs her about the adjuvant treatments and accompanying hazards
10. Concludes conversation giving her time to think about the whole issues and give
response at the earliest
Verbal communication: Interactive
This is to test your interactive ability in professional
conversations
 It occurs between the examinee and a senior
surgeon (interviewer) based on a scenario and set
questions, but supplementary comes up as
conversation goes on
 You need to

 Listen to the question very carefully: catch the reason
 Answer precisely, never say everything
 Give a chance to ask the next question that you know
 Never say anything but evidence based information
 Skip quickly if something is not known to you
Verbal communication: Interactive
Example page-1
Scenario
A one year old girl was brought to the hospital by parents as
she had facial defect since birth.
Instruction to Interviewer
Ask following questions to the examinee with regard to the
management of patient’s cleft lip and palate. You are
allowed to ask supplementary clarifying questions in
response to the answers as and when required.
1. What is the diagnosis?
2. What is the developmental basis of this abnormality?
3. What are the present problems of this baby?
4. What would be your advice to the parents regarding
feeding and airway?
5. What complications will arise if reconstruction is not
done?
6. What would be your management plan?
7. What is the rationale behind the two stage operation?
8. What further managements are required following
reconstruction ?
Verbal communication: Interactive
Example
page-2
Answer Key
What is the diagnosis?
Unilateral complete Cleft lip, alveolus and palate ( left)
What is the developmental basis of this abnormality?
Failure of the fusion of the fronto-nasal and maxillary process
What are the present problems of this baby?
Cosmetic, suckling difficulty and nasal regurgitation, impaired speech development.
What would be your advice to the parents regarding feeding and airway?
Using Soft bottle, modified tits, enlargement of hole of tit, feeding plate and for
airway- nursing in prone position(Ref. Bailey & love p-661)
What complications will arise if untreated?
Facial asymmetry, psycho-social developmental disorder, speech developmental
disorder
What would be your surgical plan?
Reconstruction of lip and soft palate at the age of5-6 months and hard palate and
gum pad 15-18 months (Ref. Bailey & love p-661)
What is the rationale behind the two stage operation?
Two stage closures encourages the physiological narrowing of the hard palate cleft to
minimize surgical dissection
What further managements are required following surgeries?
Hearing and speech therapy, dental care and facial revision surgeries
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
This is to test your ability to write surgical
documents as surgeons need to write
documents in order to communicate with
the people
You need to
 Read the scenario and the task very carefully
 Take your time in planning an outline: header>
body: each paragraph for an issue>footer
 Never miss a component ( Example: your
address, Tel,)
Written communication Example Page-1
Task
This is a written communication skills station.
You are to write a “Death summary” of a patient who has expired
3 -4 hours back, presuming that, it is an important document for
‘Death Review Committee’ of the hospital.
Instructions:
You shall have to complete the report within 200 words.
You will find in patient’s file, chronologically, bridged notes of
patient history and physical examination, investigation, treatment,
follow up and death confirmation.
Please write your code number as you start writing your report
Time limit: 10 Minutes
Written communication Example Page-2
Check list
Incorporates the following in the death summary
1. Patient particulars, admission time and date
2. Admission presentation: Provisional diagnosis and
overall condition
3. Immediate treatment on admission
4. Diagnostic workup
5. Diagnosis
6. Intervention: Brief description with time and date
7. Ongoing monitoring and progress of the disease
8. Consultations and specialty opinions
9. Situation before death(deterioration sequence)
10.Time and date of death
11.Cause leading to death
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This is for testing your surgical skills that are
essentially the standard or recommended
techniques you follow while performing a
surgical procedure
You need to
 Read the scenario and the tasks several times
 Go by the written instructions at the station
 Stick to standards of surgical skills, not you style
 Go slow, but steady; ask for assistance
Surgical skills Example page-1
Procedure
You will have to perform a basic surgical procedure on a stitching
board using available instruments and materials.
Task:
1. Close the incision made on the board by a ‘continuous
interlocking’ suture considering it as planned skin incision
2. Put surgeons’ knot at the beginning
3. Put Aberdeen knot at the end
Instructions:
1. Introduce yourself with your Code number
2. You don’t need to put on gloves
3. Use 2/0 silk on curved cutting needle
4. Ask for assistance
Allotted time: 5 minutes
Check list
Starting knot
1.
Passes the needle at the end of the incision
2.
Makes first throw with double twist
3.
Makes second throw with single twist to make a reef/squire knot
Continuation of suture
1.
Enters the needle into the skin vertically- passes the needle along its long axis- exits at an
identical point on opposite side
2.
Keeps distance of entry/exit points from incision margins equal to its depth
3.
Suture interlocks on side of the first knot
4.
Keeps distance between the stitches equal and half that of depth of the incision wound
5.
Maintains adequate tension approximating the wound margin
End knot-Aberdeen
1.
Stops the continuous suture at the other end by the final pass close to the just previous one and
forms a loop without tightening
2.
Passes several Aberdeen knots and adequately tightens by bedding those down
3.
Makes final pass of thread through loop to end the knot and cuts it
General considerations
1.
Holds needle at the tip of needle holder 2/3 away from tip
2.
Holds the wound margin with tooth dissecting forceps or skin hook while passing the needle
3.
Holds the needle holder and forceps properly
4.
Never touches the needle by hand
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Surgeons need to become skillful in a number
of areas in their practice
OSPE represents surgical practice
Stations are constructed from our daily
experiences
Mindful observation during training period
ensures a best preparation
Any question?
Any question?
Thank
you
Thank
you
Thank
You