12 Tips from Neel Burton for Acing Your OSCEs

  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.

2013 in review

The WordPress.com stats helper monkeys prepared a 2013 annual report for this blog.

Here’s an excerpt:

Madison Square Garden can seat 20,000 people for a concert. This blog was viewed about 61,000 times in 2013. If it were a concert at Madison Square Garden, it would take about 3 sold-out performances for that many people to see it.

Click here to see the complete report.

The Beauty of Latin

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)

Non Traditional Method Sparkling Wines

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.

Champagne 3: Method of Production

Like many sparkling wines, champagne is produced by the traditional or classic method, which is characterized by a second fermentation in the very same bottle in which the wine eventually comes to be sold. Although the traditional method is usually thought of as the best method for producing sparkling wine, it is the only method that does not require expensive, large scale equipment, and hence the only method that is available to the small scale producer.

The grapes that go into making champagne require both high acidity and phenolic ripeness, a combination that is much easier to achieve in the cool Champagne region than in warmer climates. So as to preserve acidity, grapes are harvested early at a low must weight. This comes at the expense of sugar content, which is made up for by the subsequent addition of sugar in the form of liqueur de tirage and liqueur de dosage and also, in some cases, by initial chaptalization (see later). In black grapes it also comes at the expense of colour, which for champagne is in fact a benefit.

The vineyards are harvested by hand and whole bunches are cut. This ensures not only that individual grapes are left undamaged but also that the juice can run off quickly along the stalks, which act as drainage channels in the press. The grapes are pressed without delay, traditionally in a basket or Coquard press although other types of press, notably the Vaslin horizontal press and the more delicate Wilmes horizontal press, are also used. Gentle pressure is applied so as to minimize the extraction of undesirable colour and tannin. By law, only 102 litres of must can be extracted from every 160 kilos of grapes. The first 80 litres to emerge are the cuvée. The cuvée is of the finest quality as it is highest in acidity and sugar and lowest in phenolics. The remaining 22 litres are the taille which may or may not be excluded, and anything beyond 102 litres is the vin de rebèche which cannot be used for champagne. After pressing, the must is clarified although some solids need to be retained to facilitate the second fermentation. The must may also be chaptalized at this stage.

The Coquard Press

Next the must is fermented to a still wine, normally in stainless steel vats although some producers such as Bollinger and Krug use (old) oak casks. Too cool a fermentation temperature encourages the formation of undesirable amylic aromas, which may mask some of the much more subtle and complex aromas of the finished champagne. Most champagne houses encourage malolactic fermentation although some, most notably Lanson, prefer to avoid it.

Grapes from different plots and parcels are vinified separately. In the spring following the harvest these vins clairs are blended along with varying proportions of reserve wine from older vintages. This process of blending or assemblage aims not only at balance and complexity but also at producing a consistent house style. As several of the numerous parameters of the savant mélange are highly vintage dependent, there can be no fixed recipe for the house style and every release is the product of the fine and expert judgement of a master blender.

The blended still wine, though full of promise, is not particularly pleasant to drink. It is bottled together with the liqueur de tirage, a mixture of wine, sugar, and yeast. The purpose of the liqueur de tirage is to induce a second, slower fermentation or prise de mousse in the bottle. Around 24 grams of sugar per litre are required to add around 1.2% of alcohol. This brings total alcohol to around 12% and also yields sufficient carbon dioxide for a bottle pressure of around 5-6 atmospheres – 5-6 times atmospheric pressure at sea level or the same pressure as in the tire of a double-decker bus!

The bottles are sealed with a crown cap and laid horizontally sur lattes in a cool cellar. The prise de mousse takes place over a period of perhaps 4-8 weeks after which the wine is left to mature, in some cases for several years, on the dead yeast or lees. During this long period, the gradual breakdown of yeast cells releases mannoproteins, polysaccharides, and anti-oxidative enzymes into the wine. This yeast autolysis results in a fuller body with a more unctuous mouthfeel; reduced bitterness and astringency; complex aromas of biscuit, bread dough, nuttiness, and acacia; and improved ageing potential. By law, non-vintage wines must sit on the lees for a minimum period of 15 months and vintage wines for a minimum period of 36 months. Many producers largely exceed these minimum requirements.

Champagne bottles sur lattes and (foreground) on pupitres.

Compared to blending and ageing on the lees, the remaining steps in the method of production of champagne add relatively little to overall quality. The bottles are first agitated so as to loosen and consolidate the sediment, a process called poignettage. The yeast deposit is then gradually moved into the neck of the bottle. Traditionally, this is carried out over 8-10 weeks on a pupitre, a wooden frame with 60 holes bored at an angle of 45 degrees on which bottles can be manually turned from horizontal to vertical. Nowadays, this process of riddling or remuage is far more likely to be carried out on a much larger scale and in a much shorter time by a mechanized gyropalette. Once the bottle is vertical, it is left in this position (sur pointes) for a further period of maturation.

Next, the crown cap and lees are removed. This process of disgorgement used to be carried out by hand or à la volée. Today it is usually carried out in an automated process that involves freezing the material in the neck of the bottle and ejecting this ice plug under the pressure of the wine. The liqueur d’expédition or dosage is then added. This consists of a mixture of the base wine and varying amounts of sugar that serves both to balance acidity and to determine the final style of the wine. By far the most common style is brut with added sugar of 6-15g/L. Other fairly common styles are extra brut with 0-6g/L and demi-sec with 35-50g/L.

A composite or agglomerated cork with whole cork attached to the base is inserted and held in place by a capsule and wire cage (muselet). But the wine is not yet ready to drink, and a further rest period is required for the dosage to marry with the wine. During this period, a number of chemical reactions between sugar in the dosage and amino acids in the wine yield additional aromas of dried fruit, toast, and vanilla that add to the overall complexity of the wine. Some authorities have argued that zero dosage wines (bone dry wines with no added sugar) are unable to benefit from this so-called Maillard reaction, as a result of which they have a relatively limited ageing potential.

To produce the smallest and largest bottle sizes (beyond jeroboam i.e. double magnum or 3 litres), the wine is disgorged into a pressure tank, the dosage is added to the tank, and the wine is rebottled – a process called transversage. No doubt there is something lost in this process, even though it may not be very much. Bottle sizes beyond jeroboam are rehoboam (4.5 litres), methusalem (6 litres), salmanazar (9 litres), balthazar (12 litres), and nebuchadnezzar (15 litres), and it is not entirely clear why they have been or should be named after biblical characters.

The method of production described above may be slightly adapted for different styles of champagne. Vintage champagne is not made every year but only in very good to exceptional years. The wines that go into the assemblage must all be from the same declared vintage and the minimum period for ageing on the lees is 36 months. Compared to non-vintage champagne, vintage champagne is richer and fuller and more apt to improve with bottle age. A producer may also indulge in a cuvée de prestige, which is normally a vintage champagne made from premium grapes and/or aged for an even longer period. Pink champagne, which accounts for about 7% of total production, is made by adding a small amount of still red wine prior to first fermentation. Champagne that is sold as ‘recently disgorged’ or similar is champagne that has benefited from prolonged yeast ageing and that has been released for sale soon after disgorgement. If consumed soon after release, this champagne can taste especially fresh, fruity, and complex.

Champagne 2: The Lie of the Land

The three grape varieties used in making champagne are chardonnay, pinot noir, and pinot meunier. All three grape varieties are planted across the champagne AOC, which is the only major single-appellation region in France. This region is located about 85km northeast of Paris at latitude 49-50° North, that is, at the northerly extreme of wine making. The climate is marginal with a mean annual temperature of 10° centigrade and all the problems that this entails, such as severe winters, spring frosts, coulure, millerandage, and hail. Nonetheless, the chalk subsoil is good at retaining the sun’s heat. It is also good at retaining water, which is relatively scarce, and accommodates the cool and damp cellars in which the wines are made and aged. The vineyards themselves predominantly face south, east, and southeast on gently undulating to moderately steep terrain that combines high sun exposure with good drainage.

In Champagne, the quality of a terroir is not demarcated according to an individual site as in Burgundy but, rather crudely, according to an entire village. On the so-called Échelle des Crus, each village within the demarcated area is given a score ranging from 80 to 100 per cent; villages with a score of 90-99 per cent are classified as premier cru and villages with the top score of 100% as grand cru. There are 41 premier cru and 17 grand cru villages, altogether accounting for just over 30% of the entire demarcated area.

Most of these premier and grand cru villages are located in just two of the five regional areas or districts, the Montagne de Reims (forested peak, 286 metres) to the north of Epernay and the Côte des Blancs to the south. The Montagne de Reims is dominated by pinot noir, which contributes structure and depth of fruit to a blend. The Côte des Blancs is an east-facing slope that is mainly planted with chardonnay, which contributes freshness and fine fruitiness to the blend, and which also has the greatest ageing potential. Some of the greatest champagnes such as Taittinger’s Comtes de Champagne and Ruinart’s Dom Ruinart are 100 per cent chardonnay, so-called blanc de blancs. In contrast, no one deliberately sets out to make a blanc de noirs, that is, a 100% blend of black grapes (pinot noir and/or pinot meunier).

The Montagne de Reims and the Côte des Blancs are quasi contiguous with the Vallée de la Marne which runs west past Hautevillers and then for some 40 or 50 kilometres to a bit beyond Château-Thierry. The Vallée de la Marne is mostly planted and particularly suited to pinot meunier. Compared to pinot noir and chardonnay, pinot meunier buds late, and so is more resistant to the spring frosts to which the Vallée de la Marne is particularly prone. In a blend, pinot meunier contributes notes of flowers and bruised apples, and an early maturing richness and fruitiness that can make for immediate appeal. All the classified villages in the Vallée de la Marne are concentrated at its chalky, eastern end not far from Epernay.

The other two districts, the Côte de Sézanne and Aube (also called the Côte des Bar) are effectively detached satellites to the south of the Côte des Blancs. Neither Sézanne nor Aube contains any grand or premier cru villages. Sézanne, which lies northwest of Troyes, is a small area mainly planted with chardonnay that does not quite achieve the same elegance as in the Côte des Blancs. Aube, which lies south east of Troyes and which is actually closer to Chablis than to Reims (with soils similar to those of Chablis), is mainly planted with pinot noir that neither quite achieves the same finesse as in the Montagne de Reims. Of particular note is that the Rosé de Riceys (which used to be a favourite of Louis XIV) and red Coteaux Champenois are made here.

In all, the champagne delimited area stands at c. 35,000 hectares spread across c. 281,000 vineyard plots (each with an average size of c. 1,200 square metres), 319 villages, and five administrative areas or départements. 67% of plantings are in the Marne, and the Marne, Aube and Aisne together account for some 99% of plantings. The remaining plantings are in the Haute-Marne and Seine-et-Marne. Of the three grape varieties, pinot noir is the most commonly planted, but pinot meunier and chardonnay are a fairly close second and third.

In terms of viticulture, the plantings are dense with vines no more than 1.5 metres apart. In all grand and premier cru vineyards, pruning must be by the taille Chablis method, preferred for chardonnay, or the Cordon de Royat method, preferred for pinot noir. Both methods retain a high degree of permanent wood which helps the vine to resist frost. Other pruning methods used for chardonnay and pinot noir are the Guyot method; for pinot meunier, the vallée de la Marne method is preferred. The maximum permitted yield used to be up to 13,000 kg/ha but from 2007 this was increased to an even higher 15,500 kg/ha for a trial period of five years in an effort to meet ever growing demand.

The champagne industry is dominated by about 100 big houses, so-called Grandes Marques or négociants-manipulants (identified as NM on bottle labels) such as Laurent-Perrier, Moët et Chandon, and Perrier-Jouët, which together account for almost 90% of all export sales. However these big houses collectively own a mere 13% of the vineyard area, which means that many are heavily reliant on purchased grapes from some 15,000 growers or récoltants. Then there are also the récoltants-manipulants (RM), the growers who make wine from the fruit of their own vineyards. Récoltants-manipulants are gaining both in numbers and in prestige, and their wines are usually much more terroir-driven that those of the big-blend houses. Growers can also sell their grapes to diverse co-operatives that fulfil a variety of functions such as pressing the fruit, completing the first fermentation, or, in the case of the co-opératives-manipulants (CM), going the whole hog and marketing the finished champagne.

For the sake of completeness, other entities are the recoltants-co-opérateurs (RC), growers who sell champagne made in their co-operative under their own name and label; societies de récoltants (SR), growers who group together to produce a champagne outside of the co-operative system; and négociants-distributeurs (ND), négociants who buy champagne that is ready for sale and market it under their own name and label. Finally, marque d’acheteur (MA) refers to a retailer such as a supermarket group that sells champagne (usually purchased from a co-operative) under its own label.