The Tough Stuff

4 07 2012

An integral part of the surgical rotation for the students at my school is something informally termed the end-of-life OSCE.  For those of you unfamiliar with medispeak, OSCE stands for Objective Structured Clinical Exam and is pronounced like ‘os-key’ when we talk about them.  They are exams with fake patients and fake physical exam findings during which you have fake conversations and arrive at a fake diagnosis and fake treatment plan.  There’s a real evaluator in the room, and you do get a real grade based on how well you did.  It’s really a stupid name, because they aren’t actually objective evaluations.

Our professors like to say that they are a very good imitation of how real patient interactions should go, which is a giant lie for a couple of reasons: 1. The OSCE sim patients have a script and they know exactly how the conversation should go, and they know exactly what the student is supposed to say.  Real patients usually don’t; 2. When a preceptor is in the room on a real patient interview, they don’t sit in the corner and take notes on how you are doing.  They participate in the conversation.

So when they told us that our surgery OSCE situations would deal with difficult end-of-life issues, I was a little more open to the idea.  In this situation, I would rather practice on a fake patient—even knowing that it’s all role playing—than blow it with a real family whose loved one is actually dying.

We were given three situations  to handle: One was a man struggling to sign a DNR order on his father’s behalf, one was a woman talking about the prognosis and palliation of her mother with advanced cancer, and one was discussing ventilator termination of a man with traumatic brain injury with the patient’s long-term, gay partner and the patient’s very Christian sister (who couldn’t stand each other).  I was glad for the learning experience, even though the exercise was graded.

Each situation, it turned out, came with a list of tasks to accomplish.  The situation with the DNR actually stated “your objective is to obtain a signed DNR order.”  The TBI patient’s objective list looked like this:

  1. Introduce yourself and clarify roles of each person present
  2. Ask the sister’s and partner’s understanding of situation and prognosis
  3. Clarify that the patient has no chance of recovery
  4. Explore the sister’s reluctance to terminate ventilator (family believes in miracles)
  5. Explore patient’s partner’s understanding of patient’s wishes
  6. Clarify the importance of surrogate decision-making, Healthcare power of attorney, and living will (which was stupid because the patient didn’t have the latter two documents)
  7. Reach a consensus about ventilator termination
  8. Schedule an appointment to speak with them the next day
  9. Say goodbye and shake hands.

All in the perfectly adequate time frame of 15 minutes.  We lost points for each objective that we didn’t meet in that time frame.  It was like that for every case.

I hated it. I really had trouble wrapping my head around the idea that every situation had to be broken down in to objectives that could be met in a quick, orderly fashion, and admittedly I couldn’t do it.  There’s something that seems so dehumanizing and sterile about that thought process that did not sit well with me.

So I did something very risky for a medical student.  Maybe it’s because it’s the end of 3rd year, and I am feeling burned out, and maybe it’s because I’m sick of blindly following directions, and maybe it’s because I simply don’t care what the surgeons of the area think of me. I consciously decided not to care about the numerical grade and to treat the sim patients as if they were really my patients.

When the time came for my OSCE, I just went through the conversation like I might with any other patient in a tough situation.  It wasn’t easy, and every one of them acted so in-character that they cried—I forgot for a few moments that it was all just role play.  In the end, each of the three discussions went very smoothly and I received a lot of positive feedback, but I didn’t always check off every objective.  Very likely, my numerical grade wasn’t high (I haven’t received it yet), and the faculty member running the exercise will probably categorize my performance as unsatisfactory because the objectives weren’t all met.

We had a de-briefing session afterward, and the surgeon who ran the session brushed off the concerns of not having enough time for the discussion.  The excuse was “you’re never going to have that kind of time, so extending the tie in the OSCE was not realistic.”

Like I said, I don’t give much credence to what the surgeons think of my patient interaction skills.  I care what my patients think.  And maybe I’m still naïve about these issues, but when all is said and done there are still people behind the disease process, and that makes it impossible to make a DNR order or a discussion about ventilator termination into a series of objectives to be met.

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One response

10 07 2012
NICU doc

Ridiculous. We withdraw care in the NICU all the time, and it happens over multiple, prolonged discussions with family members. I truly hope that the surgeon was lying. Because if that’s the way it’s done with adults (15 mins?!), then something is seriously seriously wrong.

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