Reset 10 mins Pause Candidate instructionsActor instructionsMark 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 Post information Asks about any immediate questions Addresses any ideas, concerns and expectations 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 Submit your answers to get your score.