Subfertility

This task assesses the following clinical skills: … ● Patient safety ● Communication with patients and their relatives ● Information gathering ● Applied clinical knowledge … You are a ST4 doctor working in an infertility clinic. A couple who were referred to the clinic by their GP have returned for review. She has had oligomenorrhoea for the past year. She does not report headaches, visual disturbance, galactorrhoea or hyperandrogenism, she has been trying to conceive for two years. Her partner had an orchidopexy at the age of two. The assessor will ask you some questions and then give you the results of their investigations. You will be asked to explain the results and next steps to the patient. You have 10 minutes for this task (+ 2mins initial reading time). Please check that candidate and actor have read instructions. Ask the candidate what investigations they would like to organize for this patient and her partner. Give them the results of investigations (if asked for): Pregnancy test— ve LH 45, FSH 40, E2 120 (day two of cycle) PRL— 200 TSH— 1.2 Testosterone— 0.8 USS— NAD HSG— Patent tubes Rubella immune Chlamydia swabs— ve Smear— ve Semen analysis— 10m/ ml, 32% motility, 3% normal forms Ask them if they want to arrange any further investigations. Expect candidate to ask to repeat gonadotrophins more than a month after initial measurement in order to confirm the diagnosis of Premature Ovarian Insufficiency (POI). They should also repeat the semen analysis. Tell them that repeat gonadotrophins were again elevated— FSH 35, LH 20, E2 120. Repeat semen analysis was 15m/ ml, 34% motile, with 4% normal forms. Ask the candidate to explain these results to the patient and explain next steps, including further investigation and treatment options. They should then recommend that further investigations are arranged including karyotype, an auto-immune screen, lupus anticoagulant and vitamin B12 levels to try and identify a cause for the POI. Treatment options should include the role of hormone replacement therapy and oocyte donation with IVF. Observe consultation skills including the candidate’s ability to break bad news. Record your overall clinical impression of the candidate for each domain (i.e. pass, borderline, or fail).

Management of delivery

This task assesses the following clinical skills: … ● Patient safety ● Communication with patients and their relatives ● Information gathering ● Applied clinical knowledge … Rebecca Francis is a 34- year- old lady in her second pregnancy. She has had a normal vaginal delivery two years ago. Her pregnancy remained uneventful so far. At 36 weeks, her midwife detected that the baby was in breech presentation and has referred her to the antenatal clinic to discuss further management. You will then be given some information and asked questions by the examiner. You have 10 minutes for this task (+ 2mins initial reading time). Please read instruction to candidate and actor. After the consultation with the actor patient (or in the last two minutes), tell the candidate that Rebecca underwent an unsuccessful ECV and was booked for an elective caesarean at 39 weeks. You performed her caesarean and to your surprise, you delivered a cephalic baby by caesarean section. What should you have done to prevent this? What will you do next to prevent this kind of incidence? What will you explain to Rebecca? Record your overall clinical impression of the candidate for each domain (i.e. should this performance be pass, borderline, or a fail). You are Rebecca Francis, a 34- year- old mother of two- year- old Lucy. You had a straight forward pregnancy and delivery with Lucy. You are currently 36 weeks pregnant. You were seen by your midwife yesterday for a routine check and she found the baby to be in breech position. You were sent to the antenatal clinic and have had a scan confirming that the baby is in breech position. You were told that rest of the scan, including the baby’s measurements, fluid volume around the baby and the position of the placenta are normal. You are healthy. You do not smoke and have had no alcohol in pregnancy. Your pregnancy has progressed without any problems so far. The screening test for the baby showed low risk for Down’s syndrome. Temperament: You think you are mostly a calm, level- headed woman, but you do like to be organised and in control of things.

Surgical procedures

This task assesses the following clinical skills: … ● Patient safety ● Communication with colleagues ● Applied clinical knowledge … Mrs. Ahmed is a 48- year- old lady undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy for heavy menstrual bleeding with a 20 week size fibroid. She is generally well and has undergone a left hip replacement five years ago. Your consultant has asked you to commence the surgery by opening the abdomen with a vertical subumbilical incision. She will shortly join you for the surgery. The Foundation Year 1 doctor will be assisting you in the interim. You will be presented with scenarios in the theatre. Your task is to problem solve and answer the queries of the F1 doctor. You have 10 minutes for this task (+ 2mins initial reading time). There is no role player for this scenario. This scenario checks the understanding of Monopolar diathermy and the ability to problem solve. It also assesses the understanding of safety issues surrounding electrocautery. First tell the candidate: The Theatre Assistant Practitioner (ODP) is newly qualified and normally works in the ENT theatres. You start the incision using a finger switch diathermy but it is not working What will you do? The candidate should first check if the machine is on Tell them that is was not on, but has now been switched on As soon as the machine is switched on, the machine starts beeping What should the ODP do next? If the candidate asks if there are any indications on the machine, say the sign of the returning electrodes is highlighted The candidate should check if the returning electrodes (pads) have been applied. They had not been. The ODP asks where he should apply the returning electrodes. The candidates should ask the electrode to be placed on the right buttock. The ODP asks if it is OK to put the returning electrode on the left buttock as the scrub nurse and trolley are on the right and it is convenient to apply on the left. The candidate should explain that as Mrs. Ahmed has had a hip replacement on the left, it is important to avoid applying the returning electrode near the metal implant and the scarring around it, for safety. The ODP asks that he has never seen a split returning electrode. Why is it split?

Teaching appraisal and assessment

This task assesses the following clinical skills: … ● Patient Safety ● Communication with colleagues ● Applied clinical knowledge … You are teaching practical management of shoulder dystocia to your ST1 doctor who has just started obstetrics. He/ she has witnessed a shoulder dystocia after a forceps delivery last week and is very stressed about facing one. You have a pelvis and baby model and today you are teaching the shoulder dystocia scenario. You have 10 minutes for this task (+ 2mins initial reading time). This station assesses the candidate’s ability to teach a practical skill. This will also assess their knowledge of managing shoulder dystocia. Please observe the teaching and do not interrupt. You are a ST1 doctor who has just completed the foundation training. This is your second week on the delivery suite. You have seen one shoulder dystocia after forceps delivery recently. You found the experience stressful and are now worried about facing such a scenario. Your Registrar has kindly agreed to teach you the practical management of Shoulder dystocia using the pelvis and baby model. Please do not prompt and follow the instructions of the candidate (registrar). Patient safety … ● Avoid dangerous manoeuvres fundal pressure and excessive lateral and downward traction ● Explain advanced techniques and advice the importance of using them only if experienced— Zavanelli’s manoeuvre and symphysiotomy ● Explains the importance of documentation… Communication with colleagues … ● Explains the objectives of the station ● Allows active involvement of the team/ trainee ● Promotes team working ● Makes the trainee demonstrate while talking through the steps and allows trainee to talk through while demonstrating ● Finally gives opportunity to the trainee to independently talk through and demonstrate the whole scenario… Applied clinical knowledge … ● Has knowledge of all the manoeuvres ● Demonstrates and talks through the steps ● Recognize the problem ● Call for help ● Mc Roberts manoeuvre ● Suprapubic pressure ● Consider episiotomy ● Posterior arm delivery or internal rotatory manoeuvres ● Turn into all fours ● Emphasize subsequent management ● If unsuccessful consider repeating the manoeuvres ● If experienced, consider advanced manoeuvres ● Complete delivery.

Communication skills and tips for Part 3 MRCOG Examination

Good communication skills form a fundamental principle of the patient- centred clinical consultation. The new Part 3 of the MRCOG, assesses candidates based on their ability to apply the core clinical skills in the context of real- life scenarios. It assesses five core skills domains, with three relating to communication skills; i) Communicating with patients and their families, ii) Communicating with colleagues and iii) Information gathering. Communication skills in the Part 3 clinical assessment can be assessed in many forms: … ● Exploring patient symptoms or concerns (information gathering) ● Explaining a diagnosis, investigation or treatment (information giving) ● Involving the patient in a decision (shared decision making) ● Health promoting activities ● Obtaining informed consent for a procedure ● Breaking bad news ● Communicating with relatives ● Communicating with other members of the health care team … In order to provide patient- centred care, doctors must treat their patients as partners, involving them in the decision making regarding their care and instilling in them a sense of responsibility for their own health. When the patient feels that they are part of the team it increases their satisfaction with care, increases treatment adherence and improves clinical outcomes. It is these skills that are assessed in clinical assessment tasks involving communication. Clinical assessment candidates are often assessed in two communication domains; Process and Content. In order to do well in the information gathering stations, you must be aware of the differential diagnoses that may arise with various presentations and how to explore each one independently and as a collection. When it comes to information giving or shared decision marking, candidates need to be familiar with the most recent Royal College of Obstetrics and Gynaecology guidelines and know how to interpret their meaning to the patient and their families. The Calgary- Cambridge Model is one of the most recognized communication theories in medical education (Kurtz, 1996). This theory can be adapted to fit into most clinical scenarios. Using the Calgary- Cambridge Model, you should be able to obtain the majority of the points related to process.

Gynaecological oncology

This task assesses the following clinical skills: … ● Patient safety ● Communication with patients and their relatives ● Information gathering ● Applied clinical knowledge … Your consultant has asked you to speak to Agnieska Polanski aged 38 whose smear result has shown ‘severe dyskaryosis’, HPV positive. Your task is to: … ● break the news to Agnieska about the abnormal smear ● discuss the next stage of management (i.e. colposcopy and biopsy) ● answer any questions … You do not need to take a history. You have 10 minutes for this task (+ 2mins initial reading time). Please read the instructions for candidates and actors. This station is designed to test the candidate’s ability to break bad news in a sensitive and professional way. This case involves a patient who has a severely abnormal cervical smear result (with the possibility of early cervical cancer). The candidate explains the implications of such a smear and discusses the next step in management. Record your overall clinical impression of the candidate for each domain (e.g. should this performance be pass, borderline, or a fail. You are Agnieska Polanski, aged 38 years, and you have come to an outpatient gynaecology clinic (called a colposcopy clinic) to discuss your recent cervical smear result. You have a feeling that the smear might be abnormal because the secretary refused to discuss it with you on the phone and you received a very prompt appointment to see the doctor. You love children and work part time in a local nursery and after school club whilst you are studying for a NVQ level 3 childcare qualification. Your social life is great at the moment— you live with a very supportive and loving partner Lee and are planning to get married next year. Your partner and you have planned to have children and you will probably come off the pill just before your wedding (because at your age you don’t want to leave it too long but you don’t want to look huge in your wedding dress).

Early pregnancy care

This task assesses the following clinical skills: … ● Patient safety ● Communication with patients and their relatives ● Information gathering ● Applied clinical knowledge … You are an ST4 doctor covering Early Pregnancy Assessment Unit (EPAU). You have been asked to see 24- year- old Jaz Pringle in her third pregnancy. Her LMP was six weeks ago and has presented with left iliac fossa pain and light vaginal bleeding. Your task is: … ● To take a focussed history ● Organize the necessary investigations ● Discuss the results and diagnosis with Jaz ● Agree a management plan … You have 10 minutes for this task (+ 2mins initial reading time). This is a communication skills clinical assessment task that tests the candidate’s skills to take a focussed history, interpret and explain results and agree to a management plan having discussed the options. If they ask for the urine pregnancy test, tell them it is positive. If they arrange an ultrasound, provide them with the following result. ‘An empty uterus and a 2.3cm left sided adnexal mass with well- defined gestational sac medial to the left ovary with minimal fluid in pouch of Douglas. Right ovary appeared normal. Findings are highly suggestive of left sided tubal pregnancy’. If they organize beta HCG, tell them the nurse had sent it and the result is back and it is 2900IU/ml. Record your overall clinical impression of the candidate for each domain (e.g. should this performance be pass, borderline, or a fail). You are Ms. Jaz Pringle, a 24- year- old housewife who lives with her partner of four years. You have one child delivered by caesarean section for breech (bottom first) presentation three years ago. You had developed infection post caesarean section and were very unwell. You had needed admission to the hospital for 10 days and needed IV antibiotics. This was followed by an ectopic pregnancy 18 months ago whereby you ended up having key hole surgery and removal of your right fallopian tube with ectopic pregnancy. While you have not been actively trying for another pregnancy, you and your partner are happy with the thought of another pregnancy. However, you attended hospital due to some discomfort on the left side of the tummy and some vaginal bleeding on and off for two days. You are otherwise fit and well with no allergies. The candidate should arrange a urine pregnancy test, which will be positive. They should then organize a scan in the EPAU. The scan will suggest an ectopic pregnancy in your right tube. You are now extremely upset and anxious after the scan at the thought of possibly losing the only remaining tube and being rendered infertile. You want to know all possible options and would like to save the only fallopian tube if possible.

Sexual and reproductive health

This task assesses the following clinical skills: … ● Patient safety ● Communication with patients and their relatives ● Information gathering ● Applied clinical knowledge … You are an ST4 doctor conducting a post operative ward round. Your next patient is Danielle Wilson, a 26- year- old mother of three who has undergone a left salpingectomy for ectopic pregnancy. Having explained the operation to her, she asks why you couldn’t have just sterilized her at the same time as she never wants to be pregnant again and is struggling with her health and her young children. Her notes show that she has had 2 previous terminations and takes carbamazepine and levetiracetam for epilepsy and fluoxetine for anxiety. There is nothing else of note. Explain to Danielle why she was not sterilized at the time of salpingectomy. Then make a safe and effective contraception plan which is acceptable to her. You have 10 minutes for this task (+ 2mins initial reading time). Ask the candidate and actor to read their instructions. Then ask the candidate to start their discussion with the patient. Allow the candidate to conduct the discussion undisturbed unless they are straying off the track of the question (in which case you can show them their instructions again). Rationale for not sterilising should cover… ● General inadvisability of performing procedure at a time of reproductive stress (e.g. delivery, termination of pregnancy [TOP], miscarriage, salpingectomy) ● Sterilization under age 30 associated with higher incidence of regret— this should be conveyed as a general rule of thumb rather than as a personal judgement ● Reversal not funded by NHS ● Higher failure rate when performed when pregnant ● Possible complications of sterilization— general anaesthetic, surgical trauma or if hysteroscopic day case procedure, uterine perforation, interval to confirmation of success, need for ongoing contraceptive method ● Lifetime failure rate of sterilisation 1:200 which is comparable to that of an IUS and higher than the failure rate of the contraceptive implant ● Vasectomy safer

Management of labour

This task assesses the following clinical skills: … ● Patient safety ● Communication with patients and their relatives ● Information gathering ● Applied clinical knowledge … You are an ST5 doctor in the diabetic antenatal clinic. The clinic has been particularly busy today and is running 60 minutes late. There are several different clinics running simultaneously and no extra staff available to help in the diabetic clinic. You are asked to see Claire Potter, a 28- year- old lady with Type 1 diabetes who is 32 weeks in her first pregnancy. She has no other medical risk factors and her diabetes is well controlled with no complications. A recent HBA1c was 45. Ultrasound today shows normal liquor and normal symmetrical growth plotting on her established growth curve at 75th centile. Conduct a focused antenatal review and respond to her concerns. You have 10 minutes for this task (+ 2mins initial reading time). This task assesses the communication skills and application of knowledge regarding diabetes in pregnancy. Please do not interrupt or prompt. Record your overall clinical impression of the candidate for each domain (i.e. pass, borderline, or fail). There are marks for the actor to also assign at the end of the station You are Claire Potter, a 28- year- old solicitor, 32 weeks into your first pregnancy. You have Type 1 diabetes since you were 12 and are very confident in how best to control your diabetes. You are meticulous with checking your BM’s and adjusting your insulin accordingly and they are all within range (4– 6.5). You have no complications of diabetes and no other health problems. You take short and long acting insulin and have no allergies. You do not smoke or drink alcohol. You’re dating and anomaly ultrasound scans were normal and screening tests were low risk for Down’s syndrome. Your pregnancy has been uneventful with regular clinic reviews of your diabetes. Your last scan at 28/ 40 showed the baby was growing normally. Temperament: You are a very busy professional person and do not like to be kept waiting unnecessarily. You are annoyed the clinic is running late (yet again) but are not unreasonable provided you feel you are being listened to and your concerns addressed.

Core surgical skills

This task assesses the following clinical skills: … ● Patient safety ● Communication with patients and their relatives ● Information gathering ● Applied clinical knowledge … Sarah Bener is a 28- year- old lady in her second pregnancy. She has had an elective caesarean section in her last pregnancy for a breech delivery two years ago. She has no other health problems and her pregnancy has progressed well so far. She is currently 36 weeks pregnant and has presented to the antenatal clinic to discuss the mode of delivery. You have 10 minutes for this task (+ 2mins initial reading time) Please read instructions to candidate and actor. This station assesses the candidate’s ability to come to a shared decision after discussing the pros and cons of both the options. Please do not interrupt or prompt. Record your overall clinical impression of the candidate for each domain (e.g. should this performance be pass, borderline or a fail). You are Sarah Bener, a 28- year- old house wife. You are 36 weeks pregnant. You are healthy and so far your pregnancy had progressed smoothly. You feel good baby movements. The screening test as well as the baby’s scan at 20 weeks has been normal. You have one child, Imogen, born by caesarean section two years ago. It was an elective caesarean section as Imogen was in breech position. They did try turning her (ECV), but was unsuccessful. You were very much looking forward to a normal delivery and were disappointed that you needed a caesarean section. The caesarean section was straightforward, without any complications. But you needed a few days to recover at home. You are keen to have a normal delivery this time, but want to know the options and risks of the mode of delivery. Both you and your husband have always wanted a large family, so want to know the implications of a second section. If the candidate does not mention VBAC, say that you have heard of this and can they explain more about it.