Gunners

 

Urban Dictionary – A person who is competitive,overly-ambitious and substantially exceeds minimum requirements. A gunner will compromise his/her peer relationships and/or reputation among peers in order to obtain recognition and praise from his/her superiors.

It’s good to be good…

It’s always good to want to improve your own ability, build upon your existing knowledge and broaden your knowledge base. Medicine is a continuously evolving subject that requires by law that you do the same. I’d be worried if I knew my doctor wasn’t at least trying a little bit to learn more about the subject they’d chosen for their career…

However, comparing yourself to others can be dangerous. When we go out in the world we put on our public face, our public clothes, and our public attitudes. We don’t reveal our inner fears, our problems, our weaknesses. And since everyone else is doing the exact same thing we don’t ever see theirs. This combination of caging away our own issues and not witnessing those of others gives us the false impression that they’re finding everything so much easier, or that they’re so much better off than we are. This is further perpetuated online, as Facebook and Instagram give the opportunity to sell yourself to the world as that perfectly happy, exciting and fulfilled individual that couldn’t possibly exist in real life. It’s not exactly a recipe for sound psychological well-being.

But there is a limit…

Medical schools rank their students. Presumably it’s intended as an incentive to work harder, as a higher rank apparently brings the tantalising promise of a better job, more research opportunities and greater respect. Maybe it produces better doctors, maybe it doesn’t. What it definitely does do is discourage students from helping each other out. The stakes are raised, forcing us to show that we’re not struggling, that we know the required information, that we can hack it in this apparently brutal world of medicine. People become so preoccupied with that centile rating that they will give up relationships with their peers in an attempt to make excruciatingly small gains over them, be that by hiding information or learning opportunities, or even misleading them deliberately in the hope of sabotaging this ‘competitor’ and boosting their own ranking.

WTF?

I once asked someone what topics were covered in a teaching session that I had missed through illness, and they said to me, “It’s your fault you weren’t there”Turns out it was the Krebs’ cycle…

I’ve also heard rumours of students sabotaging the computers/iPad available during OSCEs to disadvantage those yet to complete that station.

It’s crazy!

The qualities we want in our doctors are compassion, teamwork, communication and integrity. Healthcare is never done on an individual basis, it’s always a team of teams of teams, each with their own area of expertise and interest, cooperating and communicating to ensure the best outcome for the person that really matters most – the patient. You can only gain by communicating well with others. Either you find out something you didn’t know before, you deepen your own understanding of a subject, or you have that satisfying feeling of helping someone else understand something just a little bit better, and knowing that you’re helping their patients as a result.

So I ignore the rankings. Always have, always will. I don’t care if the person I’m talking to is going to score higher than me. In fact, I’m happy if they do. Why? Because I’m determined to be a good doctor – it’s what I’ve always wanted to be – so anyone scoring higher than me in the rankings has to be pretty good as well, and they might be looking after my Mum one day.

 

Don’t be that guy – help each other!

How I work

Deciding how to work

After more than fourteen years of school and six years of Medicine at University, you’d think I’d have figured out how I work best when it came to studying for exams. Surely after that many years of studying, cramming seemingly endless reams of information into my head for retrieval on the big day, I would know whether I was benefiting most from writing out notes, listening to lectures and podcasts, making flashcards, or reading the textbooks…

 

I didn’t.

 

This was a constant source of stress for me as each year I would begin the process of walking out into the lapping waters of bottomless information, and not have a clue as to how best to study. Should I try and write everything down? Type it out? Make flashcards? Just listen? Whichever tactic I tried soon became either unmanageable, tedious, or I simply didn’t think I was learning anything from the process. So what did I do?

I thought about what I do when I come to retrieving the information. That is, in exams, whenever I’m trying to remember answers from my brain and wondering why I couldn’t remember medical facts like I could with cat videos or insulting jokes, how was the information presented in my head. Was it remembering the page of notes? Remembering the lecturer’s voice? The diagram on the flashcard?

It turns out that there were three main ways that I was retrieving these facts:

  • Remembering answers to previous questions that were similar to the one in front of me
  • Recalling specific experiences I’d had on the wards
  • Diagrams that I’d drawn and re-drawn until I could do it by heart
  • Flashcards that I’d done so many times that I didn’t even have to try and remember them.

It was a very rare occasion that I would remember a piece of information from notes I’d written or textbooks I’d read. So I figured I’d stick to these four categories, and hope that my analysis wasn’t way off..

How I work now

  1. I spend as much time on the wards as possible. This is largely because final year is meant to be as much of an apprenticeship as possible; you’re learning how to do the job of those a year ahead of you, so you’ll benefit most from observing, trying (and failing) to do the same things. Your brain is very good at remembering experiences that it has because it has so many ways of programming the information; sights, sounds, smells, temperatures, emotions – think of a time you screwed something important up – bet you never had to revise that again!
  2. I make flashcards. This is largely a convenience thing as you can make one or two in a spare moment, and review them during quiet parts of the day. I use Anki, purely because it’s free on android and you have your cards with you wherever you go.
  3. Nearer the time, when exams are looming, I talk myself through a topic, while drawing out diagrams. I then use the books to check what I’ve missed, and add the information to the diagram. Then I store the diagram away until next time, and attempt to copy it perfectly. Repeat until smart.
  4. teach! You never know information properly until you can teach it to someone who knows nothing about it. If you can explain something simply to a friend or patient, then you truly understand a topic.

Find your own groove

Learning is incredibly personal, and everyone does it differently. Try different methods, see which you like, and more importantly, which ones seem to work, and focus on those, rather than spending time doing ineffective studying that bores you and doesn’t help your exam performance.

 

Good Luck!

 

 

 

Right iliac fossa mass

What on earth is that lump?

You have a young patient screaming in pain “my appendix!“, but her mother is much more worried that it might be cancer. You ask her why she thinks he has cancer, and she says

  • appendix mass
  • caecal carcinoma

“He’s had diarrhoea that floats!” to which you reply “Sounds more like Crohn’s…”

  • Crohn’s

You’re interrupted by the patient, who is now convinced her ovaries are exploding and her intestine is eating itself.

  • Ovarian mass
  • Intussusception

Do you think it could be her transplant?” asks the mother quietly – this surprises you so you look at the patient’s abdomen for scars, but instead you see a huge pulsating lump that looks like an aneurysm of some sort.

  • Pelvic kidney
  • Common iliac aneurysm

Have you had a fever?”  you ask? You’re thinking it could be an infection, either TB or an abscess.

  • Iliocaecal TB
  • Iliac lymphadenitis
  • Actinomycosis
  • Psoas abscess

The patient shakes her head, you then ask “can you push it back in?

  • Spigelian hernia

Both mother and daughter look at you like you’re an idiot, before daughter wets herself all over the bed. “What’s wrong with my bladder?” Which makes you think of her other bladder.

  • Gall bladder enlargement

The differential diagnosis for a right iliac fossa mass includes the following:

  • Appendix mass
  • Caecal carcinoma
  • Crohn’s disease
  • Ovarian mass
  • Intussusception
  • Pelvic kidney
  • Enlarged gall bladder
  • Iliocaecal TB
  • Iliac lymphadenitis
  • Psoas abscess
  • Retroperitoneal tumour
  • Actinomycosis
  • Common iliac artery aneurysm
  • Spigelian hernia

Clearly the likelihood of each is going to depend on the patient, the history, and the presentation. Caecal carcinoma is much more common in an elderly person than a teenager, while appendicitis is less likely if the patient has already had an appendicectomy…

Yellow Babies

Sometimes you have to talk to people about their problems. The incidence of this occurring rises dramatically if you become a doctor.

One of these problems is the finding that after giving birth to a child, it starts to turn yellow. This is rather unsettling for parents, and sometimes cats, and so they may ask you about (the parents) about why it’s happening. Given more than half of babies go yellow, this conversation tends to come up a lot.

Here I’ve written my two cents on how to explain it to Mum, and then some of the sciencey stuff underneath.

The conversation


“Hi, my baby’s yellow, did I do something wrong?”

Hello, my name is medical student and I’m a medical student. I’ve been asked to come and sp….”


“..yeah but why’s my baby yellow?”

“Well, could you tell me what you know so far?”


“………the baby………..it’s yellow….”

1 – It’s probably fine

Drop in a statistic like 60% of babies go yellow after birth, and it’s absolutely normal, especially if they came along a little early. Even more so if you’re breast feeding them.

2 – Why do they go yellow

The yellow is called Jaundice and it’s caused by ‘bilirubin’. It’s a normal breakdown product of the blood that the baby uses while in the womb, which is broken down after it switches to what’s called ‘adult’ blood. Since baby’s liver isn’t quite warmed up yet, this bilirubin builds up in the body, giving the yellow tinge. If it gets really really high, it can cause damage to the brain, so it’s good to check the level and make sure it’s just normal baby jaundice.

3 – What if it’s really high

If the level is a bit high, we can use a special light that helps the liver to convert this bilirubin into the molecules that baby can then get rid of. Only 1 in 20 babies needs any treatment at all.

4 – When did it start?

If it started after a day or so, it’s much more likely to be this normal baby jaundice, however if it started much sooner, it may be that we need to give the liver a bit more help, and we’d like to check that there isn’t something else going on.

5 – What else could it be?

It could be that the baby’s making too much of this bilirubin, or that there’s something stopping it being broken down. Infection can do this, or if the baby is dehydrated. There are other rare things that it could be, which it is always good to rule out.


6 – How’s their poop?

If their poop is pale and the urine very dark, then it gives us an idea as to where the problem might be, and how to fix it. Also ask about any other symptoms (irritability, incessant crying, poor feeding)

7- Anything run in the family?

Family history may suggest a pattern that we can start treating early.

8 – Any other concerns?

“Is it cancer?/Did I do something wrong?/Is it going to go back to normal colour?” All of these you can knock out the park with all that rapport and clinical acumen that you have.

Key points:

When did it start?

– Are they breast feeding?

– Any other symptoms?

– How’s their poo?

– Urine?

– Any change in behaviour?

– Full term or premature?

– Was mum on any antibiotics?

– How was delivery?

– Any problems after birth?

– Mum’s blood group?

– Family history of jaundice, or metabolic conditions?

– Patient concerns?

– Summarise

– Offer a plan and a follow up? (Usually – We’ll test the blood and see if we need to help the liver out, which most likely we won’t need to, and then if it doesn’t go away after a few days come back and we can have another look…)

The science

Jaundice – or icterus – describes a yellowing of the skin caused by the build up of bilirubin.

Usually – <25 micromol/L

Bad – >50 micromol/L

Neonatal jaundice is normal after around 24 hours until around 2 weeks. This occurs for three reasons:

You can’t ignore neonatal jaundice, though, as it could be due to:

  • haemolytic anaemia
  • infection
  • liver disease
  • metabolic disease

and severe build up of unconjugated bilirubin in the brain can cause kernicterus, especially in the basal ganglia

Bilirubin is fat-soluble, so it can cross the BBB and lead to kernicterus (encephalopathy)

If the amount of bilirubin exceeds the ability of albumin to bind it, then it can build up in the basal ganglia and brainstem nuclei

Symptoms:

  • lethargy
  • poor feeding
  • irritability
  • increased muscle tone – baby lies with arched back (opisthotonos)(67 points in scrabble)
  • seizures
  • coma

Kid’s that survive kernicterus can have

  • choreoathetoid cerebral palsy
  • sensorineural deafness
  • learning difficulties

An interesting aside: Kernicterus used to cause a lot of brain damage in kids with really bad rhesus haemolytic disease, but since the introduction of anti-D immunoglobulin for rhesus-negative mothers, there’s not a whole lot of it around…

So that’s why we care about it – but how do you go about investigating a yellow baby?

1 – when did it start?

General rule – after 24 hours = fine, before = bad

Bad is the technical term

90% of the time it’s totes fine

yeah your liver should probably pick up its game a little

If jaundice has kicked in within 24 hours, it’s likely there’s a haemolytic process afoot. This is important to spot as it can get a lot worse very quickly:

  • Rhesus haemolytic disease – usually picked up antenatally
    • may have anaemia, hydrops and hepatosplenomegaly
  • ABO incompatibility – more common that RHD, most ABO antibodies are IgM and don’t cross the placenta, but some women that are group O have IgG anti-A antibodies, than can react with the babies cells.
    • do Coombs’ test to check
  • G6PD deficiency – mainly in people from the Middle-east and Mediterranean (also Africans and Far East)
    • important to give parents information on drugs to avoid
  • Spherocytosis – much less common, usually a family history
    • Check the blood film
  • Congenital infection – usually have other signs such as
    • hepatosplenomegaly
    • thrombocytopenic purpura
    • growth restriction
    • remember it’s a conjugated hyperbilirubinaemia

If the jaundice is after 24 hours and up to 2 weeks, then this is most likely the physiological jaundice described above. The way I remember these ones is the noise the minion makes when it’s got that stupid light on it’s head in Despicable Me 2 “BIIDOOO BIIDOO”

  • Breast milk jaundice – thought to be protective as an antioxidant
  • Infection – unconjugated due to haemolysis and poor fluid intake – think UTI
  • Dehydration – may need IV fluids
  • Other – Bruising, polycythaemia and rare stuff like Crigler-Najjar 

2 – how bad is it?

Testing the jaundice is a logical next step – you can do it:

  • clinically
    • how much yellow are we talking?
  • blood test

3 – how fast is it building?

Like a sinking yellow ship it’s nice to know how bad the situation is, and how quickly it’s getting worse. Usually the level rises in a linear fashion, so keep these plotted on a chart somewhere so you’re not caught by surprise.

4 – what drugs are they on?

If you’ve given a newborn a sulphonamide or diazepam then these can displace bilirubin from albumin and make the jaundice worse. Don’t give these to a newborn. It’s silly.

So what to do?

There are 3 key things to do with a yellow child, after you’ve checked it isn’t an unfortunate highlighter incident:

  • Keep the kid hydrated and fed
  • Phototherapy
  • Exchange transfusion

The mainly used one is phototherapy, where 450nm light is used to convert bilirubin into different isomeric configurations that are water soluble. In exchange transfusion the baby’s blood is swapped bit-by-bit with donor blood. We don’t know at what level kernicterus becomes inevitable, so basically keep it as low as possible.

It won’t stop! – jaundice beyond 2 weeks

Persistent/prolonged jaundice might be due to biliary atresia, which is the main concern, but it is usually an unconjugated hyperbilirubinaemia due to:

  • Breast milk jaundice (may last up to 5 weeks)
  • Infection
  • Congenital hypothyroidism – should be picked up on the Guthrie test.

How do I know it’s conjugated?

Dark pee, pale poo.

Also hepatomegaly and poor weight gain.

Pelvic exam

This is my script for a pelvic examination. Everyone has their own, so feel free to chop and change it how you like.

Introduction:

  • “Hello, Mrs Jones, I’m Will Sloper, one of the doctors here, how are you doing today?”
  • “Can I check your date of birth quickly?”
  • “May I double check that you know what it is you’ve come here for today? Have you had one before?”
  • “Excellent, and do you understand why we do this test?”

o   Not a clue

  • “This exam is a routine test that we offer to all women over the age of 25, and it allows us to see whether there is a risk of cervical cancer further down the road. It’s not a test for cancer now, it just lets us intervene nice and early should we need to, alright?”
  • “Would you like me to explain what I’ll be doing?”

o   Yes

  • “There are two parts of today’s exam, the first is the smear test, and the other is a manual examination”
  • “For the smear test, I’ll use a soft little brush to take some cells from the cervix, so that we can send these cells off to the lab. To do this, I’ll gently insert a speculum, which will just hold the vaginal walls open so that I can see the cervix. It’ll be lubricated to make it more comfortable. Would you like to see the speculum beforehand?”

o   Yes

  • “Here’s an example, of course I’ll be using a sterile one in the examination itself”
  • “The second part of the exam is the manual exam. For this I’ll gently insert two fingers, with gloves on, into the vagina, and with the other hand I’ll press gently on your tummy. This will allow me to check that all of the reproductive organs are healthy. Is that alright?”
  • “Neither of the two parts should hurt, but they can be a little uncomfortable. It’s important that you know that you can say stop anytime, and I’ll stop straight away.”
  • “Having explained the procedures, do I have your consent to go ahead?”

Preparation:

  • “First of all do you need to go to the toilet? I will be pressing on your tummy”
  • “There will be a chaperone present, is that alright?”
  • “Would you like me to lock the door? The curtain will be drawn, but sometimes people walk in without knocking”
  • “Lastly, have you had any children?”

o   “Was that through normal delivery or Caesarean section?”

  • “Ok great, if you could head behind the curtain, and undress from the waist down, you can leave shoes and socks on if you’d prefer. If you lie on the bed, there’s a towel to cover yourself, and I’ll be in in a minute”

Wash hands

Get trolley ready:

  • Wipe with tissue and alcohol gel
  • Cover with tissue
  • Prepare the vial

o   Full name and DOB

o   Remove lid, discard seal

  • Place cytology brush on trolley
  • Squirt some lubricating jelly onto the trolley, and put the jelly down somewhere else
  • Select speculum and empty onto the trolley

o   Small if no children/caesarean

o   Medium if vaginal delivery

“Alright Mrs Jones, are you ready?”
Alcohol gel

1.       Abdominal examination

  • “Please could I ask you to slide your top up so I can have a look at your tummy first”
  • Visual inspection

o   Abdominal masses

o   Scars

o   Bruising

  • “Have you had any pain in this area?”
  • Abdominal examination

o   Press abdomen from umbilicus to pubic bone, across the width of the abdomen

o   Masses and tenderness

2.       Smear test

  • Put on gloves (NOW BE THINKING ABOUT WHAT YOU ARE TOUCHING)
  • Open the packet and assemble the speculum

o   Check it works

o   Apply a drop of lubricant to both sides but not the tip and spread with finger

  • Ask the chaperone to turn on the light
  • “Alright Mrs Jones, please could you bring your heels towards your bottom and let your knees flop out to either side”

o   “I’m just going to have a look before I do anything”

o   Inspect for signs of infection, genital warts etc

o   “Ok, I’m going to do the smear test now”

  • Part the labia with left thumb and index finger
  • With speculum horizontal, slowly insert towards the small of the back
  • When the lever reaches the inner thigh, turn so the mechanism is pointing upwards
  • When all the way in, turn left hand so that the thumb is in position to open the lever
  • With right thumb holding the base firmly in place, slowly open the speculum

o   Look inside as you do

o   When you can see the os, fix the speculum with the nut

  • If you cannot see the os, ask the patient:
  • “Mrs Jones may I ask you to put your hands under your bottom for me?”
  • Gently rotate speculum if necessary
  • Take cells

o   Insert the central bristles of the brush into the os and rotate clockwise five times

o   Push the brush to the bottom of the vial 10 times and swirl vigorously

  • Inspect brush to ensure no material is left
  • Throw the brush away
  • Ask chaperone to put lid on the vial, otherwise wait until the end to do so with non-gloved hands
  • Make sure the black lines are aligned
  • Remove speculum

o   Release nut while holding speculum open with left hand

o   Retract slowly until the blades are clear of the cervix

o   Let go of the speculum completely with the left hand and slowly remove the speculum with right hand

o   Dispose of speculum

  • “Alright Mrs Jones, I’ve finished the smear test, is it alright for me to do the manual examination now?”

3.       Bimanual exam

  • Apply a little gel to the index and middle fingers of the right hand
  • Part labia with left hand and insert the two fingers into the vagina, towards the small of the back, turning as they go in
  • Feel for the cervix

o   Try to get your fingertips underneath it into the posterior fornix

o   Push the cervix up with a steady pressure

  • “May I ask you to uncover your tummy please?”
  • Start at the umbilicus and press firmly down towards the pubic bone

o   Move down in increments until you feel the cervix moving onto your inside fingers

  • Assess the uterus for:
  • Size
  • Mobility
  • Pain
  • Position
  • Palpate the right adnexa
  • Place fingers in right lateral fornix
  • With outside hand press down the inside of the hip bone and work down in increments
  • Do the same for the left
  • Withdraw fingers and examine for blood
  • Remove gloves away from the patient
  • “Alright Mrs Jones that’s all finished”

o   Deal with vial if necessary

  • “Here’s some tissue to wipe away the gel, just pop them in the yellow bin when you’re done”
  • “I’ll let you get dressed in privacy, I’ll just wash my hands, and you let me know when you’re ready”

Clear trolley

Explanation of results:

  • “Alright, was that okay?”
  • “The smear test results will come in the post in about 2 weeks, and I’ll get a copy, as well as your GP”
  • “The vast majority of these tests are completely normal so there’s no need to worry in the mean time”
  • “In the examination everything felt healthy and normal, and sometimes there’s a little blood after a smear test. It shouldn’t be prolonged or painful, but if you have any worries then you can see your GP”
  • “Do you have any other questions for me?”
  • “Thank you for coming”

Sexy History

Asking someone about their sexual life is rarely appropriate. Asking a complete stranger about their sexual life is pretty much never appropriate.

“So, are you sexually active at the moment?”


“…single or return ticket?”

As a doctor, however you’ll need to uncover the deepest secrets of someone’s funtimes if you’re to be successful in your quest to treat their symptoms or give them any advice in the field. To do this you must build a sufficiently professional rapport that they trust you enough to divulge their sexual history, without making them or yourself too uncomfortable.

“Could you show me on this doll…?”        – not a good way to do it

To begin with, as always, make sure that you have the right patient, at the right time and in the right environment (a patient expecting a respiratory clinic is going to be rather surprised). A calm, quiet and private atmosphere is going to help, and it may be appropriate to have a chaperone present in the case of vulnerable or particularly uncomfortable patients. Then you can do what you always do with a history:

  • start with open questions
  • gradually focus on the pertinent issues
  • close with a broad summary
  • ask about concerns and expectations

“What brings you here today?” – nice open question to start off, allows the patient to lead, and gives you a chance to see what their preferred vocabulary is when it comes to genitals, sex and discharge.

“I sense a great disturbance in my glistening man-shaft”           – unlikely

“Can you tell me a little more about the discharge/smell/bleeding?”

“How would you describe the pain?”

“What do you think has caused it?”


Then, as with all histories, you want to ensure you SOCRATES the symptoms, to clarify in your mind what might be causing them:

  • Site
  • Onset
  • Character
  • Radiation
  • Associated symptoms
  • Timing
  • Exacerbating and relieving factors
  • Severity

Once you have established what the main complaint is, there are a few specific symptoms to check for, and remember to SOCRATES each one:

  • For the proud owner of a penis:
    • Have you had any pain in the penis/willy/man-shaft? (whatever the patient has said, within reason)
    • Have you had any itching?
    • Any redness?
    • Any skin changes?
    • Have you noticed any discharge?
    • Urinary symptoms:
      • Any pain when urinating/when you pee?
      • Any blood in the urine/pee?
      • Are you needing to pee more often than usual?
    • Have you noticed any swelling?
  • For the proud owner of a vagina:
    • Have you had any pain in the groin/genitals/vagina/down below?
    • Have you had any abnormal discharge?
      • What does it look like?
      • Does it smell?
    • Do you have any itching or redness?
    • Urinary symptoms
    • Any skin changes?
      • any changes around your bottom/anus/around the back?
    • Do you have pain during or after having sex/intercourse?
      • How would you describe it?
        • deep?
        • near the surface?
    • Have you had any tummy pain?
      • whereabouts?
      • SOCRATES
    • Menstrual history
      • When was your last period?
      • Are your periods usually regular?
        • how long do you normally have bleeding for?
        • have they been out of habit recently?
      • Do you have pain during your period?
      • Do you notice bleeding after having sex?
      • And do you ever notice bleeding between periods?
        • is this a change from normal for you?
    • Gynaecological history
      • Have you had any gynaecological problems in the past?
      • Ever had any gynaecological treatment or surgery?
      • When was your last smear test if you’ve had one?
        • how were the results?
        • have you ever had an abnormal smear?
    • Obstetric history
      • Is there any chance you might be pregnant at the moment?
      • Do you use contraception?
        • May I ask what it is that you use?
        • Have you had any issues with contraception in the past?

After this for both sexes, you’ll need to check for Systemic Symptoms, suggestive of a more widespread issue. Questions may include:

  • Have you had any soreness in your joints?
  • In your eyes?
  • Have you felt feverish?
  • Any rashes on the body?

Now comes the fun bit. It’s probably a good idea to give them a bit of a warning, something like:

“I have to ask a few personal questions now if that’s alright…”

Is likely to receive a better response than

“Now then now then…..      What have we been up to between the sheets….?”

In order, the questions I like to ask are:

  • Are you sexually active at the moment?”
  • “When did you last have sex?”
  • “Was that with a man or a women or both?”
  • “What did it involve?”
    • Penetrative sex?
    • Oral, Vaginal, Anal?
      • YOU NEED TO KNOW EXACTLY WHAT WENT WHERE, especially in Men who have Sex with Men (MSM)
        • was it his mouth/yours?
        • did you both receive anal sex?
  • “Are/were they from the UK or overseas, if you know?”
  • “Are they a regular sexual partner?”
  • Did you use contraception?”
    • “What was it that you used?”
    • if condom:
      • “Did you use it for everything?”
  • “Have you had any other partners in the last 3 months?”
    • If so, repeat questions for other partners

Now you can both relax a bit, and settle into some questions about general previous medical history:

“Now I need to ask a little about your general health”

  • “Have you had any sexually transmitted infections in the past?”
  • “Have any of your sexual partners had one that you know of?”
  • “Is there anything that you regularly see your GP/a doctor for?”
  • “Have you been in hospital for anything in the past?”

As always, drug history next:

  • “Do you take any regular medications?”
  • “Have you taken any antibiotics recently?”
  • “Do you have any allergies?”
    • “Do you react to any medications?”

Next up, social history

  • “Are you a smoker/Do you smoke?”
    • “How much/many packs a day?”
  • “Do you drink alcohol?”
    • “How much in a week?”
  • “Any other drugs; cocaine, heroin, cannabis?”

Last of all, HIV risk is very important to ascertain.

  • “Have you ever had an HIV test?”
  • “Have you ever injected drugs?”
  • “Have you ever had sex with a man?” (if a man)
  • “Have you ever been paid for sex?”
  • “Have you ever had sex with someone from an area where HIV is very common?”

Hopefully by the end of this you won’t have missed anything, and you’ll know more about their sexual history than… well anyone really

My OSCE top 5

OSCEs are interesting beasts. They are terrifying whilst simultaneously quite good fun, and I personally end up learning as much from doing the OSCE itself as I do revising for it in the first place.

One brand of OSCE station that comes up is Explaining and Communicating, in which one must demonstrates one’s prowess in the task of bringing a patient up to speed on a condition, treatment, test result etc. in as kind, clear and concise way as possible. You can’t drown them in information, but you have to tell them enough, and you can’t be overly reassuring but you equally don’t want to crush their spirit. So what’s the secret?

Practice. 


Not the answer people want to hear the night before an exam, but truly the only way to master a task this demanding is through experience, working out what works best for you and seeing how patients respond. However no amount of practice is going to help if you don’t have a good recipe in the first place, so here’s a summary of what should be done in any explaining station, if you want to be on the right track.

1. You’re a doctor


Or medical student. That means you have to:

  • do no harm
    • wash your hands
    • ensure you have the right paitent! 
    • don’t say anything that will unnecessarily upset your patient
    • protect vulnerable patients (eg children, abused partners, very ill patients)
  • respect the patient as an individual
    • give them accurate, relevant information
    • allow them to make their own decisions
  • do right by the patient
    • tell them what you would like to know in their position
  • try and help the patient
    • give options for treatments
    • give reassurance where appropriate
    • provide emotional support
    • ensure they always leave with a plan

Sometimes you may have to hurt the patient (giving bad news, venepuncture, reducing a fracture) but in these circumstances the others (try and help, do right by the patient) are of greater influence. Your job as a medical professional is to decide which are the most important in each situation, based on where the patient’s best interests lie. Clinical judgement. Fun.

2. What do they know already?


This bit is arguably the most useful for you as the explainer. Ask the patient what they’ve been told so far, or what they understand, and what they say will save you huge amounts of time, as you’ll then know:

  • at what level to pitch the information 
  • what they know, and so you don’t need to talk about
  • what bits they’re concerned about

The last one is important, because you might think you know what the salient information is in a particular consultation, but only the patient knows what they want to know about, and that’s why they’ve come to talk to you. So ask them and ye shall find.

3. Confidentiality is key

A doctor has a privileged position of being able to keep secrets. Patients should be able to discuss absolutely anything they like with the doctor without fear of embarrassment/repercussion. There are a very few cases where you are required by law to disseminate information to the relevant authorities (knife/gunshot wound (Police), epilepsy (DVLA) (make sure you tell patient to tell them first and say you’ll have to tell the authorities if they don’t) however the vast majority of the time, you should never ever ever share anything anyone has told you outside of the medical team working on the case. So in your explaining station, think:

  • Does this person need to know this information? 
    • (eg parent asking about their infants’s condition vs asking about adolescent’s condition)
  • Am I breaking confidentiality by revealing this?
  • Should I conduct this conversation with/without patient’s relative/partner/friend in the room?

4. Know your limits

Sometimes you won’t know the answer to their question. Don’t lie, don’t make something up, don’t say “I have no idea”, but say something useful, such as:

  • What I’ll do is print you out a leaflet with all the information that you can take home with you
  • There is fantastic information on the NHS/Patient websites 
  • I’ll double check what the current guidelines say and let you know

5. Listen


Half of the time in an OSCE you’re thinking only about what you’re going to say or do next. This is fine (to some extent) in a procedure or an examination, but in an explaining or history-taking station it’s a surefire way to get stuck. Remember:

  • The patient/actor has been given a list of answers
    • They have been given the important information that you need to elicit, so when they start telling you – actively listen to what they’re saying!
  • Thinking about what you’re going to do next can actively lead you astray
    • Particularly with history stations, you might be thinking “I have to ask about this” meanwhile the patient is telling you a symptom that completely changes your differential – listening and clarifying things they say (what type of pain/when is it worst/what does the discharge look like? will be much more likely to provide you with your answer)
  • If you’re stuck, ask them for help!
    • It’s a little more subtle than that, but saying something like ‘Is there anything else you think I should know about/Do you have any thoughts about what it might be?’ can get you out of hot water.

Of course each station will be different, and will require its own emphasis on explaining prognoses/addressing concerns etc but as long as you follow these 5 guides, you’re unlikely to do too badly.

As always – if you disagree or feel I’ve missed anything please comment!