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CNST:    Clinical Negligence Scheme for Trusts

ICAS:      Independent Complaints Advocacy Service

PALS:     Patient Advice and Liaison Services

List of contents.

  1. what is an OSCE?
  2. format of the part 2 MRCOG OSCE
  3.         the RCOG's information
  4.         the physical layout
  5.         the timing of the stations
  6. types of stations
  7.         active stations
  8.         preparatory stations
  9.         viva with examiner               
  10.                 adverse incident reporting      
  11.                 audit: prepare an audit
  12.                 audit: incomplete audit
  13.                 clinical governance               
  14.                 CNST
  15.                 complaint procedures               
  16.                 consent
  17.                 criticise a paper
  18.                 CTG: review a tracing
  19.                 diathermy               
  20.                 explain and demonstrate how you would teach something
  21.                 explain how to perform a procedure
  22.                 explain the use of an instrument
  23.                 fire drill: how to organise
  24.                 laboratory results: action needed & timing
  25.                 labour ward prioritisation
  26.                 Maternal Mortality Report: outline the key aspects
  27.                 medico-legal: write a report
  28.                 obstetric emergency
  29.                 patient information leaflet               
  30.                 protocol: write a protocol
  31.                 risk management: general information                                      
  32.                 risk management: write a report about an incident
  33.                 teach someone a procedure
  34.                 urodynamics review a print-out
  35.                 waiting list prioritisation
  36.                 ward round pre-op
  37.                 WHO safety check list in theatre
  38.                     sign in
  39.                     time out
  40.                     sign out
  41.                 ward round post-op
  42.                 web page critique:
    1. role-play version
    2. viva version
  43.                     write a prescription
  44.         role-play stations
  45.                 technique
  46.                         prepare a plan
  47.                         rattle off your headlines
  48.                         use a prepared, standard introduction with the role-players
  49.                         use good communication skills
  50.                         empty your head after each station
  51.                 clinical stations
  52.                         showing your humanity
  53.                         rattle off your headlines
  54.                         take a history
  55.                         break bad news
  56.                         bereavement counselling
  57.                         request a post-mortem examination of a stillborn baby
  58.                         deal with an angry patient
  59.                         deal with an angry relative
  60.                         deal with a parent wanting information about an under-age child
  61.                         deal with a patient who wishes to complain        


What is an OSCE?

The acronym "OSCE" stands for "Objective Structured Clinical Examination".

The "objective" bit comes from the fact that everyone has the same exam.

And the examiners having to stick strictly to the same script.

This gets over the old problem of harsh and gentle examiners.

And different degrees of complexity when dealing with real clinical cases.

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Format of the exam

The RCOG gives basic advice.

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More detailed advice from yours truly.

The physical layout.

The exam takes place in a large hall.

12 "stations" are arranged in a circuit around the hall.

Each station has a table and two or three chairs.

You sit on one side of the table.

The examiner and role-player, if there is one, sit on the other side of the table.

Sometimes there may be another consultant sitting in as an observer.

Each station has screens around it.

The information for the station is attached to the screens.

It is also stuck to the table.

The information consists of the "Candidate's Instruction".

This has to be read carefully, as it tells you exactly what you have to do.

Like the essays, there are no marks for doing stuff you have not been asked to do.

Any other information relating to the station will be there.

This could be a list of laboratory results, a list of patients on the labour ward etc.

Some candidates prefer to read the information and make any notes while outside the screens.

Others prefer to go in and read the information and make their notes on the table.

You are provided with a spiral-bound notebook, like those used by secretaries.

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Each station lasts 15 minutes.

The College says that one minute of that is initial reading time.

In practice, you could sit there reading for 14 minutes.

And then try to squeeze your answer in the remaining time.

No-one will stop you.

You will, of course, fail abysmally!

A bell is sounded one minute from the end of the station.

This is to give you time to finish and move to the next station.

It is vital that you keep an eye on the time.

If it is a role-play or viva station, make out a plan at the start.

This is the same technique that you would have used for the short essays.

You need to make sure that you have enough time to deal with all your key points.

Work out roughly how much time you think you should allocate to each point.

Then keep a careful eye on your watch.

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Types of station.

10 stations are "active stations" with an examiner or an examiner plus a role-player.

2 stations are preparatory stations.

Active stations.

These could be almost anything.

The College gives a number of examples:

  1. You may be asked to describe an operation in detail, which may include preoperative and postoperative discussions
  2. Your communications skills will be assessed by your interaction with a role-player depicting a particular scenario
  3. Your history-taking skills may be assessed
  4. You may be presented with a clinical problem and asked to explain it to a role-player
  5. You may be faced with a number of clinical problems and have to prioritise what needs to be done and by whom
  6. You may be asked to describe, demonstrate or assemble some surgical equipment or teach skills using it
  7. You may be asked to design an audit protocol
  8. You may be asked to appraise critically an information leaflet


Preparatory stations.

You have 15 minutes to prepare something.

You will then discuss it with the examiner or role-player at the next station.

It could be to write a protocol, to prepare an audit, to criticise an information leaflet.

The typical one with a role-player is that she has downloaded information from the internet.

She wants to know its value in dealing with her problem.

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Take a history.

It is important to have a memorised model of the history you will take.

This will help prevent you missing something vital.

Remember the possibility of a "hidden agenda".

There will almost certainly be one if the station is about pre-menstrual syndrome.

And one will be likely if the topic is chronic pelvic pain or postnatal depression.

I have written possible models for history-taking:

    gynaecological history

    obstetric history

Have a look and adapt them to your own style.

But, work hard to memorise them, so you can use them on the day.


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Break bad news.

You would interview the woman in a room with good soundproofing and with a nurse present.

Preferably one who has good counselliing skills

You would make sure that mobile phones are turned off and ordinary phones disconnected.

I would state these basics before starting the role-play.

It might seem a bit odd to set the scene in such a way, but it might get a few marks.

And once you start the role-play, you can't say: "We are in a quiet room with a nurse who is good at counselling and with all phones turned off so we cannot be interrupted".

It would sound decidedly odd.

You must ask if she has has anyone with her whom she would like to sit in.

"I have some difficult news.

Sometimes it is better if you have someone with you to hear the facts as well.

Do you have anyone with you whom you would like to sit in?

Is there anyone you would like to call to ask them to come?"

She will say "no" to both questions.

If she answers "yes" to the first, the College has to pay for two role-players.

And "yes" to the second means that nothing else happens during the station while you await the arrival.

Most people will use phrases like:

"I am afraid that I have some bad news for you"

or "I am sorry to say that I have some bad news for you".

This is OK and some would regard it as a good way to "break the ice".

But be careful not to use phrases like:

"I know how painful this must be"

or the dreaded "I feel your pain".

The business is not about your emotions and you have not got a clue about what she is going through unless you have had a similar experience.

Try to temper the bad news by giving good news too, though sometimes this is not possible.

"The lining of the womb is very abnormal and must be treated.

Fortunately, if we take away your womb that gives a high chance of getting rid of the problem."

But good news may not be so easy to find.

"The scan shows that the baby's head has not developed normally.

This is called 'anencephaly'.

This is a very serious condition as it means that the baby's brain has not developed normally.

And that the baby cannot survive once it is outside the womb.

There is nothing we can do to correct the problem."

You are then going to go on to talk about TOP etc. so there is not much you can do to ease the situation.

You must not pussyfoot about.

The marking system will expect you to say "cancer" if that is what you are dealing with.

If it is Down's syndrome, it is OK to talk about the good things like loving natures.

But this has to come after the tough news:

"babies with Down's syndrome have learning difficulty.

In many cases it is severe and they cannot manage at normal school.

Most importantly, few adults with Down's syndrome will be able to live independently".

You have to acknowledge that the news is distressing.

"This is distressing news and I am sure it is going to cause you a lot of upset."

Give her a chance to react.

Then respond to what she says.

Usually it will be some expression of being overwhelmed and not knowing what to say or do.

Respond by saying that this is a normal response.

And that in time the pain, distress and panic caused will lessen.

Offer the services of the nurse / midwife counsellor.

"We have a midwife who is specially trained to help in this situation.

I am sure that you would find it helpful to talk things through with her.

She will also be available to talk to you in the days ahead.

If you would like to see her, I'll call her and ask her to come to see you when we have finished our conversation.

I will also give you some information leaftets that tell you more about the condition.

And how we human beings cope with such difficult news."

Talk about questions.

Sometimes news of this kind hits so hard that you can't think of any questions.

But if you have any questions now I'll be happy to answer them.

Questions will occur to you in the days ahead.

 When we finish today, I'll arrange an appointment for you to come for another discussion.

It is usually best to bring someone with you for support and we will arrange the time to make that possible.

Write down all your questions as you think of them.

Bring the list of questions when you come back to see us.

Visiting hospitals can be very stressful and it is easy to forget things you wanted to talk about.

If you do forget anything or think of other things later, please drop me a line and I'll answer them for you.

You need to explain the management options.

This could be further investigation with referral to a paediatric cardiologist, a feto-maternal medicine expert etc.

It could be the option of TOP.

This is easy if it is anencephaly.

"One decision that you have to make is about bringing the pregnancy to an end now.

This is a very painful decision when you have been looking forward to having a baby.

And it is the last thing a mother would ever want to have to do.

But the baby cannot live whether it is born now or at full term.

And it is much safer for the mother to have the baby at this early stage than it is later.

We don't expect you to make the decision right away.

You will probably want to talk to your partner and family and, perhaps, your religious adviser.

We will give all the help we can to enable you to make the right decision.

I will give you an information leaflet that tells you all about bringing the pregnancy to an end.

Doctors call this 'termination of pregnancy'.

Basically we give you a drug to prepare the womb for labour.

After a day or so we give you a second drug to start labour.

We will make sure that you have plenty of pain relief so that you do not experience pain.

Termination of pregnancy in this situation causes a lot of psychological upset.

When you come into hospital the midwife and I will spend time with you talking about how best to cope with this.

We will also talk to you about all the tests we need to do."

This might mean arranging karyotypes etc.

But could mean postmortem if the bad news is a fetal death in utero in late pregnancy.

There is a bit about PM elsewhere in this section.

TOP is much more difficult if the condition is Down's syndrome.

You have to discuss the fact that some women with terminate pregnancies with DS, others will not.

And that it is her decision and she will be given full support whatever she decides.

You may not even be at the stage where a decision can be made about TOP.

She may need expert advice about the prognosis, possible treatments etc.


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Bereavement counselling.

This is dealt with here.

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Request consent for a post-mortem examination of a stillborn baby.

Read the bereavement counselling section first.

I think this station would be set up along the lines that the woman had been seen by the consultant / bereavement midwife.

And that the basic bereavement counselling had been done.

Your task would just be to deal with consent for post-mortem examination.

You would introduce yourself / check her name etc.

The woman has suffered a hammer blow and will still be reeling from its impact.

Don't start with: "I am really sorry to hear about your loss".

The reality is that your emotions are about the stress of having to deal with this most difficult task.

And worry about making a mess of it and causing her even more distress.

Remember, too, that the station is about her, not about you, so you and your feelings should not get a mention.

Simply state: "this is a terrible thing that has happened to you".

Don't ask how she is feeling!

She will be feeling absolutely desperate unless she is a complete psychopath.

Then you have to introduce the difficult and painful business of the post-mortem.

Now we have:

"This is a terrible thing that has happened to you.

And I have come to talk about something that is difficult and possibly distressing.

But it has to be done.

It is about examining the baby to see if we can find out what caused his / her death.

I am sure that you want to know.

We also need to know in case there is a problem that could affect another pregnancy".

If the baby has a name, you can personalise things by using the name.

Don't do the opposite and depersonalise the baby by talking about "it".

Most people have a sense of horror when post-mortem is discussed.

It is really ghoulish and even worse when it is about a baby.

Most women will feel that the baby has already "suffered enough".

And should not be put through anything else, especially if this means cutting it open.

"I'd really just like my baby to be left in peace until we can have the funeral."

You need a technique to make post-mortem less horrible.

I would suggest the analogy of an operation.

"When we are ill doctors can run loads of tests and still not find out what the problem is.

We might need an operation so the doctor can look inside to find out what is wrong.

The same applies when babies die.

There are lots of tests we can do.

We can do blood tests on the mother.

We can examine the afterbirth.

But often the best examination is to look inside the baby.

This means opening the baby like during an operation.

We call the examination a post-mortem".

It is a very difficult and upsetting thing for a mother to have to consider.

But it is often the examination that gives the best information about what happened to the baby.

We can examine the outside of the baby and arrange x-rays and so on.

But they often do not give information we need.

And sometimes the information can only be found at the post-mortem.

On the other hand, even the post-mortem does not always explain why the baby died.

I hope you will feel able to consent to the post-mortem being done.

But it is entirely a matter for you and your family and we will understand fully if you say you do not want the examination.

I don't want you to make a decision now.

It is best if you and your family have time to discuss it fully and have all your questions answered.

I'll be happy to have a further discussion with you and your family at any time.

And the support midwife will be keeping in touch and available to answer questions."

I think at this point it would be appropriate to stop and ask if she has any question.

Remember that the key to this is that the onus is on you to explain, not on her to understand.

"If you decide to have the post-mortem, it is done by a specially-trained doctor, called a paediatric pathologist.

They will know all the things that have to be looked for to find the cause of death.

After the post-mortem is over, all the organs are put back inside.

The cuts are closed up with stitches or clips, just like after an operation.

There will be a cut on the baby's tummy, another on the chest and one on the back of the head.

Once the baby is dressed, these are covered up and the baby will look the same as he / she did before the post-mortem.

Some parents do not like the idea of the baby's head being opened.

But they are OK about the tummy and chest.

It is for the parents to decide if there are limits to what can be done during the post-mortem.

And these limits will be respected."

You need to discuss tissue sampling / organ retention.

"When you have an operation, the doctor may still not be sure of what the problem is.

Sometimes little bits of tissue are taken and sent to the laboratory for further tests.

We call them biopsies.

The same happens during a post-mortem.

The biopsies are small.

The organ from which they were taken is not removed, just the little bits for the biopsies.

Sometimes biopsies are taken for research.

Modern medicine knows a huge amount.

But there is even more still to be discovered.

This can only be done through research.

Biopsies can only be taken if the parent gives consent.

The parent may consent to biopsies for further tests, but not research.

This is for the parent to decide and the parent's wishes will be followed.

Before a post-mortem can be done, the parent must give consent.

There is a consent form that must be filled in and signed.

A doctor will take you through all the sections of the consent form to make sure that you know all you need to know.

And that the doctors know exactly what your wishes and limits are."

If you are having a funeral for the baby, it can take place as soon as the post-mortem has been done.

You would now do your bit about the explanation being clear and any questions.

You would go on to mention information leaflets.

Also support organisations such as SANDS.

SANDS has a short section  on deciding about a post-mortem.


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The angry patient.

There was an infamous roleplay station in the early days of the OSCE exam.

At one station you had to talk to a mother whose baby you had delivered with forceps the night before.

The baby had died.

She wept and showed distress all through the roleplay.

You were relieved to finish this traumatic station.

But the next station had the angry husband demanding to know what you had done wrong!

I think a lot of the candidates needed counselling for post-traumatic stress after that circuit.

I don't think there has been an angry patient or relative since.

However, you would be daft not to prepare well.

Even if it does not come, working out and practising really difficult stations helps with overall technique and confidence.

A typical station would be seeing the woman the day after an operation that you had done.

During the operation a hole was made in bowel or bladder or a ureter was cut.

The principles of dealing with this station are:

  1. stay calm and don't get angry, whatever is said,

  2. don't put up with being abused,

  3. introduce yourself, but modify the usual wording as you met her yesterday,

  4. find out what she has heard from nursing staff about the problem,

  5. explain that there was a complication and make some sympathetic noises, but don't apologise,

  6. explain what you would like to talk about with regard to the operation:,

  7. explain the Trust's mechanisms for dealing with adverse incidents:

  8. offer to arrange an appointment with the consultant,

  9. discuss the complaint procedures / PALS / ICAS,

  10. discuss taking legal action.


1. Stay calm and don't get angry, whatever is said.

When we do this roleplay, I tell the role-player to be abusive.

"You are not fit to operate on a dog, never mind a human being."

"Are you sure you have been trained?"

"It disgusts me that there are people like you acting as doctors."

The abusive bit we will deal with in the next section.

Even in the roleplay you will find you are stressed by the interaction.

Stay calm!

If you get flustered, or, even worse, lose your temper, the situation is going to go into melt-down.

You get control of the situation by explaining what you want to do.

First of all to explain what happened during the operation.

Then what was done to deal with the problem.

And what impact it will have on her recovery and convalescence, e.g.

length of stay in hospital,

length of time with a bladder catheter,

timing of closure of colostomy, etc.

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2. Don't put up with being abused.

Letting her express her anger is OK up to a point.

But you don't want to put up with abuse.

She is entitled to question your ability, training, fitness to do the particular operation.

But she is not entitled to tell you that you are a useless bastard.

"I understand that you are upset and angry.

I think I would be too.

But, please do not be abusive."

If she carries on being abusive, it must have been deliberately put into her script.

The role-player is not allowed just to make things up as she goes along!

This means that the exam committee wants to see you dealing firmly with abuse.

"Please don't use abusive language.

It makes communication between us more difficult.

In addition, the hospital has a firm policy about abuse being reported and stopped."

Something along these lines should bring an end to the abuse.

I don't think abuse is likely to be a key issue in a role-play

But, have something prepared to cover the possibility.

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3. Introduce yourself.

Keep it formal.

"Hello, I am Dr. ***.

You will recall that we met yesterday and I did your operation."

Don't use first names.


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4. Find out what she has learned from the nursing staff about the problem.

"Has anyone told you about what happened during your operation?"

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5. Explain that there was a problem and make sympathetic noises, but don't apologise.

"Complications sometimes occur during surgery.

This happened during your operation.

The problem has been dealt with and I am going to tell you all about it.

I am sure that you will find this upsetting news."

Don't say "I'm sorry" or use other words that can be taken to be an apology.

Apologies suggest that you were at fault.

One of the points you will be taking care to make is that there will be a careful investigation of why the problem occurred.

Don't say that the possibility of complications was discussed pre-operatively and was included in the consent form.

This makes it seem as though they were agreeing to have the complication!

And that you think that the consent process makes the occurrence of the complication OK.

The role-player may have been told to demonstrate anger which she might do now.

"I appreciate that you are upset and angry.

What I would like to do is:

 to explain exactly what happened,

what was done about it,

what this means for your recovery

and what the hospital will do to investigate why it happened."

Then move on the the next section.

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6. Explain what you would like to talk about.

Stick strictly to the script.

Start with what was done at the operation and the complication.

It is OK to say: "when hysterectomy is done, the bladder has to be operated on too.

The bladder sits on top of the lower part of the womb and has to be separated off.

When this has been done a check is made to make sure that no damage has been done to the bladder".

But don't make up excuses: "it was an unusually difficult operation" etc.

This will get a bad reaction from the examiner as you are telling lies.

And the quick-witted role-player is going to ask why you didn't stop and get help.

If you have information about the size of the hole, give the information.

If you don't, give no information, e.g. "a small hole".

Then say what was done.

"As soon as it was realised that a complication had occurred, the bladder surgeon and my consultant were called.

The bladder surgeon is the expert in bladder operations.

He / she repaired the hole."

If you have information in the script about the prognosis, you can give the informaiton.

Otherwise you must talk in general terms.

"Most women make a full recovery from this kind of complication and have no problems in the future.

You do need to have a catheter in your bladder for 5 days to let it rest while it is healing.

The nurses will teach you how to manage the catheter, so it won't mean you spending longer in hospital."

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7. Explain the Trust's mechanisms for dealing with adverse clinical incidents.

"We call complications of this kind 'adverse clinical incidents'.

The hospital takes every adverse incident very seriously and has a full investigation of why it happened.

This is to see if anything can be done to prevent it from happening again.

I will arrange a meeting with the consultant so that you can discuss the findings of the investigation.

As I was the surgeon doing the operation, the investigation will particularly look to see if I did anything wrong.

If it finds that I did do something wrong, it will say what should be done about it.

This could mean the hospital giving me the sack.

("Getting the sack" means being kicked out of your job.

It is thought to refer to the dismissed person being given a sack in which to put their tools and belongings.)

If it found that I had done something seriously wrong, it could report me to the General Medical Council to see if I am fit to be a doctor.

It might decide that I needed more training or supervision.

Whatever it decides, you will be informed."

Most trainees find it odd that you would discuss disciplinary or other painful outcomes for the surgeon.

But this "takes the wind from the sails" of even the angriest patient.

Getting the sack is probably the worst they might have wished for you and they probably won't have thought of the GMC.

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8. Offer an appointment to see the Consultant.

A sensible Consultant would have seen the woman personally and not sent the trainee.

But not in the exam!

An appointment should obviously be offered.

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9. Explain the complaint procedures.

The complaint procedures are discussed here.

Your initial response may be that this is a daft idea and will merely encourage complaints.

I suspect that it might be worth a mark or two in the exam.

In real life it demonstrates that you are not holding anything back and are someone to be trusted.

Trust is one of the big problems we have.

There is a common suspicion that the NHS staff "close ranks" when there is a problem.

And do evertything to prevent the patient from getting to the truth.

There is an old saying: "Honesty is the best policy" and it applies here.

"After the investigation has been done and all the information given, some patients are still not satisfied.

They feel that they have been wronged and want to complain about it.

If this happens to you, we will tell you how you go about making  a complaint.

Basically, there is a complaints officer who is employed by the hospital to deal with complaints.

You can send them a letter or e-mail, phone or arrange a meeting with them.

There are also people in the PALS office whose job it is to help you with things like this.

All complaints are treated very seriously and are the responsibility of the Chief Executive.

I'll give you some information leaflets before you leave the hospital so that you have all the information you need in case you end up wanting to make a complaint."

I don't think you would need to go into a full explanation of the complaint procedures - there would not be time.

You could have a role-play or viva about the complaint procedures, but explaining the procedures would be the only task.

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10. Explain about taking legal action.

This is discussed in the section about the complaint procedures.

"A small number of patients end up disatisfied with all the explanations and complaint procedures.

They decide to sue the hospital.

Because you have had a complication, you may have family or friends telling you to do this.

If you do decide to sue, you need to be careful about how you do it as it can be very expensive.

You need a lawyer who is an expert in this kind of work.

You need to discuss with the lawyer whether you have a case and the costs.

There are ways round the costs such as a 'no win, no fee'  arrangement or legal aid.

You also need to think about the best time to take legal action.

One of the problems is that legal action may stop any investigation or complaint procedure being done in the hospital.

And it might be best to hear the results of these before you decide about legal action.

I'll give you an information leaflet before you go home that gives you all the facts you need."

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Deal with an angry relative.

This is more or less the same as the angry patient.

But remember confidentiality.   

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Parent wanting information about an under-age child.

This one is very easy.

The under-age child who is Fraser-competent can refuse to allow the release of information to the parents.

Although the process of establishing that they are Fraser-competent means trying to persuade the child to involve the parents.

Remember in a viva to discuss the expert you would ask to make the assessment of Fraser-competence.

This would be a paediatrician or child psychiatrist or psychologist.

In real life do this too.

It is not something you are likely to have to do, so you will have no experience or expertise.

You have to explain the law to the parent.

And the fact that you can't give information about any patient to anyone else without the patient's consent.

You need to explain Fraser competence and the fact that the Fraser-competent child has the right to ban parents knowing anything about their treatment.

You would sympathise that a concerned parent will always want information to make sure that nothing bad happens to the child.

But the law means that:

if a Fraser-competent child does not want the parents to know,

you cannot say if a child has even been a patient,

far less what the problem was or the treatment.

If the parent thinks the child has had some form of treatment, they will have to discuss it with the child.


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Patient who wishes to complain.

Complaint procedures are explained here.

You need to explain that complaints are treated very seriously by the hospital.

A measure of this is the fact that they are the responsibility of the Chief Executive.

You need to explain that they can get help from PALS and ICAS.

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Patient who has read a webpage.

It is important to have a memorised model of the history you will take.


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Prepare a plan.

You didn't write your short essays without spending a few minutes writing plans.

The same applies to the OSCE stations.

You can see the "Candidate's Instructions" on the screen outside the station.

So, you know what is being asked of you before you go in.

Write out the key points as headings.

Then keep an eye on your watch to make sure you use the time sensibly.

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Show your humanity.

Think back to when you first thought of becoming a doctor.

You were full of grand notions of benefitting mankind.

Perhaps you had some experience with illness in a relative or friend that particularly motivated you.

Then consider the reality of the daily grind as a doctor.

You are so busy, so much under pressure that you stop thinking of the patients as people.

When you were young you thought that you would treat them as if they were your sister, mother, best friend and so on.

Now they are just another case and a major irritant if the clinic is running late and they are assailing you with irrelevant details.

It is important to salvage your humanity from the pressures of practice.

In real life it only takes a moment or two to demonstrate understanding of the suffering that patients go through.

"That must have been really hard."

"That must have been really horrible."

"Did you find that hard to cope with?"

"How is your mother now?"

In the event of a sister with a handicapped baby, ask: "how is the baby now"?

"How is your sister coping?"

In the exam it is important too.

It makes the role-player realise that you are a kind and caring doctor.

If she likes you, it helps make the role-play go more smoothly.

And there might just be a mark in response to the question: "is this a doctor you would consult again"?

You should make it part of your routine practice to include some remark along the lines above.

Then it will be second nature in the exam.

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Rattle off your headlines.

Sometimes there is sense in quickly rattling off all your headlines at the start.

This means that you are sure to "tick" some of the examiner's boxes.

For example, with a role-player and a station about Down's syndrome you might say:

    "first of all I am going make sure you have all the information you need about Down's syndrome

    Then I am going to explain the tests we can do.

    etc. etc.".

You might forget one of your headlines during the discussion or run out of time.

You could still get some at least a mark for mentioning it in the headlines.

Similarly, in a station about writing a protocol you might dash off a dozen headlines.

Then fill in the detail.

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Have a prepared, standard introduction for the role-players.

This is dealt with in "Communication skills".

Start practising right away with patients in clinic.

Then it will be routine for you in the exam.

What if you are working outside the UK and your patients don't speak English?

It is all the more important to practise!

Get hold of friends, colleagues, family who speak English.

Practise your introduction until it trips off the tongue with ease.

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Use good communication skills.

It is vital to communicate well.

Use simple words and sentence construction.

Avoid medical jargon.

Look at the role-player.

This is covered in detail in "communication skills".

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Empty your head after each station.

It is important to forget each station as soon as it is over.

Don't carry it with you, half thinking of what you might have done better.

This will just distract you from the next station.

This is one of the main benefits you get from going on a course - it gives you the chance to practise it.

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Viva with an examiner.

You have fifteen minutes to tell the examiner what you know about a subject.

Often they just tell you what they want you to talk about.

"Tell me the current thinking on the use of HRT."

So you have to decide what to put in and what to leave out.

But they might have two or three questions to ask you to give more shape to the station.

On Fragile X syndrome the viva might be in three parts.

  1. "tell me about the Fragile X phenotype
  2. tell me about the genetics of Fragile X syndrome
  3. tell me about the implications of being a carrier."

The examiner is not allowed to help you in any way.

This is part of the "objectivity" of the exam.

Elderly male examiners might be disposed to be more helpful to beautiful young female candidates than their male counterparts.

So, no prompts or indications of how well or badly you are doing can be given.

This makes it a really stressful activity.

And something you have to practise over and over.

Get a friend or relative to be the examiner.

They sit with no expression and say nothing for the whole viva.

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Viva: clinical governance.

Some aspect of clinical governance is likely, so you have to know the topic well.

You could be asked for an overview of what clinical governance is and what it is for.

There is detailed information here.

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Viva: risk management.

  1. what is risk management?
  2. background
  3. scale of the problem
  4. how do we "do" risk management?
  5. root cause analysis
  6. suggested reading and useful websites


What is risk management?

In an ideal world, patients would only derive good from their encounters with health services.

We would be perfect ministering angels, just like we imagine ourselves to be!

There would be no adverse incidents: drug reactions, surgical misadventures etc., no complaints and certainly no legal cases.

Sadly, the real world is different.

We make mistakes.

Things we did not want or plan occur to the detriment of patients or staff.

Risk management is the process whereby we reduce the number of (ideally eliminate) such adverse incidents.

And minimise their consequences when they do occur.

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The report "An Organisation with a Memory" (OWAM) was published in June 2000.

It triggered much of the development of risk management in the NHS.

The report was by an expert group chaired by the Chief Medical Officer, giving an indication of how seriously the subject was regarded.

It was mainly about adverse events in the NHS and how we might learn to do things better.

It noted that serious adverse events were uncommon but a major problem for those suffering them and a gigantic cost to the NHS.

It highlighted the fact that:

    “such failures often have a familiar ring,

    displaying strong similarities to incidents which have occurred before

    and in some cases almost exactly replicating them.

    Many could be avoided if only the lessons of experience were properly learned”.

Vincent et al in the 2001 paper mentioned above judged that about half of adverse incidents could have been prevented by “ordinary standards of care”.





Schiff et al found that doctors were prepared to give accounts of their personal diagnostic errors.

Almost 70% of the errors were rated as of major or moderate significance.

So they did not appear to seek to hide serious mistakes and only acknowledge those that were inconsequential.

They concluded:

    "This readiness suggests that diagnostic error is not unusual in clinical practice,

    and actively soliciting such cases represents an opportunity for tapping into a hidden cache of medical errors

    that are not generally collected by existing error surveillance and reporting systems."

Schiff G, et al "Diagnostic error in medicine" Arch Intern Med 2009; 169: 1881-87. 


The scale of the problem necessitating risk management.

The DOH's publication: "An Organisation with a Memory" of 2000 gave an indication of the problem.

The authors of OWAM reckoned that adverse events affect about 1 in 10 of those admitted to hospital.

Vincent et al agreed, putting the figure at 10.8%, with about a third leading to death or moderate or worse disability.

These are horrifying figures and much higher than I would have volunteered as a guess if I had been asked.

OWAM put the consequent additional costs just from the extended stays in hospital at £2 billion per annum.

If you add the costs of loss of earnings, sick pay, compensation etc. and it is easy to see that this is an enormous problem.

Further figures in the OWAM report noted that each year:

400 people suffer lethal or serious adverse events involving medical devices,

about  10,000 people have serious adverse reactions to drugs,

about  1,150 people commit suicide despite recent contact with mental health services,

nearly 28,000 written complaints are made about clinical treatment in hospitals;

clinical negligence claims cost around £400 million,

hospital acquired infections, of which about 15% may be avoidable, cost about £1 billion.


Its conclusions were:  

·         Information on the frequency and nature of adverse events in the NHS is patchy

        and can do no more than give an impression of the problem.

        Information from primary care is particularly lacking;


·         International research (including a recent UK pilot study) has thrown light on the potential scale of the problems,

        and suggests that these may be around 850,000 adverse events each year in the NHS (range 300,000 to 1.4 million);

·         The financial costs of adverse events to the NHS are difficult to estimate but undoubtedly major - probably in excess of £2 billion a year;

·         There is evidence of a range of different kinds of failure, and of the recurrence of identical incidents or incidents with similar root causes,


·         Case studies highlight the consequences of weaknesses in the ability of the NHS as a system to learn from serious adverse events; 

·         There is a need for further work focusing specifically on how the impact of adverse events on patients, their families and staff can be minimised.

Dr. Cook, with whom I worked in Stockport, reviewed the subject in 2000.

He found reported incidences of adverse events in hospitalised patients:

        from 3.7% in the Harvard Medical Practice Study in the United States

        to almost 16% in the Quality in Australian Health Care Study.

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How do we "do" risk management?

We start off by trying to identify all the adverse incidents that could occur which would entail:

    finding out all the adverse incidents that have ever occurred

            look at data from:

                    the RCOG,

                    the National Patient Safety Agency,

                    the Medical Defence Union.

            make sure that all adverse incidents within your system are recorded systemically

            check all complaints

            check all legal actions

    imagining all the adverse incidence that could possibly occur.

Then we deploy effective defences to ensure that we are invulnerable - the Ronald Reagan missile shield philosophy.

But, being pragmatists, we know that some bad stuff will occur.

This means we need a back-up plan to minimise the consequences of adverse incidents we did not foresee or that arise through error or misadventure.

We need a system that allows staff to report incidents immediately so that remedial action can be taken.

This means the system has to be open, non-punitive etc.

And we need to incorporate the data from these incidents into the reporting system.

So we set up a system where:

    every adverse incident,

    or incident that could have become an adverse incident (a “near miss”),

    is reported and analysed.

The analysis identifies the cause(s) of the incident or near miss and leads to fortification of the defences.

Vigilance in reporting adverse incidents and their first cousins, “near misses”, means that we are dynamic and abreast of changing circumstances.

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Root cause analysis.

One of the “buzz words” you need is “root cause analysis”.

This has the tang of the tedious, boring, management-speak that immediately induces:


    a brisk desire to become a philosopher or a gardener

    or to move on to something really interesting like picking ones nose and scrutinising the results.

But bear with me! I write this in November 09 after a weekend in Scotland at a family wedding.

We stayed with long-time friends, Hugh and Sheila.

On the morning after the wedding Hugh showed me an article in the Glasgow Herald.

A woman had been admitted for mastectomy and reconstructive surgery in a prestigious Edinburgh hospital.

Fit and healthy (apart from breast cancer) she died of haemorrhage on the night of the operation.

The family were devastated and bemused.

How could such a disaster have taken place after routine surgery in a major teaching hospital?

A drain was inserted into the operation site, but no records were kept of the volume drained in the afternoon after the operation.

Other records, like pulse and BP, apparently, were not what they should have been.

Her haemorrhage was not detected until the evening, when the best efforts of the rescue posse were unavailing.

Worse still, the nurse in charge of the patient, who had failed to keep adequate records, had then falsified the records in an attempt to cover her failures.

“How could a professional person behave in this way?” my friend asked.

She had failed to look after the patient adequately and had then dissembled to protect her own miserable hide.

Hang, draw and quarter, I say!

The only apposite punishment.

This is where root cause analysis comes in.

If we just shoot the nurse and content ourselves that we have dealt with the matter, we may have missed the real cause or causes of the disaster.

Not, “take her out and torture her to death for causing the woman’s death”.

But “how on earth could a presumably competent and caring nurse behave so deficiently?”

And don’t be so presumptuous to believe that you would not be tempted to falsify records to exculpate yourself from blame!

You might not subscribe to the Gospel of John.

But the phrase "Let him who is without sin cast the first stone" is apposite, whatever our faith or lack of it.

Did she have the training and experience necessary for the tasks she faced?

Were there enough nurses on duty?

Had financial cut-backs led to dangerous staffing levels?

Had two colleagues reported sick and not been replaced?

How many other seriously ill patients was she caring for?

Were there other issues distracting her?

Had there been a medical emergency?

Was there an aggressive husband threatening violence for perceived mismanagement of his wife’s care?

Was there a blockage in the toilets meaning that she had spent an hour on the phone trying to get the plumber to come to effect a repair?

This might be a latter-day Mother Teresa placed in an impossible position, not a murderous psychopath or total inadequate.

This is root cause analysis!


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Useful reading & websites.

I hope that the information on this website will give you the basics.

Perhaps even enough for the exam.

Nonetheless, I'd be inclined to read at leas the first three of the following documents / websites.


1.     RCOG's Clinical Governance Advice 2, "Improving Patient Safety: Risk Management for Maternity & Gynaecology"

        You must read this! It was first published in 2001 (timing derived from the DOH publication “An Organisation with a Memory”, discussed below).

        It was updated in 2005 and again in 2009.

        This frequency of updating is unusual for an RCOG document, reflecting the importance now given to risk management.

2.     The WHO surgical safety check list.

        This is a way of introducing airline-type checklists into surgical practice.

        Essential to know about it for the MRCOG: Visit the National Patient Safety Agency.

        See the section on the WHO check list on this website.

3.     "Maternity Dashboard". RCOG’s Good Practice. No 7. .

        The unit decides the things it needs to monitor .

        The completed card allows "at a glance" assessment .

        Which things are OK, which are borderline and which need attention.

        There is an expectation by the RCOG that all units will adopt it.

         It is a simple concept, but best understood by seeing an example.

        The best thing is to have a look at the illustration on the RCOG website.

4.     “Reducing risk on the labour ward.”  Strachan. TOG. 2005 7: 103-107. Read this!

4.     “Risk management in obstetrics.” Walker. Recent Advances in O&G. 23. Read this!

5.     “How to investigate and analyse clinical incidents.” Vincent et al. BMJ 2000; 320:777-78.

6.     “Risk management in O&G.” Pateisky. Recent Advances in O&G. 24.

         Read this! Good, sensible advice that gives you a flavour of what this is all about.

7.     “Human error. Models and management.” Reason. Reason. BMJ 2000: 320: 768-770.

         If you find a professor of psychology called “Reason”, you have to treat him as a guru, become an avid fan and read everything he has written!

        It is a useful document that spells out the differences between the person and system approaches.

8.     “Adverse events in British hospitals.” Vincent et al. BMJ 2001; 322: 517-519 (3 March)

        This is an analysis of adverse events noted in 1014 medical and nursing records from 2 London hospitals.

        The incidence of adverse events was 10.8%, with an overall rate of adverse events of 11.7% when multiple adverse events were included.

        About half of these events were judged preventable with ordinary standards of care.

        A third of adverse events led to moderate or greater disability or death.

9.     National Patient Safety Agency publications.

10.   "Safe Births" Kings Fund 2008.

11.  Healthcare Commission. “Towards Better Births.” "Towards Better Births".

12.   “Saving Mothers’ Lives.” Maternal Mortality Report.

         Its ten top recommendations include advice about ensuring that lessons from adverse incident analyses are fed back to all relevant staff.

13.  TOG has an article: 2005;7: 103 - 107.

Much of it is taken from: "Human error: models and management" BMJ 2000; 320: 768-770 - read the instructions about signing in to get access.

This was written by James Reason, Professor of Psychology: his name ought to make it essential reading!

It is a good article which outlines the "how and why" of moving to analysis of systems rather than individual errors.

And underscores getting to the real reasons for errors happening, "root cause analysis".

And another good article in the BMJ by Vincent et al:

    "How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol".

      BMJ 2000; 320: 777-781.

If you get through all of this, you will be pretty comfortable in the exam!

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Adverse incidents & near misses.


complaints patient satisfaction survey legal suits

confidential inquiries

National Patient Satisfaction Agency



Risk management is about trying to stop things going wrong and maximising safety.

This could be anything from clinical errors to the roof falling in.

It is a vital part of clinical governance and goes hand-in-hand with optimising clinical practice.

For the exam we are talking about clinical risk, i.e. risk to patients.

But we need to remember risk to staff.

Our professional ethos should include great attention to risk management.

But, if we are lackadaisical, CNST is a powerful motivator.

It is often thought that risk management is about reducing complaints and litigation.

This is not a primary goal, though good clinical risk management will be effective in this regard.

History of risk management in the NHS.

We have always had informal risk management in clinical practice.

The consultant would discuss with a new registrar when to phone for advice or help.

And which procedures they were allowed to tackle on their own.

The DOG published "An organisation with a Memory", "OWAM" in 2000.

This detailed risk and its impact on patients in real life.

OWAM gave rise to “Building a Safer NHS for Patients”.

It noted:

In the past, most health services around the world have underestimated the scale of unintended harm or injury experienced by patients as a result of medical error and adverse events in hospitals and other health care settings.

There has been no real understanding of the approach necessary to reduce risk to patients based on analysing and learning from error and adverse events”.

But it went on to say: “This is changing. 

The whole issue of patient safety, medical error and adverse event reporting is becoming a high priority in health care systems in this country and across the world”.

Despite this the HealthCare Commission undertook a review of maternity services in 2007.

Its report "Towards Better Births", was published in 2008.

It noted that 21% of maternity departments were in the "least well performing category".

I.e. in need of serious improvement.

Key concerns were:

  1. levels of staffing in some trusts that were below average and possibly inadequate

  2. consultants not spending the recommended time on the labour ward

  3. inconsistent attendance at training sessions by doctors and midwives

  4. poor continuity of care

  5. antenatal recommendations not followed, especially in high-risk pregnancies

  6. poor communication and support for recently delivered mothers

  7. too few beds and bathrooms on labour wards

  8. poor data and IT systems prevented efficient service management.


How do we identify risk?

In an ideal world you would:

    know every possible risk

    and have perfect means of anticipating and preventing them at your disposal.

But we don't live in an ideal world.

So, we face the task of trying to identify every possible risk.

We need to:

    identify every risk that has ever occurred,

    be able to imagine every other thing that might go wrong,

But, however clever we are, we will miss things.

Incidents will still happen that cause harm or could have caused harm.

To learn from these and create appropriate defences we need to:

    record everything that did go wrong,

    record all "near misses": things that nearly went wrong, but no-one came to harm

    and be able to take steps to eliminate all the associated risk:

        create defences,

        inform the staff about these newly-identified risks and train them in the best ways of dealing with them..

You need to be able to prioritise:

There are too many risks for us to be able to draw up plans for all of them.

To prioritise, there are three main considerations:

    how dangerous would the event be?

    how likely is it to happen?

    what resources would need to be deployed to prevent it?

You might be a science fiction enthusiast and be concerned about asteroid strikes on the hospital.

Such an even would be catastrophic, but it is somewhat unlikely.

To prevent it you would need some kind of missile shield.

This would involve resources beyond those of the average Trust!

But reducing the risk of fetal and maternal damage from shoulder dystocia could simply mean better staff training in anticipating and dealing with it.

Risk management and CNST.

Risk management is an essential part of CNST, the basics of which you need to know.

Read this useful outline from NHS Scotland.


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Viva: adverse incident reporting.

This, like so many other things, is obvious once you know what it is.

Stuff happens, as they say.

I.e. things that were not planned and could have led to bad outcomes.

We are particularly interested in clinical matters.

But there are other big issues.

What if the hospital's power supply fails?

Will the back up systems of generators etc. kick in efficiently?

Are key areas and equipment like operating theatres, intensive care units and neonatal ventilators protected?

In the clinical arena there are adverse incidents and "near-misses" where the situation is usually salvaged and no one comes to harm.

But we should learn from them and take steps to prevent them recurring.

You need a "no-blame" culture so that people are encouraged to report incidents.

You then need a system to investigate them and reach conclusions.

This would normally be done through the Risk Management Team.

It would also be their job to feed back what has been learned and recommended to all the staff involved and to those planning and running the service.

If a piece of equipment malfunctions under certain circumstances, you want all the staff who use it to know about it.

But you also want the planners and managers to do something about replacing or upgrading it.

There is a nice explanation with a pictorial diagram for those who find them helpful here.

And a good summary from the MDU.

The Maternal Mortality highlighted the need for us to learn lessons from past experience.

It particularly pointed out that the whole risk management business may be carried out, but nothing be fed back to the workers.

This makes the exercise futile.

Except for the managers, who can say that it has been done and thus tick all their boxes necessary to get their bonuses!

The authors of the 2003-5 Maternal Mortality Report saw it as important enough to make it number 7 in their list of "Top Ten Key Recommendations".

The most recent Ten Top Recommendations could easily be a viva station, so make out a card and learn them!

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Risk management: write a report.

I think you would probably have a preparatory station to gather your thoughts.

But I would not rely on it and you should make sure that you have prepared this station.

1.    First of all, who has asked for the report?

        What is it to be used for?

        Don't write reports unless it has been requested by the Risk Management Committee.

2.    What kind of report is wanted?

        There are two main types:

                (a) a factual summary with no assessment / commentary.

                      these are quite difficult as you are always tempted to include opinions.

                      you would not state that the documentation was poor because the writing was poor, the date gave the month, but not the year etc.

                      you would state the facts: in places (give page numbers as examples) you could not read the writing

                                                                   the dates were recorded with the day and month but not the year.

                (b) a factual summary with your views on what appear to be deviations from ideal practice.

                        e.g. protocols not being used in a timely fashion or being altered without explanation or authority from the consultant

                        remember that the key analysis is the "root cause analysis"

                        this will entail someone senior interviewing everyone who was involved, including the patient and her partner

                        all your report is going to do is to highlight areas where the management seemed substandard

                        you are not writing the definite judgement, so don't get carried away.

                        you might write:

                                at 16.00 on ..... the patient was noted to have had a PPH in excess of 1,500 ml.

                                the protocol for PPH is normally triggered by a blood loss of 500 ml. or more.

                                in this case the protocol was not triggered and the consultant was not informed.

                                the protocol stipulates that a baseline clotting screen should be performed with the initial investigations.

                                in this case no clotting screen was done.

                         you are recording deviations from what one would expect the practice to be, but not trying to decide why they happened.

3.    Give your details:

            full name,

            grade and how long in post,

            all medical degrees and years acquired,

            courses attended and dates e.g. basic surgical skills, ALSO, laparoscopic surgery level 1, etc.

            any particular skills relevant to this case: e.g. an MD written about the management of PPH.

4.    Record who asked you to write the report and why.5.

5.    Note the type of report requested.

6.    Give the timescale.

7.    When writing the report, number all the paragraphs.

8.    It is usually useful to give a brief summary of the key facts.

9.    Then a "blow-by-blow" account of what happened.

10.   Have the report typed.

11.    Ask a colleague to check the report for typos and obvious errors.

12.   Submit two signed copies of the report and keep one for your records.


Sample question.

To get the greatest benefit, you need to do this under exam conditions.

Take 15 minutes to read the following and make notes.

Copy them and send them to me.

I'll let you have my version of the answer.


Candidate’s instructions.

Mrs Penelope Jane Brown sustained a 4th. degree tear after the delivery of her second baby.

Dr. James Peter White conducted the delivery and was asked to write a report for the Risk Management Team (RMT), to whom the incident has been reported as an adverse clinical incident.

You have been asked to look at Dr. White’s report to identify issues that the RMT need to explore further.

You have 15 minutes to read Dr. White’s report, after which you will have a viva with the examiner.

The examiner will not lead the discussion and will simply listen to what you have to say.


Dr. White’s Report.

I am Dr. J. White. I have been SpR in obstetrics and gynaecology at the Royal Infirmary for over a year.

On the 27th. September I was bleeped by a midwife on the labour ward and asked to see a Mrs Brown who needed to be delivered as there had been delay in the second stage and she was becoming exhausted.

On arrival on the labour ward I felt that Mrs Brown was not trying very hard to deliver the baby naturally and that the midwives were not making much effort to encourage her.

I advised that they should get her pushing properly and that I would go for a coffee and return in half an hour.

I returned in 50 minutes, having had a phone call from my wife about arrangements for our forthcoming holiday.

The situation was unchanged and I was not impressed with either the woman’s endeavours or the midwives’ encouragement of her efforts..

Examination showed the head to be mid-cavity.

I felt that it could get it out using forceps.

The midwives told me that her bladder was empty. I applied the forceps with ease.

The baby delivered in good condition.

I then noted that that Mrs. B. had a 4th. degree tear. I repaired this in the usual way.

I went on holiday the next day for two weeks and did not see this woman again.



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Viva: consent.

You can find information about consent here.

This is another subject you need to know well.


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Viva: criticise a paper.

This is now a popular station.

I think you should be able to do the basics when reading a paper.

And that it is unfair to expect you to be an expert when you have no editorial aspirations.

But my views don't count and you need to prepare.

I have written a paper with everything I can think might be useful.

Sit down for 15 minutes or so as you would do at a preparatory station in the exam.

Write all the important headings you can think of.

E-mail them to me.

I'll then send you my version.

I think this is the best way to prepare for this station.

If I just send you my thoughts, only a few of them are likely to stick.

And you'll be little better off in the exam.

Ideally do the preparatory station as above.

Then read my version.

And re-do the preparatory station a few days later to test your recall.



Viva: CTG.

This is basic stuff.

And another subject you need to know well.

NICE covered the basics in CG55: "Intrapartum Care" from 2007.

There are plenty of books on the subject - check the date of publication to make sure they are up-to-date.

If your unit has a training package, go through it shortly before the exam.

If it doesn't, have a look at this one.

It was written quite a long time ago, but still covers the basis.

The last time I used it I could not get it to work in Windows 7.

But this problem seems to have been resolved.

You need to be familiar with modern terminology and concepts.

And have some clue about acid-base balance.


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Viva: Maternal Mortality Report.

The 2006-8 Maternal Mortality Report was published in 2011.

You can download it from here:

I reckon that there are two main types of questions:

    one relating to the clinical facts


                main causes of direct and indirect deaths,

this is covered in the MCQ papers, particularly MCQ Paper5, question 18 and MCQ Paper 9, question 1.

    and another about the overview sections:

Back to Basics

Ten Top Recommendations.

You should know the clinical stuff from the written exam.

Get the Ten Top Recommendations and the components of "Back to Basics" on cards as some of it does not immediately come to mind.

It would make for a wonderful viva if you knew the topic and a nightmare if you did not.


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Viva: pre-op ward round.

Another station that is best thought about in advance.

What are the key things you would do on such a ward round?

Make out a card!

Then apply this to the problems posed by the station.

I would suggest:

    make sure you have read the notes carefully

    make sure you know exactly what surgery is proposed

        taking particular care if it is a unilateral procedure like oophorectomy

        and knowing the possible complications you should warn about

            especially if these are in a RCOG document, these being available here

    introduce yourself

    check you have the correct patient

    check that she has been listed for the correct procedure

        i.e. that the operation for which she is listed is the one she understands that she is to have.

it is not too late to consider alternative procedures, including not operating.

     make sure she understands:

what is entailed in the operation

what it is likely to achieve

what it cannot achieve if she has unrealistic expectations

the common and serious complications

length of stay, convalescence.

    ensure that all her questions are answered.

    ensure that she has any relevant information leaflets.

    can you spot any increased risk of problems:

with the surgery - e.g. previous surgery, obesity

with the anaesthetic - e.g. previous problems including awareness during GA

with any drugs that might be used: drug interactions, drug allergies

with blood products: Jehovah's witnesses, antibodies, previous reactions

    ensure that the WHO safety check list is being used - see next section. 



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WHO in-theatre safety check list.

The WHO launched a Surgical Safety Checklist in 2008.

It is a simple concept, drawn from high-risk industries like air travel.

We know that pilots have a standardised pre-flight check list.

Now theatres have one too, covering pre-surgery, the operation and post-surgery.

The NHS has signed up to its implementation and all hospitals are expected to use it.

It has three main parts:   

  1. sign in
  2. time out
  3. sign out.


You can guarantee that It is another topic that is going to crop up time and again in the exam.

A bit like "protocol", "audit", "fire drill" etc., it needs to be on your list of "buzz-words.

The background is the horrendous number of patients coming to harm from adverse incidents, many of which are avoidable.

135,247 adverse incidents were reported in 2007, just in England and Wales.

Some were fatal and many were potentially avoidable.

A National Patient Safety Agency has been established in the UK.

It is responsible for the National Reporting and Learning Service among other things.

It hopes to record all adverse incidents and report the data and, more importantly, potential lessons back to staff.

The National Patient Safety Agency has produced two good videos.

If you are not well-versed in the SSC, I would advise looking at both videos a couple of times.

They give a very good feel of how the checklist is done.

Video: how to do the surgical safety checklist.

Video: how NOT to do the surgical safety checklist.

Then have a look at the elements of the SSC.

You can find it here: WHO surgical safety list: chart.

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WHO in-theatre check list: "sign in"..

This has to be done by a nurse and anaesthetist at a minimum.

This is about checking;

        the patient's identity,

        the procedure she understands is to be done,

        the side of the body,  e.g. left oophorectomy, and that the site has been marked, if appropriate,

        the consent that has been obtained,

        for allergies.

Then technical stuff:

        is the anaesthetic machine ready for action?

        are intubation problems anticipated?

        what blood loss is anticipated?

        is the pulse oximeter attached and working?

    I am surprised that there is no mention of drugs that could be problematic: antihypertensives, anticoagulants etc.


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WHO in-theatre check list: "time out".

"Time out" means having a break from ones activities.

The idea here is that the theatre staff have a short break immediately before "knife to skin".

If gives a final opportunity to check that everyone knows exactly what is going to be done.

1. Have you done the basics: checked the patient's identity, the operation to be done etc?

2. Have you anticipated problems, both surgical and anaesthetic, and prepared to deal with them?

3. Have you done your routine prophylaxis - antibiotics, anticoagulants?

1. Checking the basics.

The person in charge of the checklist will ask everyone present to:

    confirm the identity of the patient,

    the operation to be done,

    the side to be operated on - right or left.

If the patient is not asleep, they are expected to chip in too.

2. Anticipating problems.

The anaesthetic, nursing and surgical teams are asked to identify any anticipated problems.

In most cases it will be possible to state that it is a routine procedure with no anticipated problems.

If problems can be anticipated, the steps necessary to deal with them need to be discussed.

Common problems would be bleeding, possible organ injury, e.g. if there are adhesions and so on.

Availability of equipment, blood products etc. to deal with the problems should be checked.

Anaesthetic problems could relate to factors like obesity.

But also to complications from co-existing pathology:

    hypertension, arrhythmia or other cardiac problem,

    lung disease,


    sickle-cell disease, thrombophilia etc.

Or from drugs:




    insulin etc.

Additional personnel may need to be available.

E.g. a bowel surgeon in cases of laparoscopic surgery to deal with dense endometriotic disease in the pelvis.

In this case confirmation would be needed about:

    bowel preparation having been done,

    the availability of the surgeon having been checked.

3. Checking everything is ready for the operation:

Is all the necessary surgical equipment ready and sterilised?

Is all other equipment available and working?

    laparoscopy monitors, X-ray machines,

    diathermy etc.

Is the necessary extra equipment available to deal with anticipated problems?

4. Prophylactic routines.

If antibiotics are needed, they should be given in the hour before surgery.

This needs to be checked.

What thromboprophylaxis is needed and has it been arranged?

    compression stockings, positioning, drugs.


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WHO in-theatre check list: "sign out".

This is done at the end of the operation.

Before the surgeon, and, ideally, other key players, have left the room.

1.  Confirm the procedure that has been done.

This may be different to what was planned.

Everyone needs to be aware of exactly what has been done.

2.  Confirm that a full count has been done:

    instruments, needles, swabs etc.

3.  Confirm that any specimens are properly labelled.

This check should ensure that:

    labelling has been done correctly

        name of patient,

        nature of the specimen etc.

    the specimen is in the appropriate medium e.g. formalin.

4.  Are there any issues relating to equipment?

This could be anything from non-availability to things breaking down.

The steps to prevent the same thing happening again need to be identified.

5.  What about recovery etc.

The plan for recovery and subsequent management should be agreed.


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Viva: post-op ward round.

 This has two main elements:

checking she is recovering well from the surgery and anaesthetic and any complications that may have arisen

that she is given full information

about what has been done

about any complication that occurred, what has been done and what cosequences might arise

convalescence, return to normal activities including employment.


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