Week 2
This week we discussed the two cases below. Some of the learnings that came out of this session were:

• Use of open body gestures, eye contact, intonation of voice and palm-up hands to put the patient at ease during a consultation

• Checking the patient understands at a couple of appropriate times along the way and if they have any questions. Use no more than 2-3 times plus at the end. If you do it too often, it comes across as false.

• When it’s a gynaecology station or if you’re taking consent for surgery on a woman - always ask the LNMP to ensure she isn’t pregnant. Secondary questions are to check which contraception is in use and if there are user dependencies, ask if there has been any deviation from normal, e.g. up to date with depot provera, any missed COC pills or condom failures.

• Ensure your responses are patient outcome focused. e.g when you state that ectopic pregnancy is a risk of tubal ligation, follow on with ‘…so if you miss a period unexpectedly, do a pregnancy test and see your GP to check the pregnancy is in the right place’

• As part of counselling for surgery, offer information on what to expect when the patient gets home - i.e. early recovery and return to usual activities.

• In general after minor surgery, patients can drive when they can sit in a car and do an emergency stop without causing pain. Major procedures will have varying lengths of time based on sitting upright, seatbelt use and how many/length of fascial repairs.

Case 3 
Scenario 

Jane Jenkins is a 32-year-old para 1 who booked under midwifery care and is referred to your antenatal clinic at 36 weeks gestation. The midwife found her baby to be in breech presentation. 

Please carry out a consultation with Jane.  

Case 4 
Scenario 

Kayla Noble is seen in your GP surgery for the first time complaining of a 12-month history of worsening menorrhagia. She is 44 years old and has 2 children. 

Please carry out a consultation and explain the need for any investigations you would like to arrange. Describe your plan of management and what she can expect from here. 

Week 1:
OSCE approaches and Birth After Caesarean

Summary of today’s tutorial (PDF)
Slides from today’s tutorial - including additional scenarios & CST guide (PDF)
VBAC/CS patient presentation

Today we spoke about OSCEs, and how to approach them. The topic discussed was birth after a previous caesarean section.

As I mentioned, the case scenarios we will need a candidate from the crowd each time. Most people don't want to come forward and be the one to take part. I get it, and the reasons for this become ingrained in us through childhood, school, and Uni.

1. Don't be different, don't bring attention to yourself

2. If I can't get it exactly right, I don't want to try

3. Avoid discomfort

The problem with this attitude is that it leads to slow learning. As a doctor, your supervisors are not focused entirely on training you. They have other tasks consuming them. But the only way to learn quickly and become an excellent doctor is to get feedback on what you do. Lots of it. Preferably close to when you do a task and with an opportunity for self-reflection followed by honest and supportive advice. Feedback is what you should constantly be seeking if you want to excel in medicine. 

Point 2 above is about perfectionism. This is very common in medical students and doctors and it's a negative trait that leads to self-doubt and ultimately, psychological harm. Good enough is actually okay and will ultimately lead to stronger growth and expertise. 

Point 3 is another big one: discomfort. The more quickly we can become comfortable with discomfort, the better. All the best learning takes place outside of your comfort zone.

When I was five years into being a consultant, I struggled with a new type of laparoscopic surgery. It seemed almost every second case took far longer than it should have, and half of them resulted in open surgery anyway because I just couldn't do it. It was demoralising for me, tedious for my theatre team and made me want to give up. But I didn't. I took the hits and persisted. Sure enough, it got easier, and it became part of my usual practice. And then anyone looking in from the outside would just see someone who makes it look easy. But I can tell you; it wasn't!

Struggle and discomfort are the dual, critical components of growth, and are simply unavoidable.

Case 1

Information for candidate

You are about to see Mrs Julie Smith, who is a 32-year-old woman, para 3 who had normal births.

She has no medical or surgical history of note, has normal periods on Microgynon combined oral contraceptive pill, takes no other medication and has no drug allergies.

Gynaecological examination in the clinic two months ago was normal.

You are seeing her in the day ward immediately pre-operatively to discuss the procedure and take consent. She is having laparoscopic sterilisation.

Case 2

Information for candidate

The patient is Mrs Karen Jacobs, a 22-year-old primigravida who is fit & healthy and has a normal singleton pregnancy.

She has just had a routine antenatal check-up at 29 weeks and has a few questions about the various options available to her for pain relief in labour. Please advise her, indicating the place for each and their advantages/disadvantages where appropriate.

In particular, she wishes to have the following questions answered:

1. What methods of pain relief could I consider during labour?

2. What are the disadvantages of an epidural?

3. If everything doesn’t go normally and I need an assisted delivery or caesarean section, what options are there to control pain?