Scenario
It is a Friday evening in your regional ED. Your patient is Mrs Thelma Brown, a 72 yo woman brought in by her daughter with a one week history of respiratory tract infection. Her daughter states that she can no longer look after her mother at home.
- History: A widow with early dementia; nil else relevant. No medications or allergies. She usually lives alone at home but for 2 days her mobility has required two persons’ assistance.
- Examination: vital signs normal; bi-basal crackles.
- Investigations: relevant blood tests normal; CXR reveals minor bi-basal changes consistent with bronchopneumonia.
Your management plan includes admission, oral antibiotics, no supplemental oxygen. In this hospital there are available medical beds but there is NO Short Stay Unit or Hospital-in-the Home service. Patients must be accepted by an inpatient unit prior to admission.
The on-call general physician, Dr Troy Young, whom you’ve not met before, is in the ED. You are going to refer Mrs Brown to Dr Young.
Question 1
Dr Young, ROLE PLAYED by an actor, is waiting for you in a private office. Other people in this scenario will NOT be present. Examiners will NOT be interacting with you or the actor.
Information for Actor
Background Information for Actor
- Important Note:
- The ACEM Fellowship Exam involves examiners and candidates from all Australian states and New Zealand. To optimise fairness for all candidates, all character and scenario features will NOT have demographic details.
- In interactions with candidates, please do NOT refer to demographic specifics. For example, you work in the general hospital instead of the Royal North Shore Hospital; you live in the inner suburbs instead of Glebe.
- The Character
- Dr Troy Young is a 39yo specialist physician, a Fellow of Royal Australasian College of Physicians (FRACP).
- In addition to working 30 hours per week as a general physician at the regional hospital, Dr Young runs a busy private practice in the same town. He is a competent, well-regarded professional. However, recent stressors of work have made him irritable lately.
- Dr Young lives with his wife and 4-month old daughter in an inner suburb. His daughter’s sleep habits occasionally disrupt his sleep, and he is frequently fatigued. Otherwise, he has no personal, social or financial problems. He enjoys good health.
- The Scene:
- It is 2100hrs on a Friday. On call for the hospital until 0800hrs the following day, you have endured a long day at your rooms and the hospital, and are fatigued. Just about to leave for dinner, you are in the ED in a private office and are referred a patient for admission.
- The case as described on the telephone is not unusual. Thelma Brown is a 72yo woman has a mild lower respiratory tract infection (LRTI), which may be treated by oral antibiotics, such as roxithromycin (RulideTM). While the illness itself may be safely treated in an outpatient setting, her pre-morbid status has apparently made her unsafe for discharge. As such, admission may be required for additional assessment and implementation of various aged care services. Your clinical unit often cares for such elderly patients, who are debilitated by otherwise minor acute conditions.
- You anticipate that his case will take considerable time to assess. Moreover, it’s not particularly fulfilling work. In your current state, you reluctant to undertake it, and resent your referring colleague. Indeed, you conclude that it may be possible to discharge this patient; you offer this option to your colleague, declaring you do not wish to see the patient.
- This colleague is the ED Consultant. S/he is an Emergency Physician – a specialist in Emergency Medicine. You have not met him/her before. S/he has personally reviewed Mrs Brown. He/she asks you review Mrs Brown.
- The ED Consultant, played by the exam candidate, will enter the room and introduce him/herself.
NOTE:
- Neither Mrs Brown nor her daughter will be part of this interaction; you have not met them.
- The “Scenario” in the preceding page is all the information provided to the candidate before s/he interacts with you. That is, s/he will NOT be aware of your own circumstances.
- Stress that the patient could be discharged and will not be admitted; you will stress that the ED Consultant has no rights of admission and therefore the ultimate decision to admit or discharge the patient is yours alone.
- State that the hospital is not able to assess the patient’s functional status on the weekend, and having her in hospital to take oral antibiotics is not good use of hospital resources.
- You think that outpatient services including a home social and functional assessment can be arranged on Monday.
Examiners Report
- Overall pass rate for this question was 47/54 (87%)
- This SCE emulated a common scenario in Emergency Medicine.
- The FEC and Examiners regard communication as a core competency and expected high standards from candidates.
- Failed candidates did not demonstrate consultant-level communication skills required for interacting with a senior peer in a challenging scenario.
ACEM Fellowship Structured Clinical Examination (SCE)
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