To be able to take a gynaecology history is a core skill for an MRCOG candidate.
This is a skill that you practise every day and you should be very good at it.
Notoriously, candidates score very badly on history-taking stations.
You are also being tested on your communication skills, so you must be sensitive to the problem but also must be very thorough in obtaining a complete history. In these stations the patients may be briefed to be difficult and may try to lead you up the wrong path. You must therefore be in control of the consultation while at the same time communicating well.
What are the pitfalls?
Most candidates are not very thorough when they take a history and, in particular, forget to enquire about family history and social history. In this day and age, one should also enquire about alcohol and recreational drug use.
At this station you have also been asked to discuss relevant investigations and treatment options with the patient. This means that you must outline the investigations, but as you are not given the results, you have to propose the treatment options depending on the results of the investigation. You must therefore be clear in your thinking as to how to get this across simply to the patient so that she can understand. It may be helpful to draw a diagram.
Preparation
As you do this every day, it is easy to practise but you need to be supervised to ensure that you are being thorough. In the exam, marks will also be awarded for being systematic rather than gleaning the information in a random fashion. The best way to practise this station is to use a real patient and ask a colleague to observe you.
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Review station 2
Early pregnancy problem – management
Candidate’s instructions
You are working in the early pregnancy assessment unit and the patient, Tracey Wall, you are about to see has just had an ultrasound scan. You have not met her before. The results of the scan are as follows: Transvaginal scan
Tracey Wall, aged 35, 123456
●
Anteverted uterus
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Fetal pole identified in uterus
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No fetal heart activity
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Sac consistent with 5 weeks’ gestation
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Both ovaries appear normal
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25 mm corpus luteal cyst seen in right ovary
Explain the significance of this ultrasound report to the patient and the future management plan.
MARKS WILL BE AWARDED FOR YOUR ABILITY TO EXPLAIN THIS
REPORT AND PLAN FURTHER MANAGEMENT
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REVIEW STATIONS
Role-player’s instructions
You are Tracey Wall, a 35-year-old married barrister and you have been referred by your general practitioner for an early dating ultrasound scan having had a positive pregnancy test. You have been trying for a baby for the past 5 years and this is your first pregnancy. You have always had a regular cycle. Your last menstrual period was 7 weeks ago, but you have had a small amount of brown discharge for 10 days.
Although initially delighted with the positive pregnancy test, you haven’t felt pregnant for the last 4 days and you are now anxious about why the ultrasonographer would not let you see the ultrasound picture of your baby, instead asking you to see the doctor currently in the antenatal clinic.
You have had no significant medical or surgical illnesses apart from appendicitis at the age of 15 and you are taking no medication. It is now over an hour since your original appointment time and you have a work appointment very soon in your chambers. You are concerned about the ultrasound findings but also feel pressed for time, wanting a clear and confident management plan from the doctor.
You are quite a bossy woman and you are used to being in charge and telling everyone what to do. The doctor is much younger than you and you treat him like a student. You want answers and you want them now.
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EARLY PREGNANCY PROBLEM – MANAGEMENT
Mark sheet
History
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Last menstrual period, regular cycle
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First pregnancy
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Symptoms
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Focused history-taking
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Social history
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Date of pregnancy test
0
1
2
3
4
Explanation of scan findings
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Non-medical jargon
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This could be a delayed miscarriage
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This could be 5 weeks’ gestation (re-checks dates)
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Cyst insignificant
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Explains that it may need evacuation
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Explains evacuation
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Management
– offers to re-scan in a week
– offers conservative management
0
1
2
3
4
5
6
7
Communication
●
Checks she has understood
●
Invites questions
●
Empathy
●
Deals with the way she speaks to you
0
1
2
3
4
5
Global score
0
1
2
3
4
Totaclass="underline"
/20
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REVIEW STATIONS
Discussion
What is this station testing?
This station is testing what you would normally do with an early pregnancy problem. Miscarriage is a very common problem in early pregnancy and you should be very familiar with how to deal with this situation. You should be able to take a concise relevant history, listing important points such as last menstrual period, symptoms of pregnancy, timing of the pregnancy test and whether the pregnancy is wanted or not.
As you are dealing with a role player, you must be sensitive to her needs, and as the management path is not clear-cut, you must be able to offer alternatives and in a way be guided by her feelings. So although you are being tested on your management skills, you are also being tested on your communication skills and it is important to check that she has understood and whether she has any further questions.
This situation may well be very emotionally charged and the role player may have been briefed to react to you in a certain way.
What are the pitfalls?
You must be focused to take a concise history and not spend all of your time taking a thorough history as the candidate’s instructions advise you to explain the significance of the report and future management plans. However, it is difficult to do this without taking a brief history.
The corpus luteal cyst is a normal finding and you must not focus upon this as a potential problem. It is not clear-cut from the scan whether this is a viable early pregnancy of only a few weeks’ gestation or whether it is a non-viable pregnancy and this must be explained to the patient. You must not be dictatorial in what you think the management should be and you must be sympathetic to what she wants.
Preparation
This is a very common problem that you are likely to encounter every week when you are on call. We are all at risk of becoming blasé about women who have miscarriages when we see them so often, but to the individual woman this can be a tragic event. It is also important to remember that one must use non-medical jargon at all times.
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Review station 3
Prioritization on delivery suite
Candidate’s instructions
With the following type of station you will receive the instructions at a preceding preparatory station where you will have adequate time to prepare yourself for the next station where the examiner will be. Your instructions are as follows: