OSCEs – Communication

1. The Angry Medical Registrar

 Subject and Curriculum Reference

Communication

Complaints management

Supervision of junior staff

Open disclosure

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Clinical Scenario Stem

You are the consultant in charge on a very busy evening shift. As you are coming out of a cubicle you hear raised voices. You see that there is a confrontation taking place in the middle of the emergency department which has caught the attention of most of the staff, patients and relatives. The medical registrar on duty this evening, Dr. Janet Stevens is waving and ECG and shouting at one of your junior registrars, Dr. Michael Green. You hear her shout “You missed an obvious anterior STEMI, you idiot! You’re obviously too stupid to be practicing medicine!”  Dr. Green is visibly upset and walks out of the emergency department.

Dr. Michael Green is a junior registrar. He is 3 years post-graduation and has been a registrar for 2 months. He is hard working, diligent and his knowledge base is appropriate for his level of experience. A few hours earlier he had told you about a 72 year old woman, Mrs. Jane Smith, who had presented with chest pain. Dr. Green’s description sounded consistent with the diagnosis of a pulmonary embolism. Dr. Green had said there were no worrying ECG changes but you had not had time to review the ECG yourself.

Dr. Janet Stevens is a hard working competent medical registrar but is known to lose her temper from time to time. She demands a very high standard of referral and the junior doctors often express that they are scared to approach her. You have not met her before.

You approach Dr. Janet Stevens to try to manage the situation.

Dr. Janet Stevens is played by an actor. Examiners will NOT be interacting with you or the actor.

 Actor instructions

The character

Dr. Janet Stevens is a 30 year old medical registrar. She has been a doctor for 6 years and a medical registrar for 2 years. She hopes to be a cardiologist but is currently doing her general medical training. She is hard working, knowledgeable and highly respected medically by her colleagues. She has very high standards set for herself in regards to her work and therefore expects high standards of all her colleagues as well. She can be very short-tempered and has a reputation for grilling junior doctors who are referring her patients and therefore they are often scared to approach her. However, she has the interests of the patients at heart and is always professional.

Dr. Stevens is also having some personal problems that are making her more grumpy than normal. She has her fellowship clinical exam coming up in 2 weeks’ time. She has been studying hard as well as working full time so she is very tired. Her exam has also put strain on her relationship with her fiancé and they have been fighting a lot.

Today she is the medical registrar on duty from 8am to 9pm. This means that she receives all the referrals of new patients that need to come into hospital today. The majority of those are from doctors in the emergency department. She then has to review them, admit then and decide their initial management. She also has to manage all the patients in the Acute Medical Unit. Her boss is the medical consultant on duty for that day. His name is Dr. Peter Atkinson. He is not in the hospital this evening but can come in and give advice over the phone if necessary. He is also known for his short-temper and Dr. Stevens is scared of making him angry as well.

 

The Scene

Dr. Stevens is having a particularly busy day as the medical registrar on duty. She has had a lot of referrals from the emergency department and there are a number of unstable patients in the Acute Medical Unit that have needed a lot of input. She is feeling stressed and slightly overwhelmed by the amount of work that she has to complete. It will mean a very late night and even less time to study for her crucial exam.

She also had another fight with her fiancé last night during which he stormed out and stayed at a friend’s place. She is very worried that her relationship will not survive the current stressful period.

Earlier today Dr. Stevens took a referral from Dr. Green. He described a 72 year old woman, Mrs. Jane Smith who had presented with chest pain. He had diagnosed her with a likely pulmonary embolism. He had given her the relevant treatment and had organised a CT scan to confirm the diagnosis. It had all sounded straight forward so Dr. Stevens accepted the referral and the patient was transferred to the Acute Medical Unit. Some hours later when Dr. Stevens had finally been able to review Mrs. Smith she discovered that Mrs. Smith had ECG changes consistent with a heart attack that should have been treated immediately with angioplasty by the cardiologists. This mistake has a number of implications. For Mrs. Smith it is likely to mean much worse heart function than if her condition had been treated immediately. It also meant that Dr. Stevens had to ring the cardiologist to explain the mistake and organise an urgent after-hours angiography. The cardiologist was not impressed as they would now have to come in after-hours and would have to manage Mrs. Smith and pick up the pieces. Dr. Stevens also had to ring her boss to explain what had happened and he had shouted at her and told her she should not have accepted the referral and should have reviewed the patient earlier. Therefore Dr. Stevens is very angry at Dr. Green for missing the diagnosis and the emergency department consultant for not picking up the mistake.

Each candidate will be in the position of the Emergency Department consultant on duty at the time of the mistake and now. They will approach you to manage the situation. It is expected that they will try to de-escalate the situation and propose a review of how the mistake occurred and how to prevent it occurring again. We would also like to find out how the candidate with manage Dr. Green. If time permits we would also like to explore open disclosure of the mistake to the patient and the medico-legal implications.

 

Some of the key points in the conversation:

  • Explain the miss-diagnosis and show the candidate the ECG
  • Express how angry you are at Dr. Green “that registrar should not be working as a doctor let alone a registrar” “he’s incompetent”
  • Express how angry you are at this emergency consultant for not checking the ECG “there should be better supervision” “why didn’t you review the ECG?”
  • Express that you will be putting in a formal complaint “I will be complaining to the director”
  • If the candidate attempts to de-escalate the situation then you will go along with that and start to calm down
  • If the candidate is confrontational and fails to de-escalate then you will continue to be angry
  • Ask what is going to happen to try to draw out the review process from the candidate “what are you going to do about this?”
  • Ask what is going to happen to Dr. Green “what are you going to do about Dr. Green?”
  • Open disclosure to patient “What am I going to tell Mrs. Smith?”
  • Medico-legal implications “What if the patient decides to sue?”

Facts:

  • A pulmonary embolism is a blood clot in the lungs which does present with chest pain
  • The ECG shows an obvious heart attack that normally would activate a train of events in the hospital that would lead to immediate specialist intervention to treat it
  • This ECG does show changes that indicate a heart attack but they are not extremely obvious ad may be missed by a junior doctor

NB:

  • The “Scenario” in the preceding page is ALL the information provided to the candidate before s/he interacts with Dr. Stevens. That is, s/he will NOT be aware of Dr. Steven’s own circumstances.
  • Candidates will only have 7 minutes to interact with the actor and will not interact with the examiners. Successive candidates will be interrupted by 3-minute breaks, during which the examiners and actor discuss the preceding candidate.
  • After a succession of 10 or less candidates, there is a longer break to permit rest and refreshments.

 

Scoring Sheet

Not met Partly met Fully met
Communication

  • Calm manner
  • De-escalation techniques
    • Recognising anger
    • Asking Dr. Stevens to sit down
    • Non-confrontational body language
  • Active listening
  • Ensuring understanding of Dr. Steven’s point of view
Complaints management

  • Acknowledging complaint
  • Ensuring that it will be investigated
  • Notification of director of ED
  • Will report back to Dr. Stevens
  • Time frame for investigation and feedback
  • Process of investigation
    • Discussion with Dr. Green
    • Review of patient notes/patient history
    • By an independent party
  • Review will produce actions
  • Actions implemented then reviewed
Management of junior doctor

  • Discuss case with Dr. Green
  • Council on how to deal with this mistake
    • Personally
    • Professionally i.e. nforma medical indemnity
  • Ways to address deficiencies e.g. ECG education
  • Review progress
Open disclosure

  • Indicate open disclosure to patient
  • Will apologise to patient
Medico-legal implications

  • Indicate will let medico=-legal department know
In order to pass need:

  • Appropriate and effective communication
  • Reasonable complaints management
  • Reasonable management of junior doctor

Author: J Haire 

 


2. Breaking Bad News

 Subject and Curriculum Reference

Patient encounters

Communication

Breaking bad news

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Clinical Scenario Stem

You are the consultant in charge in an urban emergency department at 1000 on a week day afternoon. A 73 year old man, George Stevens, has been brought in after a sudden collapse at the bowls club. When the ambulance arrived his GSC was 3, HR 48 bpm, BP 190/89 and O2 sats 82% on RA. He was intubated at the scene with no induction agents and his sats went up to 98% on 100% O2. His GCS remained 3 on route with no movement of his limbs. On arrival in the emergency department his GCS was 3, he had no voluntary movements and his pupils were mid-size and reactive. He has required no sedation. A CT brain shows a massive subarachnoid haemorrhage with significant mass effect and he is starting to get tentorial herniation. The neurosurgeons have reviewed his case and have said that any intervention is futile. The decision has been made to extubate him and let him die comfortably.

His wife, Clara Stevens has just arrived in the emergency department. She is alone. She was telephoned by friends at the bowls club and came straight to the hospital. She is waiting in the relative’s room.

You are to explain to her the situation and the fact that any further intervention is futile.

 

Actor instructions

The character

You are Clara Stevens, a 71 year old woman. You live with your husband George Stevens who is 73. You have been married for over 50 years. You have had 4 children – Anita, Sam, Clarence and Belinda. Anita and Sam live in the same town but Clarence and Belinda live interstate.

George is a retired engineer. He has been fit and active all his life. His only medical problem has been arthritis of his right hip and he has been seeing an orthopaedic surgeon about getting a hip replacement but had decided to try medication first. He takes only paracetamol and Celebrex for the pain. He plays bowls 3 times a week and has a lot of friends at the bowls club.

You are a retired accountant. You are also fit and active and have no medical problems other than some mild hypertension that you take Atacand for. You have a solid network of friends and you are actively involved in your local Rotary club.

Your marriage has been a happy one. You both have a lot of friends in this town as you have lived here for the last 40 years. You have a good relationship with all your children. You have 5 grandchildren which you see a lot, especially the ones that live in the same town and you are actively involved in their care.

 

The scene

This morning George woke as normal and had breakfast. He complained of a bad headache that came one quite suddenly just before he went to bowls but too some Panadol and went anyway to play a game that started at 9am.

You went grocery shopping.

At 9.30 am you got a call from Fred, a friend at the bowls club. He said that George had suddenly collapsed whilst playing bowls. He said he was in a bad way and the ambulance had put a tube into his mouth to help his breathing. He told you that he had been taken to the emergency department.

You immediately abandoned your shopping, rang your daughter Anita to tell her what was going one and drove to the emergency department. Anita said she would meet you at the hospital.

At triage you told the nurse who you were and they immediately brought you through the emergency department into a room. You have been told that the doctor in charge will be coming to see you straight away. You have a very bad feeling about this and you are scared this is going to be very bad news.

 

Specific instructions re the interaction

During the interaction with the candidate they will be required to tell you what has happened to your husband and that the situation is futile. They are required to tell you that there is no further medical intervention possible and that the plan is to extubate (take the breathing tube out) and to let George die comfortably.

You are very upset and shocked.

If asked if you want to wait for anyone else to arrive before you are told the situation then say no as you want to know what is going on.

Ask any questions to clarify the situation:

  • “I don’t understand, he was so well”
  • “Is there anything that can be done?”
  • “Is he still alive now?”
  • “Is he in pain?”

Also ask questions to verify what is going to happen:

  • “Can I see him now?”
  • “Can I see him before the tube comes out?”
  • “How long will he live for after the tube comes out?”
  • “Can we wait to take the tube out until my children get here? What about the children that are interstate, can we wait for them?”

 

Facts:

  • A subarachnoid haemorrhage is when a blood vessel in the brain bleeds spontaneously into the brain
  • Raised intracranial pressure and herniation is when the bleeding in the brain causes the pressure in the head to build up and eventually this damages the brain

 

NB:

  • The “Scenario” in the preceding page is ALL the information provided to the candidate before s/he interacts with Clara Stevens. That is, s/he will NOT be aware of Clara Stevens’s own circumstances.
  • Candidates will only have 7 minutes to interact with the actor and will not interact with the examiners. Successive candidates will be interrupted by 3-minute breaks, during which the examiners and actor discuss the preceding candidate.
  • After a succession of 10 or less candidates, there is a longer break to permit rest and refreshments.

 

Scoring Sheet

Not met Partly met Fully Met
General communication – Non-verbals

  • Good eye contact
  • Open posture
General communication – active listening

  • Allows relative to ask questions
  • Responds to relative appropriately
  • clarifies relatives’ understanding
Communication – verbals

  • Sympathetic approach
  • Sensitive approach
Introduction

  • Introduces self to relative
  • Establishes relative identity
  • Ensures relatives comfort
  • Asks if patient would like any support person there & offers to contact them
  • Establishes relatives current knowledge of situation
Communication – specific verbal

  • Appropriate warning statement e.g. “ Im afraid I have bad news”
  • Explain medical problem and what has happened so far
  • Explains futility of further medical intervention and how that conclusion was arrived at
  • Explain plan to extubate
  • Explicitly tells relative that patient is going to die and clarifies that relative understands this
  • Explains that patient will be kept comfortable and cared for as they die
  • Remains firm with plan to extubate
Asks if they can help contact/talk to other relatives
Offers relative opportunity to see patient and explains lines/machines etc.
Needs at least 4/5 to pass

  • Sympathetic/sensitive approach
  • Appropriate non-verbal manner
  • Clear communication of medical problem, futility of further intervention, patient is dead and plan for extubation
  • Active listening
  • Clarification of relative understanding

Author: J Haire  

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