History Taking: Breaking Bad News

History taking: breaking bad news

This station is a favourite amongst ALL OSCE exams throughout training. Whether it is breaking bad news about a new cancer diagnosis or telling a patient they cannot safely drive anymore.

The mnemonic that is commonly used is: SPIKES which stands for : Setting, Perception, Invitation, Knowledge, Emotions and Summary

SETTING:

  • Set the scene, get the chairs in the correct format to reduce fumbling in the exam

  • ensure private setting (you may need to verbalise this to the examiner!)

  • Ask the patient to come in, ask if they have anyone with them that would like to join

PERCEPTION:

  • Introduce yourself.

  • Ask the patient why they have been asked to come in, i.e. the reasons for the the bloods/chest x-ray/investigation.

    “So why have you been asked to come to see me today?”

    “I have been asked to discuss your chest x-ray, could you tell me what led up to your GP arranging this?”

    • This will allow to a) Building of a rapport b) Get their perception on their symptoms so you can then correlate this to the interpretation of the results, i.e a patient coughing up blood with a suspicious lesion on a chest x-ray. You will use their ‘perception of their symptoms’ later when breaking the bad news.

  • DO NOT jump in with giving the information. These 1-2 minutes of getting the patient to speak could make or break the success of this station

INVITATION:

  • Let the patient know that you are going to discuss the results/letter etc but BEFORE doing this, ask them WHAT and HOW much they want to know.

  • Some patients do not want all the information, some want it all. Again rapport is vital.

    ”Some people do not like to be given all the information at once, whereas others want to know everything. What would you prefer?”

KNOWLEDGE:

  • Give a “warning shot”, pause, and then continue.

    ”We have your blood tests results which might explain why you were experiencing night sweats and weight loss, which you were worried about” (link the “perception” here, it will flow nicely)

    ”George, I have the results of your chest xray (pause)..i am so sorry…(pause) it is not good news” PAUSE.

  • Provide information in small junks. Give space for the patient to react and acknowledge the information. It is so easy to just plough on with information, BUT the marks are not in your knowledge of lung cancer but in the rapport you built with the patient by how you made THEM feel.

EMOTIONS:

  • This means to stop and reflect the patients emotions back to them

    ”I am so sorry, I can see you are understandably upset”

    ”Would you like a tissue?” (Make sure there are tissues otherwise don’t ask!)

  • Do not fill the (awkward) gaps with talking, silence is precious. If they are crying, it will not help talking over them.

STRATEGY/SUMMARY

  • Leave 1 minute to put a plan together of the next step

  • Give a Patient Information Leaflet

  • Check their understanding of what has been said (sensitively)

  • Ask if they have any questions/anything they did not understand

  • Suggest a follow up date after they have absorbed the information/spoken to love ones

I hope you found the information relevant and useful.

We worry about these stations incase we come across as too abrupt or that we will freeze when the actor/patient starts crying… My one advice for success is - just listen and show empathy. It will feel odd sitting opposite someone crying/getting angry, but if you take a step back and listen, the examiner will give you marks for being human.

Stay focused and happy revision :)

History taking: RED FLAGS

History Taking: Red flags

When taking a history, make sure to remember the “red flags”. It is vital to show the examiner (who is looking at you as a possible future junior doctor) that you are a COMPETENT and SAFE doctor.

Below are a list of red flags based on systems. The list is not exhaustive and is just a guide for some common important questions.

In the (brackets) I have provided possible reasons for the questions.

Cardiology:

1) Progressing chest pain - (ACS)

“Is the chest pain getting worse?” “Is the pain now occurring at rest?”

2) Dizzy spells associated with : shortness of breath (? PE) loss of consciousness (lack of cerebral blood flow) palpitations (cardiac origin)

“Are your dizzy spells associated with loss of consciousness etc?”

Respiratory:

1) chest pain + shortness of breath

“Do you have any chest pain?” (ACS)

2) Leg swelling (1 leg DVT, 2 legs CHF)

“Have you noticed any sudden swelling of your leg/s?”

3) Haemoptysis (PE/Lung cancer)

“Have you noticed any blood in your sputum?” “What colour is your sputum?”

Gastroenterology

1) Weight loss (GI cancer)

“Have you had any unintentional weight loss?” “if so, how much and over what period of time?”

2) Blood in stool (IBD, cancer)

“Have you noticed any blood in your stool?” “What colour are your stools?”

3) Pain on swallowing/food getting stuck (upper GI cancers)

“Have you noticed food getting stuck when you swallow?” “Do you have any discomfort when swallowing food?”

Renal

1) Blood in urine (urological cancer)

“Have you noticed any blood in your urine?” “What colour is your urine?”

Neurological

1) Any new/worsening neurology (Stroke) **This may come in ‘acute station’

“Have you noticed any weakness of your arms/legs/face?”

2) Worsening headaches (SOL)

“Have your headaches got worse over time?” “Is your headache keeping you up at night?”

Musculoskeletal

1) Thoracic back pain (metastases)

“Can you tell me where the pain is exactly?” “Is your back pain disturbing your sleep?”

2) Not being able to weight bear/move joint (fracture/septic joint)

“Are you able to move the ankle?” “Can you put any weight on the foot?”

Psychiatric

1) Suicidal thoughts

“Do you have any thoughts of ending your life" “Do you ever feel that life is not worth living?”

2) Hallucinations

“Do you ever hear voices that others can’t?” “What do these voices say/tell you/do they tell you to hurt yourself or others?”

Endocrine

1) Constitutional symptoms + hyperhidrosis (phaeochromacytoma)

“Where have you noticed the sweating?”

2) Double Vision (Pituitary Adenoma)

“Do you have any double vision?” “When you look at one object, do you see two?”

Dermatological

1) Change in lesion

“Have you noticed any change in colour/size/shape of lesion?” “Does the lesion itch or bleed?”

2) Rash after starting drug (drug allergy)

“Did you notice the rash after starting the antibiotics?” “Did you experience any lip swelling/difficulty in breathing?”

I hope you found this list useful. As I was researching, I realised there are A LOT of questions, but this is not about memorising. It is about having an understanding of WHY you are asking, which will make the remembering easier.

Happy revising :)

History Taking: SOCRATES

History Taking: SOCRATES

Hello fellow medics :)

SOCRATES is a mnemonic for remembering the questions to ask after a patient presents with a ‘complaint’. Although traditionally used for “pain”, it can be adapted to suit any history (give or take!).

Remember SOCRATES/or other mnemonics are there as a prompt, and therefore it is important to have flow and listening skills.

Continue reading below to see SOCRATES broken down with some specific questions which may help.


Site: “Can you tell me in your own words where the pain is?”

“Can you point to where the pain is?”

Non pain history: “Tell me more about how you are feeling”

“Where do you feel this tightness?”

Onset: “When did the pain first start?”

“How long have you had this pain?”

“What were you doing when the (pain/symptom) first came on?”

Non pain history: “When did this shortness of breath come on?”

“When did you start to feel low?”

Character: “Describe the pain to me” (you may need to prompt the patient if they cannot find the words) “is it a stabbing pain, a dull ache, does it come and go?”

Non pain history: “Describe the colour/consistency of the stool”

“How would you describe the lump- hard, soft?”

Radiation: “Does the pain travel anywhere?”

“Is the pain just in the one place?”

Non pain history: NA

Associated symptoms: “Is there anything else you have noticed with this pain?” (this will be based on the system involved i.e. with chest pain: “Do you have shortness of breath?” etc)

Learn the associated symptoms with each presenting complaint - luckily there are lots of overlap.

Timing: “When does the pain come on?”

“Does it come and go depending on what you eat?”

“Is the pain constant?”

Non pain history: “When do you feel sick? Any specific time of the day?”

Exacerbating/Relieving factors: “What makes the pain better?” (ie movement, medications)

“What makes the pain worse?”

Non pain history: “What makes the groin lump bigger?”

“How do you manage the stiffness in your joints?”

Severity: “can you tell me how bad the pain is on a scale of 1-10?”

“What impact does this pain have on your daily activities?”

“What is this pain stopping you from doing?” (referring to the impact on ADLS- Activities of Daily Living)

Non pain history: “How far can you walk before being breathless?”

“How is your mood impacting your sleep/ability to function?”


Flow is essential in taking a history, and so a mnemonic is ideal for when your flow disappears due to anxiety of the OSCE station…and you need something to put you back on track.

Any further questions, please don’t hesitate to email/DM me- I am here to help and guide :)

Happy revising :)



6 REASONS YOU NEED MY HELP FOR OSCE SUCCESS

6 reasons you need my help for OSCE SUCCESS!

Now without sounding like I am giving a sales pitch, i want to tell you why you might need me in your revision journey.

1) Knowledge of NHS

Whether UK is your home or a new place completely, you have spent atleast the last 5-6 years in a different country with a different health system. This means that your medical training may differ from the UK process. The OSCE’s in the UK/ throughout the World are similar but those slight deviations might be the difference between a pass and fail.

2) In one place

Being an IMG, your university friends now may be scattered around the country or even the World. So it can be difficult to have that consistent person to revise with. In an ideal situation, you would have a variety of people to do OSCE revision with. Included in this “OSCE revision buddy system” should be someone who has knowledge about the NHS, OSCE and medical exam format.

3) A non judgemental environment

Revising with someone who doesn’t know you is easier. Not knowing all the common causes of chest pain wont lead to the feeling of humiliation in front of your friends (which will only hinder your learning process). It is better to have a respectful working relationship with someone outside of your social bubble.

4) Consistency

Having consistency is vital. The knowledge that you have allocated one hour a week with one person whose sole person is to help YOU pass this exam is satisfying. It allows you to frame your revision, not have fears of cancellation at the last minute or getting detracted with friends. I wont allow us to spend an hour googling the difference between a UMN and LMN lesion…

5) Planned revision

The sessions are pre planned and organised, and so before you even enter the video session, we will have a plan of action so you will know what section of work you will be working on. Meaning you can start ticking off items on your revision plan. With all this said, things will change, and we will go at the pace that suits YOUR learning.

6) Constructive feedback

Revising with friends is great, I am an advocate of this. The one issue can be receiving constructive feedback or any feedback for that. Friends can find it difficult correcting you from fearing of insulting you. There is an art to feedback to make people progress and not a) feel bad about themselves b) avoid coming to you for further practice.

I hope this has given you an insight into how I will benefit you in the next step to being a doctor in the UK.

Remember - I am not the only person you will revise with (or maybe I am- which is also fine). Whatever the dynamic, having consistency and structure is the vital component I provide.

Please feel free to send me an email if you have any questions.

Positive vibes.

WHY IS IT SO DIFFICULT TO START REVISING FOR YOUR OSCE?

Why is it so difficult to start revising for your OSCE’s?

Why is it that sometimes we just can’t seem to start revising..? We have the pens, the books..the computer…now lets start. Mind blank.

This is a very common theme amongst many medics. It can be over whelming, and the longer you try to tackle it, the harder it can be to start.

Here I have outlined some reasons why and hopefully this will allow you to take a step back, reflect and make this revision process more “fun” (well not fun, but less traumatic)

1) “there is too much to learn and keep in my brain”

  • Bite size : approach it by systems i.e Respiratory system for 1 week. This means the history, the examination, the interpretation of results, the difficult consultations etc. Approaching it as “bite size” will make the task less daunting.

  • choose the order of topics logically ie, respiratory and cardiology are closely related so would make sense to choose these topics together when revising.

Other examples are :

- Gastroenterology + renal/urology medicine
- neurology and musculoskeletal

2) “Where do I even start"?”

  • Have a time table of how you will “generally” approach the topics. Remember this will change as time goes by. You may be ahead of the time table…or may be behind (which is fine too). One great idea is to have a buffer of 1-2 weeks of no planned revision before exam, in case you fall behind. Don’t have a revision plan that takes you to the day before the exam.

3) “There are topics I just hate looking at”

  • Focus on those topics you hate. Yes, you heard me. Those horrid topics that give you anxiety, you focus on them, get good at them, and stop avoiding them, as its “sods law” they will be in that OSCE.

4) “I just spend hours looking at one page..”

  • Don’t spend ages on a topic giving you anxiety. Don’t waste time spending hours going round and round on how to analyse the anion gap…ask someone or switch off and go back to it later (and no doubt, it will make sense)

5) “It is just such a boring and time consuming thing to do right now, I want to go out and enjoy the sun!”

  • enjoy revising. Yes this is hard to believe. Make those practice OSCE sessions a fun time. Have snacks, regular break, switch off in between and enjoy. Obviously you have to get down to revising, but this is a time of embracing your communication skills, learning about what doctor you want to be, and having a chance to read around topics (which you wont get time to do, when running around on the wards as a junior doctor).

6) “the stress of how much this exam costs puts me under so much pressure”

  • yes, this exam is expensive. This is along with maybe training abroad.. BUT the cost of the exam is not the reason you HAVE to pass, it is the great achievement at the end of all of this. Do not let the cost anxiety inhibit your ability to revise- trust me, this wont be your last expensive exam (they get pricier the more qualified you get!)

Best of luck in your revision, stay focused and happy :)