OSCE Skills - Ethical issues

Hello medics,

Ethical issues are commonly tested in OSCEs and written exams throughout medical school and post graduate professional exams. It tests the ability to be a safe and competent doctor outlined by the GMC. Please see GMC website for more detailed information.

Ethical issues may arise in different scenarios in the exam ie:

1) Relative wanting to discuss family members information without consent

2) Patient has no capacity to make decisions

3) Safeguarding scenerio

The list is endless, but the principles are similar. Below are some points to get you thinking about these cases so that you can apply them whatever the case.

ACT IN PATIENTS BEST INTEREST

This is the “go to” with these cases. The patient is always at the centre of it. Your duty as a doctor is to protect them and do the best for them (which may not always be the easier or most obvious thing).

Using this as the back bone of the case and referencing back to this ie a disgruntled relative, will diminish most conflict.

CONFIDENTIALITY

No information should be disclosed for an adult unless there is written/verbal permission to do so (unless for patient safety or to other health professionals).

Now, this is not always clear cut, i.e. You may need to talk to a relative about their dying mother without searching through notes for consent.

For exam purposes, you will need to gain consent to discuss any information (in a non emergency scenario), whether that be diagnosis, test results or patient decisions.

On the wards this is really case by case, and also you have the decision to discuss with your colleagues and seniors. GMC guidelines are in place to provide help and guidance on this.

AUTONOMY

Patient have the right to make their own decision even if not the “right” decision. As long as they have capacity (I will cover this in a later blog) then they can make their own decision about their care including refusing care).

COMMUNICATION

I cannot emphasise this enough. Whatever the case, however difficult, however complicated- having effective communication skills is key.

This means, being clear in your communication, avoiding jargon, listening skills (both verbal and non verbal), not being judgemental in your tone. You may have your own agenda, but you have to listen to those around you to get anywhere. Medicine is not an isolated career, it involves patients, relatives, other health professionals.

DOCUMENTATION

All discussions and decisions should be documented in the notes (especially those decisions which were not clear cut). In the exam, you will say this to the examiner. The exam should feel like a driving test, where all actions are made obvious and safety is the top of the list.

I hope this has helped and reminded you of the principles if you are faced with an “ethical” case.

Any further information, please don’t hesitate to contact me via social media or email.

There is also time to sign up for one to one consultation skills revision if you would like more structured and focused OSCE revision with feedback.

Happy revising :)


Productivity: Forming healthy habits

Hello fellow medics,



I hope you are all well.

Thank you to everyone for reading my blog page and being part of the family of medical graduates sitting exams.

It is an odd time right now in the World BUT you being here reading this blog shows you are willing and motivated to further your skills.

Over the last few months, I have done a lot of reading around “productivity” and “habits”. Maybe it is because I have more time or maybe always been fascinated by it. Whatever the reason, I would love to share with you some interesting ideas I would picked up along the way. These ideas will hopefully help the next 1-2 years of various exams you will need to sit to work within the Foundation Programme.

It is not about the “goals” but about the “processes”.

This idea has resonated with me the most. I have always been someone who actually avoided “goals” because life is so unpredictable.

I kind of had a vague idea of some things I might want to do…we all do right? I want to get more fit, I want to be successful in my career, I want to be happy..the list can go on and on. Over the last few months with further reading and reflecting, I have realised that I can ditch the goals and actually concentrate on “processes” that will hopefully get me closer to the “goal”. Some to these are:

1) I will read 10 pages of a book a day

2) I will work out for 1 hour in the morning

3) I will do a blog post every Sunday and Tuesday

4) I will walk every day for 45 minutes

5) I will wake up at 5:30am

This has meant rather than feeling guilty about not achieving that “goal“ or even agonising over “how do i get this goal?”, it is more about having healthy processes/habits to help you get there.

This can be applied to revision: ie

1) I will revise for 1 hour every morning without any distractions

2) I will participate in OSCE revision 2 times a week

3) I will run every morning to stay mentally fit

4) I will avoid unhealthy foods that make me sleepy

These are just a few ideas and processes.

It is about becoming the person you want to be

Over the last few months, I have tried to describe myself as the person I want to be. Essentially what I mean is, I am working towards an identity that reflects my healthy habits. Ie, now when people ask me about my daily routine, I describe myself as :

“I am into fitness, I get up every morning to run”,

“I am an early riser”

“I always sleep early to maximise my sleep”

“ I don’t like watching tv for hours, and instead am into reading”.

Now without sounding like a complete geek with no life, all these things have made me feel happier and more content. Not because I am a fitness guru, but because I am slowly but surely changing things in the right direction, and I have instilled it as part of my “personality”.

Early starts

With this habit, I initially got some mixed reactions from friends and family “You wake up at 5:30am?" “…what everyday?”.

Now, most people actually want to join me. Luckily, I have always been a morning person, with my revision, essays and To-do lists. So waking up at 5:30am didn’t seem like a big deal. Saying that, it WAS tiring in the first few days…BUT now, I couldn’t imagine not waking up at that time. It is so odd how the body just adapts.

Waking up early for me:

a) Gives me a head-start- nothing is better than having a head-start on others (some friendly competition never did any harm). I like to send out important emails before the office opens!

b) Makes me grateful- Opening the windows to let the sun into your room/house, feels so good.

c) Gives me extra hours - There are more hours in the day to do my thing.

d) Lastly, it means I get into bed at a great time, and so the cycle continues.

This can be applied to revision (I know some people are “night owls” this is also fine, but really think about how staying up at night is having an impact on your life - ie eating habits, fitness, happiness - if all is good, please continue!).

Getting up early, setting your targets for the day, getting on with your jobs and feeling essentially “in control” of your morning may have some surprising and positive effects. It will be tough initially, but soon becomes the norm.

Avoid meaningless distractions

Right, now I am going to get some people saying “OK, so now you are a minimalist?”. No, not at all, I am trying, but I own many random, unnecessary objects.

What I mean by this is reducing your time on things that actually don’t have any benefit to your life. I love Netflix, it is great. My friends love it and are always telling me to watch series, and sometimes I join them in doing so.

However, I avoid sitting there for hours, endlessly watching things that leads to me feeling sluggish. Social media is a great example. It is so easy to sit there and scroll, and before you know it, you have been doing it for hours.

Having a blog and social media myself and having to use it on a regular basis, the way I get around this conundrum is to set a time limit i.e. maximum 1 hour in the morning and the evening to check my social media.

This can be applied to revision. Rather than thinking, “I am so fed up of revising, I am going to scroll on instagram” get up, stretch, get some water and get back on it.

I hope you found this information useful and non judgemental. My aim was not to alienate or make people feel useless, it is about giving you inspiration for change (but only if you want to) and hopefully help to gain focus on your revision.

Stay happy, focused and safe

x

Great Books to read:

1) Atomic Habits - James Clear

2) 5am Club - Robin Sharma

3) Tools of Titans - Timothy Ferriss

OSCE Consultation Skills: osteoarthritis and rheumatoid arthritis

Osteoarthritis vs rheumatoid arthritis

Hello fellow medics,

I hope you are all keeping well, staying focused and working towards your end goal with enthusiasm…

If you are sitting the Clinical Skills Exam (or Clinical Exam) please check out this blog.

It is a quick summary of the main differences between osteoarthritis (OA) and Rheumatoid arthritis (RA).

As always my blogs are based on the “general principles” and not the minutiae detail (there are plenty of other books to find that information). This is about getting you thinking about joint disorders, so it sticks in your brain. This hopefully will mean less to memorise (which is always a bonus).

This is a common station as it tests different areas, including: your ability to take a thorough history of presenting complaint (to differentiate between OA and RA), perform a succinct examination and convey your empathy towards the patient when considering the impact of such disorders (ie a great social history). So lets get into it…

OA vs RA

As I have stated above, the main differences can be found in any book. Usually presented as a table of some sort, with differentiating signs and symptoms.

I will just give a few main pointers that doesn’t seem to change over time.

1) RA- it is a inflammatory process. Hence, you will get inflammation of the joints with “synovitis” - this means swelling of the joint. Beware, this can also happen in OA, but less so. The swelling in RA tends to be “soggy” whereas the swelling in OA is due to the osteophytes and therefore “hard”.

2) RA presents with joint stiffness - ie > 30 minutes in the morning. This is a prominent factor in RA. Although in OA, there is “jelling” of the joint, this is less so in morning and more after sitting for prolonged times.

3) RA affects the small joints, OA the big joints. If only medicine was that simple…Technically there is overlap between both conditions, but realistically (and from an OSCE point of view: Remember the OSCE reflect the majority of cases, and is not there to trip you up)- OA affects hips and knees, and shoulders; RA affects small joints of hand and wrists.

4) RA typically affects younger people, and OA affects older population. This makes sense, as OA is a wearing away of the cartilage, affects big joints and so with “time” it will present. RA tends to have a genetic component and so can present at any age.

These are the key differing symptoms, with many over laps. Medicine is never clear cut, but if you have the principles and concepts, it makes it a whole lot easier in the exam and in “real life”.

Social history

I cannot emphasise social history enough in these consultations. The impact of both these conditions on the patients life, activities of daily living (ADL), occupation and consequently psychologically is paramount.

Knowing the patients social situation is vital. Once you know this, whatever dilemma you are faced with i.e. History taking station, Breaking bad news, disgruntled relative; you will have the correct information to connect with the patient/relative.

Ask about:

1) Living arrangements - who do they live with? Do they live in a house with stairs? Do they have steps leading up to their house?

2) Social care - Do they have any care at home ie carers twice a day? Will this need to increase?

3) Family- do they have family nearby to help with shopping?

4) Occupation- Do they have a job that involves needing to use small joints of hands ie receptionist? How will their work be impacted?

All the questions above will need to be asked to build a “diagnostic picture”, help the management and build rapport.

MDT (MULTIDISCIPLINARY team) approach

Whichever diagnosis it is (or both..), the approach will be from a MDT. So being familiar with the different agencies is important to provide patient reassurance and advice.

Some of these services will be:

1) Rheumatologist - if RA/inflammatory condition is suspected

2) Orthopaedic surgeon- if OA is very severe. Also the Orthopaedic teams are involved in RA for those patients whose joints have been heavily affected by the inflammatory process. They can fuse joints and also replace etc.

3) Occupational Therapist- to help with ADLs/work related situations/home status.

4) Social Workers- To assess if social care is needed in home ie carers

5) Physiotherapist - to help with maintaining mobility of the joint

I hope you found all the information useful above. The main aim is to give an over view, and some “light reading”!.

Please stay connected on facebook, instagram, LinkedIn and twitter for further short snippets of advice and motivation.

Please don’t hesitate to send me an email for any advice or if you would like to sign up for one:one/pairing revision session. I provide structured and to the point consultation skills to help you in passing the clinical exam.

Stay happy and safe.

x

OSCE skills: Explanation station

Hello fello medics,

I hope we are all keeping well during these testing times.

This blog will look at the principles of an Explanation Station in the OSCE. It is centred around discussing a particular investigation or procedure to a patient. This station is a favourite as it tests your communication skills, knowledge and ability to build rapport.

Some examples may include explanation of a procedure ie: OGD, colonscopy, angiogram. Explanation of a diagnosis ie Diabetes, hypertension.

Some obvious but important steps to remind yourself of:

1) Introduce yourself

2) Ask the patient if they are happy to talk to you

3) Make sure the patient is comfortable

4) Wash your hands (just get into the habit of it!)

General Structure:

  • Introduce your self

  • Ask what they know about procedure X

  • Communicate the information - small junks, stopping to allow patient to digest

    • Pro

    • cons

    • risks associated with procedure X

  • Summarise

  • Allow for questions

  • Follow up/Patient information leaflet

Set the agenda for the consultation

This depends on the information you have been provided with before the station starts. It might be that the patient is aware of reason for consultation “John has been notified they are having an angiogram, please explain” (here the patient knows the point of the consultation) or they have no prior knowledge.

If you are not sure, you might want to start with “Hello Mrs Brown, I am Dr XX, how can I help you today?”. They will then lead you from there.

Allow the patient their “golden 1 minute” to explain why they think they are here and why they are having the scan etc. This saves time and avoids confusion of trying to get the information out of them. Just let them talk and the vital (and hopefully “to the point”!) information will flow out.

Ask the patient what their thoughts are on the procedure

Ask them if they know what the test is? Have they heard of it before? Maybe their neighbour had the same procedure. Again allow the patient to talk about their ideas: they may have zero thoughts on it or know a little bit. If they haven’t heard of it, great! You can now communicate the information from a fresh prospective.

Give information in bite-sized chunks

This station is little about knowledge and more about how you convey the knowledge to the patient. It is no good being the expert on colonoscopy if you continuously speak to the patient without checking their understanding or giving yourself a moment to breathe.

Do not use medical jargon

This point follows on from the above one. You need to be able to explain a medical procedure into lay terms. This is testing your ability to communicate, so practice speaking in in non medical terms. You do want to alienate your patient with jargon. There is nothing worse than a blank or confused face looking back at you

Summarise the points and allow time for questions

Leave time to summarise the important components and ask if the patient has any questions. You may have been answering their questions whilst you were explaining, but a quick “Do you have any further questions?” is a nice gesture.

Provide a patient information leaflet

I love to end the consultation with an information leaflet. I usually suggest patient.co.uk.

Talking of patient.co.uk - this is such a great resource for practicing explaining medical procedures and diseases in a patient friendly tone. They are concise and a great revision aide.

I hope you found the information useful. Remember to keep your knowledge fresh and practice (with friends and family and with yourself in a mirror!) Become comfortable with how you speak, the tone of your voice and how you communicate.

If you need any further information or guidance, please feel free to send me an email/social media message, I am happy to help in anyway.

If you would like to sign up for structured one to one help (or even a few of you want to get together to practice with myself) via virtual modes to improve your communication skills- please sign up or send me an email. We can then have 1 hour (free!) to discuss the areas you would like help with and whether I can help. No pressure, no contracts.

Stay focused and productive x