PassDOHNS Ultimate Complete Step-by-Step DOHNS OSCE Part 2 Guide Diploma in Otolaryngology Head and Neck Surgery DO-HNS

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DOHNS OSCE

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GENERAL GUIDE AND STEP-BY-STEP APPROACH General Guide of Breaking Bad News Stations

DOHNS OSCE

The process of disclosing bad news is an attempt to achieve four essential goals: Home / Courses / DOHNS OSCE  Information gathering from patient  Provide intelligible information according to patients’ needs  Providing psychological support to reduce emotional impact  Develop a strategy in the form of treatment Copyright © 2021 Pass DOHNS ® | Credits Powered by Pass DOHNS The widely used technique to approach breaking bad news stations is the universal “SPIKES” Protocol. This protocol involves setting up a suitable environment and atmosphere for patient and family for the discussion to take place. Before disclosing the important information to the patient, candidates are expected to assess patient’s perception to gauge their knowledge prior to the discussion. This gives candidates a general idea on what piece of information should the candidates emphasize on, during the discussion. Before disclosing the news to patient, it is important to obtain invitation and approval from the patients. The next part involves breaking the news and giving them adequate information regarding their condition. Candidates would be expected to show empathy and care to make patients feel more comfortable. Before ending the discussion, the general treatment plan and management should be outlined to give patient insight on what they should expect next.

S

SETTING up the interview

P

Assessing patients’ PERCEPTION

I

Obtaining INVITATION

K

Giving KNOWLEDGE regarding the disease to patient

E

Showing EMPATHY

S

STRATEGY and SUMMARY

1. Speak in a slow, timely manner. Allow patient time to take in and digest the information given. 2. Providing warning shots is of utmost importance to allow patient to be mentally prepared for the bad news. For example, “ I am sorry, the news is not what we hoped for” “ I am so sorry, Mr Jack, but I have a bad news” 3. Appropriate and deliberate pause in between statement. 4. Allow for silence and tears. 5. Offer tissues if patient appears crying. 6. Appropriate comforting touch over shoulder and arms shows empathy and care for the patient. However, be sensitive to cultural difference as some patients may prefer against personal contact. 7. Appropriate facial expression is vital to excel in breaking bad news stations. Candidates often nd practising in front of a mirror or video-tapping the session useful for better feedback. Practice with partners and share your impression on each performance. Avoid inappropriate humour or ippant comments eg “Well, everyone will die someday”. 8. Speak frankly but compassionately. 9. Offer interdisciplinary service to enhance patient’s care, eg social welfare, clinical psychologist, hospice etc. 10. Do not argue or criticize colleagues. 11. Offer realistic hope according to the patient’s goal. 12. Allow patients to describe his or her understanding of news in own words if time factor is permissible. 13. For Non-UK trained candidates, try to familiarise with the common vocabulary used for manned stations. 14. Most importantly, PRACTICE MAKES PERFECT.

DOHNS OSCE 1. Introduction

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“Good morning, my name is _______, a 3rd year ENT doctor.

2. Con rm patient’s name & DOB

May I con rm your name and Date of Birth (DOB)

OSCE 3.DOHNS Environment

 – It’s a pleasure to meet you

consideration Home / Courses / DOHNS OSCE

First and foremost, are you comfortable on where you sitting right now?”

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“I am here today to speak to you regarding the recent scans/tests /hearing test you had. Is it alright if we discuss it right now?”

Setting 

 First of all, may I know whether you have brought anyone with you today?”  “l Would you prefer to have a family member/friend here or a nurse specialist to be here with you?”  “Before we proceed, please know that the content of our conversation will remain private & con dential.”

Perception

 “How are you doing so far?”  “Just a quick recap, could you describe to me what brought you to the clinic at the beginning?”  “Could you bring me up to speed on what you understood so far?” Explain anatomy structure (with relevant diagram) Reasons for the investigation to be done: The reason we wanted to do the test was to con rm whether you are having a cancer at your throat

“Do you have any idea what the tests might show?”

Invitation

“I have the results here with me, would you prefer me to explain now, or some other time when you are more prepared?”

Knowledge

Break the bad news: “Mr / Ms ______, I afraid that news is not what we hoped for. —- Pause—Unfortunately, the test revealed that you are having ________ . I wish that I have better news for you”  —— Pause —-–  “I know that this is a lot for you to take in, I am sorry that I have to break this news to you today.” (Speak with slow tone & pace)

If asked about detailed information which cant be answered: Answer: “So sorry Mr/Ms____, I don’t have enough information to answer that at this stage. Hopefully, we are able

to get a clearer picture of your condition in the next few weeks, once we completed further tests. I would arrange

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to get a clearer picture of your condition in the next few weeks, once we completed further tests. I would arrange

an appointment with my consultant Mr Smith to give you the best answer to your doubts.”

DOHNS OSCE Emotion / Empathy “How are you feeling right now?” Home / Courses / DOHNS OSCE

“I am glad that you tell me how you feel so I know where you are coming from.”  “I understand that this comes as a huge shock for you, my clinic and I will support you through this. I guarantee that we would try our very best to address any of your concern.” Copyright © 2021 Pass DOHNS ® | Credits Powered by Pass DOHNS “Would you prefer to further discuss your condition some other day so that you have time to settle down?” “We would support you through this. In fact, we have a team to assist you. In my team, there are social workers, who will be able to assist you in the events of any nancial dif culties. We are also ready to offer any psychological counselling if you need them.”   “I know it is painful to hear that ______________, I hope for the best for you” “I can see that you are upset, would you prefer to continue the discussion some other day?”

Additional treatment plan /

Explain regarding treatment options available

prognosis Explain regarding the prognosis of the condition

ICE

Readdress  I.C.E Ideas: “Do you understand what I have explained to you?” Concerns: “Do you have any concern that you are worried about? ” Expectation: “Is there anything that you would like us to help you with?”

Closing

“In summary, the tests that we have done showed _____________”

”Do you have any further doubts?”

“I would leave you a patient lea et regarding the condition. On the patient lea et, there are contact details of our clinic. Please do not hesitate to contact us if there is any inquiry or you need any assistance.”

“I will be glad to arrange a meeting with your family / friends if you prefer so. If there is any doubt that you would like our consultant to explain to you, I can arrange an appointment with him.”

DOHNS OSCE Closing

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“In summary, the tests that we have done showed _____________”

DOHNS OSCE”Do you have any further doubts?” Home / Courses / DOHNS OSCE

“I would leave you a patient lea et regarding the condition. On the patient lea et, there are contact details of our clinic. Please do not hesitate to contact us if there is any inquiry or you need any assistance.” Copyright © 2021 Pass DOHNS ® | Credits

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“I will be glad to arrange a meeting with your family / friends if you prefer so. If there is any doubt that you would like our consultant to explain to you, I can arrange an appointment with him.”

“Let’s meet 1 week from now, say 20th of January, after the test. Thank you and wish you well.”

COMPLETE

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BREAKING BAD NEWS STATION 1

DOHNS OSCE

Laryngeal Squamous Carcinoma

Home / Courses / DOHNS OSCE Mr Jackson is a 50 yo gentleman who presents with 4 months history of voice change. Flexible Nasoendoscopy (FNE) revealed an ulcerative mass limited to the right true cord. Biopsy was taken last week and reported Squamous Cell Carcinoma. Please break the bad news to Mr Jackson and explain regarding the diagnosis and the prognostic outcome.

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Time: 7 Minutes

1. Introduction

“Good morning, my name is _______, a 3rd year ENT doctor.

2. Con rm patient’s name & DOB

May I con rm your name and Date of Birth (DOB)

3. Environment consideration

 – It’s a pleasure to meet you

First and foremost, are you comfortable on where you sitting right now?”

Consent

“I am here today to speak to you regarding the test report of the sample taken from your throat, is it alright to discuss it right now?”

Setting

 “First of all, may I know whether you have brought anyone with you today?”  “Would you prefer to have a family member/friend here or a nurse specialist to be here with you?”  “Before we proceed, please know that the content of our conversation will remain private & con dential.”

Perception

 “How are you doing so far?  Just a quick recap, could you describe to me what brought you to the clinic at the beginning?  Could you bring me up to speed on what you understood so far?” Explain anatomy structure:

“Our voice box, which is called larynx, sits at the middle of our neck. It allows us to speak by moving the vocal cords. It also helps to protect food from going down the wrong way to lungs” Reasons for the investigation to be done:

“At times, tumour can grow at our voice box. The growth may be benign or cancerous when it spreads to other parts of the body. The reason we took the sample from your throat was to con rm the nature of the growth whether it is cancerous

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The reason we took the sample from your throat was to con rm the nature of the growth whether it is cancerous or not.” “Do you have any idea what the tests might show?” DOHNS OSCE Home / Courses / DOHNS OSCE Invitation

“I have the results here with me, would you prefer me to explain now, or some other time when you are more prepared?”

Knowledge

Break the bad news:

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“Mr Jackson, I afraid that news is not what we hoped for. —- Pause—Unfortunately, the test revealed that you are having cancer over your throat. I wish that I have better news for you “ —— Pause —–  “I know that this is a lot for you to take in, I am sorry that I have to break this news to you today.” (Speak with slow tone & pace)

Possible questions from the patient

Why is this happening to me?

Answer: “A cancerous tumour starts from one cell behaving abnormally and multiply and spread to the

surrounding. The exact reason why this occurs is unclear, however certain lifestyle behaviour such as smoking, or drinking excessive alcohol may have a higher risk of developing throat cancer. Some patients develop throat cancer without apparent reasons.

Has the cancer spread to other parts of my body?

Answer: “Through the initial examining, the cancerous appear to be con ned on your voice box. However, we

would need to run a series of test to assess the extent of the disease”

So what should I do next? Answer: “Next, we would run a series of test to stage the disease. After the scan, we would arrange a meeting

with a team of doctors consisting of the cancer doctor (oncologist) and ENT surgeon. We would then discuss the best treatment for you depending on the stage of cancer, your health condition and your wishes. If the tumour is con ned to your throat, we would most likely offer the followings: to remove the part or whole of voice box through surgery, radiation therapy or laser. The main aim of the treatment is to remove the entire cancerous tumour.”

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Has the cancer spread to other parts of my body?

DOHNS OSCE  Home / Courses / DOHNS OSCE Answer: “Through the initial examining, the cancerous appear to be con ned on your voice box. However, we

would need to run a series of test to assess the extent of the disease”

So what should I do next? Copyright © 2021 Pass DOHNS ® | Credits Powered by Pass DOHNS Answer: “Next, we would run a series of test to stage the disease. After the scan, we would arrange a meeting

with a team of doctors consisting of the cancer doctor (oncologist) and ENT surgeon. We would then discuss the best treatment for you depending on the stage of cancer, your health condition and your wishes. If the tumour is con ned to your throat, we would most likely offer the followings: to remove the part or whole of voice box through surgery, radiation therapy or laser. The main aim of the treatment is to remove the entire cancerous tumour.”

What is the difference between the options available?

Partial or Total Laryngectomy

More signi cant effect on speech compared to radiation therapy and laser surgery. There are few options for the production of speech if the voice box is removed.  TEP: This includes placing a valve between windpipe & gullet  Electrolarynx: Device to be applied on either side of the neck to produce vibration and allow speech  Esophageal Speech: Practice technique of sound produced purely through gullets All the options would be further discussed if laryngectomy is chosen.

Radiation therapy/laser surgery

Less effect on speech but may still notice a change of voice May resort to surgical removal of the voice box if treatment fails

Emotion / Empathy

Please refer to the previous station

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DOHNS OSCE Emotion / Empathy

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Please refer to the previous station

DOHNS OSCE

Home / Courses / DOHNS OSCE Additional treatment plan /

Explain regarding treatment options available (if not done).

prognosis if not done

Explain regarding the prognosis of the condition 

Copyright © 2021 Pass DOHNS ®“At | Credits Powered by Pass DOHNS this point of time, we would need to assess your general well being and scans to determine the stage of the disease. Early cancers are remarkably curable with ve-year survival or “cure rates” of 80-95% compared to advanced stages that have a survival rate of 25-50%. Because these cancers usually occur in patients in 6th  or 7th decades, as many as 15-20% die of causes other than cancer itself.”

Please refer to the previous station

ICE

Summary & Closing

“In summary, the sample we have taken from your throat has been con rmed to be cancer. Next, we would run some tests and scan to assess the stage of cancer. We would suggest a meeting with the cancer doctor and ENT surgeon to plan for the best treatment option for you.” Please refer to the previous station

COMPLETE

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Breaking Bad News Station 2

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Congrats! You have completed "Breaking Bad News Station 1".

BREAKING BAD NEWS STATION 2

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Residual Laryngeal Squamous Carcinoma Home / Courses / DOHNS OSCE Mr Aaron is a 50-year-old gentleman who has been diagnosed with Laryngeal Squamous Carcinoma. He has undergone radiotherapy. Unfortunately, his tumour did not regress and continued to grow. Explain to Mr Aaron regarding his condition and explain regarding the option of laryngectomy. Time: 7 Minutes Copyright © 2021 Pass DOHNS ® | Credits

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Remarks: Candidates are advised to explore patient’s knowledge regarding his condition. If he is not well aware of the status of recurrence / residual tumour, please approach the station as a breaking bad news station.

1. Introduction

Please refer to the general guide

2. Con rm patients name & DOB 3. Environment consideration

Consent 

Please refer to the general guide

Setting 

Please refer to the general guide

Perception

Please refer to the general guide

Invitation

Please refer to the general guide

Knowledge

Please refer to the general guide

Emotion / Empathy

Laryngectomy

Please refer to the general guide Reason for operation

“ We are suggesting an operation to remove your the

entire voice box. The main goal of the surgery is to remove the tumour as the initial radiotherapy has failed to kill the cancerous cells.”  Further radiation therapy or laser surgery is not feasible for larger tumours.  The operation will only be done if further scan shows no metastasis

Bene t of operation

 To remove the entire cancerous tumour, and prevent it from further spreading.

Alternative

 Laryngectomy, in this case, is the most recommended treatment  Unfortunately, chemotherapy alone does not

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remove the tumour as the initial radiotherapy has failed to kill the cancerous cells.”  Further radiation therapy or laser surgery is not feasible for larger tumours.

DOHNS OSCE

 The operation will only be done if further scan shows no metastasis

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Bene t of operation

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 To remove the entire cancerous tumour, and prevent it from further spreading.

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Alternative

 Laryngectomy, in this case, is the most recommended treatment  Unfortunately, chemotherapy alone does not offer the same success rate.

ICE

Please refer to the general guide

Summary & Closing

Please refer to the general guide

COMPLETE

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Breaking Bad News Station 1

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Breaking Bad News Station 3

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BREAKING BAD NEWS STATION 3

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Unilateral Profound Sensorineural Hearing Loss Home / Courses / DOHNS OSCE Mr Jackson has brought his 3-year-old son to your outpatient clinic. A hearing assessment has shown that the child is having unilateral left profound sensorineural hearing loss. Please inform Mr Jackson on the test nding and further explain his child’s condition. Time: 7 Minutes Copyright © 2021 Pass DOHNS ® | Credits 1. Introduction

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Please refer to the general guide

2. Con rm patients name & DOB 3. Environment consideration

Consent

“I understand that you have brought your child to our clinic earlier, and a hearing test was done.” “I am here today to speak to you regarding the results of your child’s hearing test, is it alright to discuss it right now?”

Setting

Please refer to the general guide

Perception

Please refer to the general guide

Explain anatomy structure: (with drawings) Our ear is divided into 3 sections, the outer, middle and inner ear. The outer ear helps to channel the sound we hear to the eardrum and middle ear. The middle ear consists of small bones which function to convert sound wave to vibration energy. The electrical signals are made in inner ear and travel along the nerve to the brain for interpretation of sound. Reasons for the investigation to be done: At times, abnormality in any section of the ear can contribute to hearing loss. The reason we have done a hearing test for your child was to nd out any abnormality in his hearing. The hearing test can often identify the section of the ear which contributes to a hearing problem.  “Do you have any idea what the tests might show?”

Invitation

“I have the results here with me, would you prefer me to explain now, or some other time when you are more prepared?”

Knowledge

Break the bad news: Mr Jackson, I afraid that news is not what we hoped for. —- Pause—U f t

t l th t t

l d th t

hild i h

i

h

i

i

i

t

hi l ft

I i h th t I

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DOHNS OSCE Invitation

BACK TO COURSE

“I have the results here with me, would you prefer me to explain now, or some other time when you are more prepared?”

Knowledge

Break the bad news:

DOHNS OSCE

Mr Jackson, I afraid that news is not what we hoped for. —- Pause—Home / Courses / DOHNS OSCE Unfortunately, the test revealed that your child is having severe hearing impairment on his left ear,  I wish that I have better news for you  ——Pause —–  “I know that this is a lot for you to take in, I am sorry that I have to break this news to you today.” Copyright © 2021 Pass DOHNS ® | Credits

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Possible questions from the patient:

What is the cause of hearing loss? The reason behind the hearing loss is not always clear. The hearing test revealed that there may be an abnormality in the inner ear. It may be associated with several factors such as infection of the baby in womb, prematurity, dif culties encountered during birth, inheritance or other medical conditions. However, some patients developed such disorder without apparent reasons.

How will having unilateral hearing loss affect my child? It may affect: 1. Directional hearing: the ability to work out the source of sound coming from. 2. Understanding speech when there is a lot of background noise 3. Understanding quiet voices or soft sounds 4. Dif cult to understand speech if ones approach your child from the side of the affected ear.

So what should I do next? Next, we are suggesting a series of test to nd for the possible cause of hearing loss. This includes imaging scans to look for any abnormality of the head and ear.

Measures parents

1. Moves the child away from noises when talking to him

can learn 2. Try to position yourself so that chid’s better ear is closest to you 3. Try to make sure background noise is kept to minimum by using soft furnishings such as curtains and carpets 4. Protect the better ear: avoid loud noise

Hearing Aid

1. CROS (Contralateral Routing of Signals) Hearing Aid

/Cochlear Implant  The aim is to help in localising the sound by channelling sound from affected ear to better ear  However, Hearing Aid does not provide the same quality of hearing as a normal ear. Thus, the child might nd it more dif cult to learn speech and language.

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DOHNS OSCE

BACK TO COURSE  The aim is to help in localising the sound by channelling sound from affected ear to better ear  However, Hearing Aid does not provide the same quality of hearing as a normal ear. Thus, the child might nd it more dif cult to learn speech and language.

DOHNS OSCE

 You would be seeing an audiologist, a hearing specialist to decide further on the options available

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2. Cochlear Implant It involves an operation to insert an internal implant into the inner ear. Unlike hearing aids, cochlear implants don’t just amplify sounds. They mimic the natural

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function of the inner ear through electronic stimulation.  Incoming sounds Powered hearing by Pass DOHNS are processed into electrical signals and then transmitted directly to the hearing nerve. Possible Complication:  bleeding  infection  device malfunction  facial nerve weakness  ringing in the ear  dizziness  poor hearing result

Can my child attend mainstream nurseries and schools?  Children with unilateral hearing loss who do not have additional needs can attend mainstream nurseries and schools.  It is important to inform the school regarding his condition While at school, it is advisable to 1. Place child’s seat closer to the teacher 2. Speak to child from the direction of better ear 3. Monitor child progress in class closely

How can I speak to my child to make my words clearer? 1. Obtain child’s attention before start speaking 2. Maintain good eye contact 3. Speak a little louder rather than raising your voice 4. Speak clearly, and naturally 5. Using hand gestures and facial expression to convey messages while speaking

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DOHNS OSCE

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4. Speak clearly, and naturally 5. Using hand gestures and facial expression to convey messages while speaking

DOHNS OSCE Home / Courses / DOHNS OSCE Emotion / Empathy

 “How are you feeling right now?”  “I understand that this comes as huge news for you, my clinic and I will support you through this. I promise that we would try our very best to address any of your concern and provide the best care to your child.”

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ICE

Please refer to the general guide

Summary & Closing

In summary, the hearing test has shown that your child is having a severe hearing loss on his left ear, with the right ear functioning well. The cause for this is not clear. We have discussed several measures to support and assist your child including options of hearing aid.

Please refer to the general guide

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Breaking Bad News Station 2

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Example of Marking Scheme

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EXAMPLE OF MARKING SCHEME Contents

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Marks 0

1

2

Home / Courses / DOHNS OSCE Introduction / Greeting Consent Environment consideration / Sitting arrangement Copyright © 2021 Pass DOHNS ® | Credits Powered by Pass DOHNS Invite relatives into consultation/ Offers Chaperon

Gauges patient’s understanding Provides an invitation Gives warning shots Explanation (Using Relevant Diagram) Show of empathy Allow time for patient to react Checks understanding Provides plans Explains prognosis/outcome Explores patient’s Idea, Concern, Expectation

Summary & Closing Offers to speak to family Offers follow up Offers extra information sources

Eye Contact Shows Professionalism Uses appropriate terminology / avoid medical jargons

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GENERAL GUIDE AND STEP-BY-STEP APPROACH

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Explanation stations require candidates to explain common ENT diagnosis, for example, Otosclerosis, Benign Paroxysmal Positional Vertigo (BPPV), Home / Courses / DOHNS OSCE Thy3 F Thyroid Nodule. The explanation station can be easily approached using an 8 steps protocol, ICE –  PIECES. 

I Copyright © 2021 Pass DOHNSIntroduction ® | Credits

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C

Consent

E

Environment Consideration

– P

Perception

I. E

Inform & Explain

C

Check Understanding

E

Explore Hidden Agendas

S

Summary  & Closing

It is best to use diagrams to illustrate your explanation. Relevant diagrams are often provided in the examination. However, it is useful to have diagrams drawn at the preparation station in case it is not prepared at the station. All of the explanation stations can be approached using the following framework.

( I ) Introduction  Con rm patient’s name & DOB

Good morning, my name is _______, a 3rd year ENT doctor. May I con rm your name and Date of Birth (DOB)? – Nice to meet you

( C ) Consent

I am here today to speak to you regarding the tests/scans /the symptoms you are having, is it alright to discuss it right now?

( E ) Environment

 “First and foremost, are you comfortable on where you sitting right now?”

Consideration

 “May I know whether you have brought anyone with you today?”  “Would you prefer to have a family member/friend or nurse specialist to be here with you?”

(P) Perception

 “How are you doing so far?” (Building rapport)  “Just a quick recap, could you describe to me what brought you to the clinic at the beginning?” (Brief history taking of chief complaint will do, do not waste too much time dwelling on it) Explore I.C.E

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Explore I.C.E

Idea Concern DOHNS OSCE

“Could you bring me up to speed on what you understood regarding your condition so far?” “Do you have any concern that you are worried about?”

Home / Courses / DOHNS OSCE

Expectation

“Mr / Ms _____, before I began to explain to you regarding your test/scan/condition, may I ask how do you handle medical information? Do you prefer the details of the medical

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( I ) Inform & (E) Explain

Powered by Pass DOHNS condition/treatment?”

1. Explain the anatomical structure (using relevant diagrams) 2. Explain the condition 3. Relate patient’s symptoms to the disorder 4. Explain treatment options

( C ) Check Understanding

Do you have any doubts? Are you following me right now? Are you clear on what we have discussed so far?

( E ) Explore Hidden

Do you have any further concern that worries you?

Agendas Readdress I.C.E

( S ) Summary & Closing

Summarise discussion

“Do you have any further doubts?” I would leave you a patient lea et regarding your condition. On the patient lea et, there are contact details of our clinic. Please do not hesitate to contact us if there is any inquiry or you need any assistance. I will be glad to arrange a meeting with your partner/family members if you prefer so. If there is any doubt that you would like to have our consultant explain to you, I can arrange an appointment with him.

Follow up plan: “Shall we meet 1 week from now, say 20th of January to review your condition?” Thank you and wish you well.

DOHNS OSCE ( E ) Explore Hidden

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Do you have any further concern that worries you?

Agendas Readdress I.C.E DOHNS OSCE   Home / Courses / DOHNS OSCE

( S ) Summary & Closing

Summarise discussion

“Do you have any further doubts?” Copyright © 2021 Pass DOHNS ® | Credits Powered by Pass DOHNS I would leave you a patient lea et regarding your condition. On the patient lea et, there are contact details of our clinic. Please do not hesitate to contact us if there is any inquiry or you need any assistance. I will be glad to arrange a meeting with your partner/family members if you prefer so. If there is any doubt that you would like to have our consultant explain to you, I can arrange an appointment with him.

Follow up plan: “Shall we meet 1 week from now, say 20th of January to review your condition?” Thank you and wish you well.

COMPLETE

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Example of Marking Scheme

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Explanation Station 1 (Detailed guide)

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EXPLANATION STATION 1 (DETAILED GUIDE) Mr Aaron is a 25 year old gentleman who has been newly diagnosed with otosclerosis. Please explain the condition to him.

DOHNS OSCE

Time: 7 minutes

Home / Courses / DOHNS OSCE ( I ) Introduction · Con rm patient’s name &

Good morning, my name is _______, a 3rd year ENT doctor. May I con rm your name and Date of Birth (DOB)

DOB Copyright © 2021 Pass DOHNS ®–|Nice Credits Powered by Pass DOHNS to meet you

( C ) Consent

I am here today to speak to you regarding the hearing tests you had, is it alright to discuss it right now?

( E ) Environment

 “First and foremost, are you comfortable on where you sitting right now?”

Consideration

 “May I know whether you have brought anyone with you today?”  “Would you prefer to have a family member/friend or nurse specialist to be here with you?”

(P) Perception

 “How are you doing so far?” (Building rapport)  “Just a quick recap, could you describe to me what brought you to the clinic at the beginning?” (Brief history taking of chief complaint will do, do not waste too much time dwelling on it) Explore I.C.E

Idea

Could you bring me up to speed on what you understood regarding your condition so far?

Concern

Do you have any concern that you are worried about?

Expectation

Mr Aaron, before I began to explain to you regarding your hearing test, may I ask how do you handle medical information? Do you prefer the details of the medical condition/treatment?

( I ) Inform &  (E) Explain

Explain the anatomical structure(using relevant diagram) Our ear is divided into 3 sections, the outer, middle and inner ear. The outer ear helps to channel the sound to the eardrum and middle ear. The middle ear consists of small bones which function to convert sound wave to vibration energy. The electrical signals are made in inner ear and travel along the nerve to the brain for interpretation of sound. Explain the condition Based on the assessment and tests we have done, you are having a condition called OTOSCLEROSIS. Before we proceed with further discussion, may I know whether you have heard about this diagnosis? Otosclerosis is a disease of bone in the middle ear, when abnormal bone forms around the delicate ear bones, making it stiff, thus reducing its vibration during sound conduction. This reduces the conduction of sound reaching

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Otosclerosis is a disease of bone in the middle ear, when abnormal bone forms around the delicate ear bones, making it stiff, thus reducing its vibration during sound conduction. This reduces the conduction of sound reaching the inner ear. It may also interfere with the production of nerve signal if the inner ear is involved.

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Home / Courses / DOHNS OSCE Possible questions from the patient 1. Why do I get otosclerosis? Copyright © 2021 Pass DOHNS ® | Credits Powered by Pass DOHNS The cause of otosclerosis is not fully understood, it tends to run in family. Therefore, patients with family history of otosclerosis are most likely to develop this. Some research suggests that otosclerosis are associated with hormonal changes such as pregnancy.

2. Will both of my ears be affected? Both ears are usually involved in otosclerosis, however, certain patients may have only 1 ear affected. The disorder only affects ear bones, bones at other parts of the body are less likely to be affected.

3. Do I need any more further testing to con rm the diagnosis? Most cases of otosclerosis are diagnosed after thorough assessment such as learning about patients’ symptoms, examination of the ear, hearing tests and ruling out other common disorders. In certain cases, an imaging scan of the head may be suggested to assess the extent of otosclerosis. However, this may not be compulsory.

Relate patient’s symptoms to the disorder Since otosclerosis causes stiffening of ear bones, you are experiencing hearing loss on the affected ear. It may take several years for the symptoms to be obvious. The severity ranges from slight to severe and may progressively worsen. You may hear a buzzing sound on the affected ear and very rarely, it may cause dizziness.

Explain treatment options There is no known cure for otosclerosis. Patients with otosclerosis have several options:

Observe & Wait

If hearing loss is mild

Hearing Aid

Device to amplify sound so the patient can ear better  Advantage: Avoid the risk of surgery  Disadvantage: Patients may nd it troublesome to carry a device around. May be cosmetically unappealing.

Surgery (Stapedotomy)

An operation to remove the diseased ear bones, and reconstruct hearing mechanism with plastic/metal prostheses. All modern prosthesis would not be affected by MRI

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Hearing Aid

Device to amplify sound so the patient can ear better  Advantage: Avoid the risk of surgery  Disadvantage: Patients may nd it troublesome to carry a device around. May be cosmetically unappealing.

DOHNS OSCE Home / Courses / DOHNS OSCE Surgery (Stapedotomy)

An operation to remove the diseased ear bones, and reconstruct hearing mechanism with plastic/metal prostheses. All modern prosthesis would not be affected by MRI scan or airport scanner, should you need one in future.

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 DOHNS Advantages: Powered by Pass 1. May not require hearing aid if hearing level acceptable following the operation. 2. If one ear affected, the operation may help to locate the direction of the sound and hear better in a noisy background. 3. If Both ears affected, the operation will be done on the poorer ear. May still need hearing aid on the opposite ear.  Disadvantages: 1. Risk of worsening hearing or total hearing loss if the inner ear is damaged (1%). 2. Dizziness (usually temporary, very rarely dizziness is prolonged) 3. Taste disturbances (taste nerve runs close to the eardrum) 4. Worsening of tinnitus. Operation is done under general anaesthesia which you will be asleep and feel no pain during the operation. The operation usually lasts for 1 hour. A cut would be made at ear opening or inside the ear canal. There would be packing material in the ear after the operation. Success rate: 80% in the hands of experienced surgeons.

( C ) Check Understanding

Do you have any doubts? Are you following me right now? Are you clear on what we have discussed so far?

( E ) Explore Hidden Agendas

Do you have any further concern that worries you? (eg Patient may be worried that he/she might have permanent total hearing loss) Readdress I.C.E

( S ) Summary & Closing

Summary:

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DOHNS OSCE ( E ) Explore Hidden Agendas

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Do you have any further concern that worries you? (eg Patient may be worried that he/she might have permanent total hearing loss)

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Readdress I.C.E Home / Courses / DOHNS OSCE

( S ) Summary & Closing

Summary:

In summary, based on our assessment and hearing test, you are having a disorder called otosclerosis. It is a disease Copyright © 2021 Pass DOHNS ® | Credits Powered by Pass DOHNS of ear bones causing hearing loss. There are several treatment options available, including watchful observation, hearing aid and surgery.” “Do you have any further doubts?” I would leave you a patient lea et regarding the condition. On the patient lea et, there are contact details of our clinic. Please do not hesitate to contact us if there is any inquiry or you need any assistance. I will be glad to arrange a meeting with your family if you prefer so. If there is any doubt that you would like to have our consultant explain to you, I can arrange an appointment with him. Follow up plan: Shall we meet 2 weeks from now, say 20th of January to review your condition. Thank you and wish you well.

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Explanation Station 2 (Detailed guide)

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Congrats! You have completed "Explanation Station 1 (Detailed guide)".

EXPLANATION STATION 2 (DETAILED GUIDE)

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A 50-year-old gentleman has been diagnosed with acoustic neuroma. Please explain the condition and answer his questions. Home / Courses / DOHNS OSCE Time: 7 Minutes.

(I) Introduction

Good morning, my name is _______, a 3rd year ENT doctor.

Copyright © 2021 Pass DOHNS ® | Credits Powered by Pass DOHNS  Con rm patient’s May I con rm your name and Date of Birth (DOB) name & DOB – Nice to meet you

(C) Consent

I am here today to speak to you regarding the scans you have done recently, is it alright to discuss it right now?

(E) Environment

 “First and foremost, are you comfortable on where you sitting right now?”

Consideration

 “May I know whether you have brought anyone with you today?”  “Would you prefer to have a family member/friend or nurse specialist to be here with you?”

(P) Perception

 “How are you doing so far?” (Building rapport)  “Just a quick recap, could you describe to me what brought you to the clinic at the beginning?” (Brief history taking of chief complaint, do not waste too much time dwelling on it) Explore I.C.E

Idea

Could you bring me up to speed on what you understood regarding your condition so far?

Concern

Do you have any concern that you are worried about?

Expectation

Mr / Ms _____, before I began to explain to you regarding your scans report, may I ask how do you handle medical information? Do you prefer the details of the medical condition/treatment?

(I) Inform & (E) Explain

Explain the anatomical structure (Using relevant diagram) Our ear is divided into outer, middle, and inner ear. In the inner ear, there are 2 main components; cochlear which involves in hearing, and vestibule, our balancing system. Cochlear is a snail-shaped chamber with uid, sound waves are converted to electrical signal and travel along a nerve to the brain. Explain the condition Initial hearing tests have shown that you having a type of hearing impairment called sensorineural hearing loss, lti

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involves in hearing, and vestibule, our balancing system. Cochlear is a snail-shaped chamber with uid, sound waves are converted to electrical signal and travel along a nerve to the brain.

Explain the condition

DOHNS OSCE Initial hearing tests have shown that you having a type of hearing impairment called sensorineural hearing loss, resulting from problem arising from inner ear or the nerve connecting to the brain. Therefore, MRI scan was done to Home / Courses / DOHNS OSCE detect any structural abnormalities of it.  “Do you have any idea what the scan might reveal?” The ® recent MRI scan showed that having a growth at the nerve for balancing, called Acoustic Neuroma. It is Copyright © 2021 Pass DOHNS | Credits Powered by you Passare DOHNS most commonly present as hearing loss at the side of growth, as it compresses the nerve which is responsible for hearing. Possible questions from the patient 1. Is this cancer? This is not a cancerous tumour, it will not spread to other parts of the body. 2. Why am I having this condition? Acoustic Neuroma is uncommon, and the cause of most cases is unknown. About 7 out of 100 Acoustic neuromas are associated with a rare genetic disorder called Neuro bromatosis Type 2. However, this condition often presents as growth on both side of the nerve, along with other presentations. 3. Am I Dying? No, this tumour grows very slowly, about 1 – 2mm per year. It has likely been there for many years, only present now when it reaches a certain size. As it is not cancerous, it will not spread to other parts of the body. 3. Do I need further testing? Acoustic neuroma is mainly detected via imaging scan following initial hearing assessment. Further testing is often not needed. Relate patient’s symptoms to the disorder As acoustic neuroma grows on the nerve for balancing, it may affect the adjacent hearing nerve. This is responsible for the hearing loss of your affected ear. This may have  happened over many years before you realised the symptoms. It can also cause symptoms including ringing sound in the ear, dizziness, imbalance problems, when walking numbness of the face, and headache if the tumour has grown considerably huge after many years.

Explain treatment options Next, you will be meeting a team of specialists consisting of brain surgeon and ENT surgeon. Most likely they would offer the following options:

1

Observe & wait

2.

Radiation therapy (stereotactic radiosurgery)

With yearly surveillance scanning Can be done if the tumour size is small (