• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a junior doctor in the acute medical team

Patient: 25 year old homosexual male patient has been admitted to hospital shortness of breath and generally unwell. Found to have fever, lymphadenopathy and bilateral apical pneumonia. He has recently been abroad and has had multiple unprotected  encounters with other men. Your consultant gained consent for a HIV test. The result has come back as HIV PCR positive. Your consultant is at an emergency and has asked you to discuss these results with the patient.

Task:

  • Gather the reason for attendance
  • Explain results of the HIV test
  • Give appropriate advice on the long term plan for this patient
  • Answer any questions the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers may be required.

You are a 25 year old male patient who has been admitted to hospital feeling really unwell with shortness of breath and generally not feeling well. You were told you had a nasty chest infection and for the last couple of days have been treated with IV antibiotics, you are actually feeling much better now. The consultant a couple of days ago said you needed a HIV test and you agreed to this.

You have recent been traveling in south east asia and have been to Vietnam, Thailand, Bali and Singapore. You had all of the vaccinations required by the travel clinic and you were extremely careful about what you ate and drank. You admit to having had multiple male sexual partners and did not use any protections as the locals did not like that. You were told by all your partners that they had recent sexual health tests which came back negative.

ICE before bad news broken

Ideas – you think you probably picked up a bug when you went traveling and you are feeling much better since the antibiotics

Concerns – that you have been in hospital for so long now

Expectations – that your most recent blood tests and imaging are looking better and hopefully you are ready for home soon.

PMH

Usually fit and well

DH

No regular medications

No known drug allergies

SH

You have never smoked

You drink socially

ICE after bad news broken

Ideas – you are sure the tests must be wrong and need repeating

Concerns – if the tests are correct that you are going to die young

After information is given you want to know:

  • Can the test be wrong
  • What is HIV
  • Can HIV be cured
  • Are you going to die young
  • What is the longer term plan now? (i.e what specialists do i need to see)
  • Can you continue to have sex?

Overall role = you are a very relaxed patient. You are not expecting the HIV test to come back negative, you think this is just an infection you picked up abroad. After the information is given you are very shocked, you go silent and you have to have everything pulled out of you. You avoid eye contact. 

You do not understand any medical jargon and require it to be explained if said by the candidate. You need to give the candidate opportunity to break down this station, you are required to give very long pauses in order to make the station uncomfortable. Make use of non-verbal cues if appropriate to show both happiness and sadness e.g hands on face covering eyes, shaking of head, ect.

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school / year / grade
Clarifies who they are talking to
Asks patient for preferred name


Introduction Introduction
Gains consent for consultation
Mentions confidentiality
Asks if patient has brought anyone else along to the consultation


Pre-knowledge Assesses what the patient already knows
Asks for events leading up to now
Explores travel history
Explores sexual history


Confirmation
Confirms patient knows about HIV test


Warning shot
‘Warning shot’ - e.g, “we have looked at your results and unfortunately, it is not good news"


Diagnosis
Provides information in a sensitive but clear manner
Plainly states diagnosis e.g “Unfortunately your HIV result has come back positive”


Information 1
Checks understanding of HIV
Discusses prognosis
Explains all positive results are re-checked with a different sample to avoid error


Information 2
Referral to GUM clinic regarding treatment
Safe sex advice
Contact travel advice


Chunks information
‘Chunks’ information to check patient has understood


Avoids jargon
Avoids medical jargon


Patient space
Provides patient with time to process information / does not try to fill the silences


When delivering information:
Candidate allows patient to lead consultation (does not talk endlessly to fill silence)
Does not attempt to solve problems
Listens and responds appropriately to cues


Following information
Responds appropriately to non-verbal cues if appropriate - e.g, “you have been very quiet, what are you thinking about”
Displays appropriate empathy


Candidate explores:
Emotions related to conversation
Recognises and validates concerns


Closing consultation
Makes appropriate arrangements for follow up
Candidate offers information leaflet or website on HIV
Offers to discuss any further questions the patient may have later


Patient score
Good rapport with patient
Active listening skills
Appropriate use of body language
Avoids medical jargon
Logical structure / does not jump around topics in consultation
Summarises and checks patient understanding



Score