12 months ago today, on the 2nd anniversary of my spouse’s death, I wrote a blog post about experiencing an urge to hit a patient (“Weathering the anniversary storm”). I explained that leading up the anniversary, communicating with patients and staff felt forced, and that conveying empathy felt fake.
This year, there have been no anniversary storms… just clear, calm and reflective waters.
Admittedly, verbal communication has been a little tricky due to a viral URTI, but laryngeal inflammation aside, I’m feeling as caring as ever. More so, if anything.
On my partner’s birthday yesterday (he was killed on the morning after his 39th birthday) I made his favourite cornbread and lit candles, reminiscing about the love and beauty he brought to my life and to the world-at-large.
Birthday cornbread
Today I’m reflecting on the blessings and opportunities he continues to bring me, albeit in absentia.
For example, a few days ago I was doing bereavement counselling with a very sad patient who’d lost her husband of sixty years. At the end of the 45 minute consultation, I felt lighter, rather than heavier as I would have done previously. As I was talking to my patient, indirectly using my lived experience to meaningfully help her, I felt my own burden lightening.
Being helped by helping others is not a new experience for me. What has changed is that the positive feelings are not always accompanied by a twinge of pain.
I’ve made it through the swamp and to the other side. It is not “getting over” my losses. It is about moving forwards, with my grief, to a new place.
I hasten to add that there are, and always will be, painful moments. Grief will never completely leave me. But the tsunami waves are less frequent, less overwhelming and, for the first time, not as predictably triggered by anniversaries and emotional interactions.
My life now is very different to that of my pre-swamp days. I am very different. Becoming a childless mother and a widow changes you irrevocably. But I have not been changed for the worse.
I am a stronger, more appreciative and more grounded person for having loved and lost.
My life is as sweet as it has ever been. Not sickly, fairy floss sweet, but rich and deeply layered, with the occasional hint of bitter to balance the sweet. It is full of meaning, purpose, humour, interest and joy. I’m lucky indeed.
I’ve gone from languishing to flourishing.
As has the tree which houses the ashes of my family.
I was asked recently, “So where do OSCE cases come from? Who writes them and how do they get chosen for use in an exam?”
These are not uncommon questions. For many, the life cycle of an OSCE case seems to be a mysterious process, shrouded in secrecy.
It’s time we had the “Where did I come from?” talk…
It starts with a twinkle in an OSCE case writer’s eye, often during a patient consultation. “This could be a good OSCE case,” the case writer muses, and from there, a case is conceived. It’s a long and complicated gestation, however, with no guaranteed delivery at the end.
OSCE case writers are neither a special breed nor an elitist group. They are a diverse mix of practising College Fellows from around the country, who are all experienced RACGP OSCE examiners specially trained in how to write OSCE cases, RACGP style.
Cases are based on real patients seen in the case writer’s own practice. They are not derived from the rare and obscure conditions we all find so interesting, but from common and/or important presentations that competent Australian GPs are expected to be able to manage.
Taking care to de-identify the patient and to ensure that the issues involved are widely applicable to Australian GPs, the case writer creates a first draft using a standard RACGP case writing template. With support and feedback from OSCE case reviewers, this initial draft may require considerable to-ing and fro-ing.
Once the first draft is complete, it gets formally reviewed by an OCSE medical educator (ME) and then road tested. Yep, road tested. Tried out by volunteer GPs who have not previously seen the case to see how it performs – which is not as much fun as taking a new car for a spin, in my opinion. Essentially, these are people willing to do OSCE cases under exam-like conditions. Some may call them dedicated, others may say masochistic, but everyone agrees that they are fulfilling an important role and helping make the OSCE better.
After the road test, the case goes through another round of review before moving to Standardisation. This is when a group of experienced OSCE examiners put its eyes on the case and marking scheme, suggests modifications if necessary, and decides on which aspects of the case (“Key Features”) are the most important. These Key Features are then bolded to assist the OSCE examiners marking the case.
After all that, the case goes into the OSCE pool, vying for selection. Unlike selection for the Australian Olympic Swimming Team which is, I’m guessing, based largely on swimming very fast in the right races, the selection of cases for the OSCE team is nuanced and complicated. It is governed by the Exam Blueprint which takes into consideration many factors such as the General Practice curriculum, the frequency a condition is seen in general practice, and the importance of being able to diagnose and manage said condition. This is why emergency presentations such as myocardial infarction occur more frequently in FRACGP exams than they are seen in a typical general practice. They are uncommon, but you really need to get the diagnosis and management right when you see them.
The “team” of cases chosen for a particular exam needs to be balanced, so that a sufficiently broad spectrum of knowledge and skills is assessed. It may seem from the outside looking in that in some exams there are very similar cases, but even when the condition is the same, the different cases test different aspects, that is, the assessment tasks are different.
An OSCE case cannot rest on its laurels after selection for a particular exam. There is more scrutiny to come: firstly by an OSCE ME (a “fresh eyes” review) followed by the Assessment Panel Chairs (APCs), then the Quality Assurance (QA) examiners and finally the assigned examiners. You would think by this stage there would be nothing left to review, but regardless of how many times a case is reviewed there can still be little typos or omissions which have slipped through the net. Cases requiring last minute adjustments get “green sheets”, on which the changes are outlined for the case’s examiners. Better to be green sheeted then yellow carded, but still, something to be avoided if possible, and with increased pre-exam reviews green sheet changes are getting fewer in number.
Finally the big day arrives and the OSCE case is role played in upwards of 45 rotations in approximately 15 exam centres around the country.
But it is still not over for an OSCE case. Post exam, the examiners and QA examiners provide feedback on the case, and the statisticians work their numerical magic to see how it stacked up. If the case fell outside certain statistical parameters (e.g. discrimination index), it goes through a further review process.
After all that, we thank the case for its service by sticking it into quarantine for several exam cycles.
After being brought out of exile, it is updated, reviewed and road tested again before it is considered for use in another OSCE.
OSCE cases, like doctors, diet fads and mobile phones, don’t last forever. At some point, each case will need to come to terms with being pulled out of the pool. After a bit of rehabilitation, the lucky ones will have a working retirement by being used for examiner training, mock OSCES and the like. Others disappear, remaining only in the memory of those who tackled them on a long ago OSCE game day….
Such is the life journey of an OSCE case.
(First published in RACGP Queensland’s Examiners’ Newsletter, August 2016)
So my group teaching session didn’t go so well – what do I do now?
When planning a workshop session, there are many things that can cause worry: “Will anyone come?”, “Will I remember what to say?”, “Will the IT work?”, “Will the room set-up be suitable?”, “Will the group be responsive and engaged?”, “Will they realise how little I actually know about this topic and turn on me?” (maybe this last one is just relevant to me?) and on the list goes.
While adequate preparation can help minimise mishaps (try to remember the 6 P’s – “Prior Preparation Prevents Piss-Poor Performance”), it is not always enough.
Things can and do go wrong for a variety of reasons, and the longer you’re in this game, the more “failures” you’ll accumulate. I use the term “failure” loosely, not limited to completely disastrous sessions in which lives are lost or spirits are broken, but to include those “sub-optimal” workshops – the sessions which, afterwards, as a facilitator, you don’t experience a mixture of relief, pride and joy, but instead feel disappointed and/or inadequate.
So what can you do with those feelings? How can you make failure work for you?
I was recently contacted by Dr Rob Park, a Queensland-based medical educator who was co-facilitating a workshop session on social media. The session was being run twice, on two consecutive days.
He called me on the Saturday night after the first session had he felt there were things that could have been done differently to improve the session. Luckily, I don’t have a social life, so talking to Rob was not an imposition. On the contrary, it was the highlight of my evening (I’m such a ME nerd!).
Rob explained that the group was challenging because of a general lack of engagement and interaction, combined with some adversarial comments and questions towards the end of the session. Not uncommon problems, especially when speaking on a topic like social media, in which levels of knowledge of interest and experience vary so widely, and on which strong opinions are often held. Rob and his co-presenters have excellent knowledge, experience and oodles of street cred on this topic, and had presented sessions on this topic before, which is a huge advantage. The trick was going to be in finding effective ways to encourage audience engagement and manage the naysayers.
It is a relatively uncommon, but fantastic learning experience, to have the chance to re-run such a session within a day or so.
In my opinion, Rob approached this learning opportunity in exactly the right way, and, having obtained his permission, I’d like to share what he did with you….
He recognised that the approach and/or content hadn’t worked well for the particular group.
He considered that it may have just been a really difficult group to engage and inspire (there are “dud” groups with which, no matter how experienced or talented you are, you cannot make a session sparkle) and therefore did not take it too personally.
While not over-personalising, he did, however, realise that a different approach/es might have resulted in a more positive outcome, and might be worth trying when he re-ran the session the following day.
He actively sought advice as to what these different approaches might be by discussing with an experienced colleague (in this case, by phoning me). We talked through what had happened and brainstormed alternative strategies.
He then put thought into how he could integrate some of these different techniques into the session.
He put these changes into practice the next day.
After the second session went very well, he reflected on why this was so.
He acknowledged that it was a different group and so the difference in outcome couldn’t entirely be attributed to the new facilitation techniques, while realising that, chances were, they made a significant difference.
He intends to keep this experience in mind when planning future teaching sessions.
Of course, there is no formula which will work every time (and how boring would that be!), and different techniques will lend themselves to different topics, audiences, group sizes etc.
The tips that Rob and I discussed to try manage the kind of challenges he faced are outlined below:
For groups who you are concerned might be quiet/ disengaged:
Get everyone talking at the beginning – either in pairs/ small groups or going around the large group if the groups is not too big/ time permits (“everyone talks once before anyone talks twice”). Usually best for the discussion to be on something relevant to the topic such as their experiences and/or what they want to get out of the session.
For groups who are likely to have different levels of experience/ learning needs, especially when you have some flexibility in content:
Ask participants the one thing they want to get out of the session at the start, and consider whiteboarding the list. Address each one either:
1) with an immediate answer (if quick and easy, and not covered later) or,
2) by saying it will be coming up in the workshop or,
3) by acknowledging that it is outside the scope of the session (preferably with information as to where to go to get more information and/or offering to talk to the person at the end of the session about it).
If the list has been whiteboarded, refer to it as you go – I like ticking the items off as they are covered, and checking that each has been covered adequately with the person who brought up the item (if I can remember who said what!).
For topics/ groups in which you expect to get resistance/ challenge/ negativity:
Try to get this out at the start and acknowledge/address head on, rather than wait until participants start making disparaging remarks/ adversarial questions later on.
Try to neutralise with (appropriate) humour when you can (I find self-deprecatory humour works best in such situations)
Recruit other audience members to pull the negative audience members into line if you can – the message is usually much more powerful if it comes from their peers.
For example, if I get a particular negative/ unhelpful question/ anecdote, I’ll often ask the rest of the group – “So what do others think?” or “Have others had experiences like this, or have yours been different?”
While this can work well, you do need to be a bit careful with this approach. I have run into trouble a couple of times. Once, two participants nearly ended up in fisticuffs. Another time, a participant ran off in tears and hid in a supply closet after a response from another participant. Mostly, however, it works well, and when it doesn’t – see it as another valuable lesson to be learned.
In summary:
When a session falls flat, it is natural to feel disheartened. Luckily, unlike in our clinical work, bad outcomes as a facilitator are rarely serious in the scheme of things. However, just like in our clinical work, when things go wrong, engaging in root cause analysis, debriefing, feedback and formulation of specific actions for improvement, can be incredibly useful strategies.
I’ve learned so much more from my failures than my successes, and I now love nothing more than a “challenging” group so I can pull out a few extra tools from my facilitator’s toolbox. Failure is never fun, but it can be your educational friend.
Thanks to Rob for approaching me for advice on this in the first place and for encouraging me to share these tips as a blog post.
I would love to hear your thoughts, experiences and tips – please comment below.
At this very moment, I’m “invigilating” the RACGP’s KFP exam (one of the three Fellowship exams) in Brisbane. To the uninitiated, the word “invigilate” is of British origin dating from the mid-1500s, specifically meaning “to watch examination candidates, especially to prevent cheating.” I know this because my mother duly informed me of such in an email this morning. I casually that mentioned to my mum, during a Skype call earlier this week, that I was going to be invigilating on Saturday and she was curious enough about the unfamiliar (to her) word to look it up.
As I look into the sea of earnest faces as they type away (yep, the exam is computer based), all I can think of is “thank God it is them and not me.” I may be the “teacher” but I reckon that if I sat the exams today, I’d probably fail.
If patients want a GP with excellent theoretical knowledge, I recommend they seek out a GP registrar who is about to sit, or has just sat, the Fellowship exams. Breadth-of-knowledge-wise at least, for most of us, it is all downhill from there.
Drs David Chessor and Suzanne Lyon – recent successful RACGP exam candidates.
In my medical educator and RACGP examiner roles I spend a lot of time working with GPs in the peri-exam phase of their careers. I’m constantly impressed with how much “stuff” they know and find myself wondering where all the “stuff” I used to know has gone. I’m not yet forty, so can’t blame age-related cognitive decline. I did get a knock to my head which resulted in six facial fractures and temporal lobe contusions, but I passed my FRACGP OSCE exam three weeks later so it can’t have done me too much harm.
And yet here am I, constantly having to look up drug doses, item numbers, clinical guidelines and the anatomy of the facial nerve. Sometimes I feel like I’m just an ignorant lump of carbon. The human brain is an unfathomably complex and wondrous organ, but its data storage and retrieval capacities are beaten hands down by a $5 USB flash drive.
What I find most frustrating is that it’s not just the old facts which have slithered out of reach: it’s the newer information too. I try to keep up. I read. I listen. I discuss. But some things just don’t stick. I’ll read an article on the newest research findings regarding the pathophysiology of chronic kidney disease, for example, and think, “Yep, I get it. Kidneys sometimes confuse me but this I understand. I follow the logic from start to finish.”
It’s like a light bulb. A light bulb which blows five minutes after I’ve closed the journal. Nothing. Ask me to explain a single pathological process and I would probably say something like, “Well it is to do with sodium and tubules… and umm… you know, it is a great article. I can email you a link if you like.”
Now before you put in a concerned call to the Medical Board, let me assure you that I am a safe and competent doctor. I’m pretty good at knowing what I don’t know, and just as importantly, knowing how to fill the gaps left by the information that sneaks out of my cranium after dark. I can Google with the best of them and I’m adept at ‘phoning a friend’.
What’s helped me most in my quest for knowledge retention is teaching. For me it is not a matter of “Those who can’t, teach”, but more a case of “If you don’t know it, teach it”. I find that there is nothing as effective for memory-boosting as explaining to others, especially with the luxury of repetition. By the third or fourth time of delivering a particular topic, the content is usually firmly cemented in my brain.
While it is all very affirming and enjoyable to teach what you know well, preparing for and then teaching things you don’t know much about is so much more valuable. If you’re up for the challenge, combining an unfamiliar topic with a knowledgeable group is even better. You can channel and feed off their combined wisdom, and practise your skill at deflecting or redirecting those tricky questions.
I may know less about more nowadays but I’m happier than I’ve ever been. Perhaps ignorance is indeed bliss.
Luckily, there is a lot more to being a good GP than the instant recall of facts and figures. For the pathophysiology of kidney disease you can always ask Dr Google, or a registrar who has just sat those dreaded exams.
I may not have been capable of passing the AKT/KFP exams if I was a candidate today, but I think I’m doing a passable job as an invigilator. I did, at least, remember the meaning of “invigilate”. Unlike my mother. For the irony of her looking up and emailing me the definition of “invigilate” this morning is that 6 months ago (at the time of the last AKT/KFP exams) my mum and I had a Skype conversation about the word, during which I explained its meaning. Perhaps “invigilate” for her is like the “pathophysiology of chronic kidney disease” for me.
The GP registrar, Dr S, took a big breath before bringing in her first patient from the waiting room. It was her first ECT (External Clinical Teacher) visit and she was probably wishing she’d been booked in for the other kind of ECT instead.
“I’ve got another doctor sitting in with me today as part of my training. Is that okay, Jacquie?”
“Sure, no problem. I’m just here for my results and a quick script,” replied the 50-something Jacquie as she walked with Dr S down the corridor.
In contrast to Dr S’ obvious discomfort, Jacquie seemed perfectly at ease — until she saw me sitting in the corner. Her eyes widened and then carefully avoided any further contact with mine. She twisted and untwisted the strap of her handbag.
“Are you okay?” Dr S asked. “You seem kind of jumpy.”
The response came through gritted teeth: “I’m fine.”
“Good news about your results. They are all normal. I’ll go through each one with you now. The arsenic level was undetectable”
“No need to go through them. Can I just get a printout please? I’m in a bit of a hurry.”
“Well, okay. You wanted a copy for your naturopath, didn’t you?”
“Umm, no. Just for me.”
Dr S looked confused.
“But didn’t your naturopath give you the list of the blood tests she wanted you to have done?”
“Umm, oh, that’s right. I forgot.”
Dr S shook her head almost imperceptibly as she printed out the results. She turned back to Jacquie.
“And your script?”
“What script?”
“You mentioned you wanted a script. Was that for temazepam?”
“No, I don’t need a script. I have a spare one at home. I forgot.”
Dr S was struck with the possibility of an interesting diagnosis. Her face lit up momentarily before settling into a caring but concerned expression.
“You seem to be having some memory problems, Jacquie. I’d like to ask you a few more questions if that’s okay?”
“Not today, I’ve got to go. Thanks.”
Jacquie flew out of the room, clutching her pathology results.
Dr S turned to me, her brow creased with concern.
“Well, I stuffed that up. Should I have handled the memory issue differently? She seemed really scatty today — she’s never been like that before. Do you think early onset dementia is a possibility?”
“Just take a deep breath. You didn’t do anything wrong. Sometimes there are other things going on.”
I smiled and explained that Jacquie was a regular patient of my practice, 50km away. She’d been in to see me only a week earlier when she’d asked for a range of unusual blood tests as requested by her naturopath. I had not ordered them. I had, however, given her a script for temazepam, which she insisted she used only occasionally.
As is the case with most registrars, Dr S soon relaxed into the ECT visit and found the experience valuable educationally.
It was valuable for me too. And for Jacquie. Somewhat to my surprise, she came back to see me, contrite, and we had a frank and open discussion about what had happened.
Her memory is just fine, although she wishes she could forget that embarrassing day.
(Names have been changed and permission has been obtained from the involved parties for this account to be published).
First published in Australian Doctor on 9th August, 2012 On an ECT visit about an encounter I had a few years back, but memorable even now…
Medicine is both a science and an art, and while knowing the causes of chronic renal failure is important (or so I’m told ;-)), there is so much more to being a good doctor.
Most start their medical training full of noble ideals and altruism (at least, that’s what they claim in their entrance interviews) but it is all too easy for medical students and registrars to quickly get overwhelmed by the enormous amount of stuff to learn. Experienced doctors too, can get stuck in work mode and lose sight of the big picture.
I believe one of the fundamental responsibilities of a medical educator is to help our learners see the wood, the trees and the forest of medicine, preferably simultaneously. Also important to remind ourselves!
I have started recommending this utterly inspiring talk from Dr Abraham Verghese about the importance of examining patients to my registrars. He encapsulates the essence of our role and influence much more eloquently than I can…
The findings of a survey of 180 doctors by Melbourne and Monash Universities hit the media in Oct 2013 after being published in MJA. The survey results showed that 55% of Australian female GPs had been sexually harassed by patients and 65% been asked for inappropriate examination. It was stated that less than 7 per cent of the GPs surveyed said they had been trained on how to deal with sexual harassment by a patient.
Reading the report prompted me to consider how we could cover this with trainees and thought that a scripted role play (*see explanation below) may be an effective method to broach this difficult topic. I wrote the short script below to use with GP registrars.
Please feel free to use and/or adapt it if you wish. All I ask is that appropriate attribution is made and that you let me know how it goes if you do run it with students or junior doctors. I always appreciate receiving feedback.
* Explanation
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.
1) Prior to the session, two volunteers are sought for reading role play (and permission is obtained – no one is ever pressured to read). I would suggest the roles are played by two females to minimise any discomfort, given the material.
2) Introduction to session
3) Scenario (projected via PowerPoint and/or read aloud)
4) Reading of dialogue by volunteers with break midway (as per script) for discussion
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:
Dr Emma consults with new patient, 72 year old Fred Jackson.
Script:
Emma: (At doorway) Fred Jackson?
(Emma comes in with Fred, an elderly man.)
Emma:(holding out her hand to shake) Hello Mr Jackson, my name is Emma Roberts. Welcome to the clinic.
Fred: Well hello Emma, aren’t you a sweet little thing?
(Fred shakes with his R hand and uses his L hand to stroke Emma’s forearm. She withdraws it quickly without any fuss or change in facial expression and motions for Fred to sit. They both sit down. Fred edges his chair a little closer to Emma’s. She edges hers back slightly)
Emma: How can I help you today, Mr Jackson?
Fred: No need for the formalities, darlin’, we’re all friends here. I’m been Freddie since the day I was born, seventy-two years ago today.
Emma: Happy birthday, Freddie.
Fred: It’s all the more happy now I’ve seen you, darlin’. You’re the kinda present I’d love to unwrap. Tasty! (drawn out pronunciation: Taste-ee)
Emma: Let’s focus on health matters, shall we?
Fred: I’m just having a bit of fun, darlin’. I don’t mean nothin’ by it. You wouldn’t begrudge an old man a bit o’ harmless fun on his birthday, now would ya love?
Emma: I’d feel more comfortable without that kind of banter, if that’s OK.
Fred: You’re a bit uptight, aren’t ya love? No worries, I’ll tone it down.
Emma: So what can I do for you today?
Fred: I know what I’d LIKE you to do for me, with those soft white hands and rosy red….
Emma:(interrupting) Freddie, that is inappropriate.
Fred: Sorry, sorry. Don’t get your cute little knickers in a twist. I’ll behave. OK, well it’s kinda embarrassing. I’ve bin havin’ problems with me waterworks. No longer Niagara Falls, more like a pissy little dribble that won’t even put out unless you talk to it real nice and buy it dinner first. (laughs at his joke) Me regular doc reckoned it is probably me prostate and wanted to stick a finger up me bum to check it out. I told him, no way any bloke is putting any of his bits in my hole – just doesn’t feel right, ya know love?
Emma: It’s a routine medical examination, Freddie, there is nothing sexual about it.
Fred: Maybe, but I’d feel a lot better if a nice young lady doctor did it. You’ll treat me gentle, I can tell. Might even be fun, and God knows, I don’t get much of that kinda fun anymore.
Stop:
Discussion: How do you think Emma is feeling right now? Why is Freddie behaving this way? (dirty old man, inappropriate but harmless/ well meaning or someone who is trying to cover up his embarrassment with “humour”) How has Emma handled things so far? What would you have done differently? What can she do now? Get volunteers to say what they think Emma’s next response should be)
Emma: First, I’ll need to take a full history and perform a general examination. If I agree that a rectal examination is indicated, I will ask my colleague, Dr Michael Harris to come in and act as chaperone.
Fred: We don’t need no chaperone, darl. I trust ya. I’ll put my bum in your hands anyday.
Emma: It is for my comfort as much as yours, Freddie. It is my policy not to perform that kind of examination without someone else present.
Fred: How about a sexy nurse then? Always fancied a threesome.
Emma: Again, I must warn you about your language, Freddie. I find it offensive and if you continue, I’m going to have to ask you to leave.
Fred: Sorry love. I’m harmless. Just like joking around.
Emma: If are not comfortable with Dr Harris being present, and you need an intimate examination, I’m afraid I’ll have to ask you to go elsewhere for the examination. I’d be happy to pass on any relevant information to the doctor of your choosing.
Fred: Blimey! Are you some kind of bloke-hating women’s libber? Talk about overreacting to a bit of friendly chat.
Stop:
Q and A in role
De-role readers
Group Discussion: Has anyone experienced inappropriate sexual behaviour from patients? How did you handle it? Stats (55% GPs 2013 study) What are your options? What systems in place in your practice?
“Are you learning a lot today, dear? Are you going to be a GP too one day?”
My face breaks into a smile for a number of reasons. I love it when, as a medical educator, I’m mistaken for a student while conducting external clinical teacher (ECT) visits.
First, if patients mix up which one of us is the registrar and which is the teacher, it usually indicates they trust and respect the doctor they’re consulting.
Second, it can help put a nervous registrar at ease. We have a chat and a laugh about it afterwards, and I can almost see their confidence level rising.
And third, it makes me feel young.
Before you try to burst my bubble, I know med students are not all bright-eyed 20-year-olds, but I still take it as a compliment.
For the uninitiated, ECT visits are compulsory components of GP training nationwide. Each involves a medical educator visiting a registrar’s practice and sitting in for a session, after which a report is written and kept on file.
There are some registrars who relish the idea of an educator observing and commenting on their clinical performances in a career they’ve only recently started.
They’re usually the same type of people who like doing karaoke without the benefit of inebriation, think nothing of standing up in front of a crowd to deliver impromptu speeches, and apply for reality TV shows.
Most, however, are at least a fraction anxious about their first ECT visit. For starters, having the name ‘ECT’ doesn’t exactly engender comfort and reassurance. Those who chose this initialism might have thought it amusing, but I haven’t seen many registrars laugh about it.
Indeed, one even told me she’d had a nightmare in which she received an electric shock every time she asked too many closed questions or didn’t pick up on non-verbal cues.
The training provider for whom I work has changed the name to ‘FACT’ (Formative Assessment Clinical Teaching). However, the FACT of the matter, as I see it, is that an ECT visit by any other name still smells of fear.
Most registrars relax into ECT visits pretty quickly and find the experiences educationally valuable. By the end of that first nerve-wracking visit, many say things like, “That was great — I wish you could come every week.” A few actually mean it!
I used to be nervous conducting ECT visits too. Back in 2005, when first starting out as a medical educator, I worried that I was too young and inexperienced. What if a registrar asked me a question I couldn’t answer? It took me a while to realise I didn’t need to know everything to be a good teacher, and that getting the registrar to look something up was not only okay, but a valid educational strategy.
In those early days, patients often mistook me for a student, but I didn’t view it as complimentary. I was still young enough to want to look older.
It was a bit like being asked for ID at a club. At 20, many people are miffed to be asked for ID: “There’s no way I look underage!” At 25, they think it’s mildly amusing: “I look underage? That’s pretty funny!” However, by 30, they are desperately hoping that someone, anyone, would mistake them for possibly being a teenager.
I’m now very comfortable being the age I am and have no desire to be a teen again. Nonetheless, the occasional medical student misidentification is not unappreciated!
I use this scripted role play in registrar sessions I facilitate on infertility to illustrate how emotionally charged and difficult consultations relating to infertility can be, and how easy it is to “put your foot in it”.
Why scripted role plays? 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. 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
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 which starts with this clip…
…and includes a discussion on while a lot of us spend a good deal of our reproductive aged lives trying NOT to get pregnant, there often there comes a time when the tables turn and pregnancy becomes the goal, not the mistake, and that unfortunately, for many, their plans don’t go to plan.
3) Definitions, statistics and the role of the GP in diagnosing/ managing the infertile patient.
4) Discussion on the psychological aspects of infertility.
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
Scripted role play on the psychological aspects of Infertility.
Characters:
Patient: Robyn, 40 year old female
GP registrar: Jeff Larson, aged 25 – 40
Script:
Jeff: Hi Robyn, I’m Jeff Larson, what can I do for you today?
Robyn: I was hoping to see Dr Kate again but the receptionist said that she’s left and you’ve taken her place.
Jeff: Yes, Kate has moved to another practice but I have access to her very thorough notes and will help you as best I can.
Robyn: That’s always happening here. I just get used to someone and they up and leave. Is it that bad a place to work?
Jeff: Not at all. It’s great. The reason that doctors come and go here is because it’s a training practice. Kate and I are registrars – GPs in training. We’re required to work at different places to improve our breadth of experience and get moved around periodically.
Robyn: I think you’re wrong about Kate – she’s no student doctor. She’s the most knowledgeable and caring doctor I’ve ever had.
Jeff:(under his breath) So her patients keep telling me. (to Robyn) GP registrars are not student doctors – we’re fully qualified doctors doing extra training in general practice. But let’s get back to why you’ve come along today…
Stop for Q and A in role, and discussion.
How are you feeling right now Jeff / Robyn? Who has had patients complain that doctors don’t stay? Who has had patients try to make you feel guilty for leaving? How do you think Jeff handled it? What would you have done differently? Do you tell patients you’re in training? How do you explain the concept of GP registrar?
Jeff: So how can I help you today?
Robyn: I need another referral to Dr Orford.
Jeff: The gynaecologist?
Robyn: Yes. I have an appointment next week and my last referral has run out.
Jeff: Sure, I can write you one. I see from your chart that you’ve been seeing him for fertility issues. Is this what the referral is for?
Robyn: Yes. I can’t get pregnant.
Jeff: I’m sorry to hear that. It’s really common in women your age. Fertility rates drop off a lot after 35.
Robyn: I’ve been trying to get pregnant since I was 29… 11 years ago. Isn’t that in my chart?
Jeff: Probably. I’m sorry, I didn’t have a chance to read it fully before you came in. Sounds like you’ve had a really difficult time of it. (pause… then trying to make a joke to lighten the mood). Well, at least you have a good excuse to get in lots of practice.
Robyn: Pardon?
Jeff:(embarrassed) I just mean that you have an excellent reason to have regular sex which will umm… help strengthen your marriage.
Robyn:(incredulous) You think not being able to have kids helps relationships?
Jeff: No, no I didn’t mean that.
Robyn: And that business-like sex on an ovulation-centred schedule is fun?
Jeff: Well maybe not always but…
Robyn: Not that our attempts to get pregnant involve sex anymore… which is one small mercy.
Jeff: Been having IVF?
Robyn: IVF, AI, DI, IUI, ICSI, donor eggs… you name it, we’ve tried it.
Jeff: So what exactly is the nature of your problem, if you don’t mind me asking?
Robyn: I have endometriosis which Dr Orford said has also affected the quality of my eggs, and my husband has a low sperm count. Triple whammy – bad pipes, bad eggs and bad sperm. We’ve just had our 14th IVF attempt.
Jeff: 14! You must be very… umm… dedicated.
Robyn: Obsessed you mean.
(Jeff tries to protest)
Robyn: No, it’s alright, I am obsessed. I have wanted nothing in life except to be a mother. Dr Orford encouraged me to stop after 8 IVF cycles, my husband drew the line at 10, but each time I said ‘just one more try” and they caved in. It’s not going to work again though. It’s the end. That’s why Dr Orford has asked me to see him next week, I need to get a referral for him to tell me he can’t see me anymore. Talk about ironic.
Jeff: So about that referral…
Robyn: I’m not ready to give up on my dream of having a family though. What can I do?
Jeff: What about surrogacy?
Robyn: There’s no one close that I can ask to do it for me and paying someone is illegal, even if you do it overseas. Besides, bad eggs, bad sperm, remember? Surrogacy is unlikely to work for us.
Jeff: Have you considered adoption?
Robyn: We’re too old- they won’t accept us. George, my husband, is 48.
Jeff: Fostering?
Robyn: They turned us down for that too. Long story.
Jeff: How about coaching a kids’ sporting team or doing some babysitting?
Robyn: Do you really think that’s anything like being a parent?
Jeff: In many ways, it’s better. You can give then back at the end and have a free and independent life.
Robyn: Do you have kids?
Jeff: Yes. 3 under 5.
Robyn: And how would feel if you had to ‘give them back at the end’?
Jeff: Sometimes I wish I could, believe me.
Robyn: You regret having them?
Jeff: Of course not! They’re the best things that have ever happened to me. It’s just that…you know… kids can be a bit…annoying sometimes.
Robyn: No I don’t know, that’s the problem. Sure, parents often complain that their kids are frustrating and restrict their lives but also say that having children is the most rewarding and fulfilling accomplishment in life. Can you honestly tell me that this is just a myth designed to help tired and stressed parents cope?
Jeff: No… maybe… I don’t know.
Robyn: I can’t help but think that I’m missing out on the best thing a person can do in life.
Jeff:(awkward pause) I’m really sorry you can’t have kids. I just don’t know what to say.
Robyn: Dr Kate would’ve.
Jeff: Shall I do that referral for you?
Q and A in role then group discussion
Where did Jeff run into trouble?
What could have he have done differently?
What do you do when patients ask you personal questions?
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?
12 months ago today, on the 2nd anniversary of my spouse’s death, I wrote a blog post about experiencing an urge to hit a patient (“Weathering the anniversary storm”). I explained that leading up the anniversary, communicating with patients and staff felt forced, and that conveying empathy felt fake.
I was asked recently, “So where do OSCE cases come from? Who writes them and how do they get chosen for use in an exam?”
Dr Genevieve Yates 