Clearly you must concentrate on her symptoms of PMS, but in a station like this it is very important that you enquire as to the effect on family, friends and work.
What are the pitfalls?
One can infer from the letter that this patient is quite desperate to receive help for this problem. She will therefore have very high expectations from the consultation and may be very emotional and have a low threshold for becoming aggressive and/or tearful. As with the antenatal history, you need to be thorough in asking about all the different histories and to be sure to include social and drug history, which includes recreational drugs. You should also do a systems functional enquiry.
Many candidates are not organized in the way they extract information.
If the patient does become aggressive then you must defuse the situation, and at the end of the consultation you must ensure that the plan of management is clear and ask her if she has any further questions, emphasizing the next point of contact.
Preparation
As with the antenatal history, you need to practise taking gynaecology histories and this can be easily done in pairs. Be systematic in how you take the history, as this will determine your global score in the examination. Where clinical examination is not mentioned, you should assume it is normal, otherwise it would have been included in the question.
33
Review station 7
Breaking bad news – anencephaly
Candidate’s instructions
You are the registrar in the Department of Obstetrics & Gynaecology. Mrs Ruth Barker, aged 28 years and pregnant for the first time, is having a scan at 16 weeks’
gestation following a raised serum alpha-fetoprotein (AFP) result. The radiographer has detected that the fetus has anencephaly and has called you in, as the patient is booked under your consultant’s care. You agree with her observations and have been asked to counsel Mrs Barker about these findings.
You are about to meet Mrs Barker and there is no doubt about the diagnosis. You have 14 minutes to counsel her about the situation.
MARKS WILL BE AWARDED FOR:
●
Explaining the diagnosis
●
Discussing options open to the patient
●
Dealing with the patient’s concerns
35
REVIEW STATIONS
Role-player’s instructions
You are Mrs Ruth Barker, a 28-year-old woman who has been referred for a scan because of an abnormal blood test (raised serum AFP – the spina bifida blood test) and so you have had an inkling that something is not quite right.
It seems that all is not well, as the radiographer has called in a doctor and the doctor has suggested you discuss things in a separate consultation room. The doctor will tell you that your baby has anencephaly (the head and brain have not formed properly) and that this is incompatible with life. You will question the doctor about the options open to you, including further tests, a second opinion and the outlook for the baby if you decide to continue the pregancy.
You are a devout Roman Catholic and need to see your priest and partner before making any decision. You ask about the possibility of organ transplantation if you carry the baby to term.
You are naturally upset and concerned about the possibility of future pregnancies and how you are going to cope with it mentally, whatever you do.
This is your first pregnancy and you have been trying to become pregnant for a few years. Otherwise you are fit and well with no family history of any significant diseases.
36
BREAKING BAD NEWS – ANENCEPHALY
Mark sheet
Explaining the diagnosis
●
Explains the results, avoiding jargon
●
Explains that the rise in serum AFP was an indication for a scan
●
Diagnosis in little doubt but would she like a second opinion
●
Allows patient to express concerns, shock and confusion 0
1
2
3
4
Discussing the options
●
Offers options of termination or continuing pregnancy
●
Timing of termination unlimited by the Abortion Act, 1991
●
Discusses the mechanics of the termination:
– intracardiac potassium chloride (possible)
– mefipristone tablets orally and then a series of five cervagem pessaries after 36 hours
– a further course may be needed if the first course does not work.
– extra-amniotic if this procedure does not work
– risk of requiring an evacuation of the uterus afterwards for retained placenta
– pain relief, as the pains are similar to labour pains 0
1
2
3
4
●
If continuing pregnancy, discusses problems:
– routine antenatal care would need to be undertaken
– risk of postmaturity as fetal pituitary stimulates onset of labour and this is likely to be absent
– difficult to get into labour as nothing pressing on the cervix
– need for operative delivery may be necessary if shoulders are difficult to deliver or if there is delay
0
1
2
3
4
Patient concerns
●
Gives them the option to come back after time to think it over
●
Postmortem examination may be useful
●
Arranges for any appropriate counselling both before and after delivery
●
Consequences for a future pregnancy, recurrence rate 1 in 30
●
Use of folic acid beneficial in a future pregnancy
●
Organ donation – would need to seek advice, but practically it is not likely to be an option
0
1
2
3
4
Global score
0
1
2
3
4
Total
/20
37
REVIEW STATIONS
Discussion
What does this question test?
This question is concerned with the candidate’s ability to counsel a patient and break bad news. The scenario is such that there is no doubt about the diagnosis.
You need to divide your time equally between the three parts of the question. This situation is really the application of knowledge plus experience. It is appreciating that anencephalic pregnancies may progress and that there are inherent risks of postmaturity and difficulty in delivering the shoulders. It is important to provide support and not judgment; forewarned is forearmed and patients will not automatically opt for termination. A decision does not need to be arrived at by the end of the consultation. However, options need to be provided, including coming back with a partner or supporter.
The examiner will check the candidate’s number and there will be no other interaction – the examiner has a purely marking role.
The role-player will have been given the scenario. She has been given key points to test candidates’ ability to apply their knowledge to the situation. The question about organ donation is one that has been asked of the author, but advice would need to be sought as organs can only be removed when the donor has died, making this a difficult area ethically. If candidates are unaware of any policies then they should explain that advice would need to be sought. This approach will be reflected in the global score as to how they have dealt with the situation.
What are the pitfalls?