Tutorial 10th. October 2011.

Website.
Podcast.
Tonight we started with a viva in which you had to talk about writing a critical incident report.
The scenario is below.
Then we went on to a critical appraisal of the RCOG's patient information leaflet on herpes in pregnancy.
http://www.rcog.org.uk/genital-herpes-pregnancy-information-for-you.
I have written some thoughts on both.

Spend 15 minutes on each, writing an outline of what you are going to say.
Send them to me and I'll let you have my thoughts on the appropriate techniques.
The critical incident instructions are:

Adverse incident report.

Candidate’s instructions.

Mrs Penelope Jane Brown sustained a 4^th. degree tear after the delivery of her second baby.

Dr. James Peter White conducted the delivery and was asked to write a statement for the Risk Management Team (RMT), to whom the incident has been reported as an adverse clinical incident.

You have been asked to look at Dr. White’s report to identify issues that the RMT need to explore further. You have 15 minutes to read Dr. White’s report, after which you will have a viva with the examiner. The examiner will not lead the discussion and will simply listen to what you have to say.

Dr. White’s Statement.

I am Dr. J. White. I have been SpR in obstetrics and gynaecology at the Royal Infirmary for over a year.

On the 27^th. September I was bleeped by a midwife on the labour ward and asked to see a Mrs. Brown who needed to be delivered as there had been delay in the second stage and she was becoming exhausted.

On arrival on the labour ward I felt that Mrs. Brown was not trying very hard to deliver the baby naturally and that the midwives were not making much effort to encourage her. I advised that they should get her pushing properly and that I would go for a coffee and return in half an hour.

I returned in 50 minutes, having had a phone call from my wife about arrangements for our forthcoming holiday. The situation was unchanged and I was not impressed with either the woman’s endeavours or the midwives’ encouragement of her.

Examination showed the head to be midcavity. I felt that it could get it out using forceps. The midwives told me that her bladder was empty. I applied the forceps with ease. The baby delivered in good condition. I then noted that she had a 4^th. degree tear. I repaired this in the usual way.

I went on holiday the next day for two weeks and did not see this woman again.

Tom McFarlane.
http://www.drcog-mrcog.info/contact.htm

Tutorial 6th. October 2011.

Website.
Podcast.

We started with a complaint. There is overlap here with the angry patient and you would need to read the roleplay carefully to see what your tasks were. The scenario is you as the SpR. A woman had a normal delivery with an episiotomy, which you repaired. She saw the GP 2 weeks later as she had a foul discarge. The GP revmoved a swab and referred her back to the clinic where you were asked to see her. We concentrated on the processes of adverse incident investigation / complaint procedures rather that dealing with an angry patient or spending too much time on how she was, though you would probably have to do that in an OSCE with questions about possible ascending infection and appropriate investigation, reassurance about fertility / ectopic risk etc.

We then went on to discuss what options remain if the local processes do not satisfy the woman.
We also had a preliminary discussion about diathermy, which is due to make a return as a viva.

Tutorial 3rd. October 2011.

Website.

Podcast.

Tonight we started with a discussion of some laboratory and other results. The usual instruction would be that the consultant is away and the secretary asks you, the SpR, to deal with some results that have come in. You have to decide on the degree of urgency and what action should be taken.

Laboratory results.

+ve MSSU at booking. No symptoms.

GTT at 34 weeks. Peak level 11.5.

FBC with ­ MCV at booking.

Thrombocytopenia at booking. 50,000.

Hydatidiform mole after evacuation of suspected miscarriage.

Histology after ERPC for incomplete miscarriage: no trophoblastic tissue.

Endometrial cancer: hysteroscopy: thickened endometrium. Histology: Anaplastic malignancy.

Endometrial cancer: MR scan: reaching serosa and upper endocervical canal.

Consultant does lap drainage of normal looking ovarian cyst. Malignant cells. Nulliparous. Wants children.

HVS: trichomonas.

Clue cells on smear. 12/52 pregnant.

Antenatal discharge: endocervical swab: chlamydia

Actinomyces on smear.

Herpes in pregnancy

Severe dyskaryosis on cervical smear at booking.

Primary infertility: FSH & LH ­ at 25 on day 3 of cycle.

Primary infertility. FSH 3, LH 12 on day 3 of cycle.

Treated with cabergoline for ­ prolactin and pituitary adenoma. +ve beta HCG.

3 cm. ovarian cyst. ­ Ca 125.

“Miscarriage” → ERPC. Histology report: Decidual reaction. No trophoblastic tissue seen.

We then had a roleplay. You are the Spr in clinic. The consultant is off sick and you have been told to run the clinic.  

The scenario is one of breaking bad news.

Age 60. Follow-up after hysteroscopy for PMB.

Histology shows poorly differentiated adenocarcinoma.

Unstable diabetes.

Tutorial 29 September 2011

Websitewww.drcog-mrcog.info.
Tutorial.
A recent exam had an OSCE station in which there was an inappropriate GP letter.
I have produced my version.
The candidate's instructions are:
1. to detail what is wrong with the letter,
2. to say what you would do apart from dealing with the clinical issues.

Candidate’s instructions.

List the things that are wrong with this letter.
What action would you take after seeing the patient?

The letter read as follows.
The Medical Centre,
Green Lane,
Broadforth-on-Sea.
Your ref: BRI 91/54843.

Re. Jennifer Houseside,
45 The Maltings,
Broadforth-on-Sea.

Please see this woman who complains of unacceptably heavy periods. She is a huge, malodorous whale and I do not envy you the task if you feel that you have to examine her. She is as stupid as she is fat and full of idiotic ideas that she gets from her equally stupid mother. She is too thick for logical reasoning to have any impact on her stupid views.
The father is a dirty, unpleasant sort and I would not be surprised if incest had contributed to their low IQs. If the human race has advanced though evolution and natural selection, what on earth were their ancestors like?
They are social parasites. None of the family has ever worked and they live off Social Security payments. I have had the misfortune to have to do the occasional home visit to various members of the family. They live in disgusting squalor. If they were pigs their living conditions would give the species a bad name. Theirs are houses in which you wipe your feet on the mat as you leave and not as you enter. They always ask you to sit, but I would not wish to ruin my clothes. And their hospitality extends to offering cups of tea, but I would rather take my chance with neat hemlock.
However, despite living on Social Security payments, they have the latest widescreen TVs and associated DVD equipment. The husband looks to me as though he indulges in low-level crime, probably shoplifting. He is a shifty character whom you would not trust and I would advise you to make sure that all valuables are locked up and out of sight when she or any of her family is around. One brother is in prison for theft to feed a heroin habit, which typifies the contribution this family makes to the greater good. Her sister is believed to be a prostitute. Certainly she has a lot of children and I doubt that any of them have the same father or that she would be able to enlighten them as to who their fathers might be. She (the sister) is a regular visitor to the Sexually Transmitted Diseases clinic where she displays a surprising range of conditions needing treatment. The sister is as fat and ugly as my patient, making one marvel at the mentality of her clients. I cannot imagine how anyone would want sexual relations with her, far less pay for the privilege.
I wish you well in your dealings with her and apologise for sending such an unpleasant lump to your clinic. This is a family that makes you wish the Abortion Act could be made retrospective!
Please do your best not to send her back to see me.
Yours sincerely,

 We then decided that it would be a good idea just to deal with this referral letter with all the abusive and inappropriate stuff removed.

We then had what would seem a very simple station about menorrhagia. As you will hear, the roleplayer was brilliant and made it a most interesting station.

The referral letter would now read:

The Medical Centre,

Green Lane,

Broadforth-on-Sea.

Your ref: BRI 91/54843.

Re. Jennifer Houseside,

45 The Maltings,

Broadforth-on-Sea.

 

Please see this woman who complains of unacceptably heavy periods.

Yours sincerely,

Jon Poutmouth.

Tutorial 26 September 2011

Website: www.drcog-mrcog.info.

Tutorial:  http://soundcloud.com/drtmcf/tutorial-26-september-2011.

We had two roleplays tonight. To spend the whole session on just 2 roleplays illustrates the need for loads of practice to get slick at doing them.

The first was a pre-op ward round.

Candidate’s Instructions.

You are a SpR doing the pre-operative ward round before today’s Day Case Unit operating list at which you will be assisting the Consultant, Mr. L. A. R. Gehead The patient you are about to see is Ms. Jane Smith who is listed for laparoscopic sterilisation.

You have been asked to do the pre-op check and to get her to sign the consent form for the procedure.

This is the first time you have met Ms. Smith. She was listed for the operation by another SpR.

The hospital notes state that she is 28 years old and has one child. Her general health is good, she does not smoke, is not on any drugs, prescribed or otherwise and has no known allergies.

The second was a consultation in the pre-pregnancy counselling clinic. The GP letter read: "Please see Jane Smith who is planning a pregnancy. Her father was recently diagnosed with Huntington's disease".

Tutorial 22 September

Website.
Tutorial.

The Maternal Mortality Report has to be a hot topic for the OSCE as it did not feature in the essays.
We started with 2 vivas. The first on the Ten Top Recommendations, the second on the chapter "Back to Basics".
We then had a roleplay. The roleplayer was healthy, nulliparous and had come for pre-pregnancy counselling as her brother has cystic fibrosis.
Finally, a viva on audit.

Tutorial 19 September

Website: www.drcog-mrcog.info.
Tutorial: http://soundcloud.com/drtmcf/tutorial-19-september-2011.
We started with a role-play with a SpR teaching a junior doctor how to do a forceps delivery.
The we had a "breaking bad news" roleplay.
Primigravida. 8 weeks. Some bleeding. Scan = non-viable pregnancy. CRL = 16 mm. No fetal heart activity. Counsel.
Sounds really easy, but it isn't and illustrates the need for loads of practice.