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MockOSCEApr06Wollongong

MockOSCEApr06Wollongong

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Wollongong Practice OSCEs

Thursday zo" April 2006

Prepared by Dr Warren Kealy-Bateman

Site Co-ordinator of Training and NSW Examinations Secretary using, based on or resembling stations released by the RANZCP (www.ranzcp.org).

Thanks to the staff who have volunteered their time and other resources in order to make this possible. In particular, thanks to Dr Alex Pilsky for Station 2.

AGENDA

CANDIDATES and OBSERVERS

>- 1.30pm

>- 2pm

>- 2.40pm >- 3.00pm >- 3.20pm >- 3.40pm >- 4.00pm >- 4.20pm

>- 4.40pm >- 4.45pm >- 4.50pm >- 4.55pm >- 5.00pm >- 5.05pm

>- 5.10pm

Level 8, Block C for registration and lunch

Tips for the OSCE. Dr Warren Kealy-Bateman

OSCE Station 1 OSCE Station 2 OSCE Station 3 OSCE Station 4 OSCE Station 5 OSCE Station 6

Feedback Station 1 Feedback Station 2 Feedback Station 3 Feedback Station 4 Feedback Station 5 Feedback Station 6

Close

EXAMINERS and ACTORS

• 2.20pm Wollongong Mental Health Unit, Block C, Level 3 Lunch and orientation to your station

o Remember to mark candidates at the level of an advanced trainee

o The Global Proficiency rating is to be marked/considered independently

o Feedback notes can be made in this practice (although they are not normally part of the examination)

• 2.40pm OSCE Stations (20 minutes each)

• 4.40pm Feedback (5 minutes each)

• 5.10pm Close

Wollongong Practice OSCEs April 2dh 2006

2

oseE Station 1

Thanks to Dr Alex Pilsky for the idea for this station. Written by Drs Pilsky and Kealy-Bateman.

Candidate Task List:

• In 14 minutes take a focussed history from Daniel and perform the relevant physical examination.

• Further history can be taken after initial history and physical examination.

• In the last 3 minutes present your findings and immediate management plan to the examiner.

Candidate brief scenario:

• You are an on-call psychiatric registrar who has been asked to see Daniel, a 29 year old man on the subacute ward. The nurse is alarmed because he has been vomiting.

• Prior to seeing Daniel you review the file. You notice that Daniel has a 6 year history of chronic schizophrenia. He is compliant with treatment and enjoys being on the subacute ward. He has been started on clozapine 2 weeks ago and is on 50mg nocte. His main difficulty is ongoing auditory hallucinations instructing him to commit suicide.

• Please take the history and perform the relevant examination.

• At 14 minutes you should interrupt the candidate and ask them to "please present your findings and the immediate management plan".

• When and if the candidate auscultates for bowel sounds please report ubowel sounds absent".

Examiners instructions:

• You are a 29 year old man who has had 6 years of distressing auditory hallucinations. They tell you to kill yourself. When you first became unwell you recall being hospitalised for two months. You think that the police

Actor's case outline and response details:

Wollongong Practice OSCEs April 2dh 2006

3

brought you to hospital but you can't quite recall all the details. You know that the medication helps to keep your thoughts clear. You have had four previous admissions of around 4 weeks each. At the last admission they suggested rehabilitation in the subacute unit because you were not coping with the cooking and cleaning in your Department of Housing unit. You forgot to pay bills. Your older sister and mother help you but your father thinks you are lazy. There are no other family members. There are no medical problems or history of surgery. You cannot recall all the medications you have been on but remember one called "zyprexie". You have also been on "modecete" but it made you "stiff like a robot". You have no allergies. You smoke marijuana, 2 joints, twice a week. You smoke one packet of cigarettes a day and drink a few beers each week. You have never taken any other drugs. There have never been problems with the police. There is a maternal aunt with schizophrenia. You were at university studying engineering when you became unwell. You do not have children or a partner.

• Presently your voices are bad telling you to commit suicide.

You have not harmed yourself before. There are no delusions or thought disorder presently. You do not feel depressed.

• Your physical symptoms are as follows: 3 hours of vomiting - profuse and severe; no diarrhoea; there is abdominal pain of a similar duration. COMPLAIN +++ ABOUT THE SEVERE VOMITING. You are oriented, do not feel febrile and have

no neck stiffness. You have not had a blow to the head.

• If, and only if, the candidate asks you what might be causing the vomiting - report that you have taken an overdose of cogentin 2mg by 50 tablets. Tell them this is in response to the command auditory hallucinations. You took this overdose while on leave about four hours earlier.

Wo/longong Practice OSCEs April 2dh 2006

4

Marking Sheet - Station 1 - Vomiting in a patient

Assessment domains and tasks Surpasses Achieves Borderline Does
(Examiners can give a tick for each point) Standard Standard not
achieve
standard
APPROACH - Old the candidate demonstrate an
appropriate professional approach to the
patient? (Proportionate value 20%)
• Endeavours to form a partnership
• Takes regard of culture. gender. ethnicity
• Demonstrates empathy and awareness
• Accommodates minor inappropriateness
• Encourages expression of concerns
• Uses appropriate languages and
explanations
ASSESSMENT - Did the candidate take an
appropriately detailed and focussed history and
examination? (Proportionate value 25%)
• Takes focussed history of the vomiting
• Uses appropriate language using mix of
open and closed questions
• Performs a relevant physical examination
focussing on the gastrointestinal system
• Enquires about psychotic, mood, anxiety
symptoms and self-harm
DIAGNOSIS - Did the candidate adequately
formulate the problem behaviour and categorise
the type of stalking? (Proportionate value 25%)
• Candidate identified the overdose of
benztropine as a response to psychotic
symptoms resulting in a paralytic ileus
MANAGEMENT - Old the candidate develop and
describe an initial management plan?
(Proportionate value 30%)
· Develops and describes a plan that is
relevant
· Includes immediate review of the
overdose including general observations.
ECG, imaging. blood tests, transfer to the
Emergency Department or appropriate
place of assessment. initiation of liaison
with non-psychiatric medical colleagues
· Suggests management that includes a
nasa-gastric tube
· Mindful that this patient must be safely
managed and may be at ongoing risk of
further self-harm and/or delirium Global proficiency rating - did the candidate demonstrate overall knowledge and performance at the defined tasks?

Definite Fail

Definite Pass

Marginal Performance

Please list any further advice for this practice examination candidate .

Wollongong Practice OSCEs April 2dh 2006

5

• In 14 minutes take a focussed history from John;

• In the last 3 minutes, present your formulation to the examiner, including diagnosis, differential diagnosis and risk assessment.

oseE Station 2

Thanks to Dr Alex Pilsky for writing this station

Candidate Task List:

Candidate brief scenario:

• John is a 23 year old man who was referred to you community clinic by the police. The following request was made:

"Please treat this young male who has been stalking a female and made threats to 'deer with her. When questioned by Constable Smith he admitted to a history of mental illness and agreed to seek help. He has no prior criminal history and was not charged."

Examiners instructions:

• At 14 minutes, you should interrupt the candidate and ask them to "please present your formulation including diagnosis, differential diagnosis and risk assessment. "

Actor's case outline and response details:

• You will be slightly irritable and reluctant to disclose the details of your stalking behaviours and use phrases like "1 made a mistake but I will never do it again. .. " "Don't you understand, I would never hurl her. .. and in any case, if

• You are a young man who agreed to see a psychiatrist after you were interviewed by police regarding a complaint from your former girlfriend.

Woflongong Practice OSCEs April 2dh 2006

6

police thought I was about to hurt someone they would have dealt with it themselves ... "

• However, if the candidate is respectful, acknowledges your distress and awkwardness of this situation and explains that it is important to know all the details in order to make the right diagnosis and if necessary to commence treatment, you respond by becoming co-operative.

• You are further reassured if the candidate explains that apart from issues related to risk, this consultation is confidential.

• On direct questioning you give the following details: you live alone; work casual shifts at petrol station; you came to the city six months ago from small rural town where unemployment was rife hoping to find work; you feel isolated from family and friends and haven't developed many new acquaintances. 3 months ago you started dating a young woman you met while surfing. There was a sexual relationship. You thought the relationship was going well until 3 weeks ago she unexpectedly announced that she liked you but wasn't sure whether she loved you and told you it was best for both if you didn't see her. You feel 'confused' about the way she ended the relationship and hope that if you persist and continue to show your affection, you will be 'reunited'. You have telephoned her at least 2-3 times a day, sent her numerous emails proclaiming your love for her and sent flowers at least twice per week.

• Initially you make a half hearted denial, but then, if a candidate refers to the police letter, you admit that during one of the phone calls which your ex answered, you became angry, suspecting she started seeing someone else and threatened to 'deal' with her. You were intoxicated at the time, having consumed half a bottle of scotch.

• You have no thoughts of hurting your ex

Wollongong Practice OSCEs April2dh 2006

7

• You have never stalked anyone in the past and have never been violent.

• You have been standing outside your ex's place at night on at least 5 occasions, trying to determine whether 'another bloke' was there.

• When asked why you are pursuing her you give several reasons: because of the way she broke up with you, you are not sure whether she really wanted to break up or just wanted you to show more affection towards her; you don't think you are 'good enough' and not sure you would be able to "find another girl who is interested in me. "

• On direct questioning you admit to "feeling down" ever since the break up and in the last week you had thoughts that I'there was no point going on with life". You never wanted to kill or hurt yourself. You haven't completely lost you ability to enjoy things you previously liked, but "it's not quite the same", your sleep, appetite, energy and concentration are unchanged.

• You have slashed your wrist at 17 y.o. when your first girlfriend broke up with you and ended up in emergency department where it was sutured. You were reviewed by the 'shrink' and told you were 'too emotional' and discharged. There was no other contact with psychiatric services and no other self harm. You don't know of any family psychiatric history.

• You missed work on 2 occasions because you were drunk and 3 times in the last week because you decided to check whether your ex was with someone else.

• You have no delusional beliefs and no hallucinations.

• You tried to cope with this situation by bingeing on alcohol but you don't drink regularly. You use no illicit drugs.

Wollongong Practice OSCEs April 2dh 2006

8

Marking Sheet - Station 2 - Stalking

Assessment domains and tasks Surpasses Achieves Borderline Does
(Examiners can give a tick for each point) Standard Standard not
achieve
standard
APPROACH - Did the candidate demonstrate an
appropriate professional approach to the
patient? (Proportionate value 20%)
· Endeavours to form a partnership
• Takes regard of culture, gender, ethnicity
· Demonstrates empathy and awareness
• Accommodates minor inappropriateness
• Encourages expression of concerns
• Uses appropriate languages and
explanations
ASSESSMENT - Did the candidate take an
appropriately detailed and focussed history?
(Proportionate value 25%)
• Takes full and detailed history using
tailored bio-psycho-social approach
• Uses appropriate language using mix of
open and closed questions
• Establishes exact nature of the stalking
• Is attuned to patient disclosure
• Enquires about psychotic, mood, anxiety
symptoms and self-harm
DIAGNOSIS - Did the candidate adequately
formulate the problem behaviour and categorise
the type of stalking? (Proportionate value 25%)
• Discusses the motivations/factors that
may have led this man to stalk
MANAGEMENT - Did the candidate develop and
describe an initial management plan?
(Proportionate value 30%)
• Develops and describes a plan that is
relevant
• Includes ongoing review, close liaison
with police and ongoing risk management
• Education of patient about the legal
consequences of ongoing stalking ,
behaviour
• Develops a plan to maximise patient'S
supports and ability to cope with the loss
of his girlfriend Definite Fail

Global proficiency rating - did the candidate demonstrate overall knowledge and performance at the defined tasks?

Definite Pass

Marginal Performance

Please list any further advice for this practice examination candidate .

Wollongong Practice OSCEs April 2dh 2006

9

oseE Station 3

Written by Warren Kealy-Bateman

• In 14 minutes take a focussed history from Vera.

• In the last 3 minutes present your formulation to the examiner, including diagnosis and differential diagnosis and the management plan.

Candidate Task List:

Candidate scenario:

• You are a registrar working in a community health team.

• Vera is a 43 year old woman who was referred to the Dialectical Behaviour Therapy (DBT) group by the mental health intake officer. Vera has just moved to this area.

• All patients are seen by your consultant prior to starting DBT to assess if the referral is appropriate. Your consultant, Dr Jones, has phoned you and is running late. She has asked that you "meke sure Vera is okay". Dr Jones has not met Vera and wonders if she is appropriate to join the DBT group as there are a few spaces coming up.

• At 14 minutes you should interrupt the candidate and ask them to "pleese present your iormuletion, including diagnosis1 differential diagnosis1 risk assessment and the meneqement".

• Please assess Vera. Her daughter was keen to attend the interview and will try to make it.

Examiner instructions (if required):

Wollongong Practice OSCEs April 2dh 2006

10

Actor's case outline:

• You have come to this interview after the intake officer suggested it. They said there was a support group run by

the service that you could come to. It is supposed to help you with self-harm.

• Previously you lived with your family in Bankstown, including your 25 year old daughter, 20 year old son and husband of 26 years. Your husband is an office worker. You are studying counselling at TAFE now, work as an Assistant in Nursing but have spent most of your adult life raising your children.

• You were born in Macedonia, the only daughter and youngest of six.

• You recall that you first had mental health problems when you were 20 years of age and moved from Macedonia to Australia.

• That is when you first started burning yourself with cigarettes, especially when you were feeling very low.

• Your husband is aware you harm yourself because it happens every few weeks.

• You cannot remember how many times you have harmed yourself - if the candidate asks you can say "nundreas".

• You openly state that your main long term problem is "burning myself with cigarettes".

• Usually your mood is "up and down", every day, and you never know what the day will bring. Conflict with others leaves you feeling very "depressed". You often feel ashamed when you have conflict with others.

• At times you explode and lash out. You destroyed your daughter's 21st birthday presents because of the sexual comments made during the speeches. You were very angry and embarrassed.

• You have been with your husband for a long time but it is an unstable and conflict prone relationship.

• You daughter oscillates between being very understanding to being quite rejecting.

• You have an idealized view of your son who is at university.

• You have long wanted to know what is wrong with you. You feel that no-one understands you.

• You do not like to be left on your own - that is usually when you harm yourself.

• You have no medical problems and currently do not take medication.

• You do not abuse drugs or alcohol and have never beenin trouble with the police.

Wollongong Practice OSCEs April 2dh 2006

11

• You are unaware of any family history of psychiatric problems.

• You are not prepared to answer any questions about childhood abuse. You simply shake your head when the candidate asks or utter "we don't talk about this".

• Your psychiatric history includes repeated presentations to GPs asking for help. You sometimes tell them that you burn yourself. One GP referred you to a psychiatrist who suggested an antidepressant. You took it for two years but it did not seem to help. Your GP tried two other antidepressants (all for at least 6 months) but they also did not help. You do not recall the name of these medications. You have not taken any medications for over 11 years. You have been hospitalised once, after an overdose, 2 years ago. Your husband then had threatened to leave you.

• In the last 4 weeks you just wish to remain in your bed. You feel "very depressed" all the time, day after day. Your daughter has been hoping to see the doctor as well todayfor she is very worried about you. You cannot remember the last time you enjoyed anything. Everyone remarks that you look very depressed and you have not been smiling at all for weeks. You feel there is no hope and that you are worthless. You feel 'bad' as a person. You feel you are wasting the doctor's time today and say "I am wasting your time". You are guilty that you have been a bad mother. You are tearful at night when you lie awake worrying about things you have done wrong in the past. Your sleep is bad and you wake early in the morning, feeling tired. Sometimes you get back to sleep but then cannot face the day. By dinner you are usually a bit better but still feel very low. You do not know if you have lost weight but your appetite is reduced. You can't concentrate on TV anymore. There are no psychotic features (and no delusional guilt). You do not wish to go on but must do so for your children. And you say to the doctor III could not even kill myself - I would get that wrong too". You have not burnt yourself for three weeks. You are unaware of any precipitants to this episode of low mood. You don't think the doctor can help you but are prepared to listen.

• You do not feel able to attend the DBT group presently.

• If your daughter arrives she will corroborate the story.

Wo/longong Practice OSCEs April 2dh 2006

12

Marking Sheet - Station 3

Major Depressive Episode and Borderline Personality Disorder

Assessment domains and tasks Surpasses Achieves Borderline Does
(Examiners can give a tick for each point) Standard Standard not
achieve
standard
APPROACH - Did the candidate demonstrate an
appropriate professional approach to the
patient? (Proportionate value 20%)
• Endeavours to form a partnership
• Takes regard of culture, gender, ethnicity
• Demonstrates empathy and awareness
· Accommodates minor inappropriateness
• Encourages expression of concerns
· Uses appropriate languages and
explanations
ASSESSMENT - Old the candidate take an
appropriately detailed and focussed history?
(Proportionate value 30%)
• Takes full and detailed history using
tailored bio-psycho-social approach
• Uses appropriate language using mix of
open and closed questions
• Establishes exact nature of the current
low mood
· Long term borderline features are also
explored
· Is attuned to patient disclosure
• Enquires about psychotic, mood, anxiety
symptoms and self-harm
DIAGNOSIS - Did the candidate adequately
formulate the patient's acute and long term
problems? (Proportionate value 20%)
· Background and Axis 2 pathology
• Current Major Depressive Episode
MANAGEMENT - Did the candidate develop and
describe an initial management plan?
(Proportionate value 30%)
• Develops and describes a plan that is
relevant
• Discusses the important of commencing
treatment for Major Depression as the
first priority. The candidate may discuss
the treatment options.
· Emphasises regular review and risk
assessment. Adopts a crisis
management plan.
0 Includes family.
0 Defers commencement in DBT group but
recognises that it may be helpful in the
future. Global proficiency rating - did the candidate demonstrate overall knowledge and performance at the defined tasks?

Definite Fail

Definite Pass

Marginal Performance

Please list any further advice for this practice examination candidate .

Woflongong Practice OSCEs April 2dh 2006

13

oseE Station 4

Written and adapted by Warren Kealy-Bateman and based on OSCE Station 3 (June 2004 RANZCP Examinations) and information from Kaplan and Sadock (2003) Synopsis of Psychiatry 9th Edition. Lippincott, Williams and Wilkins: USA, pg1233-1234.

Candidate Task List:

• Mary is a 34 year old married mother with three boys aged 9, 8 and 2 years. You have been treating Mary as an outpatient for major depression for the past ten months. Her symptoms began within a few months of the birth of her last child. She has responded well to treatment involving an SSRI, regular support, exercise and attending a local playgroup with the infant. This is the first time you have seen Mary in six months.

• In 10 minutes take a focussed history from Mary.

• In the last 7 minutes inform the mother of the likely nature of the problem and further tasks.

Candidate scenario:

• You are a registrar working in an outpatient clinic.

o Take a history of the child's behavioural disturbance from his mother;

o I nform the mother of the likely nature of the problem, including diagnoses;

o Provide appropriate advice to her regarding further assessment;

• She begins the consultation telling you she now feels completely well but wants your advice about managing the behaviour of her middle child, Robert. He is refusing medical treatment.

• Your task is to:

Wollongong Practice OSCEs April 2dh 2006

14

o Develop an immediate management plan for her difficulties with her son.

o At 10 minutes, if you have not already done so, you will be prompted to inform the mother of the likely nature of the problem and further tasks.

Examiner instructions (if required):

• At 10 minutes you should interrupt the candidate and ask them to: "Please inform the mother of the likely nature of the problem and further tasks."

Actor's case outline and response details:

• You are Mary, the married mother of three boys aged 9,8 and 2 years. You are married to Tony, a textile worker. Yo developed a postnatal depression about one month after the birth of your third child. You have responded well to antidepressants (citalopram 20mg daily), regular exercise and involvement (with your infant) in a play group. Tony and you have a good relationship - you met him in the factory 14 years ago. You initially drifted apart during the depression. Tony did not understand why you were not coping with the kids. Tony benefited from the psychoeducation provided by the mental health team and some supportive psychotherapy from his GP. He has also asked you to discuss your son

with the doctor today. You do not use drugs or alcohol, have no medical problems and have never been in trouble with the police. There is no family history of mental illness but your father was a heavy drinker. You had a good childhood, the youngest of three girls and managed to scrape through your leaving certificate (year 10). You get on well with your family who have been invaluable during recent months.

• If the candidate asks about the depression, describe previous low mood, no enjoyment, low energy, poor appetite and sleep but then redirect them and say "thet is not the problem now, I need to discuss my son".

• Robert, your 8 year old son, has been having quite significant difficulties at school. This has been occurring for over one year now but everyone seemed to cope hoping it was just a phase. The school principal called yesterday to talk about moving Robert to a different school as he was

Wollongong Practice OSCEs April 2dh 2006

15

uncontrollable in his 4th year class. He often loses his temper. He argues with adults and will not follow any requests. He deliberately annoys the other children in class. You have noticed that he regularly seems to provoke his older brother - deliberately annoying him too. When confronted he blames his classmates or his brother for the problem. He becomes quite angry and resentful whenever you decide not to meet his needs. He was most unpleasant when your husband would not take him swimming the other day - this was not a punishment - the family had other

plans. In response he got on his bike and disappeared for two hours to the local park. You, your family and the school are not coping with this oppositional behaviour. Both sets of grandparents will not look after him either because he is too difficult. He has always been a 'touchy boy' easily annoyed by others. He has few friends at school and has been invited to a birthday party only once. He likes his younger brother.

• There are no major depression, anxiety or psychotic features. While he is impulsive in his interpersonal transactions he is not inattentive - and he enjoys the play station games for hours at a time. He sleeps normally. There has been no physical aggression to others. He has not stolen or damaged anything that you know of.

• He was an expected babe who was born at full-term and achieved normal milestones, just like his brothers. There have been no physical or medical problems.

• His school reports always suggested he was an oppositional child with difficult to manage behaviour. He was, however, academically talented - reading at a much higher level. He enjoyed the Harry Potter novels. But his grades rarely reflected this.

• You are concerned about this possible change of school, feel overwhelmed by the difficulties with him at home and just wish that the teachers could manage him.

• Apart from your depression you can think of no other changes or challenges that may have precipitated this difficulty. You do not have this problem with your other boys.

Wollongong Practice OSCEs April 2dh 2006

16

Marking Sheet - Station 4 Oppositional Defiant Disorder

Assessment domains and tasks Surpasses Achieves Borderline Does
(Examiners can give a tick for each point) Standard Standard not
achieve
standard
APPROACH - Did the candidate demonstrate an
appropriate professional approach to the
patient? (Proportionate value 20%)
• Endeavours to fonn a partnership
• Takes regard of culture, gender, ethnicity
• Demonstrates empathy and awareness
• Accommodates minor inappropriateness
• Encourages expression of concerns
• Uses appropriate languages and
explanations
ASSESSMENT - Did the candidate take an
appropriately detailed and focussed history?
(Proportionate value 20%)
• Takes full and detailed history using
tailored blc-psycho-social approach
• Obstetric and mHestones
• Physical health and medications
• Depression and anxiety symptoms
• Inattention, impulsivity and activity
• Aggression
• School and peer relations
• Family system functioning
Did the candidate demonstrate adequate
proficiency in obtaining the history (10%)?
• Systematic approach using
appropriate language including
a mix of open and closed
ended Questions.
DIAGNOSIS - Did the candidate adequately
formulate and describe the relevant diagnosis
and differential diagnosis? (Proportionate value
20%)
• Oppositional Defiant Disorder
• Differential d iag noses of conduct,
attention-deficit, depression and anxiety
disorders.
MANAGEMENT - Did the candidate develop and
describe an initial management plan?
(Proportionate value 30%)
• Recommends family assessment,
including individual assessment of child,
history and academic record from school,
history from and physical examination by
GP, possible neuropsychological
assessment, possible physical
investigation (eg EEG).
· Provides some sense of timeframe
• Clear communication of what he/she wlll
do regarding the referral and future roles
- with mother and child
• Provides basic psycho-education
• Describes basics of behavioural
strategies for parents and checks
preference and understanding
• Helps identify appropriate supports:
family; school counsellor; GP; sports;
parenting groups
• Deals with medication queries
approortatelv Wollongong Practice OSCEs April 2dh 2006

17

Marking continues on the next page .

Global proficiency rating - did the candidate demonstrate overall knowledge and performance at the defined tasks?

Definite Pass

Marginal Performance

Definite Fail

Please list any further advice for this practice examination candidate .

Wollongong Practice OSCEs April 2dh 2006

18

This modified station has had the bye station removed.

oseE Station 5

Adapted from the RANZCP Sample Station 2, 2004.

Candidate Task List:

• In 17 minutes please participate in a discharge planning meeting.

Candidate brief scenario:

• In this station you will conduct a discharge meeting for a current inpatient with two staff members. Kim is the Nurse Unit Manager (NUM) and Leslie is the Community Psychiatric Nurse (CPN).

• The patient is John, a 31 year old man, currently unemployed and living in a share house prior to admission. Two years ago John dropped out of a fine arts course. He has a 7 year history of schizophrenia and has been case managed for five years. He began using illicit substances long after the onset of his psychotic illness.

• John was readmitted 8 days ago, at the request of the case manager, with deterioration in his mental state and poor selfcare. He was vague and disorganised on admission. There are chronic delusions involving extra-terrestrials. They never harm him. John has no thoughts of self-harm. He has never harmed himself. There is no mood disturbance.

• John was concerned the people in his home may be harming him. He has increased his marijuana and amphetamine use to cope with this.

-. He has never been in trouble with the police.

• His mother gives him money but has banned him from returning home.

• John has had 7 previous admissions, all in similar circumstances, where his positive symptoms settle quickly

Wollongong Practice OSCEs April 2dh 2006

19

and he returns to the community compliant with his depot antipsychotic. He is usually only in hospital for 5-10 days.

• Please refer to RANZCP Sample Station 2, 2004 for the examiners instructions, marking sheet and instructions to actors.

• Actors please feel free to add depth to the history based on your understanding of the patient from Sample Station 2.

Wollongong Practice OSCEs April 2dh 2006

20

1. Introduction and Aims

Committee for Examinations

Objective Structured Clinical Examination

Under the new Training and Assessment Regulations

SAMPLE STATION 2:

Working in a Multi-Disciplinary Team

In this station, candidates conduct a discharge planning meeting for an inpatient with the charge nurse of the Acute In-patient Unit and the patient's community case manager.

Prior to the observed discussion, the candidate reads a case history of the patient and possibly views a short video of an interview with the patient to get a 'feel' for the patient.

The patient is a young man with chronic schizophrenia and dual diagnosis, who has had seven brief admissions in the last three years in crisis situations and with significant history of drug abuse and accommodation problems. There is a moderate degree of splitting between the staff members about what should happen to the patient. The aim is for the psychiatrist to lead the group to agree on the key elements of the discharge plan to be discussed with the team to the patient and his mother at a meeting later that day.

The candidate is expected to:

• Identify key features of the discharge plan from written material and video of patient interview and the clinical discussion held in view of the examiners.

• Exercise clinical judgement to recognise impediments or opportunities and

make sensible suggestions about how to overcome these.

• Organize and establish priorities for the plan.

• Be prepared to discuss this potential plan with the patient and his mother.

• Lead a multidisciplinary team.

• Recognise and deal with a moderate degree of staff disagreement in this d iscu ssion.

• Make appropriate suggestions to the staff members about how to deal with their conflict outside of this issue.

Requirements:

People

• Two actors are required to play the charge nurse (Kim) and the case manager (Leslie). Gender is not a crucial issue, but ideally the charge nurse could be a male of the 'old school' and the case manager a female social worker. Alternatively, one of the examiners could play the CNC and the case manager could be a real clinician.

Equipment

• A table and chairs for the clinical meeting.

• The patient vignette could be enhanced by a short video of a patient discussing his accommodation, money or other social issues, which would give some indication of a reasonable settled mental state and allow the candidate to have a real person in mind in the discussion.

This station aims to cover RANZCP Curriculum sections:

• A1.6, A2.2, A3.1, K4.7, 53.1, 53.10, 53.11 and 54.1.

References:

• Clinical Practice Guidelines for Management of Schizophrenia: American Psychiatric Association.

• Draft College QA Project - Practice Guidelines for Schizophrenia. 2. Instructions to Candidate

You have 18 (eighteen) minutes to complete this station.

In this station, you will conduct a discharge planning meeting for a current inpatient with two staff members prior to meeting this patient and his mother to discuss the plan with them. You have to decide the key elements of this plan during the meeting. At the end of the session, you and the team should be prepared to meet patient and his mother.

The order of the tasks will be either A or B, depending on whether a 'bye' station is used for review of material relevant to this station:

• Brief discussion with examiner (2 minutes).

A

• Read the cllnical material (view the video) about Gary P (4 minutes).

• Discussion with two staff members, acute psychiatric unit charge nurse and patient's community case manager (12 minutes).

OR B

• Discussion with two staff members, acute psychiatric unit charge nurse (Kim) and patient's community case manager (Leslie) (16 minutes).

• This patient is the patient introduced in the vignette and video - Gary P.

• Brief discussion with examiner (2 minutes). 3. Instructions to Examiner

Lead the candidate into the room and allow him/her to perform introductions.

The examiner will:

• Tell the candidate that 'This session is based on the clinical material for Gary P. that you have just seen. You can keep the material during the discussion, but please hand it back to me at the end of the station.'

• Ask the candidate to read the patient vignette on Gary P. The candidate has four minutes and can keep the material during the discussion. The material must be handed back to the examiner at the end of the station.' OR

• Take the candidate to the discussion table and introduce the candidate to the team. Say, 'You are conducting this discharge planning meeting.' After the candidates' introductory remarks, the first actor will start talking.

• At the 10-minute mark, the examiner will warn the candidate that there are two minutes left (if the clinical material was pre-read, this would be the 14 minute mark).

• Stop the discussion after 12 minutes.

• Askthe post-discussion probe 'Are you satisfied that you have covered the major elements of the discharge plan for Tony? Is there anything else that would be important, please be succinct'. (This discussion is only 2 minutes long.)

• See the candidate out and complete checklists. 4. Instructions to Simulated Patient

Gary P

You are a 26-year-old single man, currently unemployed, was living in a share house prior to admission. Two years ago, you dropped out of a fine arts course. You have a seven-year history of schizophrenia and have been receiving case management services for five years.

You were readmitted eight days ago, at the request of your case manager, with deterioration in your mental state and self care. On admission, you were disorganized and vague in your thinking. You have a chronic delusional system about extraterrestrials visiting you. These visitors never harm you and you enjoy painting your ideas. These ideas were more prominent. You deny any thoughts of deliberate self-harm.

You felt the people in your share house were persecuting you. There was some basis to this, as you had not paid your rent and two months ago had moved into a new share house. Since then, your illicit drug use had increased (usually your limit this to use of marijuana every few days, but recently you have used intravenous amphetamines). You recognise that marijuana often makes you dysphoric, but like the effect of amphetamine.

Your mother, who gives you money, has banned you from returning home as she said you disru pted your 17-year-old brother's study. She was reluctant to give you money in this state.

You first presented at age 19 with psychotic symptoms and depression. You had auditory hallucinations of someone saying insulting things. You also felt the voices said your own thoughts. At that time, you accepted that you needed help and started on rlsperidone, with which you were intermittently compliant.

Psychotic symptoms have been clearly present without illicit drug use.

In the last three years, you have had seven admissions, all lasting 3-10 days in similar circumstances - social crisis, positive symptoms that settle quickly, related to increased illicit drug abuse. On each occasion, you have settled quickly and returned to the community.

Between episodes, you are friendly and generally cooperative, but negative symptoms and poor personal organization mean you need to be reminded for appointments.

Medically, there has been some success with atypicals, but poor compliance/social circumstances have always led to relapse. The best response has been to a depot medication. A Clozapine trial four years ago was stopped, because of falling neutrophils and cannot be rechallenged.

You have never attempted self-harm, although have shown verbal aggression to your parents. There is no other history of violence.

There is no known family psychiatric history.

You are the older of two sons; your brother Peter is a high school student. Your mother, Maria, is a doctor's receptionist and your father, Peter, works in a factory. Your parents have always been su pportive, but are worried about your inability to be independent. Maria is more active in your care than Peter. You have always been close to her.

You have lived intermittently at home until one year ago when your mother banned you. She has previously asked you to leave. She gives you money, but prefers to buy you food as you 'waste' your money.

You were an average student, arty and formed a rock band. You finished high school. You spent two years in casual jobs and playing in the band until symptoms started. You have not held further jobs for more than two weeks.

You have had relationships with some girlfriends, but none last more than a few months. You have no long-term friends, but do have multiple acquaintances.

There is no history of criminal charges.

Medication has included Flupenthixol Depot 40 mg twice a week.

You rarely use alcohol, but smoke 20-30 cigarettes per day (since age 17). You began marijuana use in high school and were a regular daily smoker between the ages of 17 and 21. You now feel it makes your symptoms worse, but find it hard to resist. You have used LSD and magic mushrooms in the past but not for at least three years. You have used amphetamines for the last five years, if available (over a few-week period, you would use it every second day, but say this is only every few months).

You are always broke, but blame it on repaying your student debt. You spend your time 'hanging around' at home or friend's houses.

Your presentation today:

• A casually-dressed young man, cooperative and friendly.

• Speech is of normal rate: no obvious formal thought disorder some references to strange experiences in the past.

• Denying hallucinations.

• Affect is reactive, mood reported as normal.

• Oriented, concentration suggests you are a little preoccupied.

• Coqnitlvely otherwise intact.

• Reference to past delusional ideas if asked directly, but say 'not now'.

• Insight says you have a mental illness and you acknowledge drugs are a problem; you say you know you shouldn't take drugs.

• Rapport good.

Investigations

• All routine investigations are normal including:

• HIV, Hepatitis, Syphilis screens done this admission

• Nursing reports on the ward show you are eating well, sleeping 9 hours each night and are generally cooperative. You will join in ward activities if asked.

Instructions to Trainer of Simulated Patient

The two actors should convey a reasonably professional attitude. However, there should be clear splitting between the two (the splitting will need to be explained to the actors if they are not mental health professionals, but these roles would be very suitable for mental health professionals). This should be obvious through these means:

• The material each presents about the patient.

• By looking away or giving a look of disapproval when the other person mentions the key elements of their dispute.

• If the candidate fails to acknowledge this difference, they should exaggerate it to force the candidate to deal with it. However, neither actor should come across as personality disordered and they should be able to show that they are both amenable to agreeing with sensible suggestions by the candidate, even if maintaining their own position.

• They should be able to cooperate if properly instructed to do so but it will remain clear they disagree. The candidate may seek a consensus but will have to state a clear preferred position and move this along. This may require giving directions. This should bring out the candidate's interpersonal skills but the actors should not make it impossible if the candidate is responding reasonably to what is happening.

The actors must also introduce and be able to emphasise the key elements of the clinical material - this is scripted.

The main area of their dispute and the cause of their splitting over the patient is that the case manager feels that Gary is only just recovering and needs a lot of time to settle in hospital while issues of accommodation and money are sorted out. The charge nurse has a pressure for beds and feels that this patient is no different to how he has been on previous admissions and as the patient wants to leave hospital, he should be encouraged to do so.

The case manager feels the pressu re of the patient's mother who has complained that Gary should be 'properly dried out' and not discharged so quickly. She is angry that the length of stay issue has compromised the previous admissions. The case manager has promised her that she will speak up on her behalf about this and intends to do so during the meeting.

The charge nurse believes the community team aren't doing their job properly as they could supervise Gary better and what's the point of keeping him so long if they won't make him stop taking illicit drugs that make him psychotic.

The candidate has to establish the plan that you as a team will put to the patient and his mother.

The candidate should be able to establish the polnts that need to be covered, but it should be clear that fairly early on in the interview there is a disagreement about the best plan between the two team members.

Kim and Leslie also should use the clinical pro forma to introduce the clinical material about accommodation, income, study, ADLs, drug use, job prospects, and family. The candidate should establish the mechanics of addressing each problem and the time frames to do the tasks, but the team should be very forthcoming with information and make suggestions.

Script: Case Manager

'Tony needs more time to settle. He is only just starting to recover now and is still fragile. He still has delusions. The big issues are, his accommodation is a problem, Mum won't have him home and he has burnt his bridges at the last place. He is short of money as he spends it allan drugs. His medication is generally OK because he is on a depot but when he gets amphetamines or meets someone with drugs, he doesn't show up at the clinic for his depot.'

Key Phrases: Key Phrases

• I am not happy because every time I bring him up her he gets discharged too early.

• The cycle just continues. We need to stop this.

• If we could control his illicit drugs, he would be OK.

• His mother is worn out because he always runs out of money and ends up on her doorstep.

• His mother won't have him back because she says that it interferes with her younger son who is in his final year of high school.

• His mother is getting frustrated with us because we don't seem to care.

Script: Charge Nurse

'He is up and about and interacting with the other patients. This is his usual pattern of behaviour but he is more settled now. He is not acutely psychotic. He is friendly and wants to go. He has his chronic ideas about space ships, but they are no interfering with his normal functioning. We have a lot of bed pressure and he needs to go as soon as possible. He says he will crash at Jason's place. Your team could follow him there,'

Key Phrases: Charge Nurse

• He always settles quickly.

• This is no different to all the previous times.

• He isn't a danger to anybody.

• It's sad, but he is just another chronic schiz with a drug problem.

• I have more acute patients waiting for beds. He could go to Jason's place, they get on OK and Jason has been fine since his discharge last month.

• There is no more treatment that he could have in hospital. He needs to go out for good case management,

Phrases both could use to ensure the candidate has to decide:

• What do you want us to do?

• I'd be happy to do that if that's what you want

• You're the consultant what do you want to do.

• Are you sure that's right?

• I don't agree with that idea - what do you think? 5. Mark Sheet

1. APPROACH

1.1 Did the candidate demonstrate an appropriately tailored professional approach to the meeting?

Very Satisfactory

Satisfactory Unsatisfactory Very

Unsatisfactory

1.2 Did the candidate demonstrate an appropriate attitude to the multidisciplinary team members?

2. Category Very Satisfactory

- Approach, Satisfactory

Attitude

Unsatisfactory Very

Unsatisfactory

1.3 Did the candidate appropriately deal with conflict resolution?

3. Category - Approach, Conflict Resolution

Very Satisfactory

Satisfactory Unsatisfactory Very

Unsatisfactory

2. EXAMINATION

lscore: 4

4. Category - Examination, Clinical

Very Satisfactory Unsatisfacto Very

Satisfacto ry Unsatisfacto

2.1 Did the candidate recognise clinical issues and use additional information/suggest appropriate management plans?

3. MANAGEMENT

3.1 Did the candidate demonstrate adequate attention to risk management, considering relative risk and a suitable management plan?

Satisfactory Unsatisfactory Very

Unsatisfactory

Very Satisfactory

IMaXimum .score: 2

6. CategoryManagement, Clinical Reasonin

Very Satisfactory

Satisfactory Unsatisfactor Very

y Unsatisfactor

y

3.2 Did the candidate demonstrate clinical integration/reasoning?

3.3 Did the candidate appropriately inform, engage and counsel the family/carer/community supports/other health care workers regarding the treatment plan, appropriately regarding their goals, capacities and preferences?

7. Category - Very

Management, Satisfactory Liaison

Satisfactory Unsatisfactory Very

Unsatisfactory

4. OVERALL PERFORMANCE

8. Category - Very Satisfactory Unsatisfactory Very
Overall Satisfactory Unsatisfactory
Performance 5. GLOBAL PROFICIENCY RATING

Did the candidate demonstrate adequate overall knowledge and performance of the task?

Definite Pass

Borderline Pass

Borderline Fail

Definite Fail

oseE Station 6

I nactive bye station

WO/longong Practice OSCEs April 2dh 2006

21

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