Simulated Patient Instructions



Patient InstructionsName of Patient:Sarah Wood 20FDescription of the patient & instructions to simulator:You are 25 yr old Sarah Wood. Your mum made the appointment & is waiting outside in the reception area because she is worried that you have lost a lot of weight whilst being away at university. Your first year has just finished and you're home for the holiday. It has been a hard year: you feel like you have struggled to fit in and make friends. You feel they don’t want to be friends with you because you are fat. You can’t think of any other reason. They all seem so thin and happy. You want to be like them and fit in. You also think you can’t get a boyfriend because of this. It all started because you thought if you lost some weight and improved your fitness, things would change for the better as you would be healthier & could maybe make friends along the way. But each time you stepped on the scales and realized you had lost weight, you felt a buzz of excitement & wanted to lose more. On the TV they are always saying how we all need to lose weight to be healthy. Also because you are relying on a student loan, you did not have much spare cash for food so it made financial sense to cut down. Like this for a while but worse for a few monthsAt present a normal day consists of an apple for lunch and something small for dinner like cereal, as long as there is not anyone around to watch. You don’t know how much you have lost as you won’t weigh yourself until you are thin enough. You do not have any problems with nausea/vomiting/swallowing/indigestion/tummy pain. You do not suffer from extreme thirst & you do not urinate more than anyone else. You open your bowels twice a week, depending on what you have eaten. You are not sleeping well at present and your mind seems to be consumed with thoughts of food. Your periods are getting more and more irregular.Your mum has always been over protective. She has started making bigger meals since you got back and has been watching to make sure you are eating. This has caused arguments. ?Ideas - Isn't it normal to want to be thin & healthy? Mum always over exaggerates.Concerns – A part of you is a bit worried though because one thing that you have noticed is that you feel more tired now than you have ever been before and you don’t know why this is. It does not make sense. Part of you wonders if mum has a point: are you doing harm to yourself?Expectations – Ideally to be able to reassure Mum that there is nothing to worry about. If the idea of an eating disorder is broached, then become tearful but then acknowledge that might be possible but that you had never thought about it that way. You would like a follow up appointment to discuss how to tackle this with the same GP within the near future.If the doctor does not engage with you in an empathetic manner, show your dissatisfaction by looking away and avoiding eye contact. Doctor’s (GP ST) InstructionsName & age of patient Sarah Wood, age 25Summary CardThis 25 year old medical student comes to you after her mother has arranged an appointment for her. She is attending alone.PMHx; IBS, Anxiety, HeadachesMeds; Microgynon 30?8 months ago; Pre-university vaccinations?12 months ago; Pill check. BP 105/65, BMI 20, Never smoked?18 months; IBS. Normal full blood count and U&E's. Started on mebeverineCSA EXAMINATION CARDPatient Name:Examination findings:Exam findingsAppears pale and thin BMI 17Abdomen soft, non-tenderBP 110/65Pulse 52bpm regular?If asked - BM 3.8CSA Case Marking SheetCase Name: Sarah WoodCase Title: Eating disorderContext of case Ability to manage primary care contact with a patient with eating disorderDeveloping and maintaining a relationship and a style of communication that makes the patient feel comfortable and is not patronising. Acquiring knowledge of the patient’s relevant context, including family, social and psychological factors. Assessment Domain:1.Data-gathering, technical and assessment skillsPositive descriptors: Clarifies the problem and nature of the decision required. Identifies physical, social and psychological problems associated with an eating disorder. Screens for depressionTakes appropriate dietary historyTakes social history and assesses social supportAssesses risk of co-existing physical or psychological problems. Negative descriptors: Makes immediate assumptions about the problem. Intervenes rather using appropriate expectant managementIs disorganised/unsystematic in gathering informationDoes not discover patient’s reasons for attendanceDoes not assess mental stateDoes not take dietary historyFails to appreciate physical conquences of anorexiaFails to explore social situation Assessment Domain:2.Clinical Management SkillsPositive descriptors: Offers appropriate and feasible management options Considers appropriate investigations ues fbc tft Demonstrates understanding of the nature of the disease and its prognosisSimultaneously manages physical and psychological implications of conditionEncourages the patient to inform/seek help from family/peers/universityComes to a patient led agreed action planFu /referral discussedNegative descriptors: Decisions on management plans are inappropriate and doctor led Management approach not based on appropriate risk assessmentFollow up arrangement are absent or disjointedFall to take account of related issuesUnable to enhance patient’s health perceptions and coping strategies. Assessment Domain:3. Interpersonal skillsPositive descriptors: Explores patient’s agenda health beliefs and preferencesAppears alert to verbal and non verbal cluesElicits psychological and social information to place the patients problem in contextWorks in partnership finding common ground to develop a shared management plan. Shows responsiveness to the patients preferences feelings and expectationsEnhances patient autonomyHas a positive attitude when dealing with problemsShows commitment to equality of care for allActs in an open non-judgemental mannerNegative descriptors: Does not enquire sufficiently about the patients perspective/ understanding Pays insufficient attention to the patients verbal and non verbal communicationFails to explore how the patients life is affected by the problemDoes not appreciate the impact of the patients psychosocial contextInstructs the patient rather than seek common groundUses a rigid approach to consulting that fails to be sufficiently responsive to the patients contributionFails to empower the patient toencourage self sufficiencyShow little visible interest/ understanding. Lacks warmth in voice/ manner. GLOBAL COMMENTSPositive descriptorsPerforms in an organises/ consistent mannerRecognises the challenges to a sufficient degreePatient centred approach and good time managementNegative descriptorsFails to perform in an organised/ consistent mannerDoes not recognise the challenge to a sufficient degreeShows disproportionate or inappropriate doctor centrednessFails to demonstrate good time managementOther aspects e.g. time keeping, consultation structure, comment on consultation skills etcPositive descriptors: Negative descriptors: Grading: Clear pass = 3, Marginal Pass = 2, Marginal Fail = 1, Clear Fail = 0Data Gathering Score = Clinical Management Score = Interpersonal Skills Score = Total for case = (max = 9)GENERIC INDICATORS FOR TARGETED ASSESSMENT DOMAINS – Crib Sheet1. DATA-GATHERING, TECHNICAL & ASSESSMENT SKILLS: Gathering & using data for clinical judgement, choice of examination, investigations & their interpretation. Demonstrating proficiency in performing physical examinations & using diagnostic and therapeutic instruments (Blueprint: Problem-solving skills, Technical Skills)Positive IndicatorsClarifies the problem & nature of decision requiredUses an incremental approach, using time and accepting uncertaintyGathers information from history taking, examination and investigation in a systematic and efficient manner. Is appropriately selective in the choice of enquiries, examinations & investigations Identifies abnormal findings or results & makes appropriate interpretationsUses instruments appropriately & fluentlyWhen using instruments or conducting physical examinations, performs actions in a rational sequenceNegative IndicatorsMakes immediate assumptions about the problemIntervenes rather than using appropriate expectant managementIs disorganised/unsystematic in gathering informationData gathering does not appear to be guided by the probabilities of disease.Fails to identify abnormal data or correctly interpret themAppears unsure of how to operate/use instrumentsAppears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations2. CLINICAL MANAGEMENT SKILLS: Recognition & management of common medical conditions in primary care. Demonstrating a structured & flexible approach to decision-making. Demonstrating the ability to deal with multiple complaints and co-morbidity. Demonstrating the ability to promote a positive approach to health (Blueprint: Primary Care Management, Comprehensive approach)Positive IndicatorsRecognises presentations of common physical, psychological & social problems.Makes plans that reflect the natural history of common problemsOffers appropriate and feasible management optionsManagement approaches reflect an appropriate assessment of riskMakes appropriate prescribing decisionsRefers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriatelySimultaneously manages multiple health problems, both acute & chronicEncourages improvement, rehabilitation, and, where appropriate, recovery.Encourages the patient to participate in appropriate health promotion and disease prevention strategies Negative IndicatorsFails to consider common conditions in the differential diagnosisDoes not suggest how the problem might develop or resolveFails to make the patient aware of relative risks of different approachesDecisions on whether/what to prescribe are inappropriate or idiosyncratic.Decisions on whether & where to refer are inappropriate.Follow-up arrangements are absent or disjointedFails to take account of related issues or of co-morbidityUnable to construct a problem list and prioritiseUnable to enhance patient’s health perceptions and coping strategies3. INTERPERSONAL SKILLS Demonstrating the use of recognised communication techniques to gain understanding of the patient's illness experience and develop a shared approach to managing problems. Practising ethically with respect for equality & diversity issues, in line with the accepted codes of professional conduct. (Blueprint: Person-Centred Approach, Attitudinal Aspects)Positive IndicatorsExplores patient’s agenda, health beliefs & preferences.Appears alert to verbal and non-verbal cues.Explores the impact of the illness on the patient's lifeElicits psychological & social information to place the patient’s problem in context Works in partnership, finding common ground to develop a shared management plan Communicates risk effectively to patientsShows responsiveness to the patient's preferences, feelings and expectationsEnhances patient autonomyProvides explanations that are relevant and understandable to the patientResponds to needs & concerns with interest & understandingHas a positive attitude when dealing with problems, admits mistakes & shows commitment to improvement.Backs own judgment appropriately Demonstrates respect for othersDoes not allow own views/values to inappropriately influence dialogueShows commitment to equality of care for allActs in an open, non-judgmental manner Is cooperative & inclusive in approach Conducts examinations with sensitivity for the patient's feelings, seeking consent where appropriateNegative IndicatorsDoes not inquire sufficiently about the patient’s perspective / health understanding.Pays insufficient attention to the patient's verbal and nonverbal communication.Fails to explore how the patient's life is affected by the problem.Does not appreciate the impact of the patient's psychosocial contextInstructs the patient rather than seeking common groundUses a rigid approach to consulting that fails to be sufficiently responsive to the patient's contributionFails to empower the patient or encourage self-sufficiencyUses inappropriate (e.g. technical) languageShows little visible interest/understanding, lacks warmth in voice/mannerAvoids taking responsibility for errorsDoes not show sufficient respect for others.Inappropriately influences patient interaction through own views/valuesTreats issues as problems rather than challengesDisplays inappropriate favour or prejudiceIs quick to judge Appears patronising or inappropriately paternalisticWhen conducting examinations, appears unprofessional and at risk of hurting or embarrassing the patientCSA Grade descriptors Key: Clear Pass -- Marginal Pass -- Marginal Fail -- Clear FailCPThe candidate demonstrates an above-average level of competence, with a justifiable clinical approach that is fluent, appropriately focussed and technically proficient. The candidate shows sensitivity, actively shares ideas and may empower the patientMPThe candidate?demonstrates an adequate level of competence, displaying a clinical approach that may not be fluent but is justifiable and technically proficient. The candidate shows sensitivity and tries to involve the patient. MFThe candidate?fails to demonstrate adequate competence, with a clinical approach that is at times unsystematic or inconsistent with accepted practice. Technical proficiency may be of concern. The patient is treated with sensitivity and respect but the doctor does not sufficiently facilitate or respond to the patient’s contribution.CFThe candidate clearly fails to demonstrate competence, with clinical management that is incompatible with accepted practice or a problem-solving approach that is arbitrary or technically incompetent. The patient is not treated with adequate attention, sensitivity or respect for their contribution.Note: All three CSA domains must be assessed in order to make the final global judgement. The descriptors in italics address interpersonal skills. The rest of the text addresses the other two domains.The standard for “competence” is at the level required for the doctor to be licensed for general practice. ................
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