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This scripted role play is useful in sessions on communication skills especially when trying to illustrate how medical jargon can be problematic and / or the skills involved with how to break bad news.  I’ve found it very useful when working with OTDs (Overseas Trained Doctors) as many OTDs need assistance with communication skills, particularly around inappropriate use of medical jargon.

It is well established that the use of role plays in communication skills training can be of great value, however unscripted role plays in group settings can be terrifying for participants, often more so for OTDs than their Australian counterparts.  Some will disengage and/or use avoidance strategies, impeding their access to learning opportunities.

Scripted and semi-scripted role plays (where dialogue is initially read rather than improvised) can be less threatening.  They provide most of the educational advantages of traditional role plays (e.g. experiential learning, development of empathy) while eliminating or reducing many of the limitations (e.g. lack of control over subject matter, quality of information imparted, performance anxiety), making them a more accessible and palatable option.

Workshop structure (approx. 45mins to 1hr):  

1)   Prior to the session, two volunteers are sought for reading role play (and permission is obtained – no one is ever pressured to read)

2)  Introduction to session

3)  Scenario (projected via PowerPoint or provided on a handout to all audience members)

4)  Reading of dialogue by volunteers

5)  Facilitator-led Q and A “in role” – which may involve some “re-winding” / additional role play by same or new volunteers.

6)  Exercise to “de-role” readers

7)  Group discussion

8)  Conclusion

Scenario:

Sally is a 32 year old pregnant woman who presented to the emergency department with a story of PV spotting this morning.  She saw Dr. Jones.

His notes read:

11/40.  G1P0.  PV spotting for 1 day.  Rh+ve.   No other medical problems, no medications, no allergies.

On examination

• Afebrile
•  No pelvic tenderness,
• No blood seen, Cervical os closed.

Reassured that PV bleeding common in early pregnancy

Plan –USS to exclude miscarriage. Review after scan.

The ultrasound report reads:

OBSTETRIC ULTRASOUND

Clinical Details
PV bleeding. ? viable pregnancy.

Report
Contained within the uterine cavity was a gestational sac. A foetus
was identified. CRL = 14.7mm = 7 weeks 6 days. Mean sac diameter =
43mm = 10 weeks 1 day.
No foetal heart was definable.
No myometrial abnormality or adnexal abnormality was identifiable.

Comment
The appearances are consistent with a non viable gestation

Dr. Jones’ shift has ended and you have been asked to discuss the test results with Sally.

Script:

SALLY: So what did the scan show doctor?

DOCTOR: I’m afraid the news isn’t good. The ultrasound revealed that your gestation is non-viable.  There is no cardiac activity.

SALLY:  The heart isn’t beating?

DOCTOR: That’s right. I’m very sorry for your loss.

SALLY: Are you saying my baby has died inside me?

DOCTOR: Yes.  I’m sorry.

SALLY: When did it happen?  I had a scan just over three weeks ago and everything was fine.

DOCTOR: There is a discrepancy between your gestational dates and foetal size which seems to indicate that the foetus stopped developing some time ago – maybe two to three weeks.

SALLY: I’ve had a dead baby in my uterus for two or three weeks?!

DOCTOR: Perhaps, impossible to know though. The good news is that the PV bleeding you’ve had indicates that the body has realised that this has happened and is getting ready to expel the products of conception.  If you prefer, we can offer you a D and C and remove the products surgically.

SALLY: Are you trying to say that I can wait and let my body deal with it naturally or else have a curette?

DOCTOR: Exactly. There are pros and cons with each approach.  Most first trimester spontaneous abortions sort themselves out and do not technically require a curette…

SALLY:  An ABORTION!  I haven’t had an ABORTION!

DOCTOR: No, no, I don’t mean a termination.  A spontaneous abortion is the medical term for a miscarriage.

SALLY: Oh.

DOCTOR: … so as I was saying, we don’t have to rush into a curette as most early miscarriages resolve without intervention, but many women decide to have the procedure. It avoids having to go through prolonged heavy bleeding and severe cramping and also, most women don’t like the thought of retaining a dead foetus for any longer than they have to.  They get “cleaned out”, so to speak and can move on.   Of course there are risks with having a D and C.  Infection, bleeding, uterine damage- even rupture, anaesthetic complications etc.  So what do you want to do?

Discussion points:

What did the doctor in this scenario do well?

What jargon did he/she use?

What would have been more appropriate terminology?

What are other things he/she have done better?