We saw the video clip of a nine month old who was admitted with breathing difficulty for 24 hours.

The clinical signs of cough, wheeze, respiratory difficulty with flaring ala nasi, eczematous rash on face, use of nebuliser was picked by all.

However evidence of child deteriorating during the treatment with nebulised medication was not noted by all, one comment was they felt the video had been reversed.

No one commented on the loud alarm going on during the second part of the video when child looked very tired, pale and flopped back on his father.

History: of onset – sudden or gradual, previous such episodes, Family history of Asthma and Examination of chest for air entry and added sounds would have help reach a diagnosis from a common differential of 3-4 common causes.

In management – ‘Routine’ bloods, ABG, electrolytes were request by many – few mentioned ABC

Pricking a child is painful and technically an assault. We all do it but think about it.
Learning points:

• Airway – Breathing – Circulation – take priority over any other test or treatment!
• Get support – Anaesthetist, ENT or Resus team.
• Do NOT subject child to any painful procedure that may precipitate respiratory arrest.
• Inform your Consultant – at the earliest possible time
• Nothing as ‘Routine’ in patient care.
• Investigations have to be with a specific aim – support or refute a working diagnosis or differential
• Watch video meticulously – do not ‘Sleep watch’. Sequence of events will affect management decisions.
• Look out for visual and audio cues in the clip.
• Summarise in an orderly sequence.
• If you do not say it – It has not been observed / noted.

If there are any other points or comments please visit and add – www.mrcpchonline.org
Anil Garg

Thank you for participating in today’s session when we started with the video station of the exam.

I gave a small PowerPoint presentation highlighting the important points that need to be kept in mind while watching the video and preparing for the discussion with the examiner: Guru Mantras.

We then had a video clip off at 24 our old baby who was jittery. There were other signs that were picked up by most participants.

The Learning  points are:

• Watch the video till the end – do not get side-tracked
• Observe minute details – do not be pre-occupied
• Put ALL signs together and in perspective to reach a Differential diagnosis
• Frame your questions carefully so to help you differential the DD.
• Common things common – UK perspective – some conditions may not be seen overseas.
• It was first exposure to Videos for some hence a steep learning curve.

If I have missed any points please add them.
Video recording will be available for 2 weeks to participants of the Learning group.

Anil Garg

COMMENTS

Dear Dr Garg Sir,
Yesterday’s communication scenario (NAS) was really an eye opener for me, how to tackle  an almost not so thought-off aspect of our daily routine pediatric care in India.
And in that odd situation how to come out with minimum damage to the probable score.
The learning points you had mentioned were truly enriching to me.
Regards,
Tamal.

Dr Maria K checked and updated on information she has looked up:
Hospital for Sick Children, Great Ormond Street – site and information leaflet

• Bone marrow biopsy is of 3 types
• GA is usually given and is not done under local anaesthetic
• Generally taken from hipbone
• Types of cells are checked

Visit GOS website and look up parent leaflets – generally adequate information for exam.
Read Gillick competent / Fraser competent
Thank you Maria.
Anil Garg

We discussed a discussion between a medical student 5th year and paediatric registrar. Medical student wanted to know about Neonatal Abstinence Syndrome, management and why two babies were being treated differently.

Arif and Prada played the role of candidate very well. The communication style of Dr V & M was good and appropriate.

However it was revealing to know that NAS, a very common problem in UK is not that well learnt in overseas countries and hence we need to raise awareness of the condition and it’s management.

The learning points were:

• Follow 2 minute Shishir rule to organize one’s thoughts
• Setting scenario – move to side room as appropriate
• 30 sec rule to ‘speak’. Do not be monotonous imparting information.
• Need to be factually correct
• If you have NO idea of the ‘task’ say so – do NOT bluff
• Ask role player what they have read – you will be given clues
• Do not bring in irrelevant information
• Organize thoughts in ‘Headings’ to discuss.
• Arrange to meet again or to present to larger group / department as a teaching episode.

Add points I may have missed or to add your comments.

Anil Garg

Thank you for attending one of the two sessions today and making them so interesting and useful. Shishir and Maria were in the hot seat and Anish and Saha were the very able role players.

The scenario was of a 15 years old young person with a suspected diagnosis of acute lymphatic leukaemia requiring a bone marrow aspiration to be performed. The task was to explain the procedure to the person and address their concerns.

The scenarios were very well handled by the candidates. The critical observers give very valid observations and substantiated them with what they had noted.

The learning points are:

• Accuracy of information – wrong information will bring down the mark awarded.
• Mention the task, better soon after introductions, so are less likely to be side tracked.
• As ‘Doctor’ you need to be in the driving seat – diagnosis are ‘Likely / suspected’
• Particular test / procedure is to confirm diagnosis and plan treatment
• No procedure can be pain free unless under GA – ‘Pain as less as possible’ with ‘medication’
• Read up Gillick competence / Fraser competence
• Avoid jargon – is have to use medical term – explain what it means.
• Will I die? Be empathic and REASSURING – with treatment we expect your will be fine’.
• How to use opening statements.
• Be doctors with hope and sunshine than doom and gloom.

If there are any points I have missed please add them on.

The sessions have been recorded with consent of the participants – scenarios and discussions. They will be available for 2 weeks in case you have been at work and unable to attend.

Anil Garg

Commnets

Dear All
Thank you for joining our first ‘later’ session at 6:00 – 7:00 pm UK time.

We covered the changes to the Clinical exam announced by RCPCH so far. We still await details of how the Clinical, extended Clinical and the Development stations will actually play out.

The video recording of the session will be available for 2 weeks for those at work and could not attend.

Communication, History and Management and Video stations are remaining the same. The total exam target time will also remain the same. I will practice on zoom in these interactive sessions I feel provides a realistic view of what will be in the exam. A lot can be observed and inferred in respect to communication skills i.e. body language, tone of voice and most crucial our response to the role player. There are likely to be professional actors who will be very realistic.

We covered important Do’s and Don’ts of communication station and importance of communication skills all across the exam. 25% marks come from here – as was pointed out some time ago my one of my colleagues.

We will continue with the two sessions on Tuesday and Thursdays 4:00-5:00 pm and 6:00-7:00 pm and monitor the attendance at these sessions for 4 weeks. We can then jointly take the decision on the way forward.

Some of you expressed your disappointment at not being able to get a place at the exam in November. In some ways it may be a blessing in that by next diet we will know more and teething troubles will have been noted and addressed.In my experience it take approximately 6 of dedicated work to feel comfortable at the exam.

I will ask if you can let me know which time will be more suitable for you so I can plan the session.

I would need a or more if willing, volunteers for the next 2 sessions to be the role player.

I intend to move to video station after.

Look forward to your reply.

Anil Garg

Thank you for participating in the session today and making it so interesting and informative.

We covered two scenarios today: NAI 2.5 yrs old and Febrile convulsion 1 year old – may seem like a repeat to some.

Vidisha acted as the role player in both scenarios and we had Dr Aloke do a good doctor job and a not so good doctor job on the two scenarios.

The execution of the scenarios was excellent with all the salient points an examiner will be looking for while marking your communication station.I was really pleased by the keen observations of the participants who picked up the positive points in the good doctor performance and all the negative points in the bad doctor performance:

Introduction / rapport building / empathy / body language on Zoom Video! besides actual spoken words.

Learning points:

• Non Accidental Injury – how to present – use ‘Safe guarding’ vs ‘NAI’
• Do NOT accuse – it is about child’s safety and working with family
• Read the task carefully
• 2 minute rule by Shishir: PLAN FIRST 2 MINUTES ONLY OF CONSULTATION WHILE WAITING.
• There after respond to the role player.
• Do not try and work out the whole scenario as you will focus on agenda and not Role player.
• Vital to try and stay on the same page as the role player.

Add and points I may have missed or comments.

Session on 22 September – Tuesday will be at 6:00 – 7:00 pm UK time.

Anil Garg

COMMENTS

We are planning to start another Interactive session on Tuesday at 6:00-7:00 pm UK time soon to assist in preparation of the Exam in November.

This is to facilitate our participants in UK, Ireland, Canada & Switzerland who find 4:00-5:00 pm UK time not very helpful with work schedules.

Please send a note if you will like to know more.

Thank you for participating in the session on communication.

I took the plunge and attempted the scenario which we had discussed previously of a newborn baby who is noted to be dusky at four hours and the clinical assessment is that he may have a cyanotic heart disease likely to be transposition of the great arteries. Dr Tamal was and excellent role player and did get across his anxiety very well. He was however, satisfied in the end.

The second scenario we did was of a one-year-old admitted following a febrile convulsion due to otitis media. The following morning during the ward round he was felt to be better and fit for discharge. However his father who had just arrived, was not happy with the medical decision and wanted the child to have a CT scan as he had found on Google. Maria was an excellent role player but technology did let us down in getting a clear understanding of communication between role player & candidate.

Learning points:

• Ensure you have Good internet connection.
• Vitally so as you can opt to take the exam from home now.
• Technology failures on your end are unlikely to get sympathy from RCPCH – I am guessing.
• “Will the child die?” is a common question – practice how to respond satisfactorily to it.
• No medication can completely eliminate the chances of future convulsions
• Tepid sponging / Cooling – can be different in context of different countries / climates
• After introductions – keep QUIET and give parent /RP chance to get across everything they want to say – DO NOT interrupt.
• This will also give you information of their prior knowledge.
• Then pick up salient points – from THEIR perspective and address them

Add your comments or points I may have missed.

Video recording of the sessions are available to participants.
Anil Garg

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