SIMULATED OFFICE ORAL SAMPLE 7

Transcription

SIMULATED OFFICE ORAL
SAMPLE 7
THE COLLEGE OF FAMILY PHYSICIANS OF CANADA
CERTIFICATION EXAMINATION IN FAMILY MEDICINE
INTRODUCTION
The Certification Examination of The College of Family Physicians of Canada is
designed to evaluate the diverse knowledge, attitudes, and skills required by
practising family physicians (FPs). The evaluation is guided by the four principles
of family medicine. The Short Answer Management Problems (SAMPs), the written
component, are designed to test medical knowledge and problem-solving skills.
The Simulated Office Orals (SOOs), the oral component, evaluate candidates’
abilities to establish effective relationships with their patients by using active
communication skills. The emphasis is not on testing the ability to make a medical
diagnosis and then treat it. Together, the two instruments evaluate a balanced
sample of the clinical content of family medicine.
The College believes that FPs who use a patient-centred approach meet patients’
needs more effectively. The SOOs marking scheme reflects this belief. The marking
scheme is based on the patient-centred clinical method, developed by the Centre
for Studies in Family Medicine at the University of Western Ontario. The essential
principle of the patient-centred clinical method is the integration of the traditional
disease-oriented approach (whereby an understanding of the patient’s condition
is gained through pathophysiology, clinical presentation, history-taking, diagnosis,
and treatment) with an appreciation of the illness, or what the disease means
to patients in terms of emotional response, their understanding of the disease,
and how it affects their lives. Integrating an understanding of the disease and
the illness in interviewing, problem-solving, and management is fundamental
to the patient-centred approach. This approach is most effective when both the
physician and the patient understand and acknowledge the disease and the illness.
In the SOOs, candidates are expected to explore patients’ feelings, ideas,
and expectations about their situation, and to identify the effect of these
on function. Further, candidates are scored on their willingness and ability
to involve the patient in the development of a management plan.
The five SOOs are selected to represent a variety of clinical situations in which
communication skills are particularly important in understanding patients and
assisting them with their problems.
Page 1
RATIONALE
The goal of this Simulated Office Oral (SOO) examination is to test the candidate’s
ability to deal with a patient who has
1.
questions about contraception;
2.
problems sleeping.
The patient’s feelings, ideas, and expectations, as well as an acceptable approach to
management, are detailed in the case description and the marking scheme.
Page 2
INSTRUCTIONS TO THE CANDIDATE
1.
FORMAT
This is a simulated office situation, in which a physician will play the part
of the patient. There will be one or more presenting problems, and you are
expected to progress from there. You should not do a physical examination
at this visit.
2.
SCORING
You will be scored by the patient/examiner, according to specific criteria
established for this case. We advise you not to try to elicit from the examiner
information about your marks or performance, and not to speak to him or her
“out of role.”
3.
TIMING
A total of 15 minutes is allowed for the examination. The role-playing
physician is responsible for timing the examination. At 12 minutes,
the examiner will inform you that you have three minutes remaining.
During the final three minutes, you are expected to conclude your
discussion with the patient/examiner.
At 15 minutes, the examiner will signal the end of the examination. You are
expected to stop immediately, and to leave any notes with the examiner.
4.
THE PATIENT
You are about to meet Ms. JANE ROBERTSON, age 28, who is new to your
practice.
SPECIAL NOTE
Because the process of problem identification and problem management plays an
important part in the score, it is in the best interest of all candidates that they not
discuss the case among themselves.
Page 3
10 CFPC Preparation Pointers for SOO Examiners
1.
The first rule for successful acting is to put yourself into the mindset of the person
you are impersonating. You have been around patients long enough to have a fairly
good idea of how patients speak, behave, and dress.
Think of the following:
•
•
•
•
The
The
The
The
defensiveness and reticence of a patient with alcoholism.
embarrassment of someone with a sexual problem.
anxiety of a person with a terminal illness.
shyness of a young teenager asking for birth-control pills.
Once you receive your SOO script, think about the following:
•
•
•
2.
How is this type of patient going to react to a new physician initially?
Will he or she be open, shy, defensive, “snarky,” supercilious, etc.?
How articulate will a person of his or her education level and social class be?
What jargon, expressions, and body language will he or she use?
What will his or her reactions be to questions a new physician asks?
Will the patient be angry when alcohol abuse is brought up?
Will he or she display reticence when questions about family relationships are asked?
Do not give away too much information! This is a common error. Allow the candidate
to conduct a patient-centred interview to obtain the information he or she needs
to zero in on the problem. The SOO is set up for you to give two or three specific
cues to focus the candidate on the real issue(s), whether it (they) be alcohol abuse,
sexual fears, worry about AIDS, etc.
You have all sweated through this exam yourself. It is normal to feel sorry for the
poor, nervous, sweating candidate sitting in front of you. This exam is the result of
years of experience on the part of the College, and the cues you are given are enough
for the average candidate to realize what the real issues are. If the candidate still has
not caught on after the two or three cues you have given as instructed in the case
script, that is his or her problem, not yours. Do not give away too much after that.
3.
Many candidates are not native English-speaking and may have language difficulties.
They may not comprehend subtle verbal cues and jargon (e.g., “I only have a couple
of beers a day, Doc”). The College is proud that so many physicians, many of whom
are older than traditional candidates and have come from foreign countries, apply for
certification. Transcultural medicine is a field onto itself, and these physicians can
perform a valuable service in providing care to Canada’s large immigrant population.
These physicians will have to attend to Canadian-born patients, as well, and in the
interest of fairness, do not act or speak differently during the examinations of these
candidates. However, do feel free to write “possibility of language difficulties” on the
score sheet if you feel this is the case.
Page 4
4.
Occasionally a candidate will get off on a tangent, or onto a completely unproductive
line of questioning. During this exam you must walk the fine line of not giving away
too much, but also of not leading the candidate down a completely inappropriate path
of inquiry. His or her time is limited. If a candidate begins a completely unproductive
line of questioning, answer “No!” (or appropriately negatively) firmly and decisively,
with proper body language. This will, in a subtle way, prevent him or her from wasting
several valuable minutes on such questioning.
5.
Do not overact. Bizarre, hysterical gestures, arm flapping, inappropriate clothes,
(e.g., a retired carpenter probably will not show up in a $500 suit, etc.), have no
place in this exam. Always try to think how this person would act with a physician
he or she had never met.
6.
As the examinations proceed, you will (we hope) truly begin to be the patient.
You will notice there will be some “doctors” with whom you feel comfortable,
some with whom you feel less comfortable, some who conduct the interview the way
you would have, and some who conduct the interview in a different way. We ask you
to mark each candidate as objectively as possible, using the criteria we supply.
7.
Remember to give the prompts! We all slip up once in a while and forget to give
a prompt. If you suddenly remember, give the prompt as soon as you can.
Sometimes you might be unsure about whether you need to give a prompt:
you may be uncertain if the candidate has already covered the material on which
the prompt is supposed to help him or her focus. When in doubt, err on the side
of giving the cue!
8.
Please pay attention to the clothing and acting instructions we give you. We find that
even a change that seems minor to you, such as wearing a long-sleeved shirt instead
of the specified “short sleeves,” has a way of changing the whole atmosphere of the
encounter for candidates.
9.
Remember to give a clear three-minute prompt! When candidates ask that their
performance be reviewed after a poor score, a common complaint is that this prompt
was not given. To prevent any misunderstanding, give both verbal and visual cues:
say something like “You have three minutes left.” and flash a three-finger sign.
After you have given the three-minute warning, you should not volunteer any new
information. Limit your responses to direct answers or clarification. If the candidate
finishes before the alarm, simply sit in silence until it goes off. Do not offer any more
information or inform him or her that he or she has time left.
10.
Remember to follow the script and assist the College by clearly and adequately
documenting important details of the interview on the reverse side of the score sheet,
particularly with “problem” candidates.
Page 5
CASE DESCRIPTION
INTRODUCTORY REMARKS
You are Ms. JANE ROBERTSON, age 28, who works as a flight attendant. You have
a concern about your contraceptive pill. You would also like to discuss a problem
with your sleep. Your regular family physician (FP), Dr. HUDSON, is on sabbatical
for one year.
HISTORY OF THE PROBLEM
Contraception
You are concerned because last month you did not have your “period.” You have
been taking the contraceptive pill for 10 years and have always had bleeding
every 28 days. You should have experienced this bleeding about three weeks ago.
You are still taking the pill as prescribed: you restarted it two weeks ago immediately
following the normal seven-day break. (You take the pill for three weeks and then
have a seven-day break, during which bleeding occurs.) You are concerned that
something is wrong. You know your body very well, and this is the first time that
you have not had bleeding. This bleeding is usually light, lasting two to three days
at the most. Usually you require one to two tampons a day at most. You have never
had any heavy periods, flooding, or cramping/pain.
You do not think you are pregnant as you have not missed any pills. In addition,
you did a home pregnancy test on your urine three days ago, and the result was
negative. You have no breast tenderness, nausea, or abdominal pain. You have
had no diarrhea and are taking no other medications. You have not used antibiotics
recently. You must keep using contraception as you definitely need birth control
(see below).
You are feeling well otherwise. You have had no vaginal discharge or irregular
bleeding in the past. You have never been pregnant. Your menarche was at
age 13, and you started using the contraceptive pill when you were 18. You do
recall that your periods were a bit irregular in your teens, but since you started
the contraceptive pill, your bleeding has been light and as regular as clockwork.
You started the pill because you became sexually active and needed birth control,
and you have been using it ever since. You are sexually active, and use condoms
in addition to oral contraceptives.
Page 6
You have no symptoms suggesting possible hypothyroidism (e.g., weight gain/loss,
dry skin, fatigue, constipation/diarrhoea, heat/cold intolerance, sweating, tremor,
etc.). You do not have any acne or hirsutism.
Sleep Problems
You would also like to discuss sleeping problems. Although you travel fairly
frequently with your job, you never really had any problems sleeping until
about two months ago. Now, you have difficulty falling asleep, and sometimes
get only three to four hours of sleep a night. You lie awake for two to three hours
before finally drifting off. Once you fall asleep, you seem able to stay asleep,
but when you wake up you do not feel well rested. You do not feel depressed or
anxious, and you have no anhedonia or panic attacks, although recently you have
been a bit preoccupied with certain aspects of your personal life (see below).
You sometimes get up and read or watch TV after you have lain awake for about an
hour. You now feel tired when you go to work, and this is starting to concern you,
particularly as your sleep pattern has been quite organized because of your work
schedule. This insomnia is starting to disrupt that pattern.
In your job as a flight attendant, you regularly cross time zones and have worked
out a way to conquer jet lag. Up until now, this approach seems to have worked for
you. For the past three years you have been working a route between Canada and
the United Kingdom regularly. You usually fly to the UK in the evening, Canadian
time. You stay hydrated during the flight and are generally busy and moving around
the cabin for the duration of the flight. When you arrive in the UK, which is usually
in the morning local time, you have a nap for about three hours, get up and stay
awake until the evening, and then go back to sleep at around 9 or 10 p.m. local
time. You then fly back to Canada the following day, leaving at around noon local
time, arriving back in Canada in the mid-afternoon. Adjusting to the time change is
easier when you fly home. You then fly back to the UK the following day. You do this
for three weeks at a time, and then you have a week off. You have not altered this
routine and you do not think the travel is causing your sleep difficulty. However,
now that you are having trouble sleeping, the system you have devised is becoming
disrupted: you have more difficulty getting up during the day after your nap,
and you cannot fall asleep in the evening.
There are no obvious environmental distractors. The room is dark and quiet,
and there are no obvious extraneous sounds or anything else that may cause
you to stay awake.
You tried to cut down on coffee when your sleep started to become disrupted,
but the last week that you worked, you actually needed to drink more coffee
as you were feeling so tired. This also disrupted your routine for staying hydrated
during the flight, as you then needed to urinate more frequently because of the
diuretic effect. For the past week you have been home and stopped the coffee
completely, but this has not helped your insomnia. You have not been able to sleep
well at all for the past six nights, and tomorrow you are leaving again for the UK
on another three-week cycle of work and travel. You are concerned about this.
Page 7
MEDICAL HISTORY
You have no past medical history of note. You have had no operations. You last had
a Pap smear about three years ago. You have never had any abnormal Pap smears.
You have been getting a Pap test every one to two years for the past five years,
usually when you get your birth control pill prescription refilled. The last time you
had a refill of your contraceptive pill from your regular FP was about two and a half
years ago.
When you were travelling to the United Kingdom approximately two years ago,
you ran out of pills and had to see a physician there to get an equivalent
preparation. You are now taking something called Mercilon. All you really know
about it is that it works well. You have had no problems with it. You believe it is
a “low dose” pill with the exact same hormones as its equivalent preparation in
Canada. That is what the physician told you (you had given the UK physician the
packaging from the pill prescribed by your Canadian FP). The UK physician gave
you a prescription for a year’s supply which you have had refilled twice now as it
was much cheaper to buy it over there (the UK has pharmacare). You have taken
this pill for the last two years and there was no change in your bleeding pattern
when you started using the UK preparation. You are planning to come in for a repeat
Pap test once Dr. Hudson comes back from her sabbatical.
MEDICATIONS
You have been taking oral contraceptives for 10 years. You take no herbal remedies,
over-the-counter sleep aids, or other medications.
LABORATORY RESULTS
None.
ALLERGIES
None.
IMMUNIZATIONS
Up to date.
Page 8
LIFESTYLE ISSUES
Tobacco:
You do not smoke.
Alcohol:
You drink wine with meals about two to three
times a week.
Caffeine:
Since you noticed that you have been having more
trouble sleeping, you have tried to decrease your
coffee intake, and limit yourself to one cup a day.
However, on your last overseas trip you drank more
coffee to stay awake. For the past week, you have
abstained from caffeine completely.
Illicit Drugs:
You do not use any recreational drugs.
FAMILY HISTORY
Your parents, NEIL ROBERTSON and JONI ROBERTSON, are well. You have
an older brother and a younger sister who are also well. All your family members
have made it a point of pride to avoid consulting doctors whenever possible,
and they are “über healthy.”
PERSONAL HISTORY
Family of Origin
You grew up in an upper middle-class home. Your parents are high-level
professionals. Your father is a researcher and your mother runs a public relations
firm. Your siblings also are successful in their chosen careers. Your brother,
IAN ROBERTSON, is a financial consultant, and your sister, SYLVIA ROBERTSON,
is in law school. Yours was a strict but loving home environment, and your parents
instilled a strong sense of discipline and confidence in you.
Your parents placed a lot of pressure on their children to succeed academically.
You did reasonably well in school, although Ian and Sylvia seemed more
academically inclined; as the middle child, you often felt that you were being
compared with both, at times unfavourably. This led to your competitive nature.
You were better at sports and played field hockey for your high school, reaching
the finals of the national championships in your last year. You were popular, and,
because of your competitive nature, you ran for and were elected president of your
student council in grade 12.
Page 9
Your parents gave you a very strong sense of what was right and wrong, and so
far you have gone through life thinking of the world in rather concrete terms.
They also pushed you always to stand up for yourself, and you are fairly confident
(some might say pushy) in your views of what you want. You are no shrinking violet
and are quite direct.
In your relationships with men, you have always been a bit choosy and in control.
You never had a problem getting dates, but your self-confidence was sometimes
a bit intimidating for your boyfriends. You first had sexual intercourse when you
were 18. You were taking contraception at the time, in anticipation of this
happening. You had about four serious and not-so-serious relationships throughout
high school and university, the longest lasting about eight months. They all ended
amicably, and you were always the one who ended them. Often this was because
you couldn’t see yourself as a lifelong partner with any of your boyfriends, and,
therefore, what was the point of carrying on?
Relationship with Bryan
You have been in a relationship with BRYAN DANKO for the past five years.
You met when you both were training to be flight attendants, and hit it off
immediately. You had similar temperaments and shared many interests, particularly
travel and sports. Like you, he was very confident and sure of himself. After a few
dates with him, you fell totally in love and were looking forward to a long future
together.
However, about three years after you started dating, Bryan grew unwell. He suffered
from general weakness of his legs and arms, which seemed to become progressively
worse. First he started dropping objects and became clumsy, often tripping and
falling for no apparent reason. Doctors were puzzled at first, but after several
months of investigations and consultations with various specialists, a diagnosis
of nemaline myopathy was made. You learned this is a relatively rare genetic disease
of skeletal muscle. Bryan has the adult-onset variant, which has a variable course.
Although his respiratory muscles are not yet affected, his recent deterioration
suggests that this may happen within the next year or so; he began to need to use
a wheelchair full time about six months ago. You have done some research on the
disease and realize that although it is not necessarily fatal, Bryan is likely to become
completely dependent on caregivers within the next one to two years and could
end up needing assisted respiration. As the disease affects only skeletal muscle,
Bryan’s cognitive abilities remain intact. However, you are starting to notice that
he now has some difficulty articulating his speech, which makes understanding him
more difficult.
About six months ago, Bryan applied for and received permanent disability status
with the provincial ministry of health. He therefore became eligible for disability
benefits and home care. He now has a personal assistant who provides some
nursing care.
Page 10
Until recently, you had decided that, come what may, you would stay with
Bryan and never abandon him. However, now that he uses a wheelchair full time,
looking after him is becoming more intense and tiring, both emotionally and
physically. Although you are still able to have sex, his general weakness and
condition are affecting your ability to be intimate with him. You are able to orally
and manually stimulate him to orgasm, but sexual intercourse is not that satisfying
for you anymore. In fact, you have not actually had sexual intercourse with Bryan
for about five months; that stopped soon after he began using a wheelchair full time.
Whenever you return from being overseas, you visit him daily and spend time
reading to him and taking him on walks in his wheelchair. Your role seems to be
changing from partner to caregiver.
You have not moved in with Bryan, and you have your own place. Around the
time that his symptoms began, you had contemplated moving in together and
were even considering marriage. Those plans were put on hold as the seriousness
of his illness became clear. Now you are starting to realize that Bryan’s future looks
bleak, and you would face the prospect of looking after him for many years as he
becomes progressively more disabled.
Bryan and you have not yet had a frank discussion about the long-term future
of the relationship. At the moment, you sense that Bryan is becoming needier
and more dependent upon you. This is a change from the original dynamic,
as you both were quite independent before this illness. Bryan seems to skirt
around the issue, although he knows the general prognosis. You realize that
fairly soon you are going to have to discuss the future. You have been putting
this off as you know the conversation will be very difficult, and currently you
feel a lot of ambivalence because you believe you must remain loyal and
committed to him.
Bryan himself does not have a lot of family support. His father, who likely had
the disease himself, was killed in a car accident when Bryan was 13, before the
disease could be fully expressed. (Your research has revealed that Bryan has the
autosomal dominant variety of the disease, which means there is a 50% chance
that his offspring will have the condition.) His mother died of breast cancer when
Brian was in his early 20s. He has a sister who lives and works on the other side
of the country. He was never particularly close to her. She does try to visit him fairly
regularly when she is in the region, but she cannot to do any more than that at the
moment, as she has a young family.
So far, you and Bryan have not discussed or formally arranged living wills,
advance directives, power of attorney, etc.
Page 11
Relationship with John
About three months ago, you began a relationship with a pilot, JOHN HELM,
who flies for the airline where you work. He is a colleague whom you grew to
know as a friend, and one evening during a stopover in London, you went out to
dinner with him and one thing led to another. You ended up having sex with him
that evening. Since that time you have been meeting regularly when both of you
are in London, which is usually about two to three times a month.
Up until now, you have been able to compartmentalize and rationalize this
relationship as an outlet for the unfulfilling physical relationship with Bryan,
because you have not contemplated leaving him. You feel that Bryan still requires
your emotional support, now more than ever as his disease seems to be progressing.
Bryan does not know about John. However, as your relationship with John continues
to develop, you are starting to contemplate the future in starker terms. You know
that John is in an unhappy relationship himself and is interested in developing his
relationship with you further. You aren’t so sure about taking things further yourself:
you enjoy the sex and physical intimacy, but you would not say that you are in love
with John. You feel a loyalty to Bryan but know, intellectually, that he is not going to
be able to sustain any sort of physical relationship with you, and that he will remain
chronically ill and possibly “linger” for years. As someone who, until now, has been
used to making relatively black-and-white decisions, you find this “shade of grey”
quite disconcerting.
EDUCATION AND WORK HISTORY
You attended university and completed a degree in geography. You did this
primarily to please your parents, as they wanted you to obtain a university
education. Your brother and sister were obviously headed for more high-powered
degrees (in business administration and law respectively). You did reasonably well,
although geography was not a subject that filled you with great passion. However, it
did pique your interest in travel and led to your decision to become a flight attendant
after graduation.
You now work as a flight attendant for Vacation Air, a charter flight company
operating primarily between Canada and Europe. You have had this job for
the past five years. On the whole you enjoy the work, as it allows you to travel.
Initially you had difficulty dealing with demanding passengers, but over the years
you have been able to relax a bit. Initially you and Bryan trained together and
worked on many of the same flights, until he became ill and had to leave work
two years ago.
FINANCES
You have no financial concerns.
Page 12
SOCIAL SUPPORTS
Bryan was your main support until he became ill.
You speak to your parents and siblings about your situation with Bryan, and,
although at first they were generally supportive, they are now concerned about
the long-term future and have intimated that you may want to consider leaving
the relationship. None of your family members have come right out and said this,
but the inference is there.
You have a close friend, LAUREN MANUEL, with whom you work. She also knows
about your situation with Bryan and is able to provide some support.
You have not yet told anyone about your relationship with John.
RELIGION
You consider yourself and your family “secular Jews.” You are not religious.
EXPECTATIONS
Because of your missed bleeding between pill cycles, you want to make sure
you don’t have a gynecological problem and to be absolutely sure you are not
pregnant. You also need to solve this sleep problem, as it is affecting your ability
to work. You are wondering about medication, although you are also concerned
about becoming addicted to medication.
Page 13
ACTING INSTRUCTIONS
You are dressed casually but neatly. You are very articulate, forthright, pragmatic,
and direct in your approach to both problems. As you explain the lack of vaginal
bleeding recently, you make clear the fact that you are sure something must be
wrong as this has never happened before in the 10 years you have been taking
the contraceptive pill. Your initial fear was that you might somehow have become
pregnant, despite complete compliance with the pill schedule. Intellectually you
know this is highly unlikely, especially as a pregnancy test result was negative,
and this is why you believe something else must be wrong.
If you are asked for the actual date of your last menstrual period, ask the candidate,
“do you have a calendar?” and if one is provided, you can work out the date three
weeks (21 days) from the current date. This is unlikely to happen.
If the candidate makes the assumption that, or seems to persist with lines of
questioning that you are really worried about being pregnant, make it clear that
although you want to be absolutely sure, you really do not believe that you are
pregnant. If you are asked what you would do if you were pregnant, you should
respond that at the moment you don’t know, and you would really have to think
more about it.
You FEEL concern, because you are worried something is medically wrong. You have
not disrupted your routine in any way and this change is quite unusual. You have no
specific IDEA about your symptoms, except that “something gynecological is going
on” and you might need to see a specialist. At the moment your FUNCTION has not
been affected and you continue to work. Your EXPECTATION is that the doctor will
order tests, identify the problem and deal with it quickly, or refer you to someone
who can sort it out so that you don’t need to worry about it anymore.
You are a bit puzzled about the sleep problem. You are a creature of habit and
routine, and do not feel anything has changed to cause the sleep disturbance.
Now you are becoming more worried, partly because you need to use caffeine to
stay awake during work and your whole sleep pattern and travel routine, to which
you have adhered over the past few years, are significantly disrupted. You are now
more irritable with “difficult passengers,” a reaction you attribute to feeling tired on
the job. Initially you aren’t sure if your sleep disturbances are related to the other
stressors in your life, particularly the concern about Bryan’s ongoing health issues
and the future of your relationship with him. However, you have not made an overt
connection yet between the timing of the start of your affair with John and the
beginning of your sleep problems. So far you have been rather analytical and
intellectual in your approach to the situation with Bryan, and thought you were
handling things well under the circumstances. You would come around to
acknowledge there may be a connection with the start of the affair with John
and your sleep disturbance if the physician/candidate is empathic and able to
relate the two.
Page 14
At first you do not volunteer the fact that Bryan is seriously and chronically ill,
partly because you don’t see a direct connection between your difficulty sleeping
and his condition. If the candidate is curious enough about the relationship,
the details will come out easily. Similarly, initially you do not volunteer any
information about your relationship with John, but if the candidate asks or probes,
you reveal the information in a straightforward fashion. A candidate may
automatically make the assumption that you are sexually active with Bryan only,
and unless there is a natural opportunity to correct the candidate, you would not
do so. A good candidate should be able to figure out the discrepancy in the story
regarding the fact that you are still concerned about possible pregnancy although
you are not having intercourse with Bryan, and seek clarification about this point
with you. A candidate may relate the start of your affair with John to the sleep
problems, and this would make sense to you. You expect to receive some sleeping
pills, but at the same time you want to be sure that nothing you take will cause
addiction or dependence.
You FEEL that your inability to sleep properly will start to affect the quality of your
work. You are tired and know you need to be alert on the job. You have no specific
IDEA about why sleeping has become more difficult, although if initially probed
you would say something like “well I guess I have been a bit preoccupied lately”.
Although you have a bit of stress in your personal life, up to now you haven’t felt
it is enough to cause sleep disruption. As far as your FUNCTION is concerned,
you are starting to feel a bit more tired and irritable on the job, and you know
that being well rested is important in your line of work. Your EXPECTATION is
that the FP will give you some medication to get your sleep back on track.
If asked specifically which contraceptive pill you are taking, you will mention that
you are currently taking a pill that you got in the United Kingdom. You saw a local
doctor there on one of your trips to obtain a refill as you were about to run out of
pills. If pressed for the name of the pill, you say you think it is called Mercilon.
You were told that it was equivalent to the pill you used to get in Canada. If asked
for the name of the pill you were previously taking in Canada, you would say that
you can’t remember. You have been using Mercilon for over two years now and
before you used to get pills with different names, depending on whether the
pharmacy was giving you a generic version. You have been told both by doctors
and pharmacists that although the names of the pills have changed, the amount
and type of hormones that you have been taking have remained constant.
If a candidate explores the illness experience in a very formulaic fashion,
for example, if after you say “I am concerned I have missed my period” and
the candidate immediately asks “How do you feel about that?” you should answer
in a puzzled way “What do you mean by that?” or “I’m sorry, I don’t get what you
mean by that”. Essentially you would react in a natural way to being directly asked
any questions regarding the illness experience if those questions come without any
context or if the candidate appears to be asking those questions in a rote manner.
You should not directly answer any questions regarding the illness experience if the
questions do not seem to make sense to you as the patient, and if you feel that the
rapport between you and the candidate is affected by this style of questioning.
You can then respond in a puzzled or irritated fashion and ask for clarification.
Page 15
CAST OF CHARACTERS
JANE ROBERTSON:
The patient, age 28, a flight attendant who
has missed bleeding between pill cycles and
is having trouble sleeping.
BRYAN DANKO:
Jane’s partner, who has nemaline myopathy.
JOHN HELM:
Jane’s colleague, a pilot with whom she
is having an affair.
NEIL ROBERTSON:
The patient’s father.
JONI ROBERTSON:
The patient’s mother.
IAN ROBERTSON:
The patient’s older brother.
SYLVIA ROBERTSON:
The patient’s younger sister.
LAUREN MANUEL:
Jane’s friend and colleague.
DR. HUDSON:
Jane’s FP, who is on a one-year sabbatical.
The candidate is unlikely to ask for other characters’ names.
If he or she does, make them up.
Page 16
TIMELINE
Today:
Appointment with the candidate.
6 weeks ago:
Last withdrawal bleed from oral contraceptive
use; you are now two weeks “overdue.”
2 months ago:
Problems with sleep started.
3 months ago:
Started having an affair with colleague.
6 months ago:
Bryan started using a wheelchair full time.
1 year ago:
Bryan diagnosed with nemaline myopathy,
a relatively rare form of muscular dystrophy.
4 years ago:
Started working as a flight attendant.
5 years ago:
Started dating Bryan while both of you were
training to be flight attendants.
6 years ago:
Graduated from university with a degree
in geography.
28 years ago:
Born.
Page 17
INTERVIEW FLOW SHEET
INITIAL STATEMENT:
“Doctor, I am concerned because I have
missed my period.”
10 MINUTES REMAINING: *
If the candidate has not brought up the issue
of problems with sleeping, the following
prompt must be said: “I’ve been having
trouble with sleeping recently.”
7 MINUTES REMAINING: *
If the candidate has not brought up the issue
of concern about oral contraception, the
following prompt must be said:
“What do you think is causing the
problem with my periods?”
(It is unlikely that this prompt will be
necessary.)
3 MINUTES REMAINING:
“You have THREE minutes left.”
(This verbal prompt AND a visual prompt
MUST be given to the candidate.)
0 MINUTES REMAINING:
“Your time is up.”
* To avoid interfering with the flow of the interview, remember that the 10- and
seven-minute prompts are optional. They should be offered only if necessary to
provide clues to the second problem or to help the candidate with management.
In addition, to avoid interrupting the candidate in mid-sentence or disrupting his
or her reasoning process, delaying the delivery of these prompts momentarily is
perfectly acceptable.
NOTE:
If you have followed the prompts indicated on the interview flow sheet, there should
be no need to prompt the candidate further during the last three minutes of the
interview. During this portion of the interview, you may only clarify points by
answering direct questions, and you should not volunteer new information.
You should allow the candidate to conclude the interview during this time.
Page 18
MARKING SCHEME
NOTE: To cover a particular area, the candidate must address
AT LEAST 50% of the bullet points listed under each numbered
point in the LEFT-HAND box on the marking scheme.
Page 19
Distinguishing a “Certificant” from a “Superior Certificant”: Exploration of the Illness Experience
While a certificant must gather information about the illness experience to gain a better understanding of the
patient and his or her problem, a superior performance is not simply a matter of whether a candidate has obtained
all the information. A superior candidate actively explores the illness experience to arrive at an in-depth
understanding of it. This is achieved through the purposeful use of communication skills: verbal and non-verbal
techniques, including both effective questioning and active listening. The material below is adapted from the
CFPC’s document describing evaluation objectives for certification (1). It is intended to be a further guide to assist
evaluators in determining whether a candidate’s communication skills reflect superior, certificant, or noncertificant performance.
Listening Skills
Cultural and Age Appropriateness
•
Uses both general and active listening skills to
facilitate communication.
Sample Behaviours
•
•
•
•
Allows time for appropriate silences.
Feeds back to the patient what he or she thinks
he or she has understood from the patient.
Responds to cues (doesn’t carry on questioning
without acknowledging when the patient reveals
major life or situation changes, such as “I just lost
my mother.”).
Clarifies jargon that the patient uses.
Non-Verbal Skills
Expressive
•
Is conscious of the impact of body language
on communication and adjusts it appropriately.
Sample Behaviours
•
•
•
•
Ensures eye contact is appropriate for the
patient’s culture and comfort.
Is focused on the conversation.
Adjusts demeanour to ensure it is appropriate
to the patient’s context.
Ensures physical contact is appropriate for the
patient’s comfort.
Receptive
•
Is aware of and responsive to body language,
particularly feelings not well expressed in a verbal
manner (e.g., dissatisfaction, anger, guilt).
•
Sample Behaviours
•
•
•
•
•
Responds appropriately to the patient’s discomfort
(shows appropriate empathy for the patient).
Verbally checks the significance of body
language/actions/behaviour
(e.g., “You seem nervous/upset/uncertain/
in pain.”).
Adapts the communication style to the patient’s
disability (e.g., writes for deaf patients).
Speaks at a volume appropriate for the patient’s
hearing.
Identifies and adapts his or her manner to the
patient according to the patient’s culture.
Uses appropriate words for children and teens
(e.g., “pee” rather than “void”).
Language Skills
Verbal
•
•
•
Has skills that are adequate for the patient to
understand what is being said.
Is able to converse at a level appropriate for
the patient’s age and educational level.
Uses an appropriate tone for the situation,
to ensure good communication and patient comfort.
Sample Behaviours
•
•
•
•
Sample Behaviours
•
Adapts communication to the individual patient
for reasons such as culture, age, and disability.
•
Asks open- and closed-ended question
appropriately.
Checks with the patient to ensure understanding
(e.g., “Am I understanding you correctly?”).
Facilitates the patient’s story
(e.g., “Can you clarify that for me?”).
Provides clear and organized information in a way
the patient understands
(e.g., test results, pathophysiology, side effects).
Clarifies how the patient would like to be addressed.
Prepared by: K. J. Lawrence, L. Graves, S. MacDonald, D. Dalton, R. Tatham, G. Blais, A. Torsein, and V. Robichaud for the Committee on
Examinations in Family Medicine, College of Family Physicians of Canada, February 26, 2010.
(1)
Allen T, Bethune C, Brailovsky C, Crichton T, Donoff M, Laughlin T, Lawrence K, Wetmore S. Defining competence in family medicine
for the purposes of certification by The College of Family Physicians of Canada: the evaluation objectives in family medicine;
2011 [cited February 7, 2011}. Available from:
http://www.cfpc.ca/uploadedFiles/Education/Defining%20Competence%20Complete%20Document%20bookmarked.pdf
Page 20
1.
IDENTIFICATION: CONCERNS WITH CONTRACEPTION
CONCERNS WITH CONTRACEPTION
Areas to be covered include:
1. amenorrhea:
• Six-week history.
• Uses contraceptive pill.
• Never missed withdrawal bleed.
2. oral contraceptive use and
associated factors:
• No missed pills.
• No recent antibiotics.
• No diarrhea/gastroenteritis.
• No nausea.
• No breast tenderness.
3. menstrual/sexual history:
• Menarche at age 13.
• Started taking the pill at age 18.
• Menstrual cycle irregular before
starting contraceptive pill.
• No history of sexually transmitted
infections.
• Never pregnant.
4. no symptoms of thyroid disease
(e.g., dry skin, fatigue,
constipation).
Superior
Certificant
Covers points
1, 2, 3, and 4.
Certificant
Covers points
1, 2, and 3.
Noncertificant
Does not cover
points 1, 2, and
3.
ILLNESS EXPERIENCE
Feelings
•
Concerned.
Ideas
•
•
I hope I am not pregnant.
There must be something wrong,
this has never happened in 10
years.
Effect/Impact on Function
•
None specific.
Expectations for This Visit
•
The FP will figure out what is
wrong.
A satisfactory understanding
of all components (Feelings, Ideas,
and Expectations) is important
in assessing this patient’s illness
experience.
Actively explores the illness experience to arrive at
an in-depth understanding of it. This is achieved
through the purposeful use of verbal and non-verbal
techniques, including both effective questioning and
active listening.
Inquires about the illness experience to arrive at a
satisfactory understanding of it. This is achieved by
asking appropriate questions and using non-verbal
skills.
Demonstrates only minimal interest in the illness
experience, and so gains little understanding of it.
There is little acknowledgement of the patient’s
verbal or non-verbal cues, or the candidate cuts the
patient off.
Page 21
2.
IDENTIFICATION: INSOMNIA
INSOMNIA
1. not sleeping:
• No early morning awakening.
• Lies awake for two to three hours
before falling asleep.
• Not feeling refreshed.
• Reads/watches TV when she
cannot sleep.
2. associated factors:
• Frequent travel across time zones.
• Developed a pattern of sleeping
that has worked for her in
the past.
• No obvious environmental
distractors
(dark and quiet room, etc.).
• Not depressed.
3. medications/substance use:
• No OTC medications to aid sleep.
• Caffeine intake has changed.
• No recreational drug use.
• Not using alcohol to help her
sleep.
ILLNESS EXPERIENCE
Feelings
•
•
Frustrated.
Worried.
Ideas
•
Is my stress affecting my sleep?
Effect/Impact on Function
•
Feeling irritable and tired at work.
Worried this problem will affect
work adversely if it continues.
Expectations for This Visit
•
She wants to discuss taking
sleeping pills.
A satisfactory understanding
of all components (Feelings, Ideas,
Effect/Impact on Function,
and Expectations) is important
in assessing this patient’s illness
experience.
4. rule out other causes of
insomnia:
• No snoring/sleep apnea.
• No chronic pain.
Page 22
Superior
Certificant
Covers points
1, 2, 3, and 4.
Certificant
Covers points
1, 2, and 3.
Noncertificant
Does not cover
points 1, 2, and
3.
Actively explores the illness experience to arrive at
an in-depth understanding of it. This is achieved
through the purposeful use of verbal and non-verbal
techniques, including both effective questioning and
active listening.
Inquires about the illness experience to arrive at a
satisfactory understanding of it. This is achieved by
asking appropriate questions and using non-verbal
skills.
Demonstrates only minimal interest in the illness
experience, and so gains little understanding of it.
There is little acknowledgement of the patient’s
verbal or non-verbal cues, or the candidate cuts the
patient off.
Page 23
3.
SOCIAL AND DEVELOPMENTAL CONTEXT
CONTEXT IDENTIFICATION
1. social history/supports:
• Both parents are well.
• Two siblings.
• One close friend in whom
she confides.
• No financial stressors.
• Works as a flight attendant.
2. Bryan:
• Has myopathy.
• Is still cognitively well/normal.
• Progressive disease but not
fatal in itself – could linger for
many years.
• Now confined to a wheelchair.
• Has not had sexual intercourse
with Jane for five months.
3. having an affair with a colleague:
• Started three months ago.
• Mainly sexual relationship.
• He wants to develop relationship
further.
4. she is reconsidering future
with Bryan.
CONTEXT INTEGRATION
Context integration measures the
candidate’s ability to
•
integrate issues pertaining to the
patient’s family, social structure,
and personal development with
the illness experience;
•
reflect observations and insights
back to the patient in a clear and
empathic way.
This step is crucial to the next phase
of finding common ground with the
patient to achieve an effective
management plan.
The following is the type of statement
that a Superior Certificant may make:
“You are dealing with a considerable
amount of stress at this moment in
time – you have missed a period
and I can see that being pregnant
at the moment would be quite
difficult for you given your situation
with your partner. You now also
have to contemplate what sort of
future relationship you will have
with Bryan and it is understandable
that this may be having an effect on
your sleep.”
Page 24
Superior
Certificant
Covers points
1, 2, 3, and 4.
Certificant
Covers points
1, 2, and 3.
Does not cover
points 1, 2, and
3.
Noncertificant
Demonstrates initial synthesis of contextual factors,
and an understanding of their impact on the illness
experience. Empathically reflects observations and
insights back to the patient.
Demonstrates recognition of the impact of the
contextual factors on the illness experience.
Demonstrates minimal interest in the impact of the
contextual factors on the illness experience, or cuts
the patient off.
Page 25
4.
MANAGEMENT: CONCERNS WITH CONTRACEPTION
PLAN
1. Reassure her that the lack of
bleeding is likely physiological
/normal variant.
FINDING COMMON GROUND
Behaviours that indicate efforts to
involve the patient include:
1. encouraging discussion.
2. Repeat pregnancy test.
3. Discuss red flags for follow-up
(e.g., persistent amenorrhoea,
abdominal pain, etc.).
4. Discuss the need for STI testing.
2. providing the patient with
opportunities to ask questions.
3. encouraging feedback.
4. seeking clarification and consensus.
5. addressing disagreements.
This list is meant to provide
guidelines, not a checklist.
The points listed should provide
a sense of the kind of behaviours
for which the examiner should look.
Superior
Certificant
Covers points
1, 2, 3, and 4.
Certificant
Covers points
1, 2, and 3.
Does not cover
points 1, 2, and
3.
Noncertificant
Actively inquires about the patient’s ideas and
wishes for management. Purposefully involves the
patient in the development of a plan and seeks his
or her feedback about it. Encourages the patient’s
full participation in decision-making.
Involves the patient in the development of a plan.
Demonstrates flexibility.
Does not involve the patient in the development of
a plan.
Page 26
5.
MANAGEMENT: INSOMNIA
PLAN
1. Explain the likely effect of her
current stressors on her inability
to fall asleep.
FINDING COMMON GROUND
Behaviours that indicate efforts to
involve the patient include:
1. encouraging discussion.
2. Discuss non-pharmacological
options to help her sleep
(sleep hygiene).
3. Discuss the use of medication
(hypnotics/sedatives).
2. providing the patient with
opportunities to ask questions.
3. encouraging feedback.
4. seeking clarification and consensus.
4. Offer counselling/support,
either by self or referral to
psychologist/social worker to
discuss her ambivalence in her
relationship with Bryan.
Superior
Certificant
Covers points
1, 2, 3, and 4.
Certificant
Covers points
1, 2, and 3.
Does not cover
points 1, 2, and
3.
Noncertificant
5. addressing disagreements.
This list is meant to provide
guidelines, not a checklist.
The points listed should provide
a sense of the kind of behaviours
for which the examiner should look.
Actively inquires about the patient’s ideas and
wishes for management. Purposefully involves the
patient in the development of a plan and seeks his
or her feedback about it. Encourages the patient’s
full participation in decision-making.
Involves the patient in the development of a plan.
Demonstrates flexibility.
Does not involve the patient in the development of
a plan.
Page 27
6.
INTERVIEW PROCESS AND ORGANIZATION
The other scoring components address particular aspects of the interview.
However, evaluating the interview as a whole is also important.
The entire encounter should have a sense of structure and timing,
and the candidate should always take a patient-centred approach.
The following are important techniques or qualities applicable to
the entire interview:
1. Good direction, with a sense of order and structure.
2. A conversational rather than interrogative tone.
3. Flexibility and good integration of all interview components;
the interview should not be piecemeal or choppy.
4. Appropriate prioritization, with an efficient and effective allotment
of time for the various interview components.
Superior
Certificant
Certificant
Noncertificant
Demonstrates advanced ability in conducting an integrated interview
with clear evidence of a beginning, a middle, and an end. Promotes
conversation and discussion by remaining flexible and by keeping the
interview flowing and balanced. Very efficient use of time, with
effective prioritization.
Demonstrates average ability in conducting an integrated interview.
Has a good sense of order, conversation, and flexibility. Uses time
efficiently.
Demonstrates limited or insufficient ability to conduct an integrated
interview. Interview frequently lacks direction or structure. May be
inflexible and/or overly rigid, with an overly interrogative tone. Uses
time ineffectively.
Page 28

SIMULATED OFFICE ORAL SAMPLE 7

Transcription

Similar documents

liry"

About the Author

Mar - Cedarcroft Home

prospective students POSTER1

Design and Technology : Resistant Materials OCR GCSE Unit A561

Best Mattress For Sleeping

HOW TO INTERVIEW CANDIDATES

High Technology

Staggers Award - Association of Black Women Physicians

Moving from Tech Staff to Tech Management