Here are some suggested questions for the student: 1. Can you tell me more about how the bruise on her cheek happened? 2. Who was with her at the time? 3. What kind of injuries has she had before in previous visits to ED? 4. Can you describe your home life - is it just the two of you living together? 5. I'd like to examine her fully to check for any other injuries. Is that okay with you? 6. I have a responsibility to ensure her safety. If I have any concerns, I may need to involve other services like social work. How do you feel about that? 7. The number and type of visits

1. YEAR 4 ISCE PERFORMANCE CRITERIA – giving information
UNSATISFACTORY BORDERLINE SATISFACTORY EXCELLENT
Communication
skills
Lack of patient centred
approach
Excessive use of closed
questions
Communication unstructured
Candidate’s
performance has
some deficiency
or deficiencies
that makes
examiner feel
unsure whether
they are good
enough to pass or
poor enough to
fail
Patient centred
Relevant use of closed questions
Clinical/examination generally
appropriate
Patient centred
Effective use of open to closed question cone
Well structured
Incorporates patient’s perspective
Effective use of communication strategies
Maintains effective communication throughout
History content Lacking focus
Lacking technique
Missing important elements
May lack direction
All important elements identified;
minor omissions only
Effectively marries content and process
Focussed, skilled and efficient
Explores all essential elements of presenting
history and important related other areas
Examination skills Lacking focus
Lacking technique
Missing important elements
Technique generally good but
hesitant and/or inefficient
All important elements identified;
minor omissions only
Clinical/examination structured
Efficient and proficient examination skills
No significant omissions
Giving information Inaccurate
Does check understanding or
recall
Missing important elements
Minor omissions Provides correct amount and type of information
Aids accurate recall and understanding
Incorporates the child and parent’s perspective -
achieving shared understanding
Involves both in shared decision making
Summarising
sentence
Rambling or unfocussed
Too long
All important details included, may be
some over inclusive. May stretch
beyond one sentence
Precise and relevant detail accurately summarising
the presentation in a SINGLE sentence
Differential
diagnosis
Too broad or too narrow
No attempt at diagnosis
Appropriate differential diagnosis
offered
No attempt to prioritise or rank
Succinct differential diagnosis with appropriate
prioritisation, ranking
Relevant details of
history and
examination
Over inclusive with extensive
irrelevant details
Poor structure
Fails to make link between
history and examination
Key points identified
Attempt at appropriate structure
Some attempts to link history and
examination
Concise, accurate
Well structured
Flowing
Key points addressed
Clearly links history and physical examination
Selection/
interpretation of
relevant
investigations
Lacks clear understanding of
appropriate investigation
Investigates inappropriately
Fails to interpret
investigations correctly
Able to select appropriate
investigations
May need some help in interpretation
Some understanding of sensitivity
and specificity of tests Some
understanding of cost/benefit
Clear understanding of the key investigations
required and their interpretation
Understands appropriate sensitivity, specificity and
costs of relevant tests
Patient centred
issues
Unaware of relevant patient
centred issues (personal,
family and social impact of
illness)
No consideration of patients
worries, beliefs and
expectations
Some awareness of patient centred
issues (personal, family and social
impact of illness)
No direct application to current illness
and management plan
Fully aware of patient centred issues (personal,
family and social impact of illness)
Good awareness of patient worries, beliefs and
expectations
Appreciates relevance to current illness and
integration into management plan
Management plan No defined management plan
Inappropriate therapeutic
interventions
No appreciation or reference
to evidence base
No attempt to monitor
progress or review
Reasonable attempt at management
plan
Key therapeutic interventions
identified
Some awareness of underlying
evidence base
Outlines plans for monitoring the
effectiveness of interventions
Imprecise strategy for progress and
review
Clear, precise, negotiated management plan
Full therapeutic plan detailed including sequential
interventions
Awareness of benefits, side effects and alternative
options
Clearly defined strategy to progress and review with
timelines
Link to prior
learning
Fails to identify links with
relevant prior learning.
Able to identify relevant prior
learning but limited integration
and application.
Fully integrates and applies relevant prior
learning to clinical presentations and the
underlying pathophysiology and
management plan.
Behaviour
consistent with
Good Medical
Practice
Demonstrates significant
deviation from these
principles
No more than minor o trivial
omissions
Fully concordant with the principles

3. ISCE Station Student Instructions – Childhood obesity
You are a 4th
year medical student attached to the GP surgery. The GP has asked you to see
the parent of a 10-year-old girl. There is an accompanying growth showing that the child is
obese. You will be expected to speak to the parent about the risks associated with childhood
obesity and health promotion through lifestyle advice.
You will be expected to undertake an interview with the parent, which should take about 20
minutes.
You then have 5 minutes to prepare your case for presentation to the examiner (a ringing tone
will sound at the end of 5 minutes). You will then present you case to the examiner in a format
similar to your usual clinical reasoning sessions. The examiner may ask you questions or
direct you if required.
This is a 45-minute station
Bells
Start – Voice please enter station & begin
10 minutes – Voice please begin your preparation for presentation
25 minutes – Voice please begin you presentation
40 minutes – Voice Please conclude you presentation in the next couple of minutes and
prepare to move on
43 minutes – Voice Please go beside your next station

5. Child obesity scenario – for actor
- You are the father and single parent of this child, her mother past away when she was
5 years old and you work a busy job.
- Neither of your diets are particularly healthy and you often eat microwave meals for
connivance.
- Your daughter is a fussy eater and can be difficult to discipline; therefore she always
gets what she wants, which is crisps, sweets and other unhealthy food.
- You do not think your daughter is fat, over weight or has any problem with her weight
that needs to be discussed.
- You take it as a personal offence of your parenting techniques on persistent
questioning on this issue
- Your daughter leads a very sedentary lifestyle goes to no after school clubs, engages in
no physical activity, avoids PE at school by writing her own sick notes and has reported
some bully regarding her weight.
Aims for the student:
- Takes a full history about the child including a medical, educational, social and lifestyle
history
- Able to sensitively draw the fathers attention to the child’s weight
- Able to explain why the child’s weight is concerning
- Able to enter a discussion about the best ways help reduce the child’s weight
- Comes to an agreed action plan with the father and promotes shared decision making
- Able to give advise on healthy living; diet advice (reducing salt intake, increasing
amount of fruit and veg etc.) and lifestyle advice (30 minutes of exercise a day)
Questions to ask:
1. What organic causes of childhood obesity would you want to exclude and how would
you investigate them? (Acquired; cushings syndrome, hypothyroidism, congenital;
prader Willi syndrome) (Weight, height, BMI, TFTs, cholesterol, dexamethasone
suppression test)
Resource:
http://www.askdoctorclarke.com/content/c508.pdf

6. ISCE Station Student Instructions – Non-accidental injury
You are a 4th
year medical student attached to an ED department. The consultant has asked
you to see the single parent of a 2-year-old girl. This the fifth time they have attended the
department this month with minor injuries. She presents today with a sore throat and the nurse
draws your attention to some cheek bruising. You will be expected to speak to the parent
about the child’s current complaint, assess the potential of a non-accidental cause for the
bruising and if necessary initiate steps to minimise risk.
You will be expected to undertake an interview with the parent, which should take about 20
minutes.
You then have 5 minutes to prepare your case for presentation to the examiner (a ringing tone
will sound at the end of 5 minutes). You will then present you case to the examiner in a format
similar to your usual clinical reasoning sessions. The examiner may ask you questions or
direct you if required.
This is a 45-minute station
Bells
Start – Voice please enter station & begin
10 minutes – Voice please begin your preparation for presentation
25 minutes – Voice please begin you presentation
40 minutes – Voice Please conclude you presentation in the next couple of minutes and
prepare to move on
43 minutes – Voice Please go beside your next station

7. Non-accidental injury scenario – for actor
- You are the father of this 2 year old girl
- You have brought your child to ED because she have a sore throat and temperature
- If asked about the bruises you mention she fell over and hurt herself
- If the student asks to examine her further you are very reluctant for her to undress
because that’s not why you brought her to the department
- You get annoyed that the focus is being put on the bruises and make hints that they
want to leave before a senior review
- There is history of domestic violence at home and the child often gets caught in the
cross fire
Aims for the student:
- Take a detailed history from the father about bruise on the cheek; how, when, who was
present
- Finds out about the social history eg. Any of children at home?
- Student needs to be aware that the previous admissions are a concern, and should
sensitively enquire about the nature of them
- The student needs to ask/ state she would like to undress and examine the child fully
- In management plan mentions about referring to children social services
- Encourages patient to stay in the Emergency Department
- Explains to the parent that they are concern that the bruise are caused by non-
accidental injury if things get more heated
Questions to ask:
1. What would be the most appropriate thing to do if the parent takes the child and leaves
the department and you think the child is in danger? “Contact the police and child
services”
2. What do you do if the child is a risk of harm? “Discuss with child services”
3. What are the other forms of child abuse? “sexual abuse, neglect, physical abuse
(fabricated and induced illness, aka munchausen by proxy), emotional abuse
Resources:
http://www.askdoctorclarke.com/content/c334.pdf
http://www.leedsplaynetwork.org.uk/wp-content/uploads/2013/04/Short-Briefing-Paper.pdf
“Working together to safeguard children - 2013”

8. ISCE Station Student Instructions – Breaking bad news
You are a foundation doctor attached to a Colorectal Department. The consultant has asked
you to see a 72-year-old gentleman attending an outpatient appointment. This patient is
awaiting the results of a recent CT scan performed for significant weight loss and an enlarged
liver. The scan showed a primary colon cancer with multiple liver metastases and several
enlarged nodes around the celiac trunk. You will be expected to explain the results of the scan
to the patient and explain the next steps towards treatment.
You will be expected to undertake an interview with the patient, which should take about 20
minutes.
You then have 5 minutes to prepare your case for presentation to the examiner (a ringing tone
will sound at the end of 5 minutes). You will then present you case to the examiner in a format
similar to your usual clinical reasoning sessions. The examiner may ask you questions or
direct you if required.
This is a 45-minute station
Bells
Start – Voice please enter station & begin
10 minutes – Voice please begin your preparation for presentation
25 minutes – Voice please begin you presentation
40 minutes – Voice Please conclude you presentation in the next couple of minutes and
prepare to move on
43 minutes – Voice Please go beside your next station

9. Breaking bad news – for actor
- You are an otherwise well 72 year old who lives alone and before admission was
otherwise independent
- You been more tired over the last few months and lost about 3 stones over the last 2
months, but have been otherwise well
- You take no regular medication, have a moderate ETOH intake and have never
smoked
- There is a family history of bowel cancer
- You are unaware of why the scan was performed, you thought it was for your kidneys
because you have some obstructive urinary symptoms
- When you are told the test was investigating for cancer you mention “Oh God, I hope I
don’t have cancer”
- When you are told you have cancer you a shocked, but are feel reassured because “the
surgeons can just chop it out”
- You have lots of questions about how things are going to manage, about prognosis
(because you need to get your affairs in order) and about what is going to happen next.
Aims for the student:
- Summarises to the patient what is know already
- Gains patient understanding for the reasons for the CT scan, mentions the word cancer
as a warning shot
- Mentions/ or make some attempt to have family/ cancer nurse specialist/ nurse present
during the consultation
- Breaks bad news in a sensitive manner making sure the word cancer is used
- Chunks and checks the information given ensuring the patient understands
- Provides patient with a way of getting questions answered after the consultation is over
- Make sure the patient knows what is going to happen next – mentions surgery is
unlikely to be an option but there maybe a role for chemotherapy, but may only be
palliative.
Questions to ask:
1. What are the different management options available to this patient? And what effects
your different options available?
2. How do you assess someone’s performance status?
3. What methods could be used to gain a histological diagnosis?
4. Who would you want to refer to, to over see the management of this patients care?
Resources:
http://www.cancerresearchuk.org/cancer-help/type/bowel-cancer/treatment/types/which-
treatment-for-advanced-bowel-cancer

10. ISCE Station Student Instructions – Alcohol excess
You are a 4th
year medical student attached to the GP surgery. The GP has asked you to see
a 40-year-old parent who has attained for a routine appointment. On entering the room you
become aware of the overpowering smell of alcohol. You will be expected to deal with the
patient’s current complaint, take a full alcohol history and promoted health living through
lifestyle advice. Recent blood results are available to you.
You will be expected to undertake an interview with the patient, which should take about 20
minutes.
You then have 5 minutes to prepare your case for presentation to the examiner (a ringing tone
will sound at the end of 5 minutes). You will then present you case to the examiner in a format
similar to your usual clinical reasoning sessions. The examiner may ask you questions or
direct you if required.
This is a 45-minute station
Bells
Start – Voice please enter station & begin
10 minutes – Voice please begin your preparation for presentation
25 minutes – Voice please begin you presentation
40 minutes – Voice Please conclude you presentation in the next couple of minutes and
prepare to move on
43 minutes – Voice Please go beside your next station

11. Blood Test results:
GGT 450 U/L (<65 U/L)
ALT 100U/L (5-45 U/L)
ALP 110 U/L (25-110 U/L)
Alb 35 (33-49 mmol/L)
Bili 15 (1-20 mmol/L)
INR 1.0
Hb 120 g/L
WCC 6.5 x 109
/L
MCV 110 fL
Alcohol excess – for actor
- You attend the GP to discuss symptoms of indigestion
- You get very sensitive and offended when alcohol is brought up as it is not the reason
you came to the GP
- You eventually admit to drinking at least a bottle of wine a night, but have no insight
that this may be excessive
- People have mentioned before about your drinking habits, but you are in denial that you
have a problem
- You have very reluctant to even consider giving up/ cutting down as you believe it is not
doing you any harm
- You have a very stressful job and you need alcohol to cope
- You are able to hold down a respectable job and drink alcohol, which is even more of a
reason that it is not a problem
Aims for the student:
- Explores the patients presenting complaints
- Acknowledges that fact that patient smells of alcohol, and proceeds to ask about this
drinking habits
- Is able to link the patients presenting complaint with alcohol as a means of persuading
the patient to discuss his intake
- Uses the CAGE questionnaire (cut down, annoyed, guilty and eye-opener)
- Determines triggers for the patients drinking
- Uses shared decision making to help overcome these triggers
- Interprets blood results and explains them to the patient as a way of help him
understand his health risks
- Gives patients information about getting further help to stop drinking
Questions to ask:
http://www.sign.ac.uk/pdf/qrg74.pdf