Clinical bitesize: Advanced Care Planning

Good evening (or morning…wherever you are in the World),

I am hoping that you are all well.

Tis the season of exams for some. I have spoken to several international students who have their finals coming up, so wishing you the best of luck if you are one of them.

Here in the UK, the days are short (and cold) and so motivation may be at a record low, but rest assure, we are nearly out the other end and then comes Spring :)

I have recently been working with some candidates on ‘Advanced Care Planning’ and so thought I would bring it you all today.

Advanced Care Planning is a topic I have lots of experience in doing and teaching. This is due to the fact that as a GP, I see lots of elderly patients. It is also a topic that if covered well and in advance, saves a lot of unnecessary panic.

Regarding OSCEs, these stations shows that you are able to be patient centred, compassionate and think ahead - all great qualities.

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Advanced Care planning:

Advanced care planning entails the following:

• Be patient centred

• Focusing on what is important to the patient

• Getting family and loved ones involved

• Making decisions in the patients best interest

• Be sensitive

• Help support patients to their decisions

There are three key elements that may be discussed in advance - in particular for a patient just diagnosed with Dementia, whereby they are at risk of not being be able to make a decision later on.

• Advanced decision to refuse treatment (ADRT)

• Lasting Power of Attorney

• Making statements about future needs and wishes

In the OSCE, you should be able to show that you can have sensitive discussions with patients (and relatives) in a mature, logical and respectful manner. Notice how it is not all about medical knowledge or being certain about a diagnosis, but more around the communication of information.

Admittedly, not all of the topics above can be covered in a 8-10 minute OSCE, but being able to approach these discussions, or plant a seed- is all showing a realistic doctor in training.

As per usual, the above is just to get you thinking and not a comprehensive guide.

In addition to the above- when helping patients make decisions, ensure you are checking mental capacity. This is a whole topic by itself!

If you would like to have one to one tutoring around medical topics/OSCES and communication skills, please get in contact.

Take care of yourselves

Lx

Super proud moment!

Hello!

Gosh it has been a long time since I have done a blog!

I have been so busy with preparing the current CSA cohort for their exams - which they passed! Due to their success I have spent the last few weeks reflecting on what I have learnt and how I will ensure that the standards of my tutoring stay at that top level.

Medical Education is so important to me. I am constantly reflecting on the best way to structure my sessions, give constructive feedback and most importantly instil confidence in my tutees.

The last two years I have learnt a great lot from my tutees and looking forward to providing sessions for the future doctors of the NHS.

I am so proud to have been part of their journey and hopefully see them succeed in the next step of their careers.

Next step for me - get ready for the next batch of candidates :)

So on that note - please get in contact if you would like one to one sessions for CSA 2022 or any other clinical exam (i.e. finals, PLAB). I am here ready to start the process again and will be hopefully be getting some people onto the team to help out (as this year showed demand was high!).

Have a great holiday and a Happy New Year xx

Rheumatology: Top 5 tips

Hello, 

Welcome fellow medics,

I hope you are all well and safe. The time is drawing near for the CSA and so on that note, I am hoping that the revision is going to plan. 

Below is a quick reminder of rheumatoid arthritis. This station can either be in the form of explaining the condition or history taking from a patient with symptoms. It can be easily mimicked by actors or even a real life patient may come in.

Here are 5 quick things to consider when consulting with a patient with suspected rheumatoid arthritis (RA). 

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1.Early morning stiffness- how long and when?

RA is an inflammatory condition that is common. The symptoms admittedly over lap with other inflammatory conditions but there are some distinct features that should make us suspect RA. RA tends to present with symmetrical small joint involvement of: pain, swelling of joint (not bone) and importantly early morning stiffness of the joints lasting > 1 hour. 

2. Impact on activities of daily living

For all conditions/symptoms we should explore the impact on ADLs (activities of daily living), but it is even more important in conditions affecting a patients function i.e. musculoskeletal and rheumatological contains. Remember to ask about dressing/washing/cooking/cleaning and working. Explore the patients life and show genuine interest in this area. 

3. Diagnosis process - urgent referral

Fortunately, there are many successful (albeit strong medications) that can now modify the disease outcome for patients with rheumatoid arthritis, as long as the diagnosis is prompt. Therefore, if you suspect RA, refer immediately (whilst awaiting blood test results). This shows that you appreciate the importance of a fast referral. 

4. Bloods

Get baseline bloods done i.e. FBC/CRP/ESR/U+Es/LFTs. A special shout out to LFTs- this is very important as you want to check LFTs before starting a patient on DMARDS, and so requesting this shows you appreciate the importance of working as a team with your colleagues in secondary care (rheumatologist) and also blood test monitoring with DMARDS. In addition, there are specific diagnostic bloodtests (which depends on the NHS trust) - Rheumatoid Factor and Anti CCP. 

5. Management - MDT approach

When explaining the condition to the patient,  make sure that you do not spend all your time talking about the ‘pharmacological management’ but also concentrate on the MDT approach. 

This includes the rheumatologist, occupational therapist, Rheumatology nurse etc. 

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I hope you found this information useful.

Best of luck with all your revision, stay focused and think of the end goal.

L x 

OSCE skills- Neurology

Good morning everyone,

Hope we are all well and revision is going at a healthy and consistent pace.

The following blog will be aimed at the peripheral neurology examination. This examination has a nice structure consisting of: inspection, tone, power, co-ordination, reflexes, sensation and completing the exam.

The following is not a comprehensive list (which can be found anywhere on internet) but more of a ‘dos’ and ‘don'ts’.

Intro:

Nothing different or exciting here, introduce yourself, check patient ID and a simple/quick explanation of what the examination includes i.e.

“I will be doing an examination of the nerves in your arms today. This will include looking, doing some movements and then checking sensation, will that be OK?” (or words to that effect).

Keep it simple and be clear, avoid medical jargon.

General inspection:

Just like a driving test, explain what you are looking for as you look. Physically look at the area that you state you are looking at, i.e. actually look at the back of the patients arms, don’t just say it.

Look for : muscle wasting, fasciculation, abnormal movements etc.

Tone:

Before checking tone, always ask the patient if they are in any pain. Tone involves lifting the arm (or leg) and moving it around in different directions, so the last thing you want to do is cause pain without checking.

For tone, you are assessing for increased/decreased tone and also cog-wheeling (increased tone + tremor).

As with all of these exams, get used to ‘normal’ by examining different people, i.e. family members, patients (anyone!). Only then can you truly appreciate ‘normal’.

Power:

When assessing for power, it is best to show the patient the movement you would like them to do, rather than try to explain it (which takes far longer and is confusing for the patient). Allow the the patient to do the movement actively before you check against resistance. Also, practise the instructions you are giving the patient - there is an issue with practising with other medics (who act as the patient) in that we tend to know the examination so do not truly listen to the instructions. Avoid this - get the ‘doctor/medical student’ to actually explain the examination.

Co-ordination:

Another example of practising the instructions in lay terms - Do not let your colleague make it easy for you!

Tendon reflexes

This needs good wrist action, and a good tap of the tendons. Be familiar with which tendon is checking which nerve root and associated nerve it is testing.

If you cannot elicit a deep tendon reflex, use ‘reinforcement’ (i.e. get the patient to either clasps their hands or grit their teeth).

Sensation:

Know your dermatomes - memorise them! It is important you check the correct areas,

For each of the modalities - light touch, pain etc - remember to compare the sides to each other.

For vibration - check the most distal joint and move up only if there is reduced sensation of vibration. This is the same for proprioception - move proximally.

Remember to ask the patient to close their eyes whilst doing these tests.

Completing the examination

This will vary depending on your medical school/curriculum i.e. PLAB/CSA, but has the common theme of: thanking the patient, asking them to get dressed, that you will now summarise the findings to the examiner., and do further examinations (i.e. upper limb near exam, cranial nerves)

When summarising the findings to the examiner, do not repeat the whole examination. You just want to give a line for each component (which should be in order of the examination). Then end with “in summary this was a normal lower limb examination” or “ this was an abnormal examination”.

I hope you found this information useful and it has got you thinking about neurology examinations in a more logical manner.

Enjoy and keep working hard

Lx

My top five tips for OSCE success

Good morning (or afternoon/evening/night, depending on where you are in the World!),

I hope you are enjoy the sun and relaxing now that summer is upon us. Saying that, it is also the time that people have started prepping for their CSA coming up in the Autumn, meaning a busy time for candidates (and me!).

A little shout out to my students who passed their medical finals resits - well done :)

It has been great working with both medical students helping them prep for their finals and also with IMGs preparing for their CSA later this year. Such a great mix of talents I have been a part of.

So as it is that time of the year for the IMGS, here are my top 5 tips for OSCE success.

1) Look and feel the part

The best advice I was given by a fellow medic was this. If you feel like a doctor/FY1, then you will most likely give off that vibe to the patient/actor and the examiner. So hold your head up high, don’t be shy, be assertive and look like the doctor who you trained to become. Don’t act or even feel like a medical student. These are professional exams, so act professional. I appreciate that for some of you, it has not been an easy journey to get to where you are, but this exam is a new start where no one knows the journey. So look and feel the part.

2) Be polite to patient/actor

There is nothing more off putting than a rude or abrupt candidate in the exam. Sometimes nerves can get the best of you, and you inadvertently come across as brash, but best you reign that in. Remember the examiner is not only looking at your medical knowledge but also how you come across to the patient. Always put the patient at the centre of the consultation, i.e. ask for consent to do something, make sure the patient is dressed after examining and thank them. It looks professional and respectful (all the labels you want as a doctor).

3) Smile

Inside you may be frowning, sad, anxious, let down, scared…but your face needs to hide all of this. Smile and be polite (see above). A smile can put the patient at ease and also give off an air of confidence but in a nice way. I agree, the smile needs to be well placed (i.e. you wouldn’t smile in a breaking bad news station) but when you first walk into the room and introduce yourself, do it with a smile.

4) Pace yourself

Slow it down to a nice pace, do not rush through the station just to finish on time, but at the expense of being kind and considerate. This is where practice comes into play, as the more stations you do under time pressures, the better you will be at judging how long you have. Do not forget the simple things - a nice intro, a nice smile, polite, thanking patient, picking up on cues, empathy etc because you are too busy looking at the watch.

5) Have humility/admit errors

I get asked this question a lot “what do I do, if I do not know the answer?”. My answer is always simple but effective - admit you don’t know, say you will find out or ask a senior and do not make it up. Having humility shows you are a safe and competent doctor (qualities the examiner is looking for). Stay within your limits, know your limitations and admit error. If you do make a mistake, just say that you got it wrong, no harm. Do not let it mess up the rest of the station or effect your confidence, brush yourself off and continue.

Hoping you found these tips helpful.

Please follow me on social media to get quick and snappy tips on the go.

If you are looking for one to one tutoring, please get in contact :)

L x