See EPAU in
1 week or SOS
Bleeding
continues **
** No indication for
Vaginal
Repeat USS as
examination
clinical decision
indicated
os open
os closed
49
REVIEW STATIONS
Examiner’s instructions/mark sheet
Candidates need to cover the following areas of discussion and can be prompted by a specific question if they do not mention them spontaneously.
Factors to be considered
●
Which patients should have been managed?
●
Evidence-based medicine
●
RCOG/national guidelines
●
Consumer interaction/expectation
0
1
2
3
4
Design the audit
●
Determine sample size
●
Establish a data sheet/proforma to identify patients’ course
●
Define outcome
●
Identify missing data and eliminate bias
●
Identify key failures in following the algorithm 0
1
2
3
4
5
6
Use of results
●
Feed results back to staff at regular audit meeting; may need to talk to GPs or hold meetings for relevant stakeholders
●
Anticipate reactions
●
Hard on the issue, soft on the individual; avoid a blame culture
●
Consider necessary organizational changes to improve or allow compliance
●
Resource implications may be an issue
●
How to achieve consistent implementation
●
Time taken for changes to be implemented
●
Decide when audit should be repeated
●
Completing the audit cycle
●
Change in protocol may not make further audit data comparable 0
1
2
3
4
5
6
Global score
0
1
2
3
4
Total
/20
50
AUDIT
Discussion
What does this question test?
This question is designed to test the candidate’s understanding of audit. The algorithm or protocol is relatively immaterial. It is not the protocol that is being criticized but the adherence to the protocol that is being tested. There may be a preparatory station prior to meeting the examiner. The examiner will expect the candidate to go through the steps of an audit cycle. If the examiner has to prompt the candidate then the marking will be reflected accordingly.
What are the pitfalls?
The major pitfall in this type of question is not understanding the audit process and instead spending the time criticizing the protocol. All UK trainees are expected to undertake some form of audit during their posts and this is the place to learn how to do it. You need to be aware of proforma or data sheets that need to be produced and whether the audit should be done on a numbers basis or over a specified time.
That will reflect the frequency of the condition. For early pregnancy problems, it may be useful to do the next 200 cases; if the subject was water birth then it may be worthwhile using a fixed time period. Most audits should be done prospectively as there is a risk of losing cases if done retrospectively, which may alter the ultimate outcome.
Advice
The following is a way of undertaking an audit. It is useful for candidates to have undertaken an audit within their own organization.
●
Agree audit scope and objectives
●
Audit methodology/design
●
Review current practice
●
Agree preferred practice
●
Design proforma/audit tool
●
Collect data
●
Analyse data
●
Conclusions/recommendations
●
Action plan
●
Re-evaluation
51
Review station 10
Obstetric history
Candidate’s instructions
The patient you are about to see has been referred to your antenatal clinic by her general practitioner. A copy of the referral letter is given below. Read the letter and obtain a relevant history from the patient. You should discuss any relevant investigations that you feel may be indicated.
The general physical examination of the patient should be taken to be unremarkable.
Dear Doctor
Would you please book Andrea Rollings for antenatal care? She is 11 weeks’ pregnant. I have enclosed some of the investigation results.
Yours sincerely
Dr Beattie
●
FBC – normal
(Andrea ROLLINGS 2.6.78)
●
Blood group – O, Rh-positive
●
VDRL – negative
●
Rubella – non-immune
●
MSU – no growth
●
USS – single live intrauterine pregnancy consistent with 11 weeks’ gestation. No other abnormalities detected
YOU WILL BE MARKED ON:
●
Obtaining an obstetric history
●
Establishing risk factors for this pregnancy
●
Discussing relevant and appropriate investigations 52
OBSTETRIC HISTORY
Role-player’s instructions
You are Andrea Rollings, a 27-year-old woman who works in the sex industry. You are single and live alone. Your periods are regular every 28 days with a 5-day bleed.
You had been using the combined oral contraceptive pill (OCP) and this pregnancy was due to a pill failure. You are unsure of the date of your last menstrual period and don’t see it as relevant when you know that the recent scan makes you 11
weeks’ pregnant. This is your first pregnancy and you have a certain amount of ambivalence towards it. You are also off-hand with anyone you see as an authority figure. You don’t make the interview easy, as you view the doctor in this way. Your personal/medical information is as follows:
●
Medical and surgical history – nil of note
●
Last cervical smear 5 years ago
●
Smokes 20/day
●
Alcohol – three whiskies/day
●
Recreational drugs – marijuana and cocaine but nothing intravenously
●
Medication and allergies – nil
53
REVIEW STATIONS
Examiner’s instructions
At this station, candidates will have 14 minutes to obtain a history relevant to the patient’s complaint. Candidates should also discuss with the patient any relevant investigations they feel are appropriate.
Investigations that need to be considered are as follows:
●
Hepatitis B and C screen
●
HIV test
●
Cervical smear
●
HVS and Chlamydia swabs
54
OBSTETRIC HISTORY
Mark sheet
Obstetric history
●
Basic obstetric history, including LMP, cycle length, EDD
●
Previous medical and surgical history and any family history of note
●
Is it planned and does she want to continue with the pregnancy?
●
Deals with social factors, looking at alcohol, cigarette and recreational drug consumption
●
How is the pregnancy progressing to date?
0
1
2
3
4
5
6
Risk factors
●
Brings out the fact that she may be at risk of HIV and substance abuse
●
How is she supporting her habits?
●
Asks about occupation
●
Emphasizes the importance of attending for routine antenatal check-ups 0
1
2
3
4
Relevant investigations