Amc Clinical


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Amc Clinical

  1. 1. Table of Contents Foreword — Joanna M Flynn ix Preface — Roger J Pepperell x Contributors xi Editorial Committee Additional Contributors Acknowledgements xvii Introduction — Vernon C Marshall 1 Role of the Australian Medical Council (AMC) — Ian B Frank 9 Construction, Scoring and Validation of Assessments — Neil S Paget 25 The AMC Multidisciplinary Clinical Assessment Task (MCAT) Format 31 — Heather G Alexander How to Use this AMC Handbook of Annotated MCATs — Vernon C Marshall 34 MCAT Format Example: Candidate Information and Tasks, Performance Guidelines 37 001 A cut to the thumb of a 22-year-old man MCAT Candidate Information and Tasks, MCAT Performance Guidelines; 44 Five Principal Categories and Domains 1 CLINICAL COMMUNICATION (C) 45 • 1-A Communication, Counselling, and Patient Education 45 — Introduction: Alan T Rose ~ MCAT Candidate Information and Tasks 002-021 51-67 ~ MCAT Performance Guidelines 002-021 68-130 CIT PG DETAILS OF MCAT SCENARIOS 002 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman 53 69 3 Advice on neonatal circumcision for a couple expecting their first child 53 72 54 75 55 77 56 79 57 81 58 84 58 87 59 90 60 92 61 95 4 Suspected hearing impairment in a 10-month-old child 5 Counselling a family after sudden infant death syndrome (SIDS) 6 Hair loss in a 38-year-old man 7 An unusual feeling in the throat in a 30-year-old man 8 Pain in the testis following mumps in a 25-year-old man 9 Contraceptive advice for a 24-year-old woman 10 Rape of a 20-year-old woman 11 Cancer of the colon in a 60-year-old man 12 Thalassaemia minor in a 22-year-old woman i
  2. 2. CIT PG ii 13 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism 14 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus 15 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida 16 A duodenal ulcer found on endoscopy in a 65-year-old man 17 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery 18 Advice on stopping smoking to a 30-year-old man 19 Excessive alcohol consumption in a 45-year-old man 20 Type 1 diabetes mellitus in a 9-year-old boy 21 Request for vasectomy from a 36-year-old man 1-B Case presentations and summaries to Examiner — Introduction: Vernon C Marshall DETAILS OF MCAT SCENARIOS 022-029 Headache, neck lump, previous shoulder dislocation, dysphagia, low back pain, knee pain, abdominal discomfort, gastric ulcer with haemorrhage 62 99 131 132-135 2 CLINICAL DIAGNOSIS (D) 2-A The Diagnostic Process — History-taking and Problem-Solving — Introduction: Reuben D Glass ~ MCAT Candidate Information and Tasks 030-043 ~ MCAT Performance Guidelines 030-043 DETAILS OF MCAT SCENARIOS 30 Jaundice in a breastfed infant 31 A convulsion in a 14-month-old boy 32 Loud and disruptive behaviour of a 6-year-old boy 33 Tremor in a 40-year-old man 34 Headache in a 35-year-old woman 35 Lethargy in a 50-year-old woman 36 Syncope in a 52-year-old man 37 A painful penile rash in a 23-year-old man 38 Primary amenorrhoea in an 18-year-old woman 39 A skin lesion on the cheek of a 50-year-old man 40 A pigmented mole on the trunk of a 30-year-old woman 41 An itchy rash on the hands of a 19-year-old woman 42 Red painful dry hands in a 30-year-old bricklayer 43 Swelling of both ankles in a 53-year-old woman 137 137 142 -154 155 -195 143 156 144 159 144 161 145 164 145 167 146 170 147 173 148 177 149 180 150 182 151 184 152 186 153 189 154 191 62 102 63 105 64 108 65 111 65 115 66 121 67 125 67 129
  3. 3. CIT PG • 2-B Physical Examination 196 — Introduction: Vernon C Marshall and Barry P McGrath ~ MCAT Candidate Information and Tasks 044-057 218 -23 3 ~ MCAT Performance Guidelines 044-057 234 -29 6 DETAILS OF MCAT SCENARIOS 044 Assessment of a comatose patient 219 235 045 Recent onset of poor distance vision in a 17-year-old male 220 241 046 A painful rash on the trunk of a 45-year-old child-care worker 221 246 047 Acute low back pain and sciatica in a 30-year-old man 222 248 048 Fever and a recent rash in a 30-year-old man 223 252 049 A heart murmur in a 4-year-old boy 224 255 050 A knife wound to the wrist of a 25-year-old man 225 257 051 Multiple skin lesions in a Queensland family 226 264 052 Subcutaneous swelling for assessment 228 274 053 Examination of the knee of a patient with recurrent painful swelling after injury 229 280 054 Assessment of hearing loss, first noted during pregnancy in a 35-year-old woman 230 282 055 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago 231 286 056 Assessment of a groin lump in a 40-year-old man 232 289 057 Eye problems in an aboriginal community 233 293 • 2-C Choice and Interpretation of Investigations 297 — Introduction: Reuben D Glass and Vernon C Marshall ~ MCAT Candidate Information and Tasks 058-064 312- 319 ~ MCAT Performance Guidelines 058-064 320- 342 DETAILS OF MCAT SCENARIOS 058 Positive test for hepatitis C in a 26-year-old woman 313 321 059 Diagnosis of 'brain death' prior to organ donation 314 325 060 Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer 315 329 061 An elbow injury in an 11-year-old schoolgirl 316 331 062 Sudden onset of chest pain and breathlessness in a 20-year-old woman 317 334 063 Atypical ureteric colic in a 25-year-old man 318 337 064 Investigation for male factor infertility in a 25-year-old man 319 340 iii
  4. 4. CIT PG 2-D The General Consultation 343 — Introduction: Barry P McGrath ~ MCAT Candidate Information and Tasks 065-073 347-354 ~ MCAT Performance Guidelines 065-073 355-396 DETAILS OF MCAT SCENARIOS 065 Acute chest pain in a 60-year-old man 348 356 066 Palpitations and dizziness in a 50-year-old man 349 363 067 Muscle weakness and urinary symptoms in a 60-year-old man 350 368 068 Aches and pains in a 62-year-old man 351 371 069 Lack of energy in a 56-year-old suntanned man 352 374 070 Recent haematemesis in a 50-year-old man 352 377 071 Anaemia in a 28-year-old pregnant woman 353 380 072 Acute vertigo in a 50-year-old man 353 383 073 Urinary frequency in a 60-year-old man 354 394 2-E The Paediatric Consultation 397 — Introduction: Peter J Vine ~ MCAT Candidate Information and Tasks 074-077 401-403 ~ MCAT Performance Guidelines 074-077 404-416 DETAILS OF MCAT SCENARIOS 74 Neonatal jaundice in the first day of life 402 405 75 Immunisation advice to the parent of a 6-week-old baby 402 408 76 Dark urine, facial swelling and irritability in a 5-year-old boy 403 412 77 Fever and sore throat in a 5-year-old boy 403 414 2-F The Obstetric and Gynaecologic Consultation 417 — Introduction: Roger J Pepperell ~ MCAT Candidate Information and Tasks 078-082 419-422 — MCAT Performance Guidelines 078-082 423-435 DETAILS OF MCAT SCENARIOS 78 Breech presentation in labour at 38 weeks in a 25-year-old woman 420 424 79 Vaginal bleeding in a 23-year-old woman 420 427 80 Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) 421 430 081 Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman 421 432 082 Vaginal bleeding after 8 weeks amenorrhoea, in a woman with previous irregular cycles 422 434 2-G The Psychiatric Consultation 436 — Introduction: Frank P Hume ~ MCAT Candidate Information and Tasks 083-089 446-454 ~ MCAT Performance Guidelines 083-089 455-481 iv
  5. 5. CIT Pfi DETAILS OF MCAT SCENARIOS 083 Medication changes for a 35-year-old woman with chronic schizophrenia 447 456 084 Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man 448 459 085 Poor work performance in a 30-year-old female police officer 449 463 086 Lifestyle stress in a 45-year-old man 450 466 087 Binge drinking in a 25-year-old man 452 470 088 Nausea, headache and feeling 'jittery' in a 30-year-old bank clerk 453 474 089 Collapse of a 30-year-old woman on the way to a court attendance 454 478 3 CLINICAL MANAGEMENT (M) 483 • 3-A Management Objectives, Therapeutics, Prevention and Public Health 483 — Introduction: Alan T Rose, Michael R Kidd and Ronald McCoy ~ MCAT Candidate Information and Tasks 090-100 489- -498 ~ MCAT Performance Guidelines 090-100 499- -536 DETAILS OF MCAT SCENARIOS 090 Acute right sided pain and haematuria in a 25-year-old man 490 500 091 Faecal soiling in a 5-year-old boy 491 503 092 Psoriasis in a 30-year-old man 492 507 093 Temporal arteritis in a 58-year-old woman 493 510 094 Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man 494 512 095 Dysuria and urinary frequency in a 40-year-old man 495 519 096 Eclampsia in a 22-year-old primigravida at 38 weeks of gestation 496 522 097 An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida 496 525 098 Bed-wetting by a 5-year-old boy 497 528 099 Acute gout in a 48-year-old man 497 531 100 Request for repeat benzodiazepine prescription from a 25-year-old man 498 534 • 3-B Clinical Procedures 537 — Introduction: Peter G Devitt and Barry P McGrath ~ MCAT Candidate Information and Tasks 101-104 543- -547 ~ MCAT Performance Guidelines 101-104 548- -563 DETAILS OF MCAT SCENARIOS 101 Resuscitation of a 24-year-old man after head and chest injury 544 549 102 Fluid balance assessment in a 50-year-old patient after abdominal surgery 545 551 103 Evaluation of lung function by spirometry in a 22-year-old man 546 558 104 A suspected fractured clavicle in a 20-year-old man 547 561 V
  6. 6. CIT PG INTEGRATED DIAGNOSIS AND MANAGEMENT (D/M) 565 4-A Clinical Perspective and Priorities 565 — Introduction: Bryan W Yeo ~ MCAT Candidate Information and Tasks 105-112 570 -577 ~ MCAT Performance Guidelines 105-112 578 -600 DETAILS OF MCAT SCENARIOS 105 Abdominal pain and vaginal bleeding after 9 weeks amenorrhoea, in a 39-year-old woman 571 579 106 Recent insomnia in a 25-year-old man 572 582 107 Dandruff or head lice in a 6-year-old girl? 573 585 108 Recent orchidectomy for a testicular neoplasm in a 28-year-old man 574 587 109 Postnatal fatigue and exhaustion in a 28-year-old woman 575 589 110 Fundus greater than dates in a 26-year-old woman at 30 weeks gestation 575 593 111 Tiredness and anaemia in a 55-year-old woman 576 596 112 Colonoscopy findings in a 24-year-old man with chronic diarrhoea 577 599 4-B Life-threatening Emergencies — Priorities of Treatment 601 — Introduction: Bryan W Yeo ~ MCAT Candidate Information and Tasks 113-118 602- 608 ~ MCAT Performance Guidelines 113-118 609- 627 DETAILS OF MCAT SCENARIOS 113 A severely ill 4-month-old baby girl with fever 603 610 114 A lethargic febrile 2-year-old boy with a rash 604 612 115 Wheezing and breathing difficulty in a 5-year-old girl 605 614 116 Cuts to the wrist of a 25-year-old man 606 618 117 Severe postpartum haemorrhage in a 25-year-old primigravida 607 622 118 Emergency management of a snake-bite in a 20-year-old man 608 625 LEGAL, ETHICAL AND ORGANISATIONAL (LEO) 628 5-A Ethical and Legal Dilemmas 629 — Introduction: Kerry J Breen ~ MCAT Candidate Information and TasKS 119-124 633- 639 ~ MCAT Performance Guidelines 119-124 640- 659 DETAILS OF MCAT SCENARIOS 119 A man requesting disclosure of his wife's medical condition 634 641 120 Obtaining consent for leg amputation in a 35-year-old man after a motor vehicle injury 635 644 121 Several bone fractures in a 9-week-old baby 636 647 VI
  7. 7. CIT PG 122 A parent requesting sterilisation of her intellectually disabled daughter 637 649 123 Blood transfusion consent for a 33-year-old pregnant woman with severe APH at 7 months 638 652 124 End-of-life request from a terminally ill patient 639 655 MCAT TRIAL EXAMINATIONS 661 • Preparatory Instructions 661 — Roger J Pepperell 16 Station Trial Assessment ~ MCAT Candidate Information and Tasks T1-T16 664 -678 ~ MCAT Performance Guidelines T1-T16 679 -730 DETAILS OF MCAT TRIAL ASSESSMENTS 125 [T1] Meconium staining of liquor in labour in a 25-year-old primigravida 665 680 126 [T2] A heart murmur in a 5-year-old girl 666 683 127 [T3] Vigorous vomiting by a 3-week-old boy 667 685 128 [T4] Urinary incontinence in a 50-year-old woman 668 688 129 [T5] Migraine in a 30-year-old woman 668 691 130 [T6] Past history of hip dislocation in a 35-year-old man 669 694 131 [T7] Tiredness in a 45-year-old man 670 696 132 [T8] Review of lung function tests in a 65-year-old man with shortness of breath 671 700 133 [T9] Assessment of a 28-year-old primigravida at 34 weeks with fundus less than dates 672 705 134 [T10] Delirium in a 25-year-old man after a burn injury 672 708 135 [T11] Chronic diarrhoea in a 45-year-old man 673 712 136 [T12] Fever, irritability and ear discharge in a 2-year-old boy 674 716 137 [T13] Review of cytology after aspiration of a breast lesion in a 28-year-old woman 675 718 138 [T14] Nocturnal hand discomfort in a 35-year-old schoolteacher 677 721 139 [T15] An attack of asthma in a 25-year-old man 677 724 140 [T16] Preparing a 30-year-old woman with suspected acute appendicitis for surgery 678 728 8 Station Trial Retest Assessment ~ MCAT Candidate Information and Tasks R1-R8 732 -739 ~ MCAT Performance Guidelines R1-R8 740 -765 DETAILS OF MCAT TRIAL RETEST ASSESSMENTS 141 [R1] Intravenous cannula insertion for antibiotic prophylaxis 733 741 142 [R2] Heartburn in a 35-year-old man 734 744 143 [R3] Spontaneous bruising and nosebleed in a 3-year-old boy 735 748 Vii
  8. 8. CIT PG 144 [R4] Nausea and vomiting in the first trimester in a 25-year-old primigravida 736 750 145 [R5] Visual difficulties in a 50-year-old man 736 753 146 [R6] Cognitive state assessment of a 50-year-old barman 737 756 147 [R7] Jaundice in a 25-year-old man 738 760 148 [R8] Assessment of prominent leg veins in a 38-year-old woman 739 763 INTERACTIVE CLINICAL ASSESSMENT — OTHER METHODS AND OSCE MODIFICATIONS 767 — Peter G Devitt and Heather G Alexander 149 Confusion and delirium after surgery in a 50-year-old man 771 773 150 Postoperative fever in a 45-year-old woman 151 The 4 station progressive OSCE 771 776 779 GLOSSARY OF TERMS AND ABBREVIATIONS 781 EPONYMS 790 APPENDICES 1. AMC Objectives of Medical Education 803 2. AMC Instructions to Standardised Patients and Clinical Examiners 806 3. MCC/AMC Clinical Task Categories; AMC Function/Process; System/Region/Speciality; and Discipline classification 810 MCATs with full Domain listing and AMC Anthology Reference 814 MCATs by Discipline (Condition and page listings only) 843 MCATs by System/Region/Speciality (Condition and page listings only) 847 MCATs by Function/Process (Condition and page listings only) 856 Suggested Additional Groupings of MCATs for self-test trial assessments 862 Guidelines for further reading 863 EPILOGUE 867 INDEX 868 Viii
  9. 9. The AMC Multidisciplinary Clinical Assessment Task (MCAT) Format Heather G Alexander The student is to collect and evaluate facts. The facts are locked up in the patient. To the patient, therefore, the student must go.' Abraham Flexner (1866-1959) Medical Education, a Comparative Study The MCAT is an integrated OSCE-style clinical examination where each candidate proceeds through the same number of stations — 16 stations in the full exam, 8 stations in the retest. CONTENT OF STATIONS At each station, two minutes are allocated for preliminary reading outside the room. An instruction sheet giving the candidate specific information and tasks required is provided. This introduces the candidate to the consultation setting and clinical situation. It may also include patient profile test results or an illustration. Specific tasks that the candidate will be asked to perform are itemised. A duplicate copy of the instructions is provided in the examination room. This is followed by eight minutes performing the required task in a room with a standardised patient. When the candidate first enters the room, the observing examiner will check that the instructions for the station have been read and will then introduce the candidate to the patient. The examiner will then observe the performance and record the candidate's performance on a tailored mark sheet. The standardised patient may be a real patient or a simulated patient (role player) who plays the role of either the patient or a relative. Doctor-patient communication performance contributes to the assessment and requires a well-trained role player. Where scenarios are based on physical examination, the 'role player' may be a real patient. The aims of the station, the tasks that candidates are askedtoperform, the key issues and assessment domainsdefined for the station are allcloselyaligned. 031 FIGUREIII. History-taking FIGUREiv. CommencingthePhysicalExamination The aims of the station, the tasks that candidates are asked to perform, the key issues and assessment domains defined for the station are all closely aligned.
  10. 10. 032 The MCAT scenarios developed for assessment purposes are designed to simulate closely real life situations within medical consultations. These may be in a general practice setting, a hospital emergency department, or a hospital inpatient or outpatient setting. Scenarios deal with different phases of illnesses. Diagnostic scenarios include the diagnostic phases of history taking, physical examination, and ordering and interpreting investigations. The management phases incorporate patient explanation and education, advice and referral, therapeutics and preventive medicine, clinical procedures and counselling. Scenarios are focused precisely so that the assessment domains, key issues and critical errors are accurately related to the station aims and the tasks set down in the candidate's instructions. Members of the AMC clinical examination panel suggest MCAT clinical scenarios based on their prevalence, seriousness, preventability and whether they can be simulated as real life situations within the inherent time constraints. Scenarios are thoroughly reviewed and approved by the multidisciplinary clinical panel prior to use. The current 16 or 8 station MCAT formats cover a broad spectrum of skills in clinical medicine, psychiatry, surgery, obstetrics/gynaecology, and paediatrics, including emergency, hospital and community practice medicine. MCAT MARKING In an MCAT, candidates are assessed at the level of a final year medical student, i.e. a doctor about to commence an intern year (PGY1). Mark sheets for examiner use. The examiner scores the candidate's performance on a mark sheet which specifies the assessment domains, key domains, and critical errors if appropriate. The assessment domains match the tasks outlined on the instructions the candidates receive during the two minutes preliminary reading. The marking domains are identified from among a total of 14 covering: • approach to patient and responses to patient's questions; • patient counselling and education; • history-taking; • physical examination choice and technique; • physical examination accuracy; • choice of investigations; • interpretation of investigations; • diagnosis and differential diagnosis; • initial management plan; • explanation of clinical procedure; • performance of clinical procedure; • familiarity with test equipment; • commentary to examiner; and • answers to examiner's questions, No single station is likely to have assessment in more than five of these domains. Each domain has a 4-point marking scale: • Very satisfactory Clear pass • Satisfactory Pass • Unsatisfactory Fail • Very unsatisfactory Clear fail
  11. 11. 033 An example mark sheet is included later with the example MCAT 001. (see page 44) Critical errors are defined and derived from one or more of the key issues, when relevant. Not all stations have critical errors. If the candidate makes a critical error the candidate is very likely to fail that station, regardless of performance in other domains, unless performance in other domains is outstanding and the critical error is deemed possibly related to lack of time or misunderstanding of the task. MCAT performance is checked and reviewed by the Clinical Panel of Examiners after each use in an examination. All details, particularly presence and definition of critical errors, are reassessed and retained or modified in light of candidate performance and examiner feedback. Station failure would probably result from two or more 'unsatisfactory — fail' assessments or one 'very unsatisfactory — fail' assessment in a key issue domain, or from making a critical error in a key issue domain. After scoring each of the domains, the examiner will provide an overall (final) rating that is either 'Pass' or 'Fail' for each station. All 16 MCAT scenarios are of equal weighting and for each scenario there are only two outcomes — pass or fail. Candidates must obtain a pass in 12 or more of the 16 stations, including a pass in at least one paediatric and one obstetric/gynaecology station, to pass the MCAT as a whole. Candidates scoring pass levels in nine or less of the 16 stations, or with failures in all three of the paediatric or obstetric/gynaecology stations, fail the examination and must resit. Candidates who pass 10 or 11 of the 16 stations (including a pass in at least one obstetric/ gynaecology station and one paediatric station) will be eligible for a pass/fail Retest Examination of 8 stations. Retest candidates will be required to pass six or more of the eight retest stations to pass the examination. Candidates scoring five or less passes will fail and be required to resit the whole examination. Heather G Alexander July 2007
  12. 12. 034 How to use this AMC Handbook of Annotated MCATs Vernon C Marshall 'In what may be called the natural method of teaching the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end.' Sir William Osier (1849-1919) The MCAT self-test scenarios are arranged in groups under the principal categories and domains tested. In each instance the reader is provided with a synopsis heading, outlining the clinical problem/condition together with the information available to the candidate and details of the task to be undertaken, exactly as this appears in the MCAT examination. INSTRUCTIONS TO CANDIDATES You may wish to attempt to complete the tasks in each of the major categories before moving to the next group. If you would prefer to review tasks by system and region, or by discipline, the appropriate groupings of these are listed in later pages. Page numbers of individual MCATs are listed in the table of contents at the beginning of the book for easy reference. After reading carefully the information provided to you for each clinical scenario and the required tasks, jot down how you will approach this consultation, how you will advise the patient or relative of your findings and recommendations, and how you would structure responses to queries from patient or examiner. Then turn the pages to check your responses against the optimum Performance Guidelines, Examiner Instructions and Commentaries. Note the station Aims, Key issues and Critical Errors outlined. In this book the scenarios are grouped into five main categories. The groupings are to some degree artificial in that communication skills are relevant to all scenarios. For example, aspects of diagnosis, management, and patient counselling and education are frequently combined to varying degree, but the groupings are arranged to emphasise and categorise the principal domains even though most scenarios are assessed over multiple domains. The five groupings below condense the total of 14 domain assessments into five categories covering skills principally in: 1. Clinical Communication (C) — with patient, relative and observer, and including a number of domains: approach to patient, patient counselling/education, history-taking, commentary to examiner, answers to patient's or examiner's questions, explanation of procedure, case presentation and summary. 2. Clinical Diagnosis (D) — includes history-taking, technique and accuracy of physical examination, choice of investigations and their interpretation, diagnosis/differential diagnosis. 3. Clinical Management (M) — includes initial management plan, performance of procedure/task, treatment and prevention of disease, clinical procedures. 4. Integrated Diagnosis and Management (D/M) — includes clinical perspectives and priorities, life-threatening emergencies, integrative reasoning skills and clinical problem-solving. 5. Legal, Ethical and Organisational (LEO) — includes scenarios where ethical and legal issues are significant.
  13. 13. INTRODUCTORY GUIDELINES for candidates (see Table below) are provided at the start of each of the main categories and their domains. After completing individual case scenarios you may find it helpful to revise your knowledge of similar and linked conditions by referring to appropriate clinical texts and references. The AMC Anthology of Medical Conditions contains other self-test strategies for individual conditions. Try making up your own variations on the conditions tested, and practise role playing and interactions with a colleague or in a group. Once you are familiar with the mechanics and time constraints, pace yourself through the trial examinations (one containing 16 stations and one containing 8 multi-disciplinary stations), and the other suggested groupings provided later in the book, under simulated examination conditions. The Editorial Committee hopes you find the examples helpful and extends its good wishes for a successful assessment. The MCAT self-test scenarios are arranged in groups under the principal categories and domains tested. In each instance the reader is provided with a synopsis heading, outlining the clinical problem/condition together with the information available to the candidate and details of the task to be undertaken, exactly as this appears in the MCAT examination. SCENARIO HEADINGS FOLLOWED IN THE AMC HANDBOOK OF CLINICAL ASSESSMENT The MCAT scenarios and performance guidelines are set out in a standardised sequence as follows. Groups of self-test candidate information and tasks are arranged under principal categories and domains tested. Table 3 MCAT Introductory Guideline Scenario Headings CONDITION AND ID NUMBER A generic and non-diagnostic summary of the presenting symptom, physical sign or investigation result in diagnostic-type cases, such as: • Assessment of acute abdominal pain in a 30-year-old woman. • Assessment of a vesicular rash in a 50-year-old man. • Review of liver function test results in a 50-year-old manwith jaundice. The diagnosis or most likely diagnosis in management/counselling-type cases, such as: • Management of shingles ('herpes zoster') in a 25-year-old woman. • Counselling the relative of a patient after recent major surgery. CANDIDATE INFORMATIO N AND TASKS Under this heading the background information and tasks are given precisely as they appear in the MCAT examination. Page references to the matching Performance Guidelines are given at the foot of each Candidate Information and Tasks sheet. YOURTASKSARETO: Lists requested tasks for candidates. 035
  14. 14. 036 Performance guidelines follow in similar category and domain groups linked to the preceding scenarios by ID number and page reference. PERFORMANCE GUIDELINES CONDITION AND Principal category and assessment domains in detail; and ID NUMBER classitication by function, system/region and discipline (see Appendix 3) are listed for each station just prior to the index. AMC Anthology of Medical Conditions reference is listed to aid further self-testing. The MCC/AMC Clinical Task Category is also listed. AIMS OF STATION A brief outline of station and assessment aims, matching the tasks. The expected responses and levels of performance required to complete the tasks successfully are outlined in the examiner instructions and commentaries. EXAMINER INSTRUCTIONS These provide the following: Instructions from examiner to standardised patient Candidate information and tasks and role player instructions are detailed and provided to examiners and standardised patients so that there is standardised behaviour across multiple patients. Cues assist in directing the consultation pathway. The instructions are set out using lay terminology to maintain realism, and outline: • Clinical setting — hospital emergency department, hospital ward or outpatient department, primary care facility, community practice office consultation. • Clinical situation — description of illness and symptoms and phase of the consultation. • Patient profile — age and gender, past history, family history, habitus, as relevant to the case. • Opening statement — one sentence provided as the patient's opening gambit. • How to play the role — advice on further responses, posture, gestures, affect, mood and ways to react to the doctor, including where the task is a physical examination. Questions to be asked by patient/role player — set down in a loose priority and which will depend on whether these have already been covered by the doctor/candidate. Any examiner questions or prompts to the candidate are also outlined, with the required responses. EXPECTATIONS OF CANDIDATE PERFORMANCE These are clarified for the examiner and match the tasks and the domains. KEY ISSUES These are selected from the assessment domains and expectations of candidate performance for each case and highlighted accordingly. CRITICAL ERROR(S) These list significant errors likely to lead to a fail performance. COMMENTARY This discusses and comments further on the condition, highlighting performance standards and common errors.
  15. 15. EXAMPLE CASE SCENARIO: The following case scenario exemplifies the formatting for a combined Diagnosis and Management MCAT. 037 MCATFORMAT EXAMPLE: Sample - Condition 001 CandidateInformationandTasks Condition 001 A cut to the thumb of a 22-year-old man You are the Hospital Medical Officer (HMO) in a hospital Emergency Department. The patient injured his left thumb at work an hour ago. He is aged 22 years and works as an orchard labourer and fruit picker. He is right handed. He was pruning fruit trees today and the pruning knife slipped and he cut his left thumb. He was wearing cotton gloves. The knife cut through the glove and cut the thumb as shown in the illustration below. Bleeding was minor and controlled by a pressure dressing, which has been removed for examination. The wound appears as a linear knife cut as shown, the edges of which have sealed after the initial bleeding which has now stopped. YOUR TASKS ARE TO: • Examine him and assess the injury. • Explain to him the nature of the injury and your recommended management. You may ask other questions of the patient as you proceed with the examination and explanation. Near the end of the eight-minute time allotted for your task, the examiner will ask you one or two questions. CONDITION001.FIGURE1. Knifewoundtotheleftthumb The Performance Guidelines for Condition 001 can be found on page 40
  16. 16. 038 Sample-Condition 001 Candidate Information and Tasks CANDIDATE ADVICE You should: Prepare and document your responses and how you would approach this task. Test yourself thoroughly after reading the MCAT Candidate Information and Tasks, before proceeding to read the performance guidelines, examiner and patient instructions and commentary which you will find on subsequent pages. Follow a similar process for the other MCATs. The best way to develop proficiency in an MCAT assessment is to work in pairs or as a group. Your colleague reads the performance guidelines and plays the patient/relative, while you read the candidate information and perform the tasks, while another group member takes the role of examiner/observer. SUMMARY OF STUDY TASKS Read the candidate information and task(s), preferably working with a colleague or group. Formulate and document a logical approach for responding to and solving the consultative problem given. Then read the performance guidelines that follow, and note the aims of the station, expectations of your knowledge and performance, key issues and critical errors and other points raised in the commentary. Check for any deficiencies in your performance. Reread the introductions to the section in which the MCAT appears. For this MCAT about a thumb wound, revise your knowledge of applied surface anatomy relevant to wounds giving risk to underlying structures and how you should check for local and distal effects of injury. Construct alternative scenarios for other wounds and self-test yourself on these (for example, injuries to radial nerve in the arm, common peroneal nerve in the leg). Revise the Anthology scenarios 113, 113H, 113J and 113K and complete the self-test exercises. Reinforce your understanding of the condition by completing other self-assessment tasks (for example from the AMC Anthology of Medical Conditions) and construct at least one other related task for solving. Finally, one complete MCAT 16 station assessment and one complete MCAT eight station assessment are provided later in the book as examples of whole examinations for trial.
  17. 17. 039 Sample-Condition 001 Candidate Information and Tasks Additional groupings of MCATs into further self-test trial examinations are also suggested at the end of the book. MCATs are also grouped into one of the principal disciplines of medicine, obstetrics/gynaecology, paediatrics, psychiatry, surgery if you wish to use the book in this way. MCATs are similarly grouped into the relevant function and process and into system/region/specialty. For these latter groups, MCATs are often listed more than once when they cover more than one system or function. Pace and test yourself through these. Keep practising within a group of your peers until fully familiar with the routine. We hope that you will find the self-discipline and requirements to adhere to logical clinical reasoning pathways in approaching the wide range of clinical problems selected for this book will stand you in good stead, not just for assessment examinations, but throughout your subsequent career. Vernon C Marshall
  18. 18. 040 Sample - Condition 001 MCAT FORMAT EXAMPLE: Performance Guidelines Condition 001 A cut to the thumb of a 22-year-old man AIMS OF STATION To assess the candidate's ability to use clinical reasoning skills to diagnose and manage important injuries associated with skin wounds. In this instance, the knife cut has severed the two extensor tendons to the thumb. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The examiner will draw the linear cut with a red marking pen on the role-playing patient, and show the patient how to respond to requests to bend his thumb and testing of sensation as follows: • You have not yet noticed and should not volunteer any information about limitation of thumb movement, until specifically asked to extend each of the two end joints, which you are unable to do. Sensation is normal. • You had a tetanus booster shot about a year ago for a leg graze and were immunised against tetanus as a child. Opening statement: • 'Will it be okay for me to go back to work tomorrow with a dressing over it now it's stopped bleeding, Doc?' Other questions to ask: • If the candidate/doctor diagnoses tendon injury with normal sensation, you will accept the recommendations for operation, and should ask about the operation 'Will I need an anaesthetic?' (Appropriate answer — Yes: regional block or general anaesthesia). • If no mention of a tetanus prophylaxis or antibiotics is made during the interview you will subsequently ask 'Will I need another tetanus shot?' (A booster dose of toxoid would be appropriate). Examiner's questions to candidate: • At the end of 6-7 minutes, if the candidate has identified that a tendon injury has occurred, the examiner should ask: 'What are the names of the injured tendons?' (Extensor pollicis longus [EPL] and extensor pollicis brevis [EPB]) and
  19. 19. 041 Sample - Condition 001 Performance Guidelines 'Which joint does each tendon act upon?' (Interphalangeal [IP] and metacarpophalangeal [MP] joint respectively). If no tendon injury has been identified just ask: 'If antibiotics are to be given, what would you choose?' (Broad spectrum cover such as one dose of amoxycillin, cephalosporin or other antibiotic). EXPECTATIONS OF CANDIDATE PERFORMANCE Cuts and stabs of various types commonly present to emergency departments. Attending doctors must be aware of the anatomy of deeper structures at risk from injuries at specific sites and the methods of diagnosing such injuries. Diagnosis of injury to the two main long thumb tendons and recognition of the treatment requirements for primary surgical repair in this 'tidy' (clean contaminated) wound. Explanation of treatment would optimally advise preparation for early surgery using local (field) block or general anaesthesia. Antibiotic and tetanus prophylaxis would be appropriate. KEY ISSUES Ability to identify deeper tendon injuries resulting from stabs or cuts. Failure to appreciate that the whole thumb extensor mechanism (involving two tendons) has been damaged would comprise a fail (unsatisfactory) in the domains of examination technique and diagnosis. Failure to name the tendons correctly would not necessarily be a fail performance, providing the presence of tendon injury was diagnosed and appropriate advice given in other areas. Failure to mention antibiotic or tetanus prophylaxis would be unsatisfactory, but would not be considered a critical error in the presence of a 'tidy' recent wound; such omission would most likely be corrected with subsequent specialist referral for surgery and anaesthesia. CRITICAL ERROR Failure to test and identify the injury to the extensor tendons would comprise a clear and irremediable fail for this station at a very unsatisfactory level.
  20. 20. 042 Sample - Condition 001 Performance Guidelines COMMENTARY The knife cut has severed the two extensor tendons to the left thumb {extensor pollicis brew's and extensor pollicis longus, from radial to ulnar side). These tendons form the margins of the anatomical snuff box as illustrated. The tendons have been severed at the knuckle level of the metacarpophalangeal joint. The patient has no obvious thumb deformity but is unable actively to extend either the metacarpophalangeal (MP) joint or the interphalangeal (IP) joint of the thumb. The digital cutaneous nerves have not been cut and distal sensation is normal apart from tenderness around the cut. Extension of the joints of the thumb occurs from the actions of: • Extensor pollicis longus (EPL) the ulnar-sided of the two thumb tendons running on the dorsal aspect of the thumb. The long tendon of EPL runs obliquely across the back of the hand after angulating around the tubercle of the radius (Lister tubercle) before inserting into the base of the distal phalanx. EPL is the prime mover and sole extensor of the terminal (interphalangeal) joint. By passing across the metacarpophalangeal (MP) and carpometacarpal (CM) joints of the thumb. EPL can also act as an accessory extensor of these joints. EPL, like other superficial tendons, may be injured by cuts and penetrating injuries. • Extensor pollicis brevis (EPB) is the lateral of the two thumb extensors. EPB runs in the same synovial sheath as the tendon of abductor pollicis longus on the lateral surface of the radius and continues over the dorsal shaft of the metacarpal to insert into the base of the proximal phalanx. EPB is the prime mover in extension of the MP joint and an accessory extensor of the CM joint. Cuts around the knuckle of the metacarpophalangeal joint are likely to sever one or both tendons. In this patient, both EPL and EPB have been severed. • Abductor pollicis longus (APL). This stout tendon, often multiple or ridged like a stalk of celery, inserts dorsolateral^ into the base of the thumb metacarpal. APL is the prime mover of radial abduction and extension of the thumb at the carpo- metacarpal joint, separating the thumb from the other digits in the plane of the palm. In this patient, radial abduction will be unaffected as APL has not been injured.
  21. 21. Sample - Condition 001 Performance Guidelines CONDITION 001. FIGURE 2. Normal Anatomy — Left hand and thumb The Examiner mark sheet for MCAT 001 follows. 043
  22. 22. 044 Candidate ID card sighted Very Satisfactory - PASS Satisfactory - PASS Unsatisfactory - FAIL Very Unsatisfactory - FAIL *-■ KEY ISSUE Covers all essential Minor technical Candidate displays Choice & Technique of Examination, aspects competently □ faults but □ one or more of the Serious errors or omissions in technique. Organisation and Sequence - minimal errors or examination following: CRITICAL ERROR? Did the candidate carry out an omissions. completed reasonably. - significant omissions appropriate focused and relevant - significant errors of examination as per examiner technique instructions? - poor technique •-■ KEY ISSUE Identified most or Minor errors in One or more Accuracy of Examination all findings □ findings. □ significant errors in □ Serious errors or omissions in findings: reported findings not Did the candidate identify the accurately. findings. consistent with physical signs physical findings accurately as CRITICAL ERROR? per examiner instructions? •^ KEY ISSUE Covered all essential Minor omissions Significant errors in Diagnosis not given. Serious Diagnosis/Differential Diagnosis aspects competently □ or errors in □ explanations of □ omissions or errors in Did the candidate formulate and - minimal or no errors or explanations of findings. findings. Wrong interpretations of findings. describe an appropriate diagnosis/ omissions. Logical, clear, Diagnosis and differential interpretations of findings. Clinical reasoning and diagnostic differential diagnosis as per examiner well organised. diagnosis appropriate to Unclear and poorly skills markedly deficient. Very poor instructions? the case even if not organised. Diagnosis organisation. Wrong diagnosis could completely accurate. inappropriate to the ;ase. result in serious harm to the patient. CRITICAL ERROR? •-. KEY ISSUE Covered all essential Minor errors but did Significant errors Serious errors or omissions. Initial Management Plan aspects competently □ not interfere with an □ which did interfere □ Inappropriate management Did the candidate formulate and - minimal errors or adequate initial with an adequate and/or management proposed is describe an appropriate initial omissions. Optimal management plan. management plan. potentially harmful to patient. management plan as per examiner instructions? management plan. CRITICAL ERROR? Answers to Questions Covered all aspects Minor errors in Significant errors in Serious errors or omissions in Answers to questions asked by completely, minimal □ answers to □ answers to questions the answers given, or complete examiner? errors or omissions. questions. indicating lack of knowledge/expertise these areas. in unfamiliarity with the subjects asked. CRITICAL ERROR? T X U) 3 < -i T CD 3 A i1 ( ^+ 1 n 1 A 1 II — o X- [11 rr nX ZS cp o Tl n § 1 O n—i in O o o GO O OVERALL RATING FOR THIS CANDIDATE FOR THIS STATION: PASS FAIL
  23. 23. Clinical Communication (C) 1-A: Communication, Counselling & Patient Education Alan T Rose 'Oh, that's your doctor, is it? What sort of a doctor is he?' Well, I don't know much about his ability, but he's got a very good bedside manner!' George du Maurier, Punch Cartoon, 15 March 1884. 1-A COMMUNICATION, COUNSELLING AND PATIENT EDUCATION Communication is the exchange of messages and thoughts by speech, signals or writing. Communication skills are employed to ensure that exchanges are readily and clearly understood. Exchanges involve the sharing of information, ideas, emotions, and empathy. Communication is the foundation on which medical consulting takes shape, supplemented by the practitioner's skill in physical examination and diagnostic reasoning. Failure of communication is an important contributor to clinical situations of perceived malpractice and is the most important factor in a high proportion of medicolegal actions. Most medical consultations and activities require the doctor and patient to communicate rationally and effectively with each other. 045 Exceptions are when the patient is an infant or is intellectually handicapped — communication is then with a relative or carer — or when the patient is unconscious (including when anaesthetised) or suffering from certain psychotic states, or when doctor and patient do not share the same language. Communication requires special techniques with patients who are blind, mute, aphonic or aphasic. Impaired hearing may affect either patient or doctor. The role of the interpreter, when required, is also critical. Involvement of third parties (such as relatives, friends, or outside agencies) requires the patient's consent. In these situations the patient's legal right to The AMC examination process places considerable emphasis on assessment of effective communication between candidate and patient during clinical consultations, during discussions with relatives, and during case presentations and commentaries. confidentiality and privacy must be respected. The AMC examination process places considerable emphasis on assessment of effective communication between candidate and patient during clinical consultations, during discussions with relatives, and during case presentations and commentaries. Written communications are important for letters of referral and discharge summaries, but are less readily assessed within the current AMC format. Verbal communication depends on a mutual understanding of the language being used and the way it is articulated. This includes pronunciation, auditory level, speed, tone and the unique voice qualities and cadences of the speaker. The AMC examination assesses communication in the English language in a medical and clinical context. English is not the first language for many IMGs, but all IMGs are required to have adequate clinical communi- cation skills in English by medical registration boards.
  24. 24. Nonverbal communication (such as facial expression, posture, gesturing, silence, and emoting) by either doctor or patient, also conveys messages as well as influencing the understanding of what is being said and its emotional context. Effective verbal and nonverbal communication in medical practice facilitates the establish- ment of empathy and rapport, trust and confidence, mutual understanding, education about the clinical condition, and satisfactory compliance with advice and treatment. The term 'bedside manner', used to describe a doctor's communication skills, was first used in a London 'Punch' cartoon by George du Maurier. Wide variations in clinical communication skills occur because of each individual doctor's inherent personality traits and individual approach to patients. These can be modified and improved by education and self awareness, so that time is saved and any frustrations felt by the doctor or dissatisfaction by the patient are minimised. Similarly, the cultural characteristics of the patient (and of the doctor) can profoundly affect the quality of doctor-patient communication. Doctors practising in Australia require multicultural competence across all fields of medicine. Special care is required in the case of Aboriginal and Torres Strait Islanders, and for culturally and linguistically diverse groups. Communication skills, although important, are not sufficient. Good communication skills must be accompanied by sound clinical skills, attitudes and professional behaviour. The (fortunately) rare physician serial criminal murderers have usually been superb communicators. Other personal factors can interfere with the doctor's use of communication skills. Many clinical realities are unpleasant to both patient and doctor. If the doctor retreats behind a professional fagade of a stilted and portentous style of speech, or adopts a pompous or pretentious attitude, or one interpreted as such, the patient can be daunted from further enquiry. Rejection by the doctor of a patient's attitude or behaviour engenders lack of understanding and trust. Value judgements of the doctor are best avoided or concealed. Care and compassion should be evident but not forced or obtrusive. This is especially important when treating users of illicit drugs or dependent alcoholics. Mention should also be made of the so-called 'difficult patient' whose underlying but sometimes unrecognised personality disorder reduces or eliminates the effectiveness of the communication skills described below. The application of communication skills Effective communication is of most value when taking a history, providing patient education about the condition diagnosed, giving advice about treatment, counselling patients, and when discussing the patient's illness with anxious relatives or friends. History-taking There are two main methods. Transition from one to the other occurs depending on the clinical setting and progress of this phase of the consultation. The aim is to define the presenting problem to a point where the diagnosis moves from possible to probable to definite. Firstly, the nondirective or 'open-ended' approach: this allows and encourages patients to outline the problem ('tell their story') in their own way while the doctor listens with little interruption. Although apparent irrelevancies may be brought up, this method gives an opportunity for patients to reveal concerns initially unstated. These concerns may explain their real reason for attending and why they have come at this particular time. 046
  25. 25. This approach is most useful when the patient is consulting the doctor for the first time about undifferentiated symptoms such as 'tiredness', 'bloating', 'being run down', 'sleep- lessness', or 'requesting a checkup'. Secondly, the directive, closed or interrogative approach: this confines the patient to the doctor's agenda. This is appropriate in emergencies and, if the problem has already been well defined, when a patient's progress is being reviewed in followup. The doctor takes early control of the interview by the use of a series of direct or closed questions. This approach is well summarised by the traditional term — history 'taking'. The directive approach risks the omission of significant information, particularly from a patient who is anxious, reticent, embarrassed, or has feelings of shame or guilt. Nonverbal communication is very useful in the nondirective approach and can replace some parts of the verbal component, for example, expressing surprise by facial expression. Transition from nondirective to directive mode occurs when the doctor begins to ask direct or closed questions, but the two modes are usually phased or overlap. The type of question used will change the direction of the interview. Using questions about pain as examples: open ended 'Tell me about the pain?' direct Where Is the pain?' closed 'Have you had this pain before?' leading 'The pain isn't severe?' A series of direct or closed questions is usually necessary to complete the history regarding occupation, past and family illness, domestic habits, medications, allergies and sensitivities, where relevant. Facilitation is also a valuable nondirective tool. Facilitation uses nonspecific inviting or encouraging remarks, for example, 'go on', 'I'm listening carefully', 'tell me more about the pain', 'anything else?', 7 see', or 'uh uh'. Listening is an essential basis of communication. Adequate time must be given and the doctor's nonverbal behaviour should indicate to the patient that the listening is attentive. Note-taking should be discreet and avoid distraction. The use of a personal computer by the doctor in the consulting room while taking a history requires, more than ever, that the doctor's nonverbal behaviour assures patients that they are being 'listened to'. Silence is not the same as listening. Silence may be the best response when there is an emotional or confrontational component in the consultation. Confrontation can defuse an issue ('Wouldn't we progress better if we leave aside for the moment your previous dissatisfaction with treatment and try to work out how best to fix things now?') but should be used with care. Frequently initial aggression or anger from the patient is better deflected in the first instance. Summarising briefly what the doctor believes the patient has said so far is often useful to confirm that mutual understanding at that point in the interview is present. As previously noted, these techniques are modified by the personality and instinctive behaviour of the doctor, who may not always be fully aware of their effect on a patient. The perceptive doctor attempts always to appreciate the patient's perspectives as well as the doctor's own. In summary, the following guidelines apply to history 'taking' from a patient presenting with a nonurgent diagnostic problem. 047
  26. 26. Following the formalities (or informalities) of introduction, the doctor should: • begin with an open-ended approach; • listen carefully and attentively; • use facilitation and open-ended questions to encourage the patient; • limit direct questions early in the interview; • use indirect and reflected questions as appropriate; • use direct and closed questions to take control at an appropriate time; • take note of any display of emotion by the patient and respond appropriately; • briefly summarise what is being learnt or understood (or not) from the patient; • gradually increase control of the interview as it proceeds; • use nonverbal communication, to supplement verbal communication; and • be alert to the patient's nonverbal behaviour. With loquacious and garrulous patients, transition from open-ended to direct questioning needs to proceed expeditiously but tactfully because of time constraints. In many of the MCAT clinical scenarios, direct questioning is essential to enable a focused history to be taken within the time period available. Communication skills are especially important when the patient has concerns other than those expressed in the first statement to the doctor. Such hidden concerns may include fears of cancer, heart disease, stroke, blindness, sexually transmitted infection, work capacity, relationships, serious illness in an unborn child or infant, dissatisfaction with treatment and feelings of grief or guilt — to mention only a few. Patient education Once the diagnosis has been made, it should be stated to the patient using both medical and lay terminology appropriate to the patient's understanding. Initial reassurance should be given when appropriate ('I'm pleased to tell you that the biopsy showed no evidence of cancer'). Failure to do so may allow patient anxiety to block the reception of other information. Reassurance may be the only therapy that is necessary — unnecessary prescribing may follow if the doctor has not understood this basic need of the patient for reassurance. The patient's knowledge and understanding of the condition should then be established so that education can be pitched at the correct level. This includes the correction of incorrect beliefs and responses to the patient's questions. The use of a chart, diagram or of printed notes, may be additionally helpful. As previously stated, anxiety may reduce the efficiency of absorbing and understanding information. Patients will also differ in their interest and tolerance of information about their ailments. Most will want to know if the condition is serious, whether it can be treated, when they will recover and resume normal activities, and what forms treatment will take, even though these questions may not be asked directly. Overloading the patient with information can be counterproductive and have unwanted effects including the creation of pessimism and anxiety. Further information can be added at a subsequent consultation. Handing out previously prepared written material is helpful for most patients but is no substitute for verbal education from the doctor. Adverse information should be given in such a way so as to not destroy hope, and also to assure the patient of the doctor's continuing support. An adequate level of understanding is the only basis on which patients can share the responsibility of decision-making about treatment and give informed consent. Many patients 048
  27. 27. however still prefer to leave all decisions to the doctor. If thought necessary, confrontation can be used to bring to the attention of patients their own responsibilities in aiding effective treatment. Giving advice about treatment The wide ranges of treatments, which may be indicated, include giving simple advice, prescribing, minor or major procedures, the use of allied health professional services, referral to another doctor or to a hospital service, and counselling. All require the use of communication skills, either verbal, nonverbal, or written. When counselling is the main component of treatment, additional special skills are required. The duration of intended treatment should be advised to the patient and opportunities for giving preventive advice taken whenever appropriate. This may involve other members of the patient's family. Prescribing should be supported by a statement of the name of the medication, which may also be written down for the patient, the dose and timing, expected effects including the most important side effects, and significant adverse reactions. Patients will also wish to know general details about any procedure which has been recommended, and what to expect when a referral has been made. Patients should not be left wondering what happens next. Certainty about followup arrangements, particularly after investigations or referral, should be made quite clear. Neglect of these can have medicolegal consequences. Patient Counselling Counselling is a term widely used in the community to describe the provision of support to individuals or groups who are experiencing significant emotional stress. Counsellors, usually with special training in psychological skills, attend survivors or observers of accidents and disasters and provide support. Doctors frequently need to give 'bad news' to patients and relatives, and are involved with bereavement and grieving responses. Allowing patients and relatives to work through their feelings by means of facilitation and attentive listening, and providing support and reassurance whenever possible, with unforced compassion and sympathetic understanding, is required every day in clinical practice. However, when 'patient counselling' is used in treatment, there are two types: directive and nondirective. As with other communication skills these may overlap or be used in an integrated way. However, one type usually predominates according to the clinical situation. Directive counselling is when straightforward advice or instruction are given to the patient. In contrast, nondirective counselling is a special communication skill which involves more than patient education or giving advice about treatment. Its objective is that the patient, instead of the doctor, is the final decision-maker and shares or accepts, in part or fully, responsibility for the subsequent course and outcome of the problem. Nondirective counselling begins with an accurate definition of the problem using the skills outlined under nondirective history-taking, particularly listening and the use of silence. The doctor then provides education about the problem including possible outcomes that are likely to follow alternative forms of behaviour or non-compliance by the patient. Patients are then asked what course they intend to follow, based on the options that have been discussed. The process may occur rapidly or may take more than one consultation to work through. It is essential for the doctor to maintain a nonjudgmental attitude throughout the process. 049
  28. 28. This skill is most useful in dealing with difficult behavioural problems such as smoking, heavy drinking, eating disorders, drug use, marital problems and when dealing with anxious parents. When the use of addictive substances is involved, counselling has shortcomings as do other techniques, but is always worth using — results can be surprisingly effective. Assessing communication skills Communication skills are assessed continuously throughout the whole of every case scenario and consultation. Other domains are usually assessed in sequential segments (for example physical examination follows history, diagnosis follows investigations, and so on). Particular communication skills are also defined within the domains in current use in the AMC examination. These are: Approach to patient • Empathy, comfort, consideration, • Explanation, using language that the patient understands (no jargon), • Checking for patient understanding, • Answering patient's, parent's or relative's questions, and • Obtaining verbal consent to proceed. History • Taking an appropriately focused medical history. Commentary to examiner • Describing the findings of physical examination with appropriate commentary; and • Presenting a case analysis in summary to the examiner. Diagnosis/differential diagnosis • Describing an appropriate diagnosis/differential diagnosis plan. Initial management plan • Describing an appropriate initial management plan. Patient counselling/education • Educating the patient/relative/carer about the condition; and • Giving appropriate counselling. Explanation of procedure • Explaining a procedure and its implications to the patient. Answering questions asked by the patient or examiner • Most scenarios include cued questions to the doctor by the patient, parent or relative; and • Some scenarios have specific prompts or questions from the examiner. Each of the above domains (plus others such as technique and accuracy of examination - 14 in all) attracts separate assessment by the examiner. The number of domains being assessed in any individual MCAT rarely totals more than five. Communication skills may affect performance in all domains. Experienced examiners, who are themselves skilled in communication, have no difficulty in integrating communication components with those of knowledge and attitudes and other clinical skills. 050
  29. 29. 051 Communication, Counselling & Patient Education Conclusion The effectiveness of virtually all consultations is enhanced by the doctor's understanding and use of communication skills. The establishment of trust and confidence, empathy and rapport, diagnostic precision, appropriate prescribing, patient education and understanding, patient compliance, and self-help lifestyle modifications are all facilitated when doctor and patient understand each other to an optimal level, as a result of the proper application of communication skills. AlanTRose
  30. 30. 1-A Communication, Counselling and Patient Education Candidate Information and Tasks MCAT 002-021 2 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman 3 Advice on neonatal circumcision for a couple expecting their first child 4 Suspected hearing impairment in a 10-month-old child 5 Counselling a family after sudden infant death syndrome (SIDS) 6 Hair loss in a 38-year-old man 7 An unusual feeling in the throat in a 30-year-old man 8 Pain in the testis following mumps in a 25-year-old man 9 Contraceptive advice for a 24-year-old woman 10 Rape of a 20-year-old woman 11 Cancer of the colon in a 60-year-old man 12 Thalassaemia minor in a 22-year-old woman 13 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism 14 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus 15 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida 16 A duodenal ulcer found on endoscopy in a 65-year-old man 17 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery 18 Advice on stopping smoking to a 30-year-old man 19 Excessive alcohol consumption in a 45-year-old man 20 Type 1 diabetes mellitus in a 9-year-old boy 21 Request for vasectomy from a 36-year-old man 052
  31. 31. 053 002-003 CandidateInformationandTasks Condition 002 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) in an antenatal clinic, seeing a 28-year-old woman for her antenatal visit at 35 weeks of gestation. She wants to discuss infant feeding with you. She has heard a lot about the benefits of breastfeeding, but her mother told her recently that babies grow better with formula feeds. She is uncertain whether she should breastfeed or formula-feed her baby. YOUR TASKS ARE TO: • Discuss the advantages and disadvantages of breast-feeding and formula-feeding with her. • Outline the steps involved in safe formula-feeding. The Performance Guidelines for Condition 002 can be found on page 69 Condition 003 Advice on neonatal circumcision for a couple expecting their first child CANDIDATE INFORMATION AND TASKS A young couple, the wife pregnant with their first child, have come to see you in a general practice to discuss with you the place of routine neonatal circumcision if their baby is a boy. YOUR TASK IS TO: ] • Discuss with the couple the perceived risks and benefits of this procedure. J The Performance Guidelines for Condition 003 can be found on page 72
  32. 32. 054 CandidateInformationandTasks Condition 004 Suspected hearing impairment in a 10-month-old child ( CANDIDATE INFORMATION AND TASKS ) You are working in a community health centre. Your next patient is a 10-month-old female infant, baby Helena, seen with her mother, who has been referred by the local child health nurse. The pregnancy and delivery were normal. The child presented to the nurse six weeks ago for review and general screening including hearing. The nurse was concerned that the baby has a hearing problem and wanted her checked by a doctor. The child's parents have never had cause to worry about her hearing. She is the third child in a healthy family and has been well, apart from a few upper respiratory infections. She is crawling, does not walk yet, but pulls herself up to standing beside a small table. Initial examination findings A busy infant girl who objects to being restrained by her parent. She babbles during assessment. Otoscopic examination is normal. No abnormal physical signs are present on general examination. The parents are puzzled at the need for referral and seek information about further investigation and management. YOUR TASKS ARE TO: • Ask the parent for additional relevant and focused history. • Counsel the parent after you have obtained a further history. • Explain possible causes of any suspected hearing loss to the parent. • Discuss your plan of management with the parent. The Performance Guidelines for Condition 004 can be found on page 75
  33. 33. Condition 005 Counselling a family after sudden infant death syndrome (SIDS) CANDIDATEINFORMATIONANDTASKS 1 You work in a general practice. You are counselling the family of a four-month-old male infant who was rushed to the Emergency Department of the local hospital the day before but was dead on arrival. The provisional diagnosis is sudden infant death syndrome (SIDS) and the baby (Andrew) is to have a Coronial autopsy. You had seen him for the first time two months previously, with his single mother, when he was thriving and developing normally and had commenced immunisations. Two days before his death you saw him again, this time with mild upper respiratory snuffles which were causing minor difficulties with breastfeeding. However, over the next two days he apparently improved, and his mother had advised you that he appeared normal and fed well from the breast just prior to his death. You are unaware of any suspicious circum- stances surrounding the death. The family members have attended to seek details of why the baby died and why an autopsy is necessary. The spokesperson for the group is the mother's sister, the aunt of the infant. The mother is also present, but is too distressed to ask any questions herself. YOUR TASKS ARE TO: • Answer the questions of the aunt relating to the death of the infant. • Counsel the aunt and family. The Performance Guidelines for Condition 005 can be found on page 77 055
  34. 34. CandidateInformationandTasks Condition 006 Hair loss in a 38-year-old man CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) working in a primary care clinic attached to a teaching hospital. This 38-year-old male newsagent has just consulted you about recent (2-3 weeks) hair loss from the scalp. One eyebrow is also affected. He is otherwise well with no significant past or family history. The patient is very concerned about possible future progression and wishes to ask you about the diagnosis and possible treatments. You have completed an examination of the scalp. The findings are as depicted below. YOUR TASKS ARE TO: • Discuss the condition with the patient. • Advise him about treatment. CONDITION006.FIGURES1AND2. The Performance Guidelines for Condition 006 can be found on page 79 056
  35. 35. Condition 007 An unusual feeling in the throat in a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 30-year-old man who is consulting you about a throat problem. He is a previous patient of the clinic, is married with two children, parents and his siblings are well. He smokes 10-15 cigarettes daily and takes 2-3 alcoholic drinks only at weekends. He had a vasectomy two years ago and has had no serious illnesses. YOUR TASKS ARE TO: • Take a focused history about his throat problem. The examiner will then give you the examination findings. • Discuss the most likely causes of the problem and its nature with the patient. • Discuss whether any investigations are necessary and if so, what is most likely to be found. . The Performance Guidelines for Condition 007 can be found on page 81 057
  36. 36. 058 008-009 Candidate Information and Tasks Condition 008 Pain in the testis following mumps in a 25-year-old man CANDIDATE INFORMATION AND TASKS Your next patient in a general practice is a 25-year-old man who consulted you five days ago because of painful swellings on both sides of his face associated with fever and malaise You made a confident diagnosis of mumps. You had previously diagnosed mumps in the patient's five-year-old son, a little less than three weeks beforehand. The son has now fully recovered. The patient's other child, aged three years, is well. You are aware that the couple have contemplated having another child. You advised the patient to rest at home, suggested paracetamol as an analgesic, and asked him to see you in a few days time before returning to work. The patient has come to see you today because of a relapse of his fever associated with the onset of severe pain in his left testis. You have found the left testis to be swollen to twice the size of the right one. It is very tender. The right testis feels normal. The patient has a temperature of 38.4 °C. His face is slightly swollen. Apart from a tachycardia, there are no other abnormal clinical signs. YOUR TASKS ARE TO: • Advise the patient of the diagnosis. • Advise him about treatment and prognosis. • Answer any questions asked by the patient. The Performance Guidelines for Condition 008 can be found on page 84 Condition 009 Contraceptive advice for a 24-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. A 24-year-old woman has come to see you for advice as to the most appropriate pill she should go on for contraception for the next two to three years. She knows that various types of pills are available and wants to know how to decide which is the most appropriate pill for her. YOUR TASKS ARE TO: • Take a further relevant and focused history. • Ask the examiner about findings you wish to elicit on general and gynaecological examination. • Advise the patient of the appropriateness of oral contraceptive pill (OCP) therapy, which pill should be given, and how it should be administered. The Performance Guidelines for Condition 009 can be found on page 87
  37. 37. Condition 010 Rape of a 20-year-old woman CANDIDATE INFORMATION AND TASKS J You are a Hospital Medical Officer (HMO) in the Emergency Department of a metropolitan general hospital. Your patient is a 20-year-old university student who is brought to the Emergency Department of the hospital because she was raped by a man that she met at a disco and who offered her a lift home. The rape occurred six hours ago after he had stopped the car in an undeveloped area. She has decided not to involve the police as the person concerned is known to her family. She has had no previous operations or illnesses and no pregnancies. YOUR TASKS ARE TO: • Take any further relevant history you require. • Ask the examiner about appropriate findings likely to be evident on initial general and gynaecological examination. • Advise the patient of the investigations required and the management you would propose. The Performance Guidelines for Condition 010 can be found on page 90 059
  38. 38. CandidateInformationandTasks Condition 011 Cancer of the colon in a 60-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. A 60-year-old man, whose father died of colon cancer, consults you following a screening colonoscopy. This revealed a lesion shown in the photograph given to the patient (see illustration below). The biopsy report confirms an adenocarcinoma of the colon. The patient insists he has no symptoms and refuses to have any operative treatment. However, he is still concerned enough to ask you what will happen if nothing is done. The specialist who did the colonoscopy said the lesion was on the left side of the colon. The patient also wishes to know what are the prospects of cure if he changes his mind and has the lesion removed by surgery, and would the surgery ever entail having a colostomy (which he dreads)? YOUR TASKS ARE TO: • Advise him what symptoms and signs may occur in the future, what complications may develop and how they would be treated. • Address his concerns and counsel him about surgery. You are not required to take any further history. CONDITION 011. FIGURE 1. Clinical notes: Biopsy of ulcerating tumour of rectosigmoid at 15 cm from anus. Biopsy report: The specimens show numerous fragments of a moderately well differentiated adenocarcinoma of the colon with invasion into the submucosal tissues.' Diagnosis: Adenocarcinoma of colon. The Performance Guidelines for Condition 011 can be found on page 92 060
  39. 39. 061 Candidate Information and Tasks Condition 012 Thalassaemia minor in a 22-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 22-year-old woman who recently had a self-limiting febrile illness, which was suspected to be infectious mononucleosis (IM). She is now fully recovered. Blood tests for IM were negative, but the full blood examination showed a hypochromic microcytic anaemia of 108 g/L. The mean corpuscular volume (MCV) was below normal (68 cubic microlitres — normal 80-101). You followed this up but there was no evidence of chronic blood loss (other than normal menstruation). Serum iron and ferritin estimations were also normal. You suspected /j-Thalassaemia minor ('Mediterranean anaemia') and this has been confirmed by electrophoresis which showed an elevated Hb H2 level (4.3%). You are aware of her Greek descent and that she has just become engaged to be married. Her fiance is also of Greek descent. The family history is that her mother, father and brother are all alive and well. Her grandparents died in Greece and both were very old. One of her father's brothers was reported to have died in childhood from an unknown cause. The patient is very worried about being told she is anaemic, and as she is to be married shortly, is worried about the effects on any of the children she hopes to have. The patient has returned to discuss her results with you. YOUR TASKS ARE TO: • Explain the nature of the condition to the patient. • Answer the patient's questions. • Advise the patient what should be done now. The Performance Guidelines for Condition 012 can be found on page 95
  40. 40. 062 013-014 Candidate Information and Tasks Condition 013 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 28-year-old woman, who had one pregnancy 18 months ago, which was complicated by deep vein thrombosis and a postpartum pulmonary embolus. She has come to see you for pre-pregnancy counselling as she wishes to conceive again. At the time of a previous assessment twelve months ago, she had ceased warfarin. When assessed six months ago, there were no sequelae or symptoms and she had no signs of chronic venous insufficiency in the legs. There are no abnormalities on physical examination and she is not overweight. YOUR TASKS ARE TO: • Take any further relevant history you require from the patient. • Advise the patient on the management she will require before and during the next pregnancy. The Performance Guidelines for Condition 013 can be found on page 99 Condition 014 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus CANDIDATE INFORMATION AND TASKS You are working in the primary care facility of a teaching hospital. Your patient is a woman aged 24 years (para 0, gravida 0), a known diabetic for 15 years and well controlled on insulin. She has come to see you for counselling and advice about possible future pregnancies. YOUR TASKS ARE TO: • Take any further relevant history you require. • Advise the patient of the information she needs to be given for pre-pregnancy counselling. The Performance Guidelines for Condition 014 can be found on page 102
  41. 41. Candidate Information and Tasks Condition 015 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) working in a primary care clinic attached to a teaching hospital. Your next patient is a 25-year-old primigravida who has just had an ultrasound performed at 18 weeks of gestation, which has revealed an anencephalic fetus (as shown in illustration below). A maternal serum screening (MSS) was done at 16 weeks and this had shown elevated levels of alpha fetoprotein. YOUR TASKS ARE TO: • Take any further relevant history. • Advise the patient, in lay terms, of the relevance of the diagnosis and the subsequent management you would propose in this pregnancy. • Advise the patient of the care you would recommend in a subsequent pregnancy. You will not be expected to request examination findings, nor to arrange any further investigations. CONDITION015.FIGURE1. Anencephalicfetusat18weeksofgestation The Performance Guidelines for Condition 015 can be found on page 105 063
  42. 42. Candidate Information and Tasks Condition 016 A duodenal ulcer found on endoscopy in a 65-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. You recently referred a 65-year-old man with a history of self-medication for arthralgia and a subsequent six week history of epigastric pain and indigestion to a gastroenterologist who performed an upper gastrointestinal endoscopy. The endoscopist told the man he had detected a duodenal ulcer and gave him a photograph of the ulcer, taken during endoscopy. The patient has come back to you seeking answers to several questions. The photograph is as shown. YOUR TASKS ARE TO: • Discuss the endoscopic findings with the patient in terms of the: ~ pathogenesis of the ulcer; ~ natural history and possible complications of the condition; and ~ treatment options available to him. CONDITION 016. FIGURE 1. The Performance Guidelines for Condition 016 can be found on page 108 064
  43. 43. 065 017-018 Candidate Information and Tasks Condition 017 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a middle-aged man booked for a total hip replacement. You referred him to an orthopaedic surgeon who has arranged elective surgery for his severely osteoarthritic hip. The patient has now come back to see you, as he has some questions and in particular, is concerned about the risks of blood transfusion (if required) and would like to find out about using his own blood for the operation. The patient wishes to discuss this with you, as he did not take in everything that was explained by the surgeon. YOUR TASKS ARE TO: • Explain the principles and indications for preoperative blood collection and intra operative autologous blood transfusion. • Answer any questions from the patient about the blood transfusion procedure. The Performance Guidelines for Condition 017 can be found on page 111 Condition 018 Advice on stopping smoking to a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. The next patient is a 30-year-old man who has returned to your practice for followup following a recent chest infection. He is a smoker (20 cigarettes per day). On his previous visit, you had told him that the 'best thing that he could do for his health would be to stop smoking'. You have examined his chest which is clinically normal. At this visit, you are expected to follow up his response to your previous advice and counsel him further about tobacco cessation. YOUR TASKS ARE TO: • Assess his motivation to stop smoking. • Counsel him appropriately. • Discuss treatment options and general resources. • Respond to any questions he may have. The Performance Guidelines for Condition 018 can be found on page 115
  44. 44. 066 Candidate Information and Tasks Condition 019 Excessive alcohol consumption in a 45-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. You are about to review a 45-year-old businessman who consulted you two days ago about his drinking after seeing a TV program about the harmful effects of alcohol. At the previous consultation you established the following: • He is drinking excessively (at least five standard drinks every day); • This is of long standing — at home, at work and socially; • He has problems at work; • He has trouble with his close family relationships; • His sexual performance is impaired; • He has had two minor traffic accidents in the last year; • He has a family history (grandfather) of alcoholism; and • On examination he is overweight (BMI 28 kg/m 2 ), hypertensive 180/90 mmHg, and has hepatomegaly. You told him that his use of alcohol appears to be excessive and you ordered liver function tests and a full blood examination. He is seeing you today for the results of the tests which are as follows: Liver Function Tests Bilirubin Total 14 umol/L (<20) ALP (Alkaline phosphatase) 50u/L (25-100) AST (Aspartate transaminase) 45 u/L* (<40) GGT (Gamma glutamyl transaminase) 63 u/L* (<50) Serum albumin 32g/L (32-45) Full Blood Examination This showed a normal haemoglobin level (145 g/L) with a macrocytosis and elevated mean corpuscular volume (MCV) of 106 fL (normal range 10-96) and some variations in red cell size and shape (anisocytosis and poikilocytosis). Other features were normal. YOUR TASKS ARE TO: • Explain the results of the tests to the patient. • Discuss the effects of the excessive alcohol consumption. • Counsel him about his drinking. You do not need to take any further history, nor perform any examination. The Performance Guidelines for Condition 019 can be found on page 121
  45. 45. 067 020-021 Candidate Information and Tasks Condition 020 Type 1 diabetes mellitus in a 9-year-old boy CANDIDATE INFORMATION AND TASKS A nine-year-old boy, Roger, is admitted to the paediatric unit to which you are the Hospital Medical Officer (HMO). This is his first presentation of insulin-dependent Type 1 diabetes mellitus. His general condition is satisfactory, not requiring intravenous resuscitation, and he has already commenced insulin therapy and has stabilised with good blood sugar control. As the Ward HMO, his mother has asked you for further information about his ongoing care in relation to his diabetes from now on. YOUR TASK IS TO: • Answer the queries the mother has, related to the ongoing care of Roger's diabetes. The Performance Guidelines for Condition 020 can be found on page 125 Condition 021 Request for vasectomy from a 36-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. You are seeing a man aged 36 years who indicates that he wishes to discuss vasectomy with you. You have enquired about his past medical, family and social history (see below). He is asymptomatic across all his body systems. Physical examination is normal, including his scrotum, testes and penis. Blood pressure is 120/70 mmHg, urinalysis normal. He is not overweight. You believe that he is in good physical health. You have already obtained the following patient details: • He has been married for 12 years and has two children (a boy aged seven and a girl aged nine years). There are no marital problems of any kind; • He is a senior constable in the police force, does not smoke but is a moderate alcohol drinker (three standard drinks a day); • He has no known drug sensitivities; • His mother, father and brother are well, as are his wife and two children; and • He is not on any medication. YOUR TASKS ARE TO: • Explain the sterilisation procedure and its consequences to the patient. • Answer the patient's questions and provide counselling accordingly. There is no need for you to take any additional history from the patient. The Performance Guidelines for Condition 021 can be found on page 129
  46. 46. 1-A Communication, Counselling& Patient Education 1-A Communication, Counselling and Patient Education Performance Guidelines MCAT 002-021 2 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman 3 Advice on neonatal circumcision for a couple expecting their first child 4 Suspected hearing impairment in a 10-month-old child 5 Counselling a family after sudden infant death syndrome (SIDS) 6 Hair loss in a 38-year-old man 7 An unusual feeling in the throat in a 30-year-old man 8 Pain in the testis following mumps in a 25-year-old man 9 Contraceptive advice for a 24-year-old woman 10 Rape of a 20-year-old woman 11 Cancer of the colon in a 60-year-old man 12 Thalassaemia minor in a 22-year-old woman 13 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism 14 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus 15 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida 16 A duodenal ulcer found on endoscopy in a 65-year-old man 17 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery 18 Advice on stopping smoking to a 30-year-old man 19 Excessive alcohol consumption in a 45-year-old man 20 Type 1 diabetes mellitus in a 9-year-old boy 21 Request for vasectomy from a 36-year-old man 068
  47. 47. 069 002 Performance Guidelines Condition 002 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman AIMS OF STATION To assess the candidate's ability to advise a young expectant mother on the advantages and disadvantages of breastfeeding and bottle-feeding. This scenario tests the candidate's ability to identify the conflict the young mother has in trying to respect what her mother has told her, while knowing that this advice is contrary to her own feelings. It also tests ability to discuss logically the advantages and disadvantages of the different feeding methods as well as testing knowledge on safe bottle-feed preparation. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 28-year-old mother having your first baby. You now have only five weeks to go and although you always hoped to breastfeed your infant, you have had some doubts about its value recently when your mother mentioned that formula-fed babies grow better than babies who have been breastfed. You have come to discuss this. You realise that you may have to defend what the doctor says to you (about breastfeeding being advantageous), and your own previously held ideas about breastfeeding, against the ideas of your mother with whose opinions you have to live. Opening statement 'My mother feels that bottle-fed babies gain more weight than breastfed babies and therefore are more healthy. What do you think, doctor?' Questions to ask if not already covered: • 'What are the advantages of breastfeeding? I would have thought it is easier to breastfeed.' • ‘Is there anything special about breast milk? I always thought there was.' • 'Do you have to prepare bottle feeds in any special way?' • 'Are the formula feeds safe? I thought they contained cow's milk and what if you are allergic to cow's milk?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should: • Be nonjudgmental, avoiding comments like 'Where on earth did your mother get such an idea?'; rather asking 'Why do you think your mother made such a recommendation?' • Discuss that while breastfeeding is the optimal method of feeding the human infant, and that the majority of mothers successfully breastfeed, a variety of reasons may prevent breastfeeding in practice, including: ~ illness in the mother; ~ failure to establish lactation, which may be hormonally based; ~ possible illness in the baby (e.g. cleft palate);
  48. 48. 70 002 PerformanceGuidelines ~ prematurity, which requires the mother to express regularly to maintain her supply; ~ previous extensive breast surgery in the mother; and ~ heightened anxiety in the mother. • Explain that if for some reason breastfeeding is unsuccessful, formula-feeding is a safe and very effective alternative. • Discuss that formulas are designed to contain the same nutritional components as breast milk, but that exact reproduction is difficult as the concentration and components of breast milk change throughout each feed. • Advise that there is no advantage of formula-feeding over breastfeeding. • Discuss the specific advantages of breastfeeding: ~ the practical advantages of being able to feed almost whenever and wherever the baby wants it without having to prepare formula, carry bottles around and without problems with sterility; ~ increased resistance of the baby to infection, from immunological constituents in breast milk including lymphocytes and antibodies; and ~ satisfaction derived from feeding the infant as well as the development of a close relationship with the infant. • In response to her mother's comment, advise that weight gain is not the only criterion for success as excess weight gain in the first 12 months of life may in fact be detrimental in later life. The candidate should stress the importance of optimal formula-feeding as follows: ~ sterility in preparing the bottle feeds is essential; ~ bottles need to be washed clean with a bottlebrush to ensure that all milk residue is removed; ~ bottles and teats need to stored in solution (e.g. Milton®), to ensure continuing sterility, but the bottles need to be rinsed free of this solution prior to use; ~ the fluid used to make the formula and to rinse the bottles should be cooled boiled water; ~ each can of formula has explicit makeup instructions on the side of the can or packet; if followed these will produce the exact required concentration; ~ there is no place for any added scoops, which can be harmful; ~ the day's requirements are best made up at the one time, although each feed can be made separately. If the former, the day's feed should be stored in the refrigerator; ~ only one day's feed at a time should be prepared in advance; and ~ each feed should contain approximately 30 ml more than it is anticipated the baby may take, and any excess discarded at the end of the feed. KEY ISSUES • Empathic answering of this young mother-to-be's questions. • Recognition that she is uncomfortable with what her mother has told her but is seeking reassurance and support for her own view which she feels is accurate. • Satisfactory explanation of the advantages and disadvantages of the different methods of feeding. • Candidates should know how formula feeds are prepared.
  49. 49. 071 002 Performance Guidelines CRITICAL ERROR - none defined COMMENTARY Ability to discuss impartially and accurately the relative merits, indications, contraindications and techniques of infant feeding by breastfeeding and by formula-feeding is a requisite for all medical graduates as outlined and is an area where good communication skills are paramount.
  50. 50. 072 003 PerformanceGuidelines Condition 003 Advice on neonatal circumcision for a couple expecting their first child AIMS OF STATION To assess the candidate's ability to give impartial advice about neonatal circumcision. EXAMINER INSTRUCTIONS The examiner will have instructed the parents as follows: You are a couple who are expecting your first baby. Your family members have suggested that if the baby is a boy he should be circumcised. You are very unsure about this, as you cannot see any reason why circumcision is essential. You have no religious beliefs that dictate that circumcision must be done. You have therefore come to discuss the process and learn what the advantages and disadvantages of the procedure are before making your own decision on the matter. Opening statement ‘We have come to discuss with you whether to have our baby circumcised.' Questions to ask unless already covered: • ‘What does the procedure involve?' • 'What are the complications that can happen?' • ‘What are the advantages of having it done?' • 'Are there any times when it definitely should or shouldn't be done?' • 'Has anyone looked into this in detail and come to any conclusions about it?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should: • give an impartial but informed explanation to the parents on the advantages and risks involved in routine neonatal circumcision; • indicate that when religious grounds are stated as the reason for the procedure, these are generally respected; and • realise that many are unaware of the actual process of circumcision and may ask for the procedure more as a ritual; and stress that the parents should consider the advantages and disadvantages of the procedure before making a decision. During the discussion, the candidate would be expected to advise along the following lines: • The perceived advantages of routine neonatal circumcision commonly quoted are: ~ Reduced incidence of urinary tract infections (UTIs) in circumcised boys. While circumcision may assist the uncircumcised boy who is suffering recurrent UTIs, routine general circumcision of all boys is not indicated to achieve this, but can be selectively applied at a later age if this situation exists. ~ Reduction in the incidence of sexually transmitted infections (STIs) and HIV infection. This remains a controversial point. The literature currently is divided on this issue, but some evidence suggests the risk of HIV infection is lessened by circumcision.
  51. 51. 073 003 Performance Guidelines ~ Circumcision is indicated for phimosis or its prevention. This is true only if all conservative methods of treatment have failed. Often, phimosis, developing after birth, is secondary to inappropriate foreskin care and subsequent trauma and scarring. If asked, the candidate should indicate the appropriate care of the foreskin, which is minimal, until the foreskin can be retracted easily, which is usually by about five years of age. ~ Neonatal circumcision minimises the risk of subsequent development of carcinoma of the penis. But poor penile hygiene associated with human papilloma virus infection is the major contributor in adults, cancer being rarely seen in men who can retract and clean the foreskin. • The recognised complications and disadvantages of routine neonatal circumcision should also be discussed and include: ~ haemorrhage; ~ infection, including septicaemia/meningitis (rare); ~ ulceration of the glans; ~ inadvertent injury to the urethra; ~ too much skin removed leading to unsatisfactory cosmetic appearance; - anaesthetic complications; and ~ secondary phimosis. The complication rate has been estimated to occur with an incidence of between 1-5% (range 0.2%—10%); but these are figures at all ages, not just in the neonatal age range. The skill of the operator is obviously of paramount importance. The most common complication is haemorrhage. • The candidate should also discuss the absolute contraindications to routine neonatal circumcision explaining each in turn: ~ hypospadias and other congenital anomalies of the penis (e.g. epispadias); ~ chordee; ~ buried penis; ~ sick infants, including jaundiced infants; ~ family history of a bleeding disorder or known recognised familial bleeding disorder possibility (e.g. haemophilia A); and ~ inadequate expertise and facilities. • The candidate should be able to explain the procedure of circumcision and indicate that: ~ it is usually done under local anaesthesia; and ~ if performed after six months of age, it is done under general anaesthesia. KEY ISSUES • The ability to discuss in an unbiased manner the perceived advantages and disadvantages of routine neonatal circumcision. • Capacity to summarise that the recommendations of various national and international paediatric and paediatric surgical associations, who have extensively reviewed the literature on the subject, do not support routine neonatal circumcision.
  52. 52. 074 003 Performance Guidelines CRITICAL ERROR - none defined COMMENTARY This topic is one that has been controversial for many years. While circumcision for religious reasons has been done for many centuries, the issue in the scenario is related to the secular trend towards routine neonatal circumcision of all males soon after birth. This has become more of a ritual rather than for any recognised medical indication, although this tendency has reduced in recent times. In fact there are many recognised complications of circumcision, not just routine neonatal circumcision, but circumcision at any age. However there are recognised medical indications for the procedure (e.g. established phimosis in boys and men). CONDITION 003.FIGURES 1AND 2. Circumcision in ancient Egypt Phimosis Many young parents are unaware of the issues involved and are often ill-informed by family members who recommend that their infant should have the procedure performed without any explanation as to why. They then request circumcision without any information about the procedure and hence the need for informed discussion to allow them to make a rational decision in the interests of their baby. This scenario illustrates that medical practitioners are obliged to provide accurate information on the risks and benefits of routine neonatal circumcision and should attempt to avoid any personal bias. The decision should be left to the parents after a full and accurate discussion. Unbiased up-to-date written material summarising the evidence should be made available to the parents. The review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for neonatal circumcision as a routine procedure. The Policy Statement on Circumcision from the Paediatric and Child Health Division of the Royal Australasian College of Physicians (September 2004) is recommended as an excellent summary with 78 references to the evidence for and against circumcision. This is available on the open website of the Royal Australasian College of Physicians under Policies (