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1. ANGRY PATIENT
You are the orthopaedic core surgical trainee on call, and you have been asked to see an angry
patient in A&E. He fractured his olecranon 4 days ago and has been waiting to hear when to come
in for the trauma list, but no-one has been in touch since. He is on the trauma board and you are
aware of the case but there have been a large number of neck of femur fractures which had to be
operated upon more urgently. He does not yet have a set date for surgery.
Candidate:
Hello, my name is Dr Joe, I am the on-call orthopaedic core surgical trainee. How can I help?
Patient:
My name is Christopher Biggins. I’ve been waiting to hear from you about my elbow operation and
no-one has called me in 4 days! I read on the internet that you can’t operate after two weeks. The
care has been absolutely negligent. I’m going to contact the patient advice and liaison service team
to complain
Candidate:
I am very sorry that you have not been contacted sir. Can you please tell me a bit more about
what happened to your elbow?
Patient:
Well, I was cycling two weeks ago and fell off my bike landing on my elbow. I came to A&E and was
seen by a doctor who sent me home in a sling explaining that I need an operation and would be
contacted later that day. I’ve been trying to get in touch with the orthopaedic team on the phone
but nobody seemed to be able to help me.
Candidate:
I’m sorry that you haven’t heard from us since then and haven’t been able to get in contact with
us.
Patient:
I haven’t been able to work, my employer is getting frustrated with me. When am I going to get my
operation?
Candidate:
I’m sorry that we have not been able to offer you an operation yet. We have had a large number
of emergency cases in the last few days which had to be prioritised. I promise that we are doing
our best to offer you an operation as soon as possible but I cannot give you a date here and now.
Patient:
I appreciate that you have had a very busy few days with emergency cases, but I should have been
kept informed of this. I haven’t been able to work for the last few days. I need to be able to keep my
employer updated too.
Candidate:
I can only apologise. We should certainly have contacted you to explain the situation and keep you
updated. I will discuss this at tomorrow’s trauma meeting with the whole team present and try to
ensure that this does not happen again.
Patient:
Thank you. When will you know when I am likely to have my operation?
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Candidate:
Unfortunately we don’t have any space on today’s operating list. I will discuss your case with the
consultant and contact you via telephone this evening to update you. Can I ensure that we have
the correct contact details for you?
Patient:
Yes. My number is 793751.
Candidate:
Thank you for your patience sir, and I will contact you myself this evening to give you an update. Is
there anything else you would like to ask at the moment?
Patient:
No. Thank you doctor.
• Saying sorry is a crucial step in dealing with an angry patient (even if it is not your fault!). It does
not admit liability, but expresses empathy for the other person’s situation. It quickly diffuses the
situation and allows you to get to the bottom of the problem.
• If you can, it is useful to offer the patient some reassurance that you will look into the problems (in
this case that he had not been contacted) and try to ensure it doesn’t happen again.
• Ensuring that you have the correct contact details reassures the patient that you intend to contact
him, and also eliminates a common source of error in taking down wrong numbers.
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2. ANXIOUS MOTHER
Mrs Kelly is the 40-year-old mother of Tom a 7-year-old child that is currently being operated on
for a possible splenic rupture. He was with his father when he apparently fell from a climbing
frame
Please talk to her about her child
Why wasn't I called about this before Tom was taken for his operation?!
Mrs Kelly, I am very sorry that you haven't been contacted before now. I am Nadeem, one of the
surgical doctors.
Can I ask what you know about what has happened to Tom?
I received a call an hour ago from my ex-husband telling me that Tom had fallen off a climbing frame
and was now having an operation. I have rushed in to see him but he's already been taken away for
the operation.
WHAT IS GOING ON?!
Mrs Kelly, you are right, Tom apparently fell off his climbing frame and has seriously hurt himself. I
apologise again that you weren't able to see Tom before he was taken to the operating theatre,
but unfortunately the case was an emergency, and therefore we could not wait until you had
arrived.
What operation is he having?

The scan we did when Tom first came in suggested that he has suffered a ruptured spleen, an
organ in the abdomen. He is having an operation to repair this.
Could he die?
A ruptured spleen is a serious condition, and that is why we acted so quickly in getting Tom into
the operating theatre.
He is now in very good and experienced hands, and we hope he will do well. However, his
condition remains serious, and there is a possibility he could die from his injury.
What has David, my ex-husband told you?

He has told us that he was in the garden when Tom's suddenly called out in pain, as he had fallen
from a height from a climbing frame. He was complaining of abdominal pain, and because David
noticed a big bruise on the side of Tom's chest he called an ambulance.
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Has anything like this happened before?
No, nothing, but...

David and I went through a difficult divorce recently, brought about because he is always stressed
and drinks too much. He is a good father and would never hurt Tom but I am concerned that he
might not have supervised him properly due to his drinking.
You won’t tell anyone this will you?
I will have to share this information Mrs Kelly. In any case like this we need to take extra
precautions to ensure that your child is going to be safe.
There are standard procedures we need to take. These include finding out more about Tom's
situation at home and we would ask you to help us with this.
I need to involve a named child protection consultant, and we routinely involve child protection
services to make sure that everything we do is in Tom's best interest.
Do you have concerns about your husband?
No, I guess I am just anxious. What happens when Tom gets out of the operation now?
Our first priority is Tom's medical care, ensuring he makes a good recovery.
We can't discharge him until we have undertaken a full examination, and made sure that his GP is
aware that there may be concerns.
We would like to talk to you and your husband further to build up a complete picture of Tom's life.
We will wait until Tom is out of his operation to do this if that's ok
4
Ok, I understand this, I just really want my boy to be ok
He's in good hands, and I'll let you now as soon as I hear anything.
Do you have any other questions?
I am here if you need to discuss anything, please just let the nurses know and they will contact me
What the actress was told

Name Sarah Kelly
Attititude: Very anxious and a little angry
What you know: You received a call an hour ago from your ex-husband telling you that Tom, your 7-
year old-son, had fallen off a climbing frame and was now having an operation. You have rushed in
to see him. You have no idea what is going on and are anxious for information
Responses: First words should be “why wasn’t I called about this before Tom was taken for his
operation?” If the explanation is good, they apologise and they tell you that the operation was done
as an emergency therefore there wasn’t time to call you. You should then calm down, otherwise
remain angry and get angrier until they apologise. Ask information about the procedure and ask him
if there are risks. If appropriate, ask “could he die?” Appear upset, and leave a gap of silence. The
candidate should respond appropriately by allowing this silence. After around a 20 second silence,
you should ask what your ex-husband has told them. If prompted, mention that you have gone
through a difficult divorce recently, brought about because he is always stressed and drinks too
much. He is a good father and would never hurt the child but you are concerned that he might not
have supervised Tom properly due to his drinking. Ask what the candidate will do with that
information and ask them to keep it to themselves. Ask when you can take him home if everything is
OK. Close by explaining that you understand and will wait until Tom is out of theatre. If they offer to
talk to you again later, thank them.
KEY INFORMATIONS
You are tested on how well you deal with an anxious and potentially angry mother of a sick child.
You have to give her information in a sensitive way, but ensure that she understands the potentially
serious condition her son is in.
Reassure the mother that her son is in the right place, and that he is having the operation he needs.
His life is at risk, but he is receiving the best possible care.
The mother should have been contacted before the operation, be honest and admit this. You don’t
know why the registrar wasn’t able to do so, so be honest, apologise and move on.
It is important to show empathy and understanding of the mother’s feelings.
Find out about the child’s social situation, whether there have been any other incidents like this,
other admissions to hospital and whether she has concerns. Once these concerns are raised, it is
important to explain that you will have to involve child protection services, and that you are doing so
in the child’s best interests.
The following is adapted from the BMA’s child protection toolkit:
In child protection cases, a doctor’s primary responsibility is to the well being of the child or children
concerned. Never delay taking emergency action.
Any doctor seeing a child who raises concerns must ensure follow-on care. In particular, children
must not be discharged from hospital without a full examination.
Wherever possible, the involvement and support of those who have parental responsibility for, or
regular care of, a child should be encouraged, in so far as this is in keeping with promoting the best
interests of the child or children concerned.
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When concerns about deliberate harm to children or young people have been raised, doctors must
keep clear, accurate, comprehensive and contemporaneous notes. This must include a future care
plan and identify the individual with lead responsibility.
Wherever a doctor sees a child who may be at risk, he or she must ensure that systems are in place
to ensure follow-up care. As full a picture as possible of the circumstances of a child at risk must be
drawn up.
Where a child presents at hospital, inquiries must be made about any previous admissions
Where a child is admitted to hospital, a named consultant must be given overall responsibility for
the child protection aspects of the case.
Any child admitted to hospital about whom there are concerns about deliberate harm must receive
a thorough examination within 24 hours unless it would compromise the child’s care or wellbeing.
Where a child at risk is to be discharged from hospital, a documented plan for the future care of the
child must be drawn up
A child at risk must not be discharged from hospital without being registered at an identified GP
Remember to summarise and check understanding.
Close the consultation by thanking her and washing your hands. Turn to the examiner in case they
have any questions. In this case there are none, so you are asked to move on.
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3. ASSESSING CONFUSION
Mrs Joy is an 84-year-old lady who has hypertension but was otherwise fit and well. She is due to
have an elective hip replacement tomorrow and has been admitted to the ward for
preassessment. The nurses have called you because they are concerned that this lady is confused,
and have spoken to her daughter, who tells them the patient is not normally confused.
Assess this patient’s confusion and answer some questions from the examiner.
Please assess this patient’s confusion

Hello Mrs Joy, I am James one of the surgical trainees. How are you today?
I am ok, but don't really know where I am
Would you mind if I asked you some questions to test your memory?
Yes of course
How old are you?

What time is it to the nearest hour?
Can you remember this address? 24 West St. I will ask you this at the end
What year is it?
What is the name of this place?
What is my job? And what is the job of this person (e.g. a nurse)?
What is your date of birth?
When did WW2 end?
Who is the current prime minister?
Can you count backwards from 20-1?
What was that address I asked you to remember?
Mrs Joy knows that her age is 84,

She doesn't know the hour, or remember the address
She thinks it is 2020
She believes she is in her house
She doesn't know what you or the nurse does
She correctly states her date of birth is 07/07/1928
She has forgotten when WW2 ended
Does not know the current prime minister
And fails to count backwards from 20
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What is her ATMS?
Mrs Joy's AMTS is 2
What would you do next?

I would take a history from the patient, the notes, family members and her GP and perform a
thorough systemic examination.
My initial investigations would include a urine dip and MSU, blood tests including inflammatory
markers, haematinics and thyroid function tests.
Imaging should be arranged, firstly a chest X-ray and then a CT head if there are any neurological
signs, or after other investigations return as negative.
I would consider asking the medical registrar to see the patient to either take over care or give
appropriate advice.
Should the operation go ahead?

No. The operation is non urgent, therefore it can be postponed until the cause of the confusion has
resolved. I would talk to my consultant and the anaesthetist in charge of the case to inform them of
the confusion and ask their advice before cancelling it
What is your differential diagnosis?

My main differential for this lady’s acute confusion is a urinary tract infection. Other causes include
other sources of infection, metabolic abnormalities such as renal or hepatic failure, hypoglycaemia
and hyperthyroidism, hypoxia, hyperthermia, vitamin deficiency such as thiamine deficiency,
medication such as steroids, opiates or other sedating medication, and being in an unfamiliar
environment on the background of dementia.

Name: Wendy Smith
Attitude: Confused, pleasant
What you know: You think you are at home and the doctor has come to see you. You don’t know
why you would be in hospital as you feel very well. You sometimes have difficulty walking because of
pains in your hip, but it’s not bothering you at the moment. You have no other medical problems
that you know of, and you think you take no pills.
Responses: You know your date of birth, but are unable to answer any of the other memory
questions you are asked. You have no weakness in your arms or legs. If asked, say that you think you
have had pain when you last spent a penny (urinated).
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KEY INFORMATIONS
When assessing a patient's confusion in the OSCE it is important to start like any consultation, and
ask an open question, allowing the actor to point you in the right direction.
The AMTS was introduced in 1972 as a tool to rapidly assess delirium or dementia in the elderly. A
score of < 6 suggests a significant cognitive deficit, although further tests are needed to delineate
the cause further.
The questions are:
How old are you?
What time is it to the nearest hour?
Can you remember this address? 24 West St. I will ask you this at the end
What year is it?
What is the name of this place?
What is my job? And what is the job of this person (e.g. a nurse)?
What is your date of birth?
When did WW2 end?
Who is the current prime minister?
Can you count backwards from 20-1?
What was that address I asked you to remember?
To fully assess a confused patient you must take a history and collateral history, for instance from
her family, or the GP. You need to know her premorbid state, how rapidly she has declined, and
associated symptoms. A fully examination is necessary.
Tests to aid your diagnosis include a septic screen consisting of bedside observations, inflammatory
markers, urine dip and chest xray, and a confusion screen consisting of B12 and folate, thyroid
function and a CT head.
Involving the medical team would be important if you felt that you couldn't find a simple easily
reversible cause.
The commonest differential for this lady’s acute confusion would be a urinary tract infection
however other causes include other sources of infection, metabolic abnormalities such as renal or
hepatic failure, hypoglycaemia and hyperthyroidism, hypoxia, hyperthermia, vitamin deficiency such
as thiamine deficiency, medication such as steroids, opiates or other sedating medication, and being
in an unfamiliar environment on the background of dementia.
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10
4. BREAKING BAD NEWS
Mrs Balotelli has terminal lung cancer that has spread to brain and bone. After discussion in the
MDT it was decided that the only treatment option was palliative chemotherapy. Your consultant
Mrs Murphy a thoracic consultant surgeon has completed a Do Not Attempt Resuscitation order
due to likely futility of any attempt at CPR.
You are asked to speak to the patient’s family who is unaware of the diagnosis or the DNAR order.
You must give the diagnosis and inform her of the DNAR order and the reasons behind it
I am Mrs Balotelli's daughter, thank you for coming to speak to me, how is she?
Hello, nice to meet you, I am Fay the surgical SHO. Can I start by finding out what you know about
your mother's condition?
I know she is under investigation for a lump in the chest, which I realise might be cancer. I pray it is
not.
Otherwise she appears to be weaker than she used to be, and has lost weight but I am unaware of
any other problems.
Can you tell me what the diagnosis is? I have permission to hear it without my mother being here,
from her
I can tell you the diagnosis as your mother's scans were recently discussed in the multidisciplinary
meeting. Would you like me to arrange for anyone else to be present?
No, there isn't anyone really. Is it bad news?

Unfortunately it is bad news.
You mother has lung cancer that has spread to her brain and to bone. There is nothing we can do
to cure her of this.
The patient's relative is visibly upset. In the OSCE how would you deal with this?
I would leave a silence, offer a tissue if needed, and wait for the relative to speak first.
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Why can't you just chop out the lung cancer?
Unfortunately removing the lung tumour would not help as the cancer has moved to the brain and
bone, and the experts have agreed that she would not respond to chemotherapy or radiotherapy
How would you inform the relative of the DNAR order?

Because her prognosis is so poor, we feel that we shouldn't be trying to do anything too aggressive
for her as it is likely to do more harm than good. In particular, if she stops breathing, we feel that
trying to resuscitate her would not be in her best interests. Because of this, the consultant has
signed a do not attempt resuscitation order.
What do you think about this?
I completely disagree with that and I want it changed. I want my mother to have all possible
treatment, I don't want her to die!
I understand that. We don't want her to die either.
The decision to not resuscitate does not mean that we wont treat your mother. If she were to suffer
any complication such as an infection, that we were able to treat then we would, of course, do so. It
means that if her heart stops beating then we wouldn't try to restart it, as doing so is very unlikely to
work and he quality of life would be poor were she brought back.
Isn't it my legal right as her daughter to decide if my mum gets resuscitation or not?
In this case it is actually the doctors who legally have to decide what treatment is best. We take into
account her view, and the views of her relatives, but if we know that giving a treatment is not going
to work, then we have to judge that it is not in her best interests.
I understand. I know my mother, and she wouldn't have wanted the resuscitation if it wasn't going
to do her some good.
Thank you. I am always here if you want to talk to me again, just ask the nurse and she will contact
me

Name: Francesca Balotelli
Attitude: Very anxious about your mother, and would like her to have maximal treatment, but don’t
want her to suffer.
What you know: Your mother is under investigation for a lump in the chest, which you realize might
be cancer, but have hope it is not. Otherwise she appears to you to be weaker than she used to be,
and has lost weight but you are unaware of any other problems. You had an aunt who died of lung
cancer last year, and are concerned that your mum will too unless she receives surgery.
Responses to the candidate: Open with “How is she?” in an anxious manner. When told the
diagnosis, ask why can’t they just chop out the lung cancer? Understand if you are told that
removing the lung tumour would not help as the cancer has moved to the brain and bone, and that
the experts have said that she would not respond to chemo or radiotherapy If DNAR order not
mentioned, prompt with “what happens if she were to stop breathing?“ When told about the DNAR
order, indicate that you disagree and want it changed, as you want your mother to receive all
available treatment. If not mentioned, say surely it’s my legal right to decide if my mum gets treated.
Be angry until they explain that DNAR does not mean that she will not be treated, and that
complications such as infections etc will still be treated. Understand if told that the DNAR order only
applies if your mother’s heart stopped beating. Express that if it won’t cure her, then your mother
wouldn’t have wanted to be treated. Thank the doctor if appropriate.
12
Key Information
How to score empathy points:
Remember to be natural and don’t use every suggestion here by rote each time. Be sensitive to the
situation and act appropriately.
Allow appropriate pauses.
Do not be afraid of silences.
Offer to return later if they would prefer.
Respect their point of view, and establish the reason for it if you disagree.
Offer to put them in touch with further support.
DNAR guidance from the joint statement from the British Medical Association, the Resuscitation
Council (UK) and the Royal College of Nursing October 2007
“Clinicians should ensure that those close to the patient, who have no legal authority, understand
that their role is to help inform the decision-making process, rather than being the final decision-
makers. Great care must be taken when people other than the patient make or guide decisions that
involve an element of quality-of-life assessment, because there is a risk that health professionals or
those close to the patient may see things from their own perspective and allow their own views and
wishes to influence their decision, rather than those of the patient. These considerations should
always be undertaken from the patient’s perspective. The important factor is whether the patient
would find the level of expected recovery acceptable, taking into account the invasiveness of CPR
and its low likelihood of success, not whether it would be acceptable to the healthcare team or to
those close to the patient, nor what they would want if they were in the patient’s position. Doctors
cannot be required to give treatment contrary to their clinical judgement, but should be willing to
consider and discuss patients’ wishes to receive treatment, even if it offers only a very small chance
of success or benefit”
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5. CONSENT FOR COLONOSCOPY
You have been asked by your consultant to consent Mr Mead, a 59 year old, for a colonoscopy.
When you read through the clinic notes, you see that he has been suffering with PR bleeding and
weight loss over the past 2 months.
Candidate:
Hello Mr Mead, I am Mr Roberts’ SHO and I have been asked to talk to you about an investigation
he would like to arrange for you. Can I just start by asking you what you understand so far?
Actor:
Sure, no problem. From what I gather, Mr Roberts wants to use a camera to have a look into my
bowel to see where the bleeding’s coming from.
Yes that’s right. The camera test is called a colonoscopy.

It is a camera, known as an endoscope, which is inserted through the back passage and into the large
bowel. {You can draw a quick diagram to demonstrate this}. The camera then relays the image onto
a TV screen so we can have a look inside and see what may be causing your symptoms. It is a very
accurate way of looking at the lining of the bowel to see if there is any disease.
We may also need to take some tissue samples from the lining of bowel to help us with our
diagnosis. Normally this doesn’t hurt.
Does that make sense so far?
Actor:
Yes it does, it doesn’t sound particularly pleasant! Will I be awake for the procedure?
Candidate:
I can appreciate that. No, you will be given sedation and analgesia.
Actor:
Are there any alternatives to having this done?
Candidate:
Yes, a barium enema is an alternative, which involves the insertion of contrast solution into the
back passage and X rays are then taken. However, this does not provide as much detail as an
endoscopic investigation and we cannot take tissue samples for analysis.
Actor:
Oh right, I better have the colonoscopy then. Are there any risks?
Candidate:
No procedure is without risk. The risks are:
- Bleeding from the site of the tissue sampling. Usually this stops on its own and if it doesn’t it can
be treated with cauterisation or injection treatment. The risk is 1 in 200.
- The sedation can sometimes cause breathing or blood pressure problems so this is monitored
closely following the procedure.
- A more serious risk is perforation or a tear in the bowel lining which nearly always needs an
operation to repair. The risk is 1 in 1000.
15
Actor:
Can I eat and drink as normal beforehand?
Candidate:
So that we can have a good clear view of the bowel, you will need to be on a low fibre diet and
drink plenty of fluids 2 days prior to the procedure. The day before, you should have clear fluids
only including black tea/coffee with sugar, glucose drinks, clear soups.
You will also need to take a laxative which will explain when to take it on the label.
Actor:
Should I take my blood pressure tablets in the morning?
Yes, take your regular medications in the mornings.
Actor:
What about my aspirin?
My GP gave it to me as a precaution because I have high blood pressure and my father died of a
heart attack.
Candidate:
Because of the risk of increased bleeding, you will have to stop your aspirin 7 days before the
procedure. You can restart it immediately after the procedure.
Do you have any other questions?
Actor:
Yes, just one more. How long will it take to get the results of the tissue sample?
Candidate:
The results of the tissue biopsy take 2 weeks. You will be seen in the outpatient clinic following
the procedure to discuss the findings of the investigation.
Actor:
Thank you.
Key Information
-Introduce yourself and gain understanding of what the patient understands so far.
-Explain the procedure and tissue sampling. It is helpful to draw a diagram if you can do this quickly.
-Explain that sedation and analgesia are administered.
-Explain alternatives and limitations – barium enema.
-Risks – Bleeding, infection, risks of sedation, perforation.
-Explain bowel preparation methods.
-Inform them when to be NBM and to take their regular medications.
-Summarise if necessary and keep checking that they understand the information
-Offer information leaflet.
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6. CONSENT FORM 4
You are the CT1 in Orthopaedics. Mrs Audrey Dixon, an 89 year old lady has been admitted with a
fractured neck of femur. She has Alzheimer’s and cannot give consent for her operation. The
consultant on call has asked you to complete a consent form 4 and would also like you to talk to
the patient’s family.
Guidelines for speaking to relatives

• Where at all possible ensure you are in the appropriate environment. Most commonly a relatives
room or an office where you know you will not be disturbed is the most appropriate place.
• Ensure that there are no distractions: you should leave your bleep with a colleague so that you are
not disturbed at a sensitive time
• You should always have another member of the MDT present with you, most commonly another
doctor or nurse who knows the patient
• Ensure that you know the patient’s history
• Ascertain how much the relative or patient knows
• Show empathy
• Pitch your information-giving and language at the correct level
• Provide information as to how the patient or relative can contact you if they have further
questions
Candidate:
Introduce yourself
If more than one family member is present and they do not volunteer the information , it is always
good practice to ask their relationship to the patient
Actor:
“I am John Dixon, Audrey’s son. Thank you for coming to speak to me”
Candidate:
Start with an open-ended question
“Can I ask how much you know about the reason for your Mum’s admission to hospital?”
Actor:
“I know she fell over at the care home and has possibly broken her hip.”
Slight pause
“Is her hip broken”?
Candidate:
At this point you are breaking bad news so you should fire a warning shot first.
“Unfortunately it’s not good news”.
Slight pause...
“Your Mum has broken her hip”.
After telling a patient or relative any form of bad news it is essential to pause and allow a period
of silence. This will give them time to process what you have just said. Do not continue with the
conversation until the patient or relative is ready.
Actor:
Appears upset says:
“Thats really bad, is’nt it? Can you tell me more?”
17
Often, relatives will ask this, but you should be careful not to overload them with information. Leave
things open at the end of your conversation so they know they can come back to you, or someone
else, with their questions.
Candidate:
Before discussing consent, it is well worth addressing the issue of why an operation is required. In
this case, we know that neck of femur patients have higher morbidity and mortality from
conservative management of their fracture (if fit enough for anaesthetic).
“It is a serious injury but we are able to fix her hip it with an operation”
Actor:
“Really?”
“That great, obviously my Mum cannot give permission but I am happy to give permission on her
behalf”.
Candidate:
“In this situation sir, where your Mum cannot give her own consent as an adult, it is the
responsibly of the doctors looking after her. We will of course be asking your....”
You are cut off by the actor....
Actor:
Becomes agitated.
“What do you mean”?
“She is my mother and I am not letting you lot operate on her without my permission. I know my
legal rights”!
Under these circumstances, an NHS consent form 4 is used to provide consent for the operation.
There is a section on this that encourages discussion with a relatives family but it is not a legal
requirement. Ultimately the decision rests with the clinician.
The following text has been quoted from the current NHS consent form 4
Section D Involvement of the patient’s family and others close to the patient
“The final responsibility for determining whether a procedure is in an incapacitated patient’s best
interests lies with the health professional performing the procedure. However, it is good practice to
consult with those close to the patient (eg spouse/partner, family and friends, carer, supporter or
advocate) unless you have good reason to believe that the patient would not have wished particular
individuals to be consulted, or unless the urgency of their situation prevents this. “Best interests” go
far wider than “best medical interests”, and include factors such as the patient’s wishes and beliefs
when competent, their current wishes, their general well-being and their spiritual and religious
welfare”.
Source: Consent form 4 from the Department of Health website
Candidate:
“I understand your concern for you Mum and we want you to be a part of the consent process. In
this situation we use a consent form 4, which is used when a patient cannot consent for an
operation, as in your Mum’s case because of her Alzheimer’s disease. This consent form is
ultimately signed by the medical team but we like to discuss our plans with any relatives and then
they can sign the consent in agreement with the proposed operation”.
Although the relative (unless they have medical Lasting Power of Attorney) has no legal say in the
patient's care, it is worth involving them in the consent process and communicating the surgical
team's plans. The majority of complaints in this area arise from poor communication with families.
18
Actor:
Appears more calm after you last statement.
“I understand. I am sorry for getting annoyed, I am just so worried about my Mum”
Candidate:
“I understand sir. We will look after her”.
“Do you have any questions”?
Make sure the relative knows who they can speak to about any further questions or issues. If that
is someone other than yourself, make sure they have the contact details.
Actor:
“Yes, when will my Mum have her operation”?
This is always a difficult question to answer, whether in an exam or on the ward! It can very easily
reignite a sensitive situation. You should have a model answer for this question.
Never commit to an exact time. By saying you will go and check with the team in theatre and keep
the relatives informed you are showing the examiner that you can think on your feet. More
importantly you are showing the relatives that you have you best interest of their loved one at the
forefront.
Candidate:
“The operation is planned for today. I will go and check with the team in theatre and let you
know”
Actor:
“Thank you”.
Candidate:
Close the conversation by saying that you can be contacted by the nurses if there are any other
questions or concerns that arise and that you will keep Mr Dixon informed
Before closing the conversation ask Mr Dixon if he would like to go and see his mother.
Although this conversation may seem short, if you are delivery your statements at the right pace and
allowing appropriate silences then it should take 8 - 10 minutes.
Key Information
Guidelines for talking to relatives:
• Where at all possible ensure you are in the appropriate environment. Most commonly a relatives
room or an office where you know you will not be disturbed is the most appropriate place.
• Ensure you their are no distractions: You should leave you bleep with a colleague so that you are
disturbed at a sensitive time
• Ensure that you know the patients history
• Show empathy
• Give a warning sign before you deliver the bad news
• Follow this by an appropriate pause. Do not be scared of silence
• Pitch your information giving at the correct level
questions
An NHS consent form 4 is used when:
• “ the patient is unable to comprehend and retain information material to the decision; and/or”
19
• the patient is unable to use and weigh this information in the decision-making process; or”
• “the patient is unconscious”.
• It must also be documented on the consent form as to why the treatment cannot wait until the
patient recovers capacity.
Further to this you must declare on the consent form that:
• “To the best of my knowledge, the patient has not refused this procedure in a valid advance
directive. Where possible and appropriate, I have consulted with colleagues and those close to the
patient, and I believe the procedure to be in the patient’s best interests”.
Source: Consent form 4 from the Department of Health website
20
7. CONSENT FOR OESOPHAGO-GASTRO-DUODENOSCOPY (OGD)
You have been asked by your consultant to consent Mr Jarvis, a 64 year old, for an OGD. When
you read through the clinic notes, you see that he has been suffering with dysphagia and
indigestion for the past 4 weeks.
Candidate:
Hello Mr Jarvis, I am Mr Smith’s SHO and I have been asked to talk to you about an investigation
he would like to arrange for you. Can I just start by asking you what you understand so far?
Actor:
Sure no problem. From what I gather, Mr Smith wants to put a camera down to have a look to see
why I’m having all these problems with my swallowing and heartburn.
Candidate:
Yes that’s right. The camera test is called an oesophago-gastro-duodenoscopy, which is shortened
to OGD.
It is a camera, known as an endoscope, which is inserted through the mouth, down the food pipe,
into the stomach and along to the first part of the small bowel. {You can draw a quick diagram to
demonstrate this}
The camera then relays the image onto a TV screen so we can have a look inside and see what may
be causing your symptoms. We may also need to take some tissue samples from the lining of your
digestive tract to help us with our diagnosis. Typically, this doesn’t hurt.
Does that make sense so far?
Actor:
Yes it does, it doesn’t sound very nice though! Will I be awake for the procedure?
Candidate:
Yes I can appreciate that. There are two options. You can either have local anaesthetic sprayed
into your throat to numb the area or you can be sedated (that is, not asleep but you won't
remember). The benefit of having local anaesthetic spray means that you can go home straight
after the procedure and you can drive. You would just need to avoid hot drinks until the numbness
has worn off in around 30-60 minutes. If you have sedation, you will need someone to accompany
you home and stay with you until the next day. You cannot drive for 24 hours. You will likely be
able to go home the same day if you are well and have managed something to eat and drink.
Actor:
I see. I think I would prefer to be sedated. Are there any alternatives to having this done?
Candidate:
Yes. You can have a barium swallow/meal X ray, which involves drinking a contrast solution and
then having sequential X rays. This is not as informative as an OGD and we wouldn’t be able to
take tissue samples to help with the diagnosis with this investigation.
Actor:
Oh right, I think the OGD sounds like the better option.
Candidate:
Unfortunately, no procedure is without risk. The possible risks involved with this procedure are:
- Bleeding from the site of tissue sampling.
- Infection, such as a chest infection if some fluid passes into the lungs.
- There is also a risk of damage to the teeth from the endoscope.
21
- A slightly more serious risk is a perforation or tear of the lining of the digestive tract which may
need an operation to repair. The risk of this is 1 in 1000.
It is normal to expect a sore throat for a few days afterwards.
Actor:
What about eating around the time of the OGD?
Candidate:
If your appointment is in the morning, take no food or drinks after midnight.
If your appointment is in the afternoon, you may have a light breakfast no later than 8am, but no
food or drinks after that.
Small amounts of water are ok to take up to two hours before the procedure.
Actor:
Should I taKe my blood pressure tablets in the morning?
Candidate:
Yes, take your regular medications in the morning.
Have you got any more questions?
Actor:
Yes, how long will it take to get the results of the tissue sample?
Candidate:
It takes 2 weeks to get the results of the tissue biopsy. You will be seen in the outpatient clinic
following the procedure to discuss the findings of the investigation.
Actor:
Thank you, I think that is everything.
Key Information
-Introduce yourself and gain understanding of what the patient understands so far.
-Explain the OGD procedure and tissue sampling. It is helpful to draw a diagram if you can do this
quickly.
-Explain that it can be done under local anaesthesia or sedation.
-Explain alternatives – barium swallow/meal Xray.
-Expect a sore throat afterwards.
-Risks – Bleeding, infection, damage to teeth, perforation.
-Inform them when to be NBM and to take their regular medications.
-Summarise if necessary and keep checking that they understand the information.
-Offer information leaflet.
22
8. DISCUSSION OF DO NOT ATTEMPT RESUSCITATION (DNAR) ORDERS
You are the CT1 in Ear, Nose and Throat. Mr Christopher Rogers, a 94 old gentleman has just been
admitted with supraglottitis. He has stridor and is working hard with regards to his breathing.
After discussion with the anesthetic team, they feel that should Mr Rogers require intubation his
prognosis of being successfully extubated would be very poor. Mr Scott, your consultant has said
that a surgical tracheostomy would be very difficult due to Mr Roger’s severe kyphosis. You have
been asked to discuss Mr Rogers’ resuscitation status with his son who has just arrived. Mr Rogers
has had 3 previous myocardial infarctions, and suffers with COPD and peripheral vascular disease.
Guidelines for breaking bad news:

• Appropriate environment. Most commonly a relatives room or an office where you know you will
not be disturbed is the most appropriate place.
• Ensure that there are no distractions: You should leave your bleep with a colleague so that you are
• Show empathy
• Give a warning sign or shot before you deliver the bad news and follow this by an appropriate
pause. Do not be scared of silence
• Try and pitch your language at the correct level, do not get too technical
Candidate:
Introduce yourself and allow any colleagues present with you to introduce themselves (it is often a
good idea to have a nurse with you).
If more than one family member is present and they do not volunteer the information, it is always
good to ask their relationship to the patient.
Actor:
“I am Oliver Rogers, Christopher’s eldest son. Thank you for coming to speak to me”
Candidate:
“Can I ask how much you know about your Dad’s health and current condition?”
Actor:
“I know that his breathing and heart have been bad for a number of years now. In the past week his
breathing has become noisier and he has generally felt unwell. Do you know what has caused this? Is
it serious?"
Candidate:
A diagnosis of supraglottitis in any patient is serious but more so in an elderly patient with pre
existing cardiac and respiratory disease.
You are breaking bad news so you should fire a warning shot first.
“I afraid it is serious”..
“We know that your Dad has supraglottitis. This is most commonly caused by an infection that
leads to swelling around the voice box / airway and that is why his breathing has been noisy and
23
difficult for him. Unfortunately at present his breathing is not responding to treatment and he is
getting very tired”.
of silence. This will give them time to process what you have just said and will also allow you time
to gauge their feelings and reaction. Do not continue with the conversation until the patient or
relative is ready.
Actor:
In a slightly broken voice:
“Is my Dad going to die”?
Candidate:
“I am afraid he might die”
Pause to gauge the relative's response, and allow them to speak if they wish, before continuing.
”If the infection does not respond to treatment then he may die as the swelling around his voice
box will prevent him breathing”. We are giving all the treatment we can at present”.
Pause...
“However, if you dad’s breathing stops we feel that resuscitation would be very traumatic for him
and if he survived his quality of life would be poor. Due to this we would like put a do not
resuscitate order in place. Do you know what that means?”
Actor:
Actor becomes agitated by your last statement.
“So if he stops breathing your not going to do anything?”
This is a common question during discussion about DNARs, so be prepared for it.
Candidate:
Remain calm and composed
“I stress that we are providing all active treatment that we can at present to prevent your Dad’s
breathing stopping. But if the infection gets worse his breathing may stop. In that instance we
could try to get it started again, but this would be through very aggressive treatment and your
Dad’s quality of life following this would be very poor, especially in view of his heart and lung
disease. Therefore, if your Dad’s breathing stops we would prefer to make him as comfortable as
possible."
It is important to stress that a DNAR form, is not a 'Do Not Treat' order.
Actor:
“I understand, but it’s very hard to hear these things about your own Dad”
Pause...
“But he has said before that if he did stop breathing he wouldn't want anyone to revive him”.
Remember, unless a relative has Lasting Power of Attorney (medically, not financially) then legally
their word has no weight. It is, however, extremely important to involve them in any decision
regarding a DNAR and take the time to explain the rationale behind it. Thanks to hospital-based TV
shows, cardiovascular resuscitation has become somewhat glorified, and it can sometimes be
difficult to explain that despite best efforts, very few attempts are successful, and often those that
are result in much poorer quality of life for the patient.
Candidate:
Confirm that Mr Roger’s son understands and is happy with the DNAR order.
Ask if there are any other questions.
24
Follow this up by saying that you can be contacted by the nurses if there are any other questions
or concerns that arise.
Before closing the conversation ask Mr Rogers’ son if he would like to go and see his Dad.
Although this conversation may seem short, if you are delivery your statements at the right pace
and allowing appropriate silences then it should take 8 - 10 minutes.
Key Information
When breaking bad news you should have the following points in your mind:
• Ensure there are no distractions: you should leave your bleep with a colleague so that you are not
disturbed at a sensitive time
• Show empathy
• Give a warning sign or shot before you deliver bad news and follow this by an appropriate pause.
Do not be scared of silence
• Pitch your information giving at the correct level
Decisions relating to cardiopulmonary resuscitation. A joint statement from the British Medical
Association, the Resuscitation Council (UK) and the Royal College of Nursing. October 2007
http://www.resus.org.uk/pages/dnar.pdf
Main messages:
• “Decisions about CPR must be made on the basis of an individual assessment of each patient’s
case”.
• “Advance care planning, including making decisions about CPR, is an important part of good clinical
care for those at risk of cardiorespiratory arrest”.
• “Communication and the provision of information are essential parts of good quality care”.
• “It is not necessary to initiate discussion about CPR with a patient if there is no reason to believe
that he patient is likely to suffer a cardiorespiratory arrest”.
• “Where no explicit decision has been made in advance there should be an initial presumption in
favour of CPR”.
• “If CPR would not re-start the heart and breathing, it should not be attempted”.
• “Where the expected benefit of attempted CPR may be outweighed by the burdens, the patient’s
informed views are of paramount importance. If the patient lacks capacity those close to the patient
should be involved in discussions to explore the patient’s wishes, feelings, beliefs and values”.
• “If a patient with capacity refuses CPR, or a patient lacking capacity has a valid and applicable
advance decision refusing CPR, this should be respected”.
• “A Do Not Attempt Resuscitation (DNAR) decision does not override clinical judgement in the
unlikely event of a reversible cause of the patient’s respiratory or cardiac arrest that does not match
the circumstances envisaged”.
• “DNAR decisions apply only to CPR and not to any other aspects of treatment”.
25
9. EXPLAINING A PROCEDURE
Mr Sreedharan is a 70-year-old man who is due to undergo a colonoscopy. He had noticed a
change in bowel habit and weight loss over the past year, and has had the colonoscopy arranged
by his GP. He has some questions about the procedure
Discuss the procedure with Mr Sreedharan and answer the questions he has.
How would you open the consultation?

I would introduce myself and start with an open question for instance
Hello I am Jamie the surgical SHO, I understand you have come for a colonoscopy and have some
questions about the procedure. Can I start by asking what you know about the procedure please?
Hi Jamie, nice to meet you, I'm Aditya.

I'm actually a bit confused as to why I am here for the colonoscopy. I know my GP arranged it but I
don't really know why. Could you explain?
Of course, but, could I start by finding out if you have had any symptoms related to your bowels
recently?
Yes I have, I first noticed a change in my bowel habit about a year ago, but only recently went to the
GP because I realised my trousers had became loose making me realise that I had lost weight. The
GP arranged a blood test and this colonoscopy. I don't really know what a colonoscopy is, would you
mind explaining it to me?
Of course. A colonoscopy is a camera test, where a thin camera is used to look at the insides of
your bowel. It involves having a camera about as wide as a 2 pence piece inserted in your back
passage to have a look at the large intestine. The pictures generated will appear on a screen.
Before hand you shouldn’t have any food for 6 hours, but can drink clear liquid. You will be given
laxatives to clear your bowels out to allow us to see clearly. You will be awake for the procedure
but receive sedation medication which means you will not mind the procedure too much, and
won’t remember it clearly. It also means you will be drowsy after the procedure and can’t drive so
it is important to arrange transport home afterwards.
During the procedure you may feel as if you are passing wind as air is passed into the bowel, you
shouldn’t feel embarrassed. The operator may ask you to move around onto your side or back at
certain times. Take your time as you do this. They may take a tissue sample or remove small
growths for testing if they see them. This will not hurt.
Why do I need a colonoscopy?

The reason for a colonoscopy is because a change in your bowel habit can sometimes mean there
is something happening on the inside of your bowel. We need to find out about this as early as
possible as the earlier we find out someone has a medical problem the earlier it can be treated
What could be happening inside my bowel to cause my symptoms?

The sort of things we are looking for include inflammation and abnormal growths. If we see
evidence of this we take a sample so that we can analyse further and decide on further
management.
26
By growths do you mean cancer?
A growth can represent cancer yes, and this is one of the things we are hoping to rule out. A
growth can also represent a benign tumour, which once removed shouldn't cause you any more
problems, or be a precancerous lump, meaning that it will one day turn into cancer. The
colonoscopy allows us to find this information out, and treat the precancerous lumps before they
turn into a cancer.
What happens if something is found, will I be told what it is straight away?

It normally takes a while for the histology, which involves looking at cells under a microscope, to
return. Once it does we will discuss the results with a multidisciplinary team of experts so that the
best management can be decided on. We will then contact you to arrange a time to come back in
to receive the results, This will usually be within two weeks of the procedure.
When this happens it is a good idea to ask a close friend or relative to come in with you.
The good news is that you are in good hands and having the investigation that you need to find
out the cause for your symptoms.
What are the risks for this procedure?

The most serious risk in a colonoscopy is damage to the bowel wall. This occurs very rarely; you
should see a doctor if you experience any abdominal pain, a fever, shortness of breath, vomiting
or significant amount of blood in your stool afterwards, although if a biopsy is taken, a small
amount of blood is normal.
You may also feel bloated and have wind-pains, which should disappear within 24 hours.
Occasionally, the colonoscopy will have to be repeated.
The surgeon performing the procedure will go through the risks in more detail for you later.
How long does a colonoscopy last?

The procedure itself will last around 20-30 minutes, with time around it to explain the procedure,
gain consent, and position you.
What foods should I avoid after the procedure or can I eat normally?
You can eat normally after the procedure
What is the Dukes classification of colon cancer?

The Duke's classification is a system used to stage colon cancer based on level of invasion. It has
been replaced in clinical practice by the TNM staging system
What the actor was told

Name: Aditya Sreedharan
Attitude: Confused as to why you need the colonoscopy as your GP arranged it without fully
explaining the reasons for it.
27
What you know: You have had a change in your bowel habit, which you first noticed about a year
ago, but only recently presented to your GP when your trousers became loose and you realised that
you had lost weight. The GP arranged a blood test and this colonoscopy which you understand to
mean that the specialist doctors will look at the insides of your bowel. You don’t know what the
procedure involves or why it is being done
Responses: You should start by asking politely for an explanation of the procedure before moving on
to ask why the procedure is being done. Look and sound confused if medical jargon is used.
Understand when simple terms or a diagram is drawn for you. When the doctor mentions why you
are having it, if the word cancer is used straight away, then appear shocked and upset saying no one
had told you that was a possibility. If they use terms like a mass/lump etc, push them to what that
means, and ask directly could this be cancer? Ask about the risks of the procedure and the other
questions on the mark scheme
Key Information
This station is testing how well you can communicate the need for a procedure and what the
procedure involves.
Start by washing your hands and introducing yourself.
Find out it they’ve had a colonoscopy before and what they know about the procedure.
When explaining a colonoscopy, it is important to break the explanation down:
“It is a camera test to look at the insides of your bowel. It involves having a camera about as wide as
a 2 pence piece inserted in your back passage to have a look at the large intestine. The pictures
generated will appear on a screen. Before hand you shouldn’t have any food for 6 hours, but can
drink clear liquid. You will be given laxatives to clear your bowels out to allow us to see clearly. You
will be awake for the procedure but receive sedation medication which means you will not mind the
procedure too much, and won’t remember it clearly. It also means you will be drowsy after the
procedure and can’t drive so it is important to arrange transport home afterwards. During the
procedure you may feel as if you are passing wind as air is passed into the bowel, you shouldn’t feel
embarrassed. The operator may ask you to move around onto your side or back at certain times.
Take your time as you do this. They may take a tissue sample or remove small growths for testing if
they see them. This will not hurt.
The reason for a colonoscopy is because a change in your bowel habit can sometimes mean there is
something happening on the inside of your bowel. We need to find out about this as early as
possible as the earlier we find out someone has a medical problem the earlier it can be treated.“
You should briefly explain the risks and state that they will be discussed more thoroughly with the
patient during the consent process.
“Risks include damage to the bowel wall which occurs very rarely and you should see a doctor if you
experience abdominal pain, fever, shortness of breath, vomiting or significant amount of blood in
your stool; however if a biopsy is taken, a small amount of blood is normal. You may feel bloated and
have wind-pains, which should disappear within 24 hours. Occasionally, the colonoscopy may have
to be repeated. The surgeon performing the procedure will go through the risks in more detail for
you later.
If asked is it cancer, explain that among other things the test is being done to rule out a cancer.
Carefully explain that the procedure following the test, including that the histology takes a while to
return, that the case will be discussed in a multidisciplinary team of experts, and that he will be
contacted to arrange a time to receive the diagnosis. Suggest that when this happens, a close friend
or relative can come in with him. Reassure him that he is in good hands and having the investigation
that he requires
28
When explaining procedures, use of a diagram can help patient understanding, and there will usually
be a pen and paper available to you; if not you can ask the examiner for this.
Remember to use the 4 key communication techniques to maximise your marks
Establish a rapport by asking an open question - this allows them to talk and set the scene for you
and points to where the marks are going to be
Split longer answers into 3 parts - this gives your answer a beginning, middle and end, keeping the
examiners attention by sign posting what you are saying, and prevents you from waffling
Actively listen, by leaning in when the patient is talking, using active encouragement, eg "I
understand..." and leaving appropriate pauses to allow them to express their feelings - feelings that
will undoubtedly be on the mark scheme!
Summarise the consultation, keeping things brief and asking them if there is anything else they
would like to ask - allowing you to sweep up any remaining marks that you have missed to this point
29
10. HAEMATURIA
You are the CT1 in Mr Howard’s urology clinic. Mr Jones is a 61 year old man who has been
referred to clinic with haematuria. You have been asked by your consultant to take a history,
present your findings to him and he will then ask you some questions about the case
Candidate:
Hello, my name is Tom Robinson, I am a core surgical trainee working for Mr Howard. How can I
help you today?
Actor:
Well, the main reason I am here is because I’ve noticed my urine becoming redder over the last
month.
Candidate:
Okay. Tell me a bit more about this reddening of your urine.
Actor:
I’ve noticed that when I go to the bathroom, my urine comes out very red. It doesn’t hurt, but it’s
quite scary.
Candidate:
Is it painful when you pass urine?
Actor:
No
Candidate:
Have you had anything like this before?
Actor:
No
Candidate:
Do you have any other problems with your waterworks?
Actor:
I have had to get up in the middle of the night to go to the bathroom in the last year which is
unusual for me. I’d just put it down to age really.
Candidate:
Have you had any unintentional weight-loss recently?
Actor:
Yes actually. I’ve lost about a stone in the last few months
Candidate:
Do you have any other medical conditions?
Actor:
No
Candidate:
Do you take any regular medications?
Actor:
No
30
Candidate:
Do you have any allergies?
Actor:
No
Candidate:
What is your occupation?
Actor:
Well, I’m retired now but I used to work in the rubber dye industry.
Candidate:
Do you smoke?
Actor:
Yes. A bit too much probably. I smoke about 2 packs a day, and have done for 20 years.
Candidate:
Are there any medical problems which seem to run in the family?
Actor:
Well, my dad had COPD and my mum died of lung cancer when she was 75.
Candidate:
I’m sorry to hear that. Do you suffer from any other problems at the moment, for example do you
get breathless easily, suffer from chest pains, dizziness, constipation?
Actor:
No
Candidate:
What do you feel may be causing your symptoms?
Actor:
Well, to be honest doctor I’m worried it might be cancer.
Candidate:
Why do you think it might be cancer?
Actor:
My mate had the same problem a few years ago and was diagnosed with cancer. Do you think it
could be?
Candidate:
It is one of many possibilities, but I really cannot say anything for definite until we have run a few
more tests.
Is there anything else that you would like to ask me?
Actor:
No, thank you doctor
Examiner:
I’m going to stop you there. Please present your history.
31
Candidate:
I saw Mr Jones in the urology clinic today. He is a 61 year old smoker who previously worked in the
rubber dye industry. He presents with a one month history of painless haematuria with associated
weight loss of one stone over the last 3 months, and nocturia. He is otherwise fit and well, takes no
medications, has no allergies, and has a family history significant for lung cancer and COPD. He is
concerned about the possibility of having cancer.

The most important diagnoses to exclude are bladder cancer and renal cell carcinoma. Given his age,
smoking history, occupational history, and recent weight loss these would be at the top of my
differential.
Other diagnoses to be considered include infection, stones, or trauma of the kidneys, ureters,
bladder, prostate or urethra.
What else would you like to do to narrow down your differential?

I would like to perform a full examination of the patient looking particularly for abdominal masses
and evidence of metastatic disease.
Further, I would like to perform simple bedside investigations including urine dipstick to confirm
haematuria, assess for presence of infection, and send a sample off for cytology.
I would want to take bloods including FBC looking for anaemia, U&Es looking for renal dysfunction,
clotting screen, and PSA to assess for prostate cancer. This could followed up with imaging including
cystoscopy, USS or CT.
Let’s say now that we are several months down the line and we have diagnosed transitional cell
carcinoma of the bladder. What treatment strategies are available?
The patient would be managed in a multidisciplinary setting with the input of specialist urology
surgeons, pathologists, radiologists, oncologists, and specialist nurses.
The type of treatment would depend upon the stage and grade of tumour, patient factors, and the
latest evidence base available.
Treatment can include non-surgical options e.g. chemotherapy, radiotherapy, and surgical options
e.g. transurethral resection of bladder tumour, radical cystectomy.
Key Information
• Painless frank haematuria should be considered to be cancer until proven otherwise.
• Key aspects of the history include exposure to carcinogens e.g. smoking, rubber dye.
• The patient will often have an idea of cancer in their mind.
• Keep in mind the other causes of haematuria as there are simple tests for many of them e.g.
dipstix for UTI.
• The management of a patient with cancer always starts with the multidisciplinary team.
32
11. HIDDEN DIAGNOSIS
You are asked by the nurses to talk to Mr Barry Jones, the son of Jennifer Jones a patient under
your care. Mrs Jones is a 78-year-old lady who was admitted following a fall. She had a CT head
yesterday which shows a right-sided lesion suggestive of a malignant tumour. The patient has not
yet been told the news.
The patient’s son would like to speak to you about his mother’s condition and recent scan. She has
given you permission to discuss anything about her including the results of the scan with her son.
How would you open the consultation?
After introducing myself I would start with an open question, to find out what the relative knows
already.
"Hello, I am James the surgical doctor looking after your mum. I understand you wanted to talk to
me about your mother's care. Can I ask what you know so far?"
"Thank you for taking care of Mum. I know she came in because of a fall, but has made a good
recovery back to normal. She had a scan yesterday, and I wanted you to discuss them with me first,
as she is doing we and I don't want her upset if there is anything bad on it. Mum has given you
permission to tell me the results first"
How would you respond?

I would suggest it would be better if we all discussed the results of the scan together so that we can
talk about what we are going to do next.
He replies angrily that his mother has asked him to find out the results first, and explicitly given you
permission to tell him the results.
What would you do?

I would apologise and check with the patient that she wants me to give her son the information
before I speak to her.
If the patient wants me to tell her son first, and he is insisting on this I would give him the results
without his mother present, but explain that it is important for us all to discuss the results together
soon afterwards.
33
How would you approach giving the results, presuming you had confirmed with your consultant
that you should do so in the manner the relative has asked for?
I would give a warning shot, by saying that the scan has shown something abnormal. I would follow
this up by suggesting that we can't be sure what the abnormal lesion is, but that there is a possibility
that it could be a tumour.
Following the silence the station might go as follows

"Do you mean this could be cancer?"
There is a possibility it could be cancer, however we wont know until we discuss the scan at the
multidisciplinary team meeting with the radiologists and oncologists, and decide what the next step
is going to be
"What happens next"

Once we have discussed your mothers case, we will consider whether she needs a biopsy, to allow
us to diagnose exactly what the lesion is. After this we will be able to give you more information
about her management options.
"I'd like you not to tell her about this yet, as she's happy at the moment, and I don't want this news
to upset her"
I understand that you want to protect your mother. However I think it is important that she know's
everything that we do so that she is able to understand what is going to happen next.
She should be allowed to decide on what investigations and treatment she will accept, and to do so,
she needs to be fully informed and involved in all discussions.
Normally patients are much happier when they know the reason for their symptoms than if they are
kept in the dark. Therefore I have to give her the same information that I have given you.
I hope you understand?
The relative eventually agrees that you will tell his mother.
How would you close the consultation?
I would summarise our discussion and arrange a time in the next few hours when I can return and
talk to the patient with her son present. I would also offer to bring a senior along with me if they
wished to ask further questions regarding future management
What the actor was told

Name: Barry Jones
34
Attitude: Concerned about your mother
What you know: Your mother has been complaining about left sided weakness for a few weeks now,
and now she has had a fall, you are concerned that she may have had a stroke or even worse brain
cancer. You are very close to your mother and don’t feel that she should be told if the diagnosis is a
bad one. You would like to know the results of the scan and for the doctor to agree to not tell your
mother as you think she would react very badly, and as she is doing so well, you don’t feel she would
want to know what the diagnosis was anyway.
Ask the candidate to promise to withhold information from your mother. Become initially cross if
they say they have to inform your mother, and then become placated if they give an explanation
making you realize that it is better for your mother to know.
Key Information
When speaking to a relative it is essential to ensure you have consent from the patient for the
discussion. In this case it is made explicit in the scenario.
Start by washing your hands and introducing yourself. Find out what they know by asking an open
question. “Can I ask what you know so far?”
Actively listen to the relative’s answer.
When breaking bad news, it is important to first give a warning shot “I’m afraid the news isn’t good.
Unfortunately you are right that there is something happening in your mother’s head. The CT scan
that we performed shows a mass in the brain.”
If appropriate after giving this information you can pause and leave a silence to allow the
information to sink in.
The treatment pathway for a possible brain tumour is the same as for any other cancer. It involves
obtaining a tissue diagnosis and discussion in an MDT where a decision over the best course of
action will be made.
If at any point in the OSCE you are asked for information that you don’t know the answer for, you
should explain that you will arrange for one of your senior colleagues to come and give the
information rather than make anything up.
When asked to keep the CT results a secret you should be empathetic to the sons concerns, and ask
whether his mother has previously stated a wish not to be told of any serious diagnosis, or whether
she has an advanced directive stating this. If not, you need to explain why it is important that the
patient is told of her CT result. This is so that she is aware of treatment options, and of what will
happen over the next couple of weeks. She should be allowed to decide on what investigations and
treatment she will accept, and to do so, she needs to be fully informed and involved in all
discussions. Reassure the son that normally patients are much happier when they know the reason
for their symptoms than if they are kept in the dark.
Establish rapport by asking an open question - this allows them to talk and set the scene for you and
points to where the marks are going to be
would like to ask - allowing you to sweep up any remaining marks that you have missed to this point.
Arrange a time in the next few hours when you can come back and talk to the patient with her son
present.
35
12. JEHOVAH’S WITNESS
Mr Ungwe is a 67-year-old man who is due to have a craniotomy for a removal of a highly vascular
brain tumour. Normally this would require 4 units of blood to be crossmatched; however Mr
Ungwe is a Jehovah’s witness and he has previously stated that does not want a blood transfusion.
Talk to Mr Ungwe about the operation with particular attention on the possibility of a blood
transfusion.
Please explain the operation Mr Ungwe is going to have including the possibility of a transfusion,
using the information you have
Hello Mr Ungwe, I am Rosa one of the surgical SHOs, I wanted to discuss the operation you're due to
have if that's ok?
Can I start by finding out what you know?
He responds, "I know I am going to have an operation to take out a brain tumour. If it goes well,
please God, I will be cured. I understand there are risks"
Yes. We are planing an operation to take the tumour out of your head. It is a risky operation mainly
because the tumour can bleed a lot. Therefore I wanted to get your permission to crossmatch and
store some blood so that it is available if the need arose.
Would that be okay?
He refuses as he is a Jehovah's witness and believes it is wrong to receive a blood transfusion.

He asks you, "What are the risks if I don't?"
The tumour is a vascular tumour, which means that it can bleed a lot. We will do our best to avoid
this but bleeding can be unavoidable sometimes. The risks if we can't stop the bleeding are that we
have to abandon the operation before the tumour is completely removed. It could also cause a
serious stroke, and there is an increased risk that you could die.
He understands this but still refuses a blood transfusion.
How would you check the patient has capacity to make this decision?
I would ask them to relay the information and the risks of refusing a transfusion back to me.
Patient's have capacity to refuse treatment even life saving treatment if they can understand, retain
and weigh up the information, and are able to communicate their decision by any means
36
Who would you inform of this decision?
I would discuss the refusal of a blood transfusion with the consultant neurosurgeon, anaesthetist,
and liase with theatre staff
Should the operation be considered safe without a transfusion what precautions can be taken to
reduce the risk?
Preoperatively, I would check the baseline Hb; if low it may be worth postponing the operation and
establishing a higher baseline Hb. I would discuss the case with a haematologist and consider
erythropoietin to increase the preoperative Hb. I would consider starting IV fluids to ensure good
hydration in the run up to the operation.
Intraoperatively, a quick operation by an experienced consultant is preferable, with focus on

haemostasis. We could use a cell salvager to allow blood lost to be replaced in an autologous
transfusion. Good communication between the anaesthetic and surgical team is important to ensure
that blood loss is anticipated and treated quickly with fluid replacement.
Postopratively, I would ensure adequate hydration, recheck the Hb immediately after the operation,
then again in the evening and morning after. I would hand this patient to the on call surgical team
and clearly document the refusal of transfusion under any circumstances in the notes.

I would close by summarising our discussion and documenting it in the notes.
For instance
We have been through some of the risks of the operation, and discussed why we would recommend
that you have blood available for a transfusion. You have decided to refuse a transfusion, even in the
event that it is needed to save your life. As you understand all of the risks, we will respect your
decision and I will make sure everyone involved in your care is aware of it.
37
I have told you that we will take extra precautions to minimise the risk of significant blood loss, and
you are happy with these precautions.
Do you have any further questions?
What the actor is told

Name: Ken Ungwe
Attitude: Adamant that you will not have a blood transfusion as you are a Jehovah’s witness and you
believe that doing so is a sin.
What you know: You have a brain tumour that is operable, but the operation is risky. You have been
told by the house officer that you may need a transfusion as the tumour can bleed a lot. You have
told them you don’t want a transfusion, and if necessary to cancel the operation. A senior house
officer has come to you to discuss your options.
Responses: You get angry if the candidate insists that you must have blood available for the
operation, but otherwise are pleasant and inquisitive. When it is established that you will not have a
transfusion, you should ask, “what are the alternatives to a transfusion?” You may prompt if they
don’t mention preoperative measures, intraoperative measures and postoperative measures. If not
mentioned you should ask, “is there a risk I could die?”
Key Information
In any refusal of treatment station, it is important to empathise with the patient to understand why
they are refusing the treatment. In the case of a Jehovah’s witness, it is important not to assume
refusal of blood products. Instead you should explain why a transfusion could become necessary and
why it is advisable. Explain to them the risks of the procedure, including heavy bleeding. It is
important to emphasise that by refusing a blood transfusion there is an increased risk to their life in
the event of a haemorrhage.
Establish capacity to make a decision by checking they understand this.
A patient has capacity if they can
Understand the information relevant to the decision
Retain the information relevant to the decision
Use or weigh the information
Communicate the decision (by any means)
Once established it is important to respect patient autonomy by allowing their decision to stand,
whatever that decision is.
Assuming the operation is in their best interests and the risk of haemorrhage doesn’t out weigh the
benefit the operation will provide, there are other alternatives to a blood transfusion.
Preoperatively, it is important to check baseline Hb; if low it may be worth postponing the operation
and establishing a higher baseline Hb. Discuss the case with a haematologist and consider
erythropoietin to increase the preoperative Hb. Good hydration is important in the run up to the
operation, so consider starting IV fluids
Intraoperatively, measures can be taken to reduce the risk. A quick operation by an experienced
consultant is preferable, with excellent haemostasis an imperative. Use of the cell salvager will allow
38
blood lost to be replaced in an autologous transfusion. In addition for some certain operations (e.g.
when treating epistaxis) transexamic acid can be used to reduce heavy bleeding.
Postopratively, you should ensure adequate hydration, recheck the Hb immediately after the
operation, then again in the evening and morning after. It is important to let the on call surgical
team know about this patient and the refusal of a transfusion, with clear documentation in the
notes.
Establish a rapport by asking an open question - this allows them to talk and set the scene for you
and points to where the marks are going to be
would like to ask - allowing you to sweep up any remaining marks that you have missed to this point
39
13. LEG PAIN, CLAUDICATION
You are the CT2 in Mr Harrison’s vascular clinic. You have been asked to see Mr Walters who is a
55 year old man with lower leg pain. Your consultant wants to you take a history from him, and
then come and present the findings to him. You will be asked a series of questions about the case.
Candidate:
Hello, I am Joseph Sabaya. I am a core surgical trainee working for Mr Harrison. How can I help
you?
Actor:
I have had these pains in my legs for the last 6 months. It is really bothering me. I can’t sleep.
Candidate:
Tell me a bit more about these pains, when do you get them?
Actor:
Well, they come when I’m walking, particularly in the calves.
Candidate:
Do you ever get woken up at night by the pain?
Actor:
Yes in fact, but the pain seems to be in my feet at night. I have to dangle my feet over the bed to
relieve the discomfort.
Candidate:
How far can you walk before having to stop because of the pain?
Actor:
About 100 meters.
Candidate:
Has it suddenly become worse or has it gradually worsened over the months?
Actor:
It has gradually worsened over the months.
Candidate:
Do you get any pain at rest?
Actor:
No. Only when I’m asleep at night, otherwise rest seems to relieve the pain.
Candidate:
Do you suffer from any other medical problems, for example diabetes?
Actor:
Yes, I have type two diabetes mellitus and am taking metformin
Candidate:
Have you or anyone in your family ever suffered from a heart attack or stroke or had problems
with pains in Che legs?
Actor:
My father died of a heart attack aged 60, and my mother died of a stroke aged 70.
40
Candidate:
Do you smoke?
Actor:
Yes, about 3 packets a day for as long as I can remember.
Candidate:
Do you take any other medications?
Actor:
No
Candidate:
Do you have any allergies?
Actor:
No
Candidate:
Aside from the leg pains, is there anything else causing you trouble at the moment, for example do
you get chest pains or short of breath?
Actor:
No
Candidate:
Thank you. Is there is anything you would like to ask me?
Actor:
No, thank you doctor.
Examiner:
Please present your findings.
Candidate:
I saw Mr Walters in the vascular clinic today. He is a 61 year old overweight smoker with lower leg
pains for the last 6 months, limiting his exercise tolerance to 100 metres and causing him pain at
night in his feet which resolves with resting his feet over the bed. He does not suffer from rest pain.
He suffers from type two diabetes mellitus and takes metformin for this. Otherwise he is fit and well.
He has a positive family history for vascular disease (mother had a stroke, father had a heart attack).

The history is consistent with chronic arterial ischaemia causing vascular claudication, however other
diagnoses should be considered including deep venous thrombosis and spinal claudication.
How would you distinguish clinically between spinal claudication and vascular claudication?
Spinal claudication is due to lumbar spinal canal stenosis, and patients suffer from paraesthesia
predominantly in a poorly localised distribution compared to the severe pain localised to the calves
and feet in vascular claudication.
What is critical ischaemia?

This is ischaemia severe enough to threaten the limb, and is clinically defined by rest pain, and ankle
brachial pressure index (ABPI) measurement less than 0.5.
41
How does the acutely ischaemic leg present?
The clinical signs and symptoms consist of pain, pallor, pulselessness, paraesthesia, paralysis and
perishing cold (“the six Ps”).
This comes on suddenly, often in the presence of atrial fibrillation, absence of previous vascular
disease, and the presence of normal pulses in the other foot.
Key Information
• This is a history of chronic vascular ischaemia of the lower limb.
• Other “mimics” include spinal claudication and deep venous thrombosis.
• Acute vascular limb ischaemia is a vascular emergency and must be recognised and dealt with
promptly.
• Critial limb ischaemia requires relatively urgent intervention, therefore it is important to
specifically ask about rest pain, and exercise tolerance.
• Most patients with chronic vascular claudication will have a personal and/or family history and/or
risk factors for vascular disease.
42
14. TELEPHONE REFERRAL
You are the surgical SHO at a DGH. Mrs Franklin is a 50-year-old lady who had a laparoscopic
cholecystectomy 4 days ago. She has been complaining of abdominal pain since the operation and
you have noticed bile in her abdominal drain.
Your consultant has asked you to refer her to Prof Adli at the Royal Free Hospital in London. Spend
10 minutes reviewing the notes, and then you will be asked to phone him and refer the patient.
There is a 10 minute preparation station
You are given a set of notes to flick through
Clinical assessment
43
Clinical assessment
Clinical Assessment
44
Bloods
Operation Note
45
The patient is sent for a scan.
Here is image that is seen.
Please call Prof Adli at the Royal Free Hospital in London and ask him for advice and refer the
patient to him for ongoing care.
Hello, my name is Sandra, I am the surgical SHO working for Mr Jameesh at the Crawfields Hospital. I
am calling to speak to Prof Adli, the hepatobiliary consultant to ask advice on a patient who has a
bile leak day 4 post-laparoscopic cholecystectomy. Could I check that I am speaking to Prof Adli,
please?
Yes, I am Professor Adli, how can I help?

Mrs Smith is a 50-year-old previously fit and well lady who underwent a laparoscopic
cholesystectomy 4 days ago. She has been complaining of abdominal pain since, and today we have
noticed bile in the drain. Clinically she is slightly jaundiced, and on examination she is not peritonitic
but has generalized abdominal pain; she is also tachycardic and pyrexic.
Her bloods from 2 days ago show a slightly raised bilirubin, ALP and CRP. Full blood count and U+Es
were normal.
So far we have started fluid resuscitation and antibiotics and arranged for an ultrasound.
We suspect that she has a bile leak, and I was hoping to refer her for transfer to your specialist care
for definitive treatment, if possible.
Why do you think her CRP is up? Is there an infection?

As the CRP is an acute phase protein, it is likely to be raised due to the operation. The trend is
showing it to be decreasing, and in this patient the pattern of symptoms fits with a bile leak.
When were those bloods taken?

Unfortunately the last set of bloods were taken 2 days ago. I apologise that I don't have a more
recent set available, but I'll make sure they are sent as soon as I am off the phone
46
What does the Ultrasound scan show?
The ultrasound scan shows a bile leak (black arrow).
What do you think the diagnosis is and what investigation do you think this patient needs?
We suspect this patient has had a bile leak; therefore she needs an ERCP to identify the location of
injury and the presence of any retained stones.
What does ERCP stand for and what does it involve?

ERCP stands for Endoscopic Retrograde CholangioPancreatography. It is an X-ray examination of the
common bile duct and the pancreatic duct.
It involves an operator passes a flexible telescope down the oesophagus into the duodenum. Dye is
injected through the ampulla of Vater to allow the bile ducts, pancreatic duct, gallbladder and
hepatic ducts to be visualised when an X-ray is taken. A bile leak will be shown by extravasation of
dye into the abdomen.
How is this managed?

First the patient is stabilized, fluids and antibiotics commenced
Referral to a tertiary hepatobiliary centre is appropriate
Definitive management is either by stent placement or operative management which aims to restore
biliary continuity via a bilioenteric anastomosis such as a Roux-en-Y choledochoduodenostomy.
There are no beds available at this hospital at the moment. How do you think we should proceed?
I will alert the bed managers in both hospitals of the urgency of the transfer and ask if they have any
way of creating a bed for this patient, for instance, by facilitating the discharge or repatriation of a
patient.
47
What the Professor was told:
Name: Prof Adli, eminent hepatobiliary professor.
Attitude: You are friendly, but like the message to be to the point.
What you know: Nothing about this patient
Responses: Once the introductions have been made, let the candidate give you the information at
their own pace. Ask them for any details that they have failed to tell you eg "When were those
bloods done?", "2 days ago and no blood since?!"
Turn the station into a viva once the information has been accurately presented to you. Ask the set
questions on the mark scheme
Key Information
It is important in the preparation station to get a feel quickly for what the most important
information is. Make notes as if you were the one receiving the referral. Make sure you check the
date and time of the investigations and circle all the abnormal results.
Referral to a Professor might appear daunting, but you should follow the same process as you do for
any referral
Open by introducing yourself and the reason for your call, asking if you are speaking to Prof Adli.
For instance:
“My name is X, I am the surgical SHO working for X at the X Hospital. I am calling to speak to Prof
Adli, the hepatobiliary consultant to ask advice on a patient who has a bile leak day 4 post-
laparoscopic cholecystectomy. Could I check that I am speaking to Prof Adli?”
Give the key clinical history succinctly:
‘Mrs Franklin is a 50-year-old previously fit and well lady who underwent a laparoscopic
cholesystectomy 4 days ago. She has been complaining of abdominal pain since, and today we have
noticed bile in the drain. Clinically she is not periotonic but has generalized abdominal pain; she is
tachycardic, but otherwise stable.
Her bloods show….
So far we have ….
I was hoping to refer her for transfer to your specialist care.’
Notice that the blood tests results were 2 days old, which the prof will undoubtedly pick you up on.
Apologise and assure him you will send a set of bloods today.
You should thank the professor for accepting the patient once a bed does become available and
indicate that you will facilitate this process.
To find a bed in a hospital, it is important to make the bed manager in both hospitals aware of the
urgency of the transfer. They may be able to hasten the transfer out or discharge of another patient
to accommodate your patient.
Remember to summarise the plan, and thank the Professor for his advice
48
49
15.SELF DISCHARGE
You are the on call surgical registrar. Please talk to Mr Donald, find out why he wants to go home,
and explain why he must stay in.
James Donald is a 27-year-old man who presented with right iliac fossa pain. History, examination
and investigation including US and bloods point to a possible but not definite appendicitis
Mr Jones the colorectal surgeon has reviewed him and decided that he wants to observe the
patient in hospital for the next 24 hours, with a view to a laparoscopic appendicectomy in the
morning if he fails to improve and an emergency appendicectomy overnight if he deteriorates.
The patient is feeling a little better, and although he still has some pain, it is bearable and he has
asked to speak to you about letting him go home.
What would you do before speaking to him?

I would review the notes and investigation results and speak to the consultant involved as it may be
that the patient is safe to be discharged.
After speaking with the consultant, he tells you that this patient should stay in as his life is at risk if
he does not.
The patient asks to be medically discharged regardless as he lives near the hospital, “its probably
nothing” and his young family is at home. Your wife will be able to look after you and bring you back
in if you feel any worse, and you don’t mind coming back in in the morning to see the consultant
again.
How would you respond?

I would spend some time establishing why the patient wants to be discharged. If there is something I
can change to make him agree to stay, I would make it happen if possible.
I would explain why going home is not medically advisable and stress that the consultant, the expert
in this field, wants him observed overnight. This means there is a real possibility that he could get
worse. I would stress that if he goes home he could become seriously unwell and even die.
50
He still wishes to go home, can you keep him in hospital against his wishes?
If he has capacity to make a decision then I can't prevent him from going home even if the decision
does not seem to be a sensible one. He will have to self-discharge.
How would you assess his capacity?

I would ask him to repeat what I have told him back to me to check capacity to make this decision.
If he can understand the risks associated with him going home, retain that information, weigh it up
and communicate his decision back to me then he has capacity to make the decision.
He demonstrates his capacity to make this decision. What must you do now?
As I cannot discharge him medically, I would explain that he needs to self-discharge, explaining that
he is responsible for the consequences of the decision.
He must sign a legal document that states that the clinical scenario was explained, continued
admission was medically advised, the potential consequences of self-discharge have been explained
and he takes responsibility for any adverse outcomes.
The patient asks: "Can I have some pain killers to take home with me?"
As he is self-discharging, I cannot officially give him any to take home medication (TTOs), however I
would advise him to buy appropriate analgesia from a chemist.
He agrees and signs the self discharge document.

What advice would you give him?
Once it is established that he will self-discharge, I would give him information on what symptoms to
look out for and what to do if the symptoms return or worsen, suggesting that he should attend A&E
and ask them to contact the me or surgical SHO directly.
I would also arrange for the patient to be seen by the team as a ward attender or outpatient if he is
able to return the next day.
Who would you inform of the patient's decision?

I would inform the consultant in question, the consultant on call if different and the bed manager.

I would close the consultation by summarising what we have discussed. For instance:
"Mr Donald, you have decided to self discharge and signed the appropriate documentation,
therefore I am going to sum up what we have been through. You know you could have appendicitis,
and that the medical advice is to keep you in hospital. You understand the risks of not being in
hospital, which include becoming more unwell and possibly even dying. You have accepted
responsibility for those risks. We have discussed what signs to look out for, and that you will return
51
to hospital if you feel more unwell. Our door is always open. You will return tomorrow to see the
consultant in the morning.
Could you repeat that back to me so I can check I have got it right, and please ask any questions you
have"
What the actor was told in this station.

Your name is James Donald a 27-year-old who has come to hospital with abdominal pain, which the
doctors say might be appendicitis. You are feeling a bit better now than when you presented 8 hours
ago, the morphine has helped your pain, you have had all the investigations and you understand
that the consultant feels you don’t need an emergency operation but wants to watch you overnight.
You are otherwise fit and well, and are not confused.
You have decided that you don’t want to stay in hospital as “its probably nothing” and your young
family is at home. Your wife will be able to look after you and bring you back in if you feel any worse,
and you don’t mind coming back in in the morning to see the consultant again.
You are aware that your life is at risk if you go home, but feel that this risk is small, you also
understand that you should come back in immediately if you feel worse.
You ask the candidate to discharge you and prescribe some painkillers
You get frustrated if the candidate insists that you should stay in and angry if they tell you are not
allowed to leave. If this happens you should ask, “don’t I have the right to decide what I should do?
Can’t I discharge myself?”
If the candidate explains that he cannot discharge you as he does not feel it is safe to do so, but that
if you understand the risks you can self discharge signing a form saying it is against medical advise
you are appeased. Tell them that you do understand the risks, but you want to self discharge and
will sign the form
They are not able to convince you to stay no matter what they tell you
Repeat wish for painkillers if necessary.
52
Key Information
Self discharge is a common scenario you will have experienced in the hospital itself. In the OSCE it is
more formalised and you need to display a range of different communication skills to score full
marks - and remember these marks are as valuable as the marks for anatomy, so spend time
practicing!
It is important to spend sometime establishing why he wants to be discharged. If there is something
you can change to make him agree to stay, you need to find out about it and if possible make it
happen.
You then need to explain why going home is not medically advisable. Stress that the consultant
wants him observed which means there is a serious possibility that he could get worse. You must
stress that if he goes home he could become seriously unwell and even die.
Ask him to repeat what you have told him back to you to check capacity to make this decision.
Remember that if he can understand the risks associated with him going home, retain that
information weigh it up and communicate his decision back to you then regardless of whether it is a
sensible decision, you must accept it.
As you cannot discharge him medically, you should explain that he needs to self-discharge,
explaining that he is responsible for the consequences of the decision.
He must sign a legal document that states that the clinical scenario was explained, continued
admission was medically advised, the potential consequences of self-discharge have been explained
and the patient takes responsibility for adverse outcomes.
As he is self-discharging, you cannot give him any take home medication; however you can advise
him to buy analgesia from a chemist.
Once it is established that he will self-discharge, you should give him information on what to look
out for and what to do if the symptoms return or worsen, suggesting that he should attend A&E and
ask them to contact the surgical SHO directly.
You can arrange for the patient to be seen if he is able to return the next day.
You must inform the consultant and bed manager as soon as possible about the outcome of the
consultation.
Remember to display appropriate body language throughout the scenario. This is best done by
forgetting that this is an actor, and imagine instead that this is a real patient who is under your care.
The much used mark scheme phrase "ideas, concerns and expectations" wants you to find out what
the patient thinks about the current issue, what is worrying them and what they want from you.
Covering these issues is a good way to demonstrate your empathy in the communication station and
score the communication marks in other stations.
Summarise the discussion and check their understanding to close the consultation.
53
54
16.RADIOLOGY REQUEST
You are the core surgical trainee in General Surgery on call. You have been asked by your registrar
to organise a CT scan of the abdomen and pelvis TONIGHT for a 51 year old man with severe left
iliac fossa pain, localised peritonitis and raised inflammatory markers. He is otherwise fit and well.
His observations show a sinus tachycardia and raised temperature of 38.9 degrees. You have to
discuss the request with the radiology registrar on call.
Candidate:
Hello. My name is Dr Thompson. I am the general surgical core surgical trainee on call. Am I
speaking to the radiology registrar on call?
Actor:
Yes. How can I help you?
Candidate:
I would like to arrange an urgent CT of the abdomen & pelvis of a 51 year old man who was
admitted to the surgical assessment unit yesterday evening with acute left iliac fossa pain, and
localised peritonitis, please.
Actor:
Okay. Put a request in and I’ll arrange it for the morning.
Candidate:
Actually, I would really like the CT to happen tonight, if possible. I am concerned that he may have
a collection or localised perforation of the bowel given his worsening clinical examination findings.
Actor:
If you’re worried about perforation shouldn’t you be taking him to theatre rather than wasting time
with a CT scan? We are extremely busy at the moment and this doesn’t sound like it is going to
change your management
Candidate:
I appreciate that you are busy. My registrar has examined the patient and feels that a CT scan is
the best first course of action. He has been on treatment for diverticulitis for 24 hours and is
getting worse. He is very keen that we get this done this evening to guide us.
Actor:
Okay, what are you going to do this evening if it does show a perforation?
Candidate:
I will review the scan with my registrar and consultant. If it shows a significant perforation we may
have to take him to theatre tonight. It may also guide us to an alternative diagnosis.
Actor:
Okay. What is his renal function?
Candidate:
I do not have the renal function results to hand. I will check his renal function as soon as I am off
the phone and call you back with the results.
Actor:
Does he have any co-morbidities which might put him in a high risk group for contrast?
55
Candidate:
He doesn’t have any risk factors for renal impairment, and he is not allergic to contrast.
Actor:
Okay. Give me his details and put a request through on the computer system. I will contact the
radiographers to see if we can get it done soon.
Key Information
• These scenarios typically start with a preparation station to familiarise yourself with the patient’s
history and examination findings based upon a set of case notes.
• Ordering imaging out of hours can be a challenge as there are fewer resources available.
• It is important to be clear about what you want in terms of imaging and urgency, with a clear
rationale.
• You may be challenged more than you would be during normal working hours, particularly as a
junior doctor, but it is important to stay calm and focus on the clinical issues.
• It is important not to make things up – this will reflect very badly in the exam scenario.
56
17. MAKING A REFERRAL
Mr Choi is a 56-year-old gentleman who presented with symptoms of a ruptured appendix. He is
unwell and will need an emergency laparotomy, which has been arranged. His past medical history
includes chronic renal failure, an MI two years ago, and hypertension.
You have 10 minutes to prepare after which you should discuss this patient with the ITU registrar
on call to get advice on management and arrange an HDU bed postop.
There is a 10 minute preparation station
Please review the patient's notes
Clinical assessment
57
Clinical assessment
Clinical assessment
58
Drug chart
Observation chart
59
Blood results
ABG
Please refer this patient to the ITU registrar on call to get advice on management and arrange an
HDU bed postoperatively
Hello, my name is Mr Jones. I am the surgical SHO working for Mr Hendry the colorectal consultant
at the Newcastle Royal Infirmary. I am calling to speak to the ITU registrar to ask advice on an unwell
patient who has been today admitted and is going to require a laparotomy. I would also like to
arrange an HDU bed postoperatively. Could I check who I am speaking to, please?
Hello, I'm Dr Patel the ITU registrar. Could you tell me more about the patient please? I have to
see an unwell patient in HDU in around 10 minutes so please could you keep the story to the point
Mr Choi is a 59 year old with a background of chronic renal failure, an MI and hypertension, who
presented with a perforated appendix and has gone into acute renal failure, with hyperkalaemia. His
bloods tests show an potassium of 6.1, an creatinine of 240 up from a baseline of 175.
His ABG shows a metabolic acidosis, with a high lactate and high negative base excess.
Please could I have some advice on optimisation before theatre and would it be possible to arrange
an HDU bed?
60
What medication is the patient on?
They are on Bisoprolol, Ramipril, Simvastatin, Paracetamol and we have just started IV coamoxiclav
on microbiology advice.
Why do you think the lactate is high?

The most likely cause is sepsis secondary to perforation of the appendix
During the hypoperfusion of tissues, reduced oxygenation results in anaerobic respiration producing
lactic acid as the end point, and utilising it for energy production.
What is sepsis?
Sepsis is the presence of clinical signs of SIRS, the systemic inflammatory response syndrome
criteria, associated with infection either suspected or confirmed by culture or Gram stain.
The SIRS criteria are:
Temp > 38 or < 36
HR > 90
RR > 20 or PaCO2 < 4.3
WCC > 12 or < 4
What does the chest X-ray show?

We haven't arranged one yet, but I will do so as soon as I get off the phone.
Why do you think the patient is in renal failure?

The most likely mechanism is pre-renal failure secondary to sepsis. He has a background of chronic
renal failure making him more susceptible to an acute insult.
How do you think we should optimise this patient for theatre?

The patient is already on IV antibiotics. We should commence IV fluids to prehydrate him, as he
appears septic and under filled, although in light of their his MI I would be careful not to overload
him.
I would withhold his beta blocker and ACE inhibitor until his blood pressure improves.
He may warrant closer monitoring, with arterial and central venous monitoring, as his high
potassium, sepsis, and renal failure suggest he could deteriorate rapidly.
Do they meet the criteria for HDU admission?

Yes they do, as they require support for a single failing organ system, they don't require advanced
respiratory support and there is a reversible cause.
61
Dr Patel tells you he will come and review the patient before theatre, and asks you to liaise with the
anaesthetic registrar who is running the emergency list.
He will arrange an HDU bed for your patient post op.
What the ITU registrar was told

Name: Dr Patel - you are acting as the ITU registrar.
Attitude: You are quite busy, but able to listen to the history and advise on management,
What you know: There is one HDU bed available and a neurosurgical registrar who has requested a
bed for a subarachnoid haemorrhage has just phoned you. The patient is currently GCS 14, and is
coming over to have an external ventricular drain inserted for hydrocephalus. The reason for their
HDU admission is that they require observation in the event of deterioration.
Responses: Open by saying that you have to see an unwell patient in HDU in around 10 minutes so
please could they keep the story to the point. Be friendly if they summarise the story telling you
from the start that they want advice and to arrange a bed. Otherwise, interrupt and ask them what
exactly they want from you. Ask them for the clinical picture, for the blood tests, the comparison to
the previous tests and the ABGs. Go through their medications. Ask what the bowel sounds are –
(doesn’t have that information available). Ask what the chest X-ray shows (hasn’t had one). Advise
them to arrange a portable chest X-ray when they get of the phone. Ask what management has been
initiated. What is her premorbid status? Ask if this patient meets the criteria for HDU admission.
Suggest that they prehydrate this patient before theatre and that they inform the on call
anaesthetist that will be doing the case. Hold off the beta-blocker and the ACEI. You will come see
the patient and liaise with the on call anaesthetist and the neurosurgeon regarding the last bed.
Key Information
It is important in the preparation station to get a feel quickly for what the most important
information is. Make notes as if you were the one receiving the referral. Make sure you check the
date and time of the investigations and circle all the abnormal results.
Open by introducing yourself and the reason for your call, asking if you are speaking to the ITU
registrar.
For instance:
“My name is Dr Jones. I am the surgical SHO working for Mr Jones the colorectal consultant at the
Newcastle Royal Infirmary. I am calling to speak to the ITU registrar to ask advice on an unwell
patient who has been today admitted and is going to require a laparotomy. I would also like to
arrange an HDU bed postoperatively. Could I check who I am speaking to?”
When you are asked for the information, give it concisely. A good technique is to start, “Mr Jones is a
56 year old with a background of X, who presented with a perforated appendix and has gone into
acute renal failure, with hyperkalaemia. His bloods tests show … (here give the abnormal ones only,
the SpR can ask you if there are any further results he wants) and his ABG shows a metabolic
acidosis, with a high lactate, and a potassium of Y”
62
Do not ever lie in a station (or in real life…). If you don’t have the information, apologise, admit you
don’t know and indicate that you will find out as soon as you get off the telephone. If the SpR insists
you find this information out first, you should apologise again for not having it available but suggest
that you go through the information that you do have first so that if anything else is missing, or if
urgent action needs to be undertaken it can be.
HDU admission criteria:
Patient’s requiring support for a single failing organ system
Patient does not require advanced respiratory support
Patient’s requiring more detailed monitoring than can be provided on the ward
Post operative patients who require post op monitoring for more than a few hours
Patients being stepped down from ITU
ITU admission criteria:
Patients requiring or likely to require advanced respiratory support – intubation and mechanical
ventilation
Patients requiring the support of two or more organ systems
Patients with a severe chronic impairment of one or more organ system who now require support
for an acute reversible failure of another organ system
A reversible disease process
HDU is categorized as level 2 care, and ITU as level 3 care.
Level 0 Ward
Level 1 Ward with critical care team input
Level 2 HDU – for detailed observation, a single organ failure or following major surgery
Level 3 ITU – for support of two or more failing organs, or patients requiring ventilation
63
64
18. LIVERPOOL CARE PATHWAY
You are the CT1 on call. Overnight a patient with end stage pancreatic cancer was admitted. Mr
Peter Smith is well known to your consultant and on the post take ward round you release that Mr
Smith is dying. Your consultant asks you to do everything you can to make him comfortable and
speak to Mr Smith’s wife about the Liverpool Care Pathway (LCP).
This station should be treated as a combination of breaking bad news and information giving. You
have to tell the Mrs Smith that her husband is dying, then discuss and provide information on the
Liverpool Care Pathway.
Although the LCP has been in the media recently in a particularly negative light, and has been
withdrawn from circulation in some trusts, this station contains a number of tricky aspects of
communication that are vital to practice in similar situations.
Guidelines for breaking bad news:

• Ensure that there are no distractions: You should leave your bleep with a colleague so that you are
• Show empathy
• Give a warning sign or shot before you deliver the bad news and follow this by an appropriate
pause. Do not be scared of silence
• Try and pitch your language at the correct level, do not get too technical
Mrs Smith has arrived and you are going to talk to her...
Candidate:
Introduce yourself and allow any colleagues present with you to introduce themselves
Actor:
“I am Jackie Smith, Peter’s wife. Thank you for coming to speak to me”
Candidate:
“Can I ask how much you know about your husband’s current condition?”
It is vital to know how much the relative does or does not know, so even though you may feel the
urge, do not rush into breaking bad news.
Actor:
“I know that he has terminal pancreatic cancer. He has been getting weaker and weaker over the
past few weeks and his pain is getting unbearable”
There is a pause and Mrs Smith becomes upset whilst asking:
“Is Peter dying”?
65
Candidate:
You are breaking bad news so you should fire a warning shot first.
“I am afraid it is not good news”.
Pause...
“Unfortunately, your husband is dying”.
of silence. This will give them time to process what you have just said. Do not continue with the
conversation until the patient or relative is ready.
Actor:
“I was expecting this but not so quick. Will he pass away today”?
It is impossible to tell how someone will react to this information. Try practicing with a fellow
candidate a variety of reactions from sadness to anger and see how you get on: the actors in the
exam can act all of them!
Candidate:
“It’s very hard to say how long, but in that time we want to make your husband as comfortable as
possible. To do this we are guided by the Liverpool Care Pathway”
Before you can ask do you know what that means, the actor becomes angry.
Voice raised
“Oh no, not that pathway, I read about it in the newspaper. You just let people starve and ignore
them to speed up their death! Under no circumstances is Peter to be put on that !”
Unfortunately this is a common reaction: while placing a patient on the LPC is a clinical decision, it is
vital to communicate the rationale for this to the family.
Candidate:
Remain calm and composed
“I understand your concerns and under no circumstance would we starve or ignore Mr Smith.
There has been a lot of publicity about the Liverpool Care Pathway recently and not all good. Can I
explain exactly what the pathway is”?
Actor:
With reservation...
“Ok, tell me”.
Candidate:
“The Liverpool Care Pathway or LCP as some people call it is a pathway used to give dignity in the
dying. We would not withhold food or fluids unless from your husband. At all times we will make
your husband as comfortable as possible by providing pain relief, anti-sickness medications and
we will not be using deep sedation. We will provide regular mouth care and change his position in
bed to make him as comfortable as possible as long as it is not too distressing. We will not be
carrying out any routine tests as they can also be distressing and do not give us any added
information, but we will regularly review Mr Smith’s condition. I would like to stress that we will
provide the best care possible for your husband and you can spend as much time on the ward with
your husband as you wish”.
Actor:
“That is very different from the newspapers”
66
Candidate:
“I agree”.
Pause and then ask:
“Are you happy Mrs Smith for use the LCP?”
"Do you have any further questions?"
Actor:
Yes, I am. Thank you for explaining it so clearly”.
"I have one question. I would like a Catholic priest to come and see my husband. Is that possible?”
Candidate:
The LCP does not restrict any religious beliefs
“That is not a problem. We will arrange for that”.
Close the conversation by saying that you can be contacted by the nurses if there are any other
questions or concerns that arise.
Then ask Mrs Smith if she would like to go and see her husband.
Although this conversation may seem short, if you are delivery your statements at the right pace and
allowing appropriate silences then it should take 8 - 10 minutes.
Key Information
When breaking bad news you should have the following points in your mind:
• Ensure that there are no distractions: you should leave your bleep with a colleague so that you are
• Show empathy
• Give a warning sign or shot before you deliver bad news and follow this by an appropriate pause.
Do not be scared of silence
• Pitch your information-giving at the correct level
questions
The Liverpool Care Pathway was developed in the late 1990s for the care of terminally ill cancer
patients. Since then the scope of the LCP has been extended to include all patients deemed dying.
• The LCP has been recognised nationally and internationally as a good model to support the dignity
of a dying patient. It is supported by the GMC and NICE.
• The LCP is built around maintaining the highest possible dignity of the dying patient
• The LCP should be used when there is no further treatment that a patient can have and it is
recognised that they are in the last days or hours of their life
• The LCP does not hasten death. It is not euthanasia
• The LCP does not stop a patient from having oral intake or artificial hydration
• The LCP does not use deep, prolonged sedation
• The LCP does not interfere with a patient religious beliefs
• The LCP should be regularly reviewed (every 4 hours)
• Through the pathway good communication is essential with the patient, relatives and amongst the
MDT
67
We would recommend that you look at a copy of the LCP at your place of work.
Source:
Marie Curie Cancer Care website http://www.liv.ac.uk/mcpcil/liverpool-care-pathway/
68

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COMMUNICATION

What operation is he having?

What has David, my ex-husband told you?

No, nothing, but...

What the actress was told

Please assess this patient’s confusion

I am ok, but don't really know where I am

How old are you?

Mrs Joy knows that her age is 84,

What would you do next?

Should the operation go ahead?

What is your differential diagnosis?

What the actress was told

No, there isn't anyone really. Is it bad news?

How would you inform the relative of the DNAR order?

What the actress was told

Yes that’s right. The camera test is called a colonoscopy.

Yes, take your regular medications in the mornings.

Guidelines for speaking to relatives

Guidelines for breaking bad news:

How would you open the consultation?

Hi Jamie, nice to meet you, I'm Aditya.

Why do I need a colonoscopy?

What could be happening inside my bowel to cause my symptoms?

What happens if something is found, will I be told what it is straight away?

What are the risks for this procedure?

How long does a colonoscopy last?

What is the Dukes classification of colon cancer?

What the actor was told

What is your differential diagnosis?

What else would you like to do to narrow down your differential?

How would you respond?

What would you do?

Following the silence the station might go as follows

"What happens next"

What the actor was told

Would that be okay?

He refuses as he is a Jehovah's witness and believes it is wrong to receive a blood transfusion.

He understands this but still refuses a blood transfusion.

Intraoperatively, a quick operation by an experienced consultant is preferable, with focus on

How would you close the consultation?

What the actor is told

What is your differential diagnosis?

What is critical ischaemia?

Yes, I am Professor Adli, how can I help?

Why do you think her CRP is up? Is there an infection?

When were those bloods taken?

The ultrasound scan shows a bile leak (black arrow).

What does ERCP stand for and what does it involve?

How is this managed?

What would you do before speaking to him?

How would you respond?

How would you assess his capacity?

He agrees and signs the self discharge document.

Who would you inform of the patient's decision?

How would you close the consultation?

What the actor was told in this station.

Why do you think the lactate is high?

What does the chest X-ray show?