There is a fracture... OSCE by Michael

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

You are approached by a junior doctor regarding Julia, a 42-year-old female who rolled her ankle off a gutter and sustained an isolated right ankle fracture. She has referred the patient to orthopaedics but reports that the orthopaedic reg was unhappy with the referral and became abusive over the phone.

View attached:  Attachment 1  Attachment 2  Attachment 3

Instructions for the candidate

You are the consultant on. You are to explain the x-ray findings to the junior doctor and then discuss the case with the orthopaedic registrar.

Domains being examined

  • Medical Expertise
  • Communication
  • Leadership and Management
  • Professionalism
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

Junior Doctor:
You have fully assessed Julia who had a simple mechanical fall and has an isolated ankle fracture. The foot is neurovascularly intact. She has had analgesia and imaging as shown. You called the ortho reg to refer, and he told you you were "a bit useless" when you could not adequately describe the ankle fracture classification. He stated he was "very busy" and "why don't you just put on a backslab and refer her to fracture clinic? Or go find someone who knows what they're doing?".

You are a little upset after the interaction.

"Can you call the ortho reg for me?". If the inappropriate behaviour is not discussed on the initial phone call, "He really made me feel bad and was quite abusive earlier. I don't think that's appropriate", then "I really think someone should tell him to behave better".

Ortho reg:
You received a call from a junior doctor in ED who could not provide a detailed history nor adequately describe the fracture ("a fractured right ankle with involvement of both tibia and fibula"). You are in the midst of a busy clinic and late for your theatre time, and have an exam in a week, and do not have patience at present for any incompetence.

"Yes someone called me, but they had no idea what was going on. What's the story?"

You did not get an appreciation of the injury type. When confronted with your behaviour you are initially defensive due to the poor quality of referral, but if the candidate is convincing you agree that your behaviour was inappropriate and apologise.

For the examiner

It is expected that the candidate will review the history, x-rays and details of the interaction between the junior doctor and the ortho registrar.

The candidate should then be prompted to call the ortho reg.

Domains Assessment Objectives

Medical Expertise
Description and management of simple fractures

Communication
Clear explanation to junior doctor.
Open communication with ortho reg

Leadership and Management
Advocacy for staff and ensuring good clinical care for patient

Professionalism
Maintaining an objective and professional rapport with junior doctor and ortho reg.

Other Assessment Notes

1. X-ray and clinical management
- This is a Weber C fracture, which will most likely require operative fixation. There is no imminent need for reduction or intervention.

2. Discussion with ortho reg
- Clear referral with sufficient detail and suggested management plan
- Open discussion about behaviour and clearly defining appropriate behaviour and communication
- If unresponsive to feedback, this should be stepped up to include their consultant


Images courtesy of Radswiki via radiopaedia: http://radiopaedia.org/cases/weber-c-ankle-fracture-1


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