Amc handbook of clinical assessment 2007

Table of Contents
Foreword — Joanna M Flynn ix
Preface — Roger J Pepperell x
Contributors xi
Editorial Committee
Additional Contributors
Acknowledgements xvii
Introduction — Vernon C Marshall 1
Role of the Australian Medical Council (AMC) — Ian B Frank 9
Construction, Scoring and Validation of Assessments — Neil S Paget 25
The AMC Multidisciplinary Clinical Assessment Task (MCAT) Format 31
— Heather G Alexander
How to Use this AMC Handbook of Annotated MCATs — Vernon C Marshall 34
MCAT Format Example: Candidate Information and Tasks, Performance
Guidelines 37
001 A cut to the thumb of a 22-year-old man
MCAT Candidate Information and Tasks, MCAT Performance Guidelines; 44
Five Principal Categories and Domains
1 CLINICAL COMMUNICATION (C) 45
• 1-A Communication, Counselling, and Patient Education 45
— Introduction: Alan T Rose
~ MCAT Candidate Information and Tasks 002-021 51-67
~ MCAT Performance Guidelines 002-021 68-130
CIT PG
DETAILS OF MCAT SCENARIOS
002 Advice on breastfeeding versus bottle-feeding for a 28-year-old
pregnant woman 53 69
3 Advice on neonatal circumcision for a couple expecting their first child
53 72
54 75
55 77
56 79
57 81
58 84
58 87
59 90
60 92
61 95
4 Suspected hearing impairment in a 10-month-old child
5 Counselling a family after sudden infant death syndrome (SIDS)
6 Hair loss in a 38-year-old man
7 An unusual feeling in the throat in a 30-year-old man
8 Pain in the testis following mumps in a 25-year-old man
9 Contraceptive advice for a 24-year-old woman
10 Rape of a 20-year-old woman
11 Cancer of the colon in a 60-year-old man
12 Thalassaemia minor in a 22-year-old woman
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ii
13 Pre-pregnancy advice to a 28-year-old woman with previous
thromboembolism
14 Pre-pregnancy advice to a 24-year-old woman with Type 1
diabetes mellitus
15 An anencephalic fetus diagnosed at 18 weeks gestation in a
25-year-old primigravida
16 A duodenal ulcer found on endoscopy in a 65-year-old man
17 Advice on autologous blood transfusion to a 55-year-old man
awaiting elective surgery
18 Advice on stopping smoking to a 30-year-old man
19 Excessive alcohol consumption in a 45-year-old man
20 Type 1 diabetes mellitus in a 9-year-old boy
21 Request for vasectomy from a 36-year-old man
1-B Case presentations and summaries to Examiner
— Introduction: Vernon C Marshall
022-029 Headache, neck lump, previous shoulder dislocation,
dysphagia, low back pain, knee pain, abdominal discomfort, gastric
ulcer with haemorrhage
62 99
131
132-135
2 CLINICAL DIAGNOSIS (D)
2-A The Diagnostic Process — History-taking and Problem-Solving
— Introduction: Reuben D Glass
~ MCAT Candidate Information and Tasks 030-043 ~
MCAT Performance Guidelines 030-043
30 Jaundice in a breastfed infant
31 A convulsion in a 14-month-old boy
32 Loud and disruptive behaviour of a 6-year-old boy
33 Tremor in a 40-year-old man
34 Headache in a 35-year-old woman
35 Lethargy in a 50-year-old woman
36 Syncope in a 52-year-old man
37 A painful penile rash in a 23-year-old man
38 Primary amenorrhoea in an 18-year-old woman
39 A skin lesion on the cheek of a 50-year-old man
40 A pigmented mole on the trunk of a 30-year-old woman
41 An itchy rash on the hands of a 19-year-old woman
42 Red painful dry hands in a 30-year-old bricklayer
43 Swelling of both ankles in a 53-year-old woman
137
137
142 -154
155 -195
143 156
144 159
144 161
145 164
145 167
146 170
147 173
148 177
149 180
150 182
151 184
152 186
153 189
154 191
62 102
63 105
64 108
65 111
65 115
66 121
67 125
67 129

CIT PG
• 2-B Physical Examination 196
— Introduction: Vernon C Marshall and Barry P McGrath
~ MCAT Candidate Information and Tasks 044-057 218 -23
3
~ MCAT Performance Guidelines 044-057 234 -29
6
044 Assessment of a comatose patient 219 235
045 Recent onset of poor distance vision in a 17-year-old male 220 241
046 A painful rash on the trunk of a 45-year-old child-care worker 221 246
047 Acute low back pain and sciatica in a 30-year-old man 222 248
048 Fever and a recent rash in a 30-year-old man 223 252
049 A heart murmur in a 4-year-old boy 224 255
050 A knife wound to the wrist of a 25-year-old man 225 257
051 Multiple skin lesions in a Queensland family 226 264
052 Subcutaneous swelling for assessment 228 274
053 Examination of the knee of a patient with recurrent painful
swelling after injury 229 280
054 Assessment of hearing loss, first noted during pregnancy in a
35-year-old woman 230 282
055 Examination of a 20-year-old woman who dislocated her
shoulder 6 months ago 231 286
056 Assessment of a groin lump in a 40-year-old man 232 289
057 Eye problems in an aboriginal community 233 293
• 2-C Choice and Interpretation of Investigations 297
— Introduction: Reuben D Glass and Vernon C Marshall
~ MCAT Candidate Information and Tasks 058-064 312- 319
~ MCAT Performance Guidelines 058-064 320- 342
058 Positive test for hepatitis C in a 26-year-old woman 313 321
059 Diagnosis of 'brain death' prior to organ donation 314 325
060 Breast biopsy concerns in a 20-year-old woman with a family
history of breast cancer 315 329
061 An elbow injury in an 11-year-old schoolgirl 316 331
062 Sudden onset of chest pain and breathlessness in a
063 Atypical ureteric colic in a 25-year-old man 318 337
064 Investigation for male factor infertility in a 25-year-old man 319 340
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2-D The General Consultation 343
— Introduction: Barry P McGrath
065 Acute chest pain in a 60-year-old man 348 356
066 Palpitations and dizziness in a 50-year-old man 349 363
067 Muscle weakness and urinary symptoms in a 60-year-old man 350 368
068 Aches and pains in a 62-year-old man 351 371
069 Lack of energy in a 56-year-old suntanned man 352 374
070 Recent haematemesis in a 50-year-old man 352 377
071 Anaemia in a 28-year-old pregnant woman 353 380
072 Acute vertigo in a 50-year-old man 353 383
073 Urinary frequency in a 60-year-old man 354 394
2-E The Paediatric Consultation 397
— Introduction: Peter J Vine
74 Neonatal jaundice in the first day of life 402 405
75 Immunisation advice to the parent of a 6-week-old baby 402 408
76 Dark urine, facial swelling and irritability in a 5-year-old boy 403 412
77 Fever and sore throat in a 5-year-old boy 403 414
2-F The Obstetric and Gynaecologic Consultation 417
— Introduction: Roger J Pepperell
— MCAT Performance Guidelines 078-082 423-435
78 Breech presentation in labour at 38 weeks in a 25-year-old woman 420 424
79 Vaginal bleeding in a 23-year-old woman 420 427
80 Cessation of periods in a 30-year-old woman on the oral
contraceptive pill (OCP) 421 430
081 Positive culture for Group B streptococci (GBS) at 36 weeks of
gestation in a 26-year-old woman 421 432
082 Vaginal bleeding after 8 weeks amenorrhoea, in a woman with
previous irregular cycles 422 434
2-G The Psychiatric Consultation 436
— Introduction: Frank P Hume
iv

CIT Pfi
083 Medication changes for a 35-year-old woman with chronic
schizophrenia 447 456
084 Demand for urgent treatment for 'sudden hair loss' from a
29-year-old man 448 459
085 Poor work performance in a 30-year-old female police officer 449 463
086 Lifestyle stress in a 45-year-old man 450 466
087 Binge drinking in a 25-year-old man 452 470
088 Nausea, headache and feeling 'jittery' in a 30-year-old bank clerk 453 474
089 Collapse of a 30-year-old woman on the way to a court attendance 454 478
3 CLINICAL MANAGEMENT (M) 483
• 3-A Management Objectives, Therapeutics, Prevention and Public Health 483
— Introduction: Alan T Rose, Michael R Kidd and Ronald McCoy
~ MCAT Candidate Information and Tasks 090-100 489- -498
~ MCAT Performance Guidelines 090-100 499- -536
090 Acute right sided pain and haematuria in a 25-year-old man 490 500
091 Faecal soiling in a 5-year-old boy 491 503
092 Psoriasis in a 30-year-old man 492 507
093 Temporal arteritis in a 58-year-old woman 493 510
094 Acute idiopathic facial nerve palsy ('Bell Palsy') in a
095 Dysuria and urinary frequency in a 40-year-old man 495 519
096 Eclampsia in a 22-year-old primigravida at 38 weeks of gestation 496 522
097 An abnormal glucose tolerance test (GTT) in a 34-year-old
primigravida 496 525
098 Bed-wetting by a 5-year-old boy 497 528
099 Acute gout in a 48-year-old man 497 531
100 Request for repeat benzodiazepine prescription from a
• 3-B Clinical Procedures 537
— Introduction: Peter G Devitt and Barry P McGrath
~ MCAT Candidate Information and Tasks 101-104 543- -547
~ MCAT Performance Guidelines 101-104 548- -563
101 Resuscitation of a 24-year-old man after head and chest injury 544 549
102 Fluid balance assessment in a 50-year-old patient after
abdominal surgery 545 551
103 Evaluation of lung function by spirometry in a 22-year-old man 546 558
104 A suspected fractured clavicle in a 20-year-old man 547 561
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CIT PG
INTEGRATED DIAGNOSIS AND MANAGEMENT (D/M) 565
4-A Clinical Perspective and Priorities 565
— Introduction: Bryan W Yeo
~ MCAT Candidate Information and Tasks 105-112 570 -577
~ MCAT Performance Guidelines 105-112 578 -600
105 Abdominal pain and vaginal bleeding after 9 weeks amenorrhoea,
in a 39-year-old woman 571 579
106 Recent insomnia in a 25-year-old man 572 582
107 Dandruff or head lice in a 6-year-old girl? 573 585
108 Recent orchidectomy for a testicular neoplasm in a
109 Postnatal fatigue and exhaustion in a 28-year-old woman 575 589
110 Fundus greater than dates in a 26-year-old woman at
30 weeks gestation 575 593
111 Tiredness and anaemia in a 55-year-old woman 576 596
112 Colonoscopy findings in a 24-year-old man with chronic diarrhoea 577 599
4-B Life-threatening Emergencies — Priorities of Treatment 601
— Introduction: Bryan W Yeo
~ MCAT Candidate Information and Tasks 113-118 602- 608
113 A severely ill 4-month-old baby girl with fever 603 610
114 A lethargic febrile 2-year-old boy with a rash 604 612
115 Wheezing and breathing difficulty in a 5-year-old girl 605 614
116 Cuts to the wrist of a 25-year-old man 606 618
117 Severe postpartum haemorrhage in a 25-year-old primigravida 607 622
118 Emergency management of a snake-bite in a 20-year-old man 608 625
LEGAL, ETHICAL AND ORGANISATIONAL (LEO) 628
5-A Ethical and Legal Dilemmas 629
— Introduction: Kerry J Breen
~ MCAT Candidate Information and TasKS 119-124 633- 639
119 A man requesting disclosure of his wife's medical condition 634 641
120 Obtaining consent for leg amputation in a 35-year-old man after
a motor vehicle injury 635 644
121 Several bone fractures in a 9-week-old baby 636 647
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CIT PG
122 A parent requesting sterilisation of her intellectually disabled
daughter 637 649
123 Blood transfusion consent for a 33-year-old pregnant woman
with severe APH at 7 months 638 652
124 End-of-life request from a terminally ill patient 639 655
MCAT TRIAL EXAMINATIONS 661
• Preparatory Instructions 661
— Roger J Pepperell
16 Station Trial Assessment
~ MCAT Candidate Information and Tasks T1-T16 664 -678
~ MCAT Performance Guidelines T1-T16 679 -730
DETAILS OF MCAT TRIAL ASSESSMENTS
125 [T1] Meconium staining of liquor in labour in a 25-year-old
primigravida 665 680
126 [T2] A heart murmur in a 5-year-old girl 666 683
127 [T3] Vigorous vomiting by a 3-week-old boy 667 685
128 [T4] Urinary incontinence in a 50-year-old woman 668 688
129 [T5] Migraine in a 30-year-old woman 668 691
130 [T6] Past history of hip dislocation in a 35-year-old man 669 694
131 [T7] Tiredness in a 45-year-old man 670 696
132 [T8] Review of lung function tests in a 65-year-old man with
shortness of breath 671 700
133 [T9] Assessment of a 28-year-old primigravida at 34 weeks
with fundus less than dates 672 705
134 [T10] Delirium in a 25-year-old man after a burn injury 672 708
135 [T11] Chronic diarrhoea in a 45-year-old man 673 712
136 [T12] Fever, irritability and ear discharge in a 2-year-old boy 674 716
137 [T13] Review of cytology after aspiration of a breast lesion in a
138 [T14] Nocturnal hand discomfort in a 35-year-old schoolteacher 677 721
139 [T15] An attack of asthma in a 25-year-old man 677 724
140 [T16] Preparing a 30-year-old woman with suspected acute
appendicitis for surgery 678 728
8 Station Trial Retest Assessment
~ MCAT Candidate Information and Tasks R1-R8 732 -739
~ MCAT Performance Guidelines R1-R8 740 -765
DETAILS OF MCAT TRIAL RETEST ASSESSMENTS
141 [R1] Intravenous cannula insertion for antibiotic prophylaxis 733 741
142 [R2] Heartburn in a 35-year-old man 734 744
143 [R3] Spontaneous bruising and nosebleed in a 3-year-old boy 735 748
Vii

CIT PG
144 [R4] Nausea and vomiting in the first trimester in a 25-year-old
primigravida
736 750
145 [R5] Visual difficulties in a 50-year-old man 736 753
146 [R6] Cognitive state assessment of a 50-year-old barman 737 756
147 [R7] Jaundice in a 25-year-old man 738 760
148 [R8] Assessment of prominent leg veins in a 38-year-old woman 739 763
INTERACTIVE CLINICAL ASSESSMENT — OTHER METHODS AND OSCE
MODIFICATIONS
767
— Peter G Devitt and Heather G Alexander
149 Confusion and delirium after surgery in a 50-year-old man 771 773
150 Postoperative fever in a 45-year-old woman
151 The 4 station progressive OSCE
771 776
779
GLOSSARY OF TERMS AND ABBREVIATIONS 781
EPONYMS 790
APPENDICES
1. AMC Objectives of Medical Education 803
2. AMC Instructions to Standardised Patients and Clinical Examiners 806
3. MCC/AMC Clinical Task Categories; AMC Function/Process;
System/Region/Speciality; and Discipline classification
810
MCATs with full Domain listing and AMC Anthology Reference 814
MCATs by Discipline (Condition and page listings only) 843
MCATs by System/Region/Speciality (Condition and page listings only) 847
MCATs by Function/Process (Condition and page listings only) 856
Suggested Additional Groupings of MCATs for self-test trial assessments 862
Guidelines for further reading 863
EPILOGUE 867
INDEX 868
Viii

The AMC Multidisciplinary Clinical
Assessment Task (MCAT) Format
Heather G Alexander
The student is to collect and evaluate facts. The facts are locked up in the patient. To
the patient, therefore, the student must go.'
Abraham Flexner (1866-1959)
Medical Education, a Comparative Study
The MCAT is an integrated OSCE-style clinical examination where each candidate
proceeds through the same number of stations — 16 stations in the full exam, 8 stations in
the retest.
CONTENT OF STATIONS
At each station, two minutes are allocated for preliminary reading outside the room. An
instruction sheet giving the candidate specific information and tasks required is provided.
This introduces the candidate to the consultation setting and clinical situation. It may also
include patient profile test results or an illustration. Specific tasks that the candidate will be
asked to perform are itemised. A duplicate copy of the instructions is provided in the
examination room.
This is followed by eight minutes performing the required task in a room
with a standardised patient. When the candidate first enters the room, the
observing examiner will check that the instructions for the station have
been read and will then introduce the candidate to the patient. The
examiner will then observe the performance and record the
candidate's performance on a tailored mark sheet. The standardised
patient may be a real patient or a simulated patient (role player) who
plays the role of either the patient or a relative. Doctor-patient
communication performance contributes to the assessment and requires
a well-trained role player. Where scenarios are based on physical
examination, the 'role player' may be a real patient.
The aims of the
station, the tasks
that candidates are
askedtoperform,
the key issues and
assessment
domainsdefined
for the station are
allcloselyaligned.
031
FIGUREIII.
History-taking
FIGUREiv.
CommencingthePhysicalExamination
The aims of the station, the tasks that candidates are asked to perform, the key issues
and assessment domains defined for the station are all closely aligned.

032
The MCAT scenarios developed for assessment purposes are designed to simulate closely real
life situations within medical consultations. These may be in a general practice setting, a hospital
emergency department, or a hospital inpatient or outpatient setting. Scenarios deal with different
phases of illnesses. Diagnostic scenarios include the diagnostic phases of history taking, physical
examination, and ordering and interpreting investigations. The management phases incorporate
patient explanation and education, advice and referral, therapeutics and preventive medicine,
clinical procedures and counselling. Scenarios are focused precisely so that the assessment
domains, key issues and critical errors are accurately related to the station aims and the tasks set
down in the candidate's instructions.
Members of the AMC clinical examination panel suggest MCAT clinical scenarios based on their
prevalence, seriousness, preventability and whether they can be simulated as real life situations
within the inherent time constraints. Scenarios are thoroughly reviewed and approved by the
multidisciplinary clinical panel prior to use. The current 16 or 8 station MCAT formats cover a
broad spectrum of skills in clinical medicine, psychiatry, surgery, obstetrics/gynaecology, and
paediatrics, including emergency, hospital and community practice medicine.
MCAT MARKING
In an MCAT, candidates are assessed at the level of a final year medical student, i.e. a doctor
about to commence an intern year (PGY1).
Mark sheets for examiner use.
The examiner scores the candidate's performance on a mark sheet which specifies the
assessment domains, key domains, and critical errors if appropriate. The assessment domains
match the tasks outlined on the instructions the candidates receive during the two minutes
preliminary reading.
The marking domains are identified from among a total of 14 covering:
• approach to patient and responses to patient's questions;
• patient counselling and education;
• history-taking;
• physical examination choice and technique;
• physical examination accuracy;
• choice of investigations;
• interpretation of investigations;
• diagnosis and differential diagnosis;
• initial management plan;
• explanation of clinical procedure;
• performance of clinical procedure;
• familiarity with test equipment;
• commentary to examiner; and
• answers to examiner's questions,
No single station is likely to have assessment in more than five of these domains.
Each domain has a 4-point marking scale:
• Very satisfactory Clear pass
• Satisfactory Pass
• Unsatisfactory Fail
• Very unsatisfactory Clear fail

033
An example mark sheet is included later with the example MCAT 001. (see page 44)
Critical errors are defined and derived from one or more of the key issues, when relevant. Not
all stations have critical errors. If the candidate makes a critical error the candidate is very likely to
fail that station, regardless of performance in other domains, unless performance in other
domains is outstanding and the critical error is deemed possibly related to lack of time or
misunderstanding of the task. MCAT performance is checked and reviewed by the Clinical Panel
of Examiners after each use in an examination. All details, particularly presence and definition of
critical errors, are reassessed and retained or modified in light of candidate performance and
examiner feedback.
Station failure would probably result from two or more 'unsatisfactory — fail' assessments or one
'very unsatisfactory — fail' assessment in a key issue domain, or from making a critical error in a
key issue domain.
After scoring each of the domains, the examiner will provide an overall (final) rating that is either
'Pass' or 'Fail' for each station.
All 16 MCAT scenarios are of equal weighting and for each scenario there are only two outcomes
— pass or fail. Candidates must obtain a pass in 12 or more of the 16 stations, including a pass in
at least one paediatric and one obstetric/gynaecology station, to pass the MCAT as a whole.
Candidates scoring pass levels in nine or less of the 16 stations, or with failures in all three of the
paediatric or obstetric/gynaecology stations, fail the examination and must resit.
Candidates who pass 10 or 11 of the 16 stations (including a pass in at least one obstetric/
gynaecology station and one paediatric station) will be eligible for a pass/fail Retest Examination
of 8 stations. Retest candidates will be required to pass six or more of the eight retest stations to
pass the examination. Candidates scoring five or less passes will fail and be required to resit the
whole examination.
Heather G Alexander
July 2007

034
How to use this AMC Handbook of
Annotated MCATs
Vernon C Marshall
'In what may be called the natural method of teaching the student begins with the
patient, continues with the patient, and ends his studies with the patient, using books
and lectures as tools, as means to an end.'
Sir William Osier (1849-1919)
The MCAT self-test scenarios are arranged in groups under the principal categories and
domains tested. In each instance the reader is provided with a synopsis heading, outlining
the clinical problem/condition together with the information available to the candidate and
details of the task to be undertaken, exactly as this appears in the MCAT examination.
INSTRUCTIONS TO CANDIDATES
You may wish to attempt to complete the tasks in each of the major categories before
moving to the next group. If you would prefer to review tasks by system and region, or by
discipline, the appropriate groupings of these are listed in later pages. Page numbers of
individual MCATs are listed in the table of contents at the beginning of the book for easy
reference.
After reading carefully the information provided to you for each clinical scenario and the
required tasks, jot down how you will approach this consultation, how you will advise the
patient or relative of your findings and recommendations, and how you would structure
responses to queries from patient or examiner. Then turn the pages to check your
responses against the optimum Performance Guidelines, Examiner Instructions and
Commentaries. Note the station Aims, Key issues and Critical Errors outlined.
In this book the scenarios are grouped into five main categories. The groupings are to some
degree artificial in that communication skills are relevant to all scenarios. For example,
aspects of diagnosis, management, and patient counselling and education are frequently
combined to varying degree, but the groupings are arranged to emphasise and categorise
the principal domains even though most scenarios are assessed over multiple domains.
The five groupings below condense the total of 14 domain assessments into five categories
covering skills principally in:
1. Clinical Communication (C) — with patient, relative and observer, and including a
number of domains: approach to patient, patient counselling/education, history-taking,
commentary to examiner, answers to patient's or examiner's questions, explanation of
procedure, case presentation and summary.
2. Clinical Diagnosis (D) — includes history-taking, technique and accuracy of physical
examination, choice of investigations and their interpretation, diagnosis/differential
diagnosis.
3. Clinical Management (M) — includes initial management plan, performance of
procedure/task, treatment and prevention of disease, clinical procedures.
4. Integrated Diagnosis and Management (D/M) — includes clinical perspectives and
priorities, life-threatening emergencies, integrative reasoning skills and clinical
problem-solving.
5. Legal, Ethical and Organisational (LEO) — includes scenarios where ethical and legal
issues are significant.

INTRODUCTORY GUIDELINES for candidates (see Table below)
are provided at the start of each of the main categories and their
domains.
After completing individual case scenarios you may find it helpful to
revise your knowledge of similar and linked conditions by referring
to appropriate clinical texts and references. The AMC Anthology of
Medical Conditions contains other self-test strategies for individual
conditions.
Try making up your own variations on the conditions tested, and
practise role playing and interactions with a colleague or in a group.
Once you are familiar with the mechanics and time constraints,
pace yourself through the trial examinations (one containing 16
stations and one containing 8 multi-disciplinary stations), and the
other suggested groupings provided later in the book, under
simulated examination conditions.
The Editorial Committee hopes you find the examples helpful and
extends its good wishes for a successful assessment.
The MCAT self-test
scenarios are arranged
in groups under the
principal categories
and domains tested. In
each instance the
reader is provided with
a synopsis heading,
outlining the clinical
problem/condition
together with the
information available to
the candidate and
details of the task to be
undertaken, exactly as
this appears in the
MCAT examination.
SCENARIO HEADINGS FOLLOWED IN THE AMC HANDBOOK OF CLINICAL
ASSESSMENT
The MCAT scenarios and performance guidelines are set out in a standardised sequence as
follows. Groups of self-test candidate information and tasks are arranged under principal
categories and domains tested.
Table 3 MCAT Introductory Guideline Scenario Headings
CONDITION
AND ID
NUMBER
A generic and non-diagnostic summary of the presenting symptom,
physical sign or investigation result in diagnostic-type cases, such as:
• Assessment of acute abdominal pain in a 30-year-old woman.
• Assessment of a vesicular rash in a 50-year-old man.
• Review of liver function test results in a 50-year-old manwith
jaundice.
The diagnosis or most likely diagnosis in management/counselling-type
cases, such as:
• Management of shingles ('herpes zoster') in a 25-year-old
woman.
• Counselling the relative of a patient after recent major surgery.
CANDIDATE
INFORMATIO
N AND
TASKS
Under this heading the background information and tasks are given
precisely as they appear in the MCAT examination.
Page references to the matching Performance Guidelines are given at
the foot of each Candidate Information and Tasks sheet.
YOURTASKSARETO: Lists requested tasks for candidates.
035

036
Performance guidelines follow in similar category and domain groups linked to the preceding scenarios by ID
number and page reference.
PERFORMANCE GUIDELINES
CONDITION AND Principal category and assessment domains in detail; and
ID NUMBER classitication by function, system/region and discipline (see
Appendix 3) are listed for each station just prior to the index.
AMC Anthology of Medical Conditions reference is listed to aid further self-testing. The MCC/AMC
Clinical Task Category is also listed.
AIMS OF STATION A brief outline of station and assessment aims, matching the tasks. The
expected responses and levels of performance required to complete the
tasks successfully are outlined in the examiner instructions and
commentaries.
EXAMINER
INSTRUCTIONS
These provide the following:
Instructions from examiner to standardised patient
Candidate information and tasks and role player instructions are detailed
and provided to examiners and standardised patients so that there is
standardised behaviour across multiple patients. Cues assist in directing the
consultation pathway. The instructions are set out using lay terminology to
maintain realism, and outline:
• Clinical setting — hospital emergency department, hospital ward
or outpatient department, primary care facility, community practice
office consultation.
• Clinical situation — description of illness and symptoms and
phase of the consultation.
• Patient profile — age and gender, past history, family history,
habitus, as relevant to the case.
• Opening statement — one sentence provided as the patient's
opening gambit.
• How to play the role — advice on further responses, posture,
gestures, affect, mood and ways to react to the doctor, including
where the task is a physical examination.
Questions to be asked by patient/role player — set down in a loose
priority and which will depend on whether these have already been covered
by the doctor/candidate. Any examiner questions or prompts to the
candidate are also outlined, with the required responses.
EXPECTATIONS
OF CANDIDATE
PERFORMANCE
These are clarified for the examiner and match the tasks and the
domains.
KEY ISSUES These are selected from the assessment domains and expectations of
candidate performance for each case and highlighted accordingly.
CRITICAL ERROR(S) These list significant errors likely to lead to a fail performance.
COMMENTARY This discusses and comments further on the condition, highlighting
performance standards and common errors.

EXAMPLE CASE SCENARIO:
The following case scenario exemplifies the formatting for a combined Diagnosis and
Management MCAT.
037
MCATFORMAT EXAMPLE: Sample - Condition 001
CandidateInformationandTasks
Condition 001
A cut to the thumb of a 22-year-old man
You are the Hospital Medical Officer (HMO) in a hospital Emergency Department.
The patient injured his left thumb at work an hour ago. He is aged 22 years and works
as an orchard labourer and fruit picker. He is right handed. He was pruning fruit trees
today and the pruning knife slipped and he cut his left thumb. He was wearing cotton
gloves. The knife cut through the glove and cut the thumb as shown in the illustration
below. Bleeding was minor and controlled by a pressure dressing, which has been
removed for examination.
The wound appears as a linear knife cut as shown, the edges of which have sealed
after the initial bleeding which has now stopped.
YOUR TASKS ARE TO:
• Examine him and assess the injury.
• Explain to him the nature of the injury and your recommended management.
You may ask other questions of the patient as you proceed with the examination and
explanation.
Near the end of the eight-minute time allotted for your task, the examiner will ask
you one or two questions.
CONDITION001.FIGURE1.
Knifewoundtotheleftthumb
The Performance Guidelines for Condition 001 can be found on page 40

038
Sample-Condition 001
Candidate Information and Tasks
CANDIDATE ADVICE
You should:
Prepare and document your responses and how you would approach this task. Test
yourself thoroughly after reading the MCAT Candidate Information and Tasks, before
proceeding to read the performance guidelines, examiner and patient instructions and
commentary which you will find on subsequent pages.
Follow a similar process for the other MCATs. The best way to develop proficiency in an
MCAT assessment is to work in pairs or as a group. Your colleague reads the performance
guidelines and plays the patient/relative, while you read the candidate information and
perform the tasks, while another group member takes the role of examiner/observer.
SUMMARY OF STUDY TASKS
Read the candidate information and task(s), preferably working with a colleague or
group.
Formulate and document a logical approach for responding to and solving the consultative
problem given.
Then read the performance guidelines that follow, and note the aims of the station,
expectations of your knowledge and performance, key issues and critical errors
and other points raised in the commentary. Check for any deficiencies in your performance.
Reread the introductions to the section in which the MCAT appears.
For this MCAT about a thumb wound, revise your knowledge of applied surface anatomy
relevant to wounds giving risk to underlying structures and how you should check for local
and distal effects of injury. Construct alternative scenarios for other wounds and self-test
yourself on these (for example, injuries to radial nerve in the arm, common peroneal nerve
in the leg). Revise the Anthology scenarios 113, 113H, 113J and 113K and complete the
self-test exercises.
Reinforce your understanding of the condition by completing other self-assessment tasks
(for example from the AMC Anthology of Medical Conditions) and construct at least one
other related task for solving.
Finally, one complete MCAT 16 station assessment and one complete MCAT eight station
assessment are provided later in the book as examples of whole examinations for trial.

039
Sample-Condition 001
Additional groupings of MCATs into further self-test trial examinations are also suggested at
the end of the book. MCATs are also grouped into one of the principal disciplines of
medicine, obstetrics/gynaecology, paediatrics, psychiatry, surgery if you wish to use the
book in this way. MCATs are similarly grouped into the relevant function and process and
into system/region/specialty. For these latter groups, MCATs are often listed more than
once when they cover more than one system or function.
Pace and test yourself through these.
Keep practising within a group of your peers until fully familiar with the routine. We hope
that you will find the self-discipline and requirements to adhere to logical clinical reasoning
pathways in approaching the wide range of clinical problems selected for this book will
stand you in good stead, not just for assessment examinations, but throughout your
subsequent career.
Vernon C Marshall

040
Sample - Condition 001 MCAT FORMAT
EXAMPLE:
Performance Guidelines
Condition 001
A cut to the thumb of a 22-year-old man
AIMS OF STATION
To assess the candidate's ability to use clinical reasoning skills to diagnose and
manage important injuries associated with skin wounds. In this instance, the knife cut
has severed the two extensor tendons to the thumb.
EXAMINER INSTRUCTIONS
The examiner will have instructed the patient as follows:
The examiner will draw the linear cut with a red marking pen on the role-playing
patient, and show the patient how to respond to requests to bend his thumb and
testing of sensation as follows:
• You have not yet noticed and should not volunteer any information about limitation
of thumb movement, until specifically asked to extend each of the two end joints,
which you are unable to do. Sensation is normal.
• You had a tetanus booster shot about a year ago for a leg graze and were
immunised against tetanus as a child.
Opening statement:
• 'Will it be okay for me to go back to work tomorrow with a dressing over it now it's
stopped bleeding, Doc?'
Other questions to ask:
• If the candidate/doctor diagnoses tendon injury with normal sensation, you will
accept the recommendations for operation, and should ask about the operation
'Will I need an anaesthetic?'
(Appropriate answer — Yes: regional block or general anaesthesia).
• If no mention of a tetanus prophylaxis or antibiotics is made during the interview
you will subsequently ask
'Will I need another tetanus shot?'
(A booster dose of toxoid would be appropriate).
Examiner's questions to candidate:
• At the end of 6-7 minutes, if the candidate has identified that a tendon injury has
occurred, the examiner should ask:
'What are the names of the injured tendons?'
(Extensor pollicis longus [EPL] and extensor pollicis brevis [EPB])
and

041
Sample - Condition 001
'Which joint does each tendon act upon?'
(Interphalangeal [IP] and metacarpophalangeal [MP] joint respectively).
If no tendon injury has been identified just ask:
'If antibiotics are to be given, what would you choose?'
(Broad spectrum cover such as one dose of amoxycillin, cephalosporin or other
antibiotic).
EXPECTATIONS OF CANDIDATE PERFORMANCE
Cuts and stabs of various types commonly present to emergency departments.
Attending doctors must be aware of the anatomy of deeper structures at risk from
injuries at specific sites and the methods of diagnosing such injuries.
Diagnosis of injury to the two main long thumb tendons and recognition of the
treatment requirements for primary surgical repair in this 'tidy' (clean contaminated)
wound.
Explanation of treatment would optimally advise preparation for early surgery
using local (field) block or general anaesthesia.
Antibiotic and tetanus prophylaxis would be appropriate.
KEY ISSUES
Ability to identify deeper tendon injuries resulting from stabs or cuts.
Failure to appreciate that the whole thumb extensor mechanism (involving two
tendons) has been damaged would comprise a fail (unsatisfactory) in the domains
of examination technique and diagnosis.
Failure to name the tendons correctly would not necessarily be a fail performance,
providing the presence of tendon injury was diagnosed and appropriate advice
given in other areas. Failure to mention antibiotic or tetanus prophylaxis would
be unsatisfactory, but would not be considered a critical error in the presence of
a 'tidy' recent wound; such omission would most likely be corrected with
subsequent specialist referral for surgery and anaesthesia.
CRITICAL ERROR
Failure to test and identify the injury to the extensor tendons would comprise a clear
and irremediable fail for this station at a very unsatisfactory level.

042
COMMENTARY
The knife cut has severed the two extensor tendons to the left thumb {extensor pollicis
brew's and extensor pollicis longus, from radial to ulnar side). These tendons form the
margins of the anatomical snuff box as illustrated. The tendons have been severed at
the knuckle level of the metacarpophalangeal joint. The patient has no obvious thumb
deformity but is unable actively to extend either the metacarpophalangeal (MP) joint or
the interphalangeal (IP) joint of the thumb. The digital cutaneous nerves have not
been cut and distal sensation is normal apart from tenderness around the cut.
Extension of the joints of the thumb occurs from the actions of:
• Extensor pollicis longus (EPL) the ulnar-sided of the two thumb tendons running
on the dorsal aspect of the thumb. The long tendon of EPL runs obliquely across
the back of the hand after angulating around the tubercle of the radius (Lister
tubercle) before inserting into the base of the distal phalanx. EPL is the prime
mover and sole extensor of the terminal (interphalangeal) joint. By passing across
the metacarpophalangeal (MP) and carpometacarpal (CM) joints of the thumb.
EPL can also act as an accessory extensor of these joints. EPL, like other
superficial tendons, may be injured by cuts and penetrating injuries.
• Extensor pollicis brevis (EPB) is the lateral of the two thumb extensors. EPB runs
in the same synovial sheath as the tendon of abductor pollicis longus on the lateral
surface of the radius and continues over the dorsal shaft of the metacarpal to
insert into the base of the proximal phalanx. EPB is the prime mover in extension of
the MP joint and an accessory extensor of the CM joint. Cuts around the knuckle of
the metacarpophalangeal joint are likely to sever one or both tendons. In this
patient, both EPL and EPB have been severed.
• Abductor pollicis longus (APL). This stout tendon, often multiple or ridged like a
stalk of celery, inserts dorsolateral^ into the base of the thumb metacarpal. APL is
the prime mover of radial abduction and extension of the thumb at the carpo-
metacarpal joint, separating the thumb from the other digits in the plane of the palm.
In this patient, radial abduction will be unaffected as APL has not been injured.

CONDITION 001. FIGURE 2.
Normal Anatomy — Left hand and thumb
The Examiner mark sheet for MCAT 001 follows.
043

044
Candidate ID card sighted Very Satisfactory - PASS Satisfactory - PASS Unsatisfactory - FAIL Very Unsatisfactory - FAIL
*-■ KEY ISSUE Covers all essential Minor technical Candidate displays
Choice & Technique of Examination, aspects competently □ faults but □ one or more of the
Serious errors or omissions in
technique.
Organisation and Sequence - minimal errors or examination following: CRITICAL ERROR?
Did the candidate carry out an omissions. completed reasonably. - significant omissions
appropriate focused and relevant - significant errors of
examination as per examiner technique
instructions? - poor technique
•-■ KEY ISSUE Identified most or Minor errors in One or more
Accuracy of Examination all findings □ findings. □ significant errors in □ Serious errors or omissions in
findings: reported findings not
Did the candidate identify the accurately. findings. consistent with physical signs
physical findings accurately as CRITICAL ERROR?
per examiner instructions?
•^ KEY ISSUE Covered all essential Minor omissions Significant errors in Diagnosis not given. Serious
Diagnosis/Differential Diagnosis aspects competently □ or errors in □ explanations of
□ omissions or errors in
Did the candidate formulate and - minimal or no errors or explanations of findings. findings. Wrong interpretations of findings.
describe an appropriate diagnosis/ omissions. Logical, clear, Diagnosis and differential interpretations of findings. Clinical reasoning and diagnostic
differential diagnosis as per examiner well organised. diagnosis appropriate to Unclear and poorly skills markedly deficient. Very poor
instructions? the case even if not organised. Diagnosis organisation. Wrong diagnosis could
completely accurate. inappropriate to the ;ase. result in serious harm to the patient.
CRITICAL ERROR?
•-. KEY ISSUE Covered all essential Minor errors but did Significant errors Serious errors or omissions.
Initial Management Plan aspects competently □ not interfere with an □ which did interfere
□ Inappropriate management
Did the candidate formulate and - minimal errors or adequate initial with an adequate and/or management proposed is
describe an appropriate initial omissions. Optimal management plan. management plan. potentially harmful to patient.
management plan as per examiner
instructions?
management plan. CRITICAL ERROR?
Answers to Questions Covered all aspects Minor errors in Significant errors in Serious errors or omissions in
Answers to questions asked by completely, minimal
□ answers to
□ answers to questions the answers given, or complete
examiner? errors or omissions. questions. indicating lack of
knowledge/expertise
these areas.
in unfamiliarity with the subjects asked.
CRITICAL ERROR?
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OVERALL RATING FOR THIS CANDIDATE FOR THIS STATION: PASS FAIL

Clinical Communication (C)
1-A: Communication, Counselling &
Patient Education
Alan T Rose
'Oh, that's your doctor, is it? What sort of a doctor is he?'
Well, I don't know much about his ability, but he's got a very good bedside manner!'
George du Maurier, Punch Cartoon, 15 March 1884.
1-A COMMUNICATION, COUNSELLING AND PATIENT EDUCATION
Communication is the exchange of messages and thoughts by speech, signals or writing.
Communication skills are employed to ensure that exchanges are readily and clearly
understood. Exchanges involve the sharing of information, ideas, emotions, and empathy.
Communication is the foundation on which medical consulting takes shape, supplemented
by the practitioner's skill in physical examination and diagnostic reasoning. Failure of
communication is an important contributor to clinical situations of perceived malpractice
and is the most important factor in a high proportion of medicolegal actions.
Most medical consultations and activities require the doctor and
patient to communicate rationally and effectively with each other.
045
Exceptions are when the patient is an infant or is intellectually
handicapped — communication is then with a relative or carer —
or when the patient is unconscious (including when
anaesthetised) or suffering from certain psychotic states, or
when doctor and patient do not share the same language.
Communication requires special techniques with patients who
are blind, mute, aphonic or aphasic. Impaired hearing may
affect either patient or doctor. The role of the interpreter, when
required, is also critical. Involvement of third parties (such as
relatives, friends, or outside agencies) requires the patient's
consent. In these situations the patient's legal right to
The AMC examination
process places
considerable emphasis
on assessment of
effective communication
between candidate and
patient during clinical
consultations, during
discussions with
relatives, and during
case presentations and
commentaries.
confidentiality and privacy must be respected.
The AMC examination process places considerable emphasis on assessment of effective
communication between candidate and patient during clinical consultations, during
discussions with relatives, and during case presentations and commentaries. Written
communications are important for letters of referral and discharge summaries, but are less
readily assessed within the current AMC format.
Verbal communication depends on a mutual understanding of the language being used
and the way it is articulated. This includes pronunciation, auditory level, speed, tone and
the unique voice qualities and cadences of the speaker. The AMC examination assesses
communication in the English language in a medical and clinical context. English is not the
first language for many IMGs, but all IMGs are required to have adequate clinical communi-
cation skills in English by medical registration boards.

Nonverbal communication (such as facial expression, posture, gesturing, silence, and
emoting) by either doctor or patient, also conveys messages as well as influencing the
understanding of what is being said and its emotional context.
Effective verbal and nonverbal communication in medical practice facilitates the establish-
ment of empathy and rapport, trust and confidence, mutual understanding, education about
the clinical condition, and satisfactory compliance with advice and treatment.
The term 'bedside manner', used to describe a doctor's communication skills, was first
used in a London 'Punch' cartoon by George du Maurier.
Wide variations in clinical communication skills occur because of each individual doctor's
inherent personality traits and individual approach to patients. These can be modified and
improved by education and self awareness, so that time is saved and any frustrations felt
by the doctor or dissatisfaction by the patient are minimised.
Similarly, the cultural characteristics of the patient (and of the doctor) can profoundly affect
the quality of doctor-patient communication. Doctors practising in Australia require
multicultural competence across all fields of medicine. Special care is required in the case of
Aboriginal and Torres Strait Islanders, and for culturally and linguistically diverse groups.
Communication skills, although important, are not sufficient. Good communication skills
must be accompanied by sound clinical skills, attitudes and professional behaviour. The
(fortunately) rare physician serial criminal murderers have usually been superb
communicators.
Other personal factors can interfere with the doctor's use of communication skills. Many
clinical realities are unpleasant to both patient and doctor. If the doctor retreats behind a
professional fagade of a stilted and portentous style of speech, or adopts a pompous or
pretentious attitude, or one interpreted as such, the patient can be daunted from further
enquiry. Rejection by the doctor of a patient's attitude or behaviour engenders lack of
understanding and trust. Value judgements of the doctor are best avoided or concealed.
Care and compassion should be evident but not forced or obtrusive. This is especially
important when treating users of illicit drugs or dependent alcoholics. Mention should also
be made of the so-called 'difficult patient' whose underlying but sometimes unrecognised
personality disorder reduces or eliminates the effectiveness of the communication skills
described below.
The application of communication skills
Effective communication is of most value when taking a history, providing patient education
about the condition diagnosed, giving advice about treatment, counselling patients, and
when discussing the patient's illness with anxious relatives or friends.
History-taking
There are two main methods. Transition from one to the other occurs depending on the
clinical setting and progress of this phase of the consultation. The aim is to define the
presenting problem to a point where the diagnosis moves from possible to probable to
definite.
Firstly, the nondirective or 'open-ended' approach: this allows and encourages patients
to outline the problem ('tell their story') in their own way while the doctor listens with
little interruption. Although apparent irrelevancies may be brought up, this method gives
an opportunity for patients to reveal concerns initially unstated. These concerns may
explain their real reason for attending and why they have come at this particular time.
046

This approach is most useful when the patient is consulting the doctor for the first time
about undifferentiated symptoms such as 'tiredness', 'bloating', 'being run down', 'sleep-
lessness', or 'requesting a checkup'.
Secondly, the directive, closed or interrogative approach: this confines the patient to
the doctor's agenda. This is appropriate in emergencies and, if the problem has already
been well defined, when a patient's progress is being reviewed in followup. The doctor
takes early control of the interview by the use of a series of direct or closed questions.
This approach is well summarised by the traditional term — history 'taking'. The directive
approach risks the omission of significant information, particularly from a patient who is
anxious, reticent, embarrassed, or has feelings of shame or guilt.
Nonverbal communication is very useful in the nondirective approach and can replace some
parts of the verbal component, for example, expressing surprise by facial expression.
Transition from nondirective to directive mode occurs when the doctor begins to ask direct
or closed questions, but the two modes are usually phased or overlap. The type of question
used will change the direction of the interview. Using questions about pain as examples:
open ended 'Tell me about the pain?'
direct Where Is the pain?'
closed 'Have you had this pain before?'
leading 'The pain isn't severe?'
A series of direct or closed questions is usually necessary to complete the history regarding
occupation, past and family illness, domestic habits, medications, allergies and sensitivities,
where relevant.
Facilitation is also a valuable nondirective tool. Facilitation uses nonspecific inviting or
encouraging remarks, for example, 'go on', 'I'm listening carefully', 'tell me more about the
pain', 'anything else?', 7 see', or 'uh uh'.
Listening is an essential basis of communication. Adequate time must be given and the
doctor's nonverbal behaviour should indicate to the patient that the listening is attentive.
Note-taking should be discreet and avoid distraction. The use of a personal computer by the
doctor in the consulting room while taking a history requires, more than ever, that the doctor's
nonverbal behaviour assures patients that they are being 'listened to'. Silence is not the same
as listening. Silence may be the best response when there is an emotional or confrontational
component in the consultation.
Confrontation can defuse an issue ('Wouldn't we progress better if we leave aside for the
moment your previous dissatisfaction with treatment and try to work out how best to fix
things now?') but should be used with care. Frequently initial aggression or anger from the
patient is better deflected in the first instance.
Summarising briefly what the doctor believes the patient has said so far is often useful to
confirm that mutual understanding at that point in the interview is present.
As previously noted, these techniques are modified by the personality and instinctive
behaviour of the doctor, who may not always be fully aware of their effect on a patient. The
perceptive doctor attempts always to appreciate the patient's perspectives as well as the
doctor's own.
In summary, the following guidelines apply to history 'taking' from a patient presenting with
a nonurgent diagnostic problem.
047

Following the formalities (or informalities) of introduction, the doctor should:
• begin with an open-ended approach;
• listen carefully and attentively;
• use facilitation and open-ended questions to encourage the patient;
• limit direct questions early in the interview;
• use indirect and reflected questions as appropriate;
• use direct and closed questions to take control at an appropriate time;
• take note of any display of emotion by the patient and respond appropriately;
• briefly summarise what is being learnt or understood (or not) from the patient;
• gradually increase control of the interview as it proceeds;
• use nonverbal communication, to supplement verbal communication; and
• be alert to the patient's nonverbal behaviour.
With loquacious and garrulous patients, transition from open-ended to direct questioning
needs to proceed expeditiously but tactfully because of time constraints. In many of the
MCAT clinical scenarios, direct questioning is essential to enable a focused history
to be taken within the time period available.
Communication skills are especially important when the patient has concerns other than
those expressed in the first statement to the doctor. Such hidden concerns may include
fears of cancer, heart disease, stroke, blindness, sexually transmitted infection, work
capacity, relationships, serious illness in an unborn child or infant, dissatisfaction with
treatment and feelings of grief or guilt — to mention only a few.
Patient education
Once the diagnosis has been made, it should be stated to the patient using both medical
and lay terminology appropriate to the patient's understanding. Initial reassurance should be
given when appropriate ('I'm pleased to tell you that the biopsy showed no evidence of
cancer'). Failure to do so may allow patient anxiety to block the reception of other information.
Reassurance may be the only therapy that is necessary — unnecessary prescribing may
follow if the doctor has not understood this basic need of the patient for reassurance.
The patient's knowledge and understanding of the condition should then be established so
that education can be pitched at the correct level. This includes the correction of incorrect
beliefs and responses to the patient's questions. The use of a chart, diagram or of printed
notes, may be additionally helpful.
As previously stated, anxiety may reduce the efficiency of absorbing and understanding
information. Patients will also differ in their interest and tolerance of information about their
ailments. Most will want to know if the condition is serious, whether it can be treated, when
they will recover and resume normal activities, and what forms treatment will take, even
though these questions may not be asked directly. Overloading the patient with information
can be counterproductive and have unwanted effects including the creation of pessimism
and anxiety. Further information can be added at a subsequent consultation. Handing out
previously prepared written material is helpful for most patients but is no substitute for
verbal education from the doctor.
Adverse information should be given in such a way so as to not destroy hope, and also to
assure the patient of the doctor's continuing support.
An adequate level of understanding is the only basis on which patients can share the
responsibility of decision-making about treatment and give informed consent. Many patients
048

however still prefer to leave all decisions to the doctor. If thought necessary, confrontation
can be used to bring to the attention of patients their own responsibilities in aiding effective
treatment.
Giving advice about treatment
The wide ranges of treatments, which may be indicated, include giving simple advice,
prescribing, minor or major procedures, the use of allied health professional services,
referral to another doctor or to a hospital service, and counselling. All require the use of
communication skills, either verbal, nonverbal, or written. When counselling is the main
component of treatment, additional special skills are required.
The duration of intended treatment should be advised to the patient and opportunities for
giving preventive advice taken whenever appropriate. This may involve other members of
the patient's family.
Prescribing should be supported by a statement of the name of the medication, which may
also be written down for the patient, the dose and timing, expected effects including the
most important side effects, and significant adverse reactions.
Patients will also wish to know general details about any procedure which has been
recommended, and what to expect when a referral has been made.
Patients should not be left wondering what happens next. Certainty about followup
arrangements, particularly after investigations or referral, should be made quite clear.
Neglect of these can have medicolegal consequences.
Patient Counselling
Counselling is a term widely used in the community to describe the provision of support to
individuals or groups who are experiencing significant emotional stress. Counsellors,
usually with special training in psychological skills, attend survivors or observers of
accidents and disasters and provide support.
Doctors frequently need to give 'bad news' to patients and relatives, and are involved with
bereavement and grieving responses. Allowing patients and relatives to work through their
feelings by means of facilitation and attentive listening, and providing support and
reassurance whenever possible, with unforced compassion and sympathetic
understanding, is required every day in clinical practice.
However, when 'patient counselling' is used in treatment, there are two types: directive and
nondirective. As with other communication skills these may overlap or be used in an
integrated way. However, one type usually predominates according to the clinical situation.
Directive counselling is when straightforward advice or instruction are given to the patient.
In contrast, nondirective counselling is a special communication skill which involves more
than patient education or giving advice about treatment. Its objective is that the patient,
instead of the doctor, is the final decision-maker and shares or accepts, in part or fully,
responsibility for the subsequent course and outcome of the problem. Nondirective
counselling begins with an accurate definition of the problem using the skills outlined under
nondirective history-taking, particularly listening and the use of silence. The doctor then
provides education about the problem including possible outcomes that are likely to follow
alternative forms of behaviour or non-compliance by the patient. Patients are then asked
what course they intend to follow, based on the options that have been discussed. The
process may occur rapidly or may take more than one consultation to work through. It is
essential for the doctor to maintain a nonjudgmental attitude throughout the process.
049

This skill is most useful in dealing with difficult behavioural problems such as smoking,
heavy drinking, eating disorders, drug use, marital problems and when dealing with
anxious parents.
When the use of addictive substances is involved, counselling has shortcomings as do
other techniques, but is always worth using — results can be surprisingly effective.
Assessing communication skills
Communication skills are assessed continuously throughout the whole of every case
scenario and consultation. Other domains are usually assessed in sequential segments
(for example physical examination follows history, diagnosis follows investigations, and so
on). Particular communication skills are also defined within the domains in current use in
the AMC examination. These are:
Approach to patient
• Empathy, comfort, consideration,
• Explanation, using language that the patient understands (no jargon),
• Checking for patient understanding,
• Answering patient's, parent's or relative's questions, and
• Obtaining verbal consent to proceed.
History
• Taking an appropriately focused medical history.
Commentary to examiner
• Describing the findings of physical examination with appropriate commentary; and
• Presenting a case analysis in summary to the examiner.
Diagnosis/differential diagnosis
• Describing an appropriate diagnosis/differential diagnosis plan.
Initial management plan
• Describing an appropriate initial management plan.
Patient counselling/education
• Educating the patient/relative/carer about the condition; and
• Giving appropriate counselling.
Explanation of procedure
• Explaining a procedure and its implications to the patient.
Answering questions asked by the patient or examiner
• Most scenarios include cued questions to the doctor by the patient, parent or relative; and
• Some scenarios have specific prompts or questions from the examiner.
Each of the above domains (plus others such as technique and accuracy of examination -
14 in all) attracts separate assessment by the examiner. The number of domains being
assessed in any individual MCAT rarely totals more than five. Communication skills may
affect performance in all domains. Experienced examiners, who are themselves skilled in
communication, have no difficulty in integrating communication components with those of
knowledge and attitudes and other clinical skills.
050

051
Communication, Counselling
& Patient Education
Conclusion
The effectiveness of virtually all consultations is enhanced by the doctor's understanding
and use of communication skills. The establishment of trust and confidence, empathy and
rapport, diagnostic precision, appropriate prescribing, patient education and
understanding, patient compliance, and self-help lifestyle modifications are all facilitated
when doctor and patient understand each other to an optimal level, as a result of the proper
application of communication skills.
AlanTRose

1-A Communication, Counselling and Patient Education
MCAT 002-021
2 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman
13 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism
14 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus
15 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida
17 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery
052

053
002-003
Condition 002
Advice on breastfeeding versus bottle-feeding for a 28-year-old
pregnant woman
CANDIDATE INFORMATION AND TASKS
You are a Hospital Medical Officer (HMO) in an antenatal clinic, seeing a 28-year-old
woman for her antenatal visit at 35 weeks of gestation. She wants to discuss infant feeding
with you. She has heard a lot about the benefits of breastfeeding, but her mother told her
recently that babies grow better with formula feeds. She is uncertain whether she should
breastfeed or formula-feed her baby.
YOUR TASKS ARE TO:
• Discuss the advantages and disadvantages of breast-feeding and formula-feeding
with her.
• Outline the steps involved in safe formula-feeding.
Condition 003
Advice on neonatal circumcision for a couple expecting their first child
A young couple, the wife pregnant with their first child, have come to see you in a general
practice to discuss with you the place of routine neonatal circumcision if their baby is a boy.
YOUR TASK IS TO: ]
• Discuss with the couple the perceived risks and benefits of this procedure. J

054
Condition 004
Suspected hearing impairment in a 10-month-old child
( CANDIDATE INFORMATION AND TASKS )
You are working in a community health centre. Your next patient is a 10-month-old female
infant, baby Helena, seen with her mother, who has been referred by the local child health
nurse. The pregnancy and delivery were normal. The child presented to the nurse six
weeks ago for review and general screening including hearing. The nurse was concerned
that the baby has a hearing problem and wanted her checked by a doctor. The child's
parents have never had cause to worry about her hearing. She is the third child in a healthy
family and has been well, apart from a few upper respiratory infections.
She is crawling, does not walk yet, but pulls herself up to standing beside a small table.
Initial examination findings
A busy infant girl who objects to being restrained by her parent. She babbles during
assessment. Otoscopic examination is normal. No abnormal physical signs are present on
general examination. The parents are puzzled at the need for referral and seek information
about further investigation and management.
YOUR TASKS ARE TO:
• Ask the parent for additional relevant and focused history.
• Counsel the parent after you have obtained a further history.
• Explain possible causes of any suspected hearing loss to the parent.
• Discuss your plan of management with the parent.

Condition 005
Counselling a family after sudden infant death syndrome (SIDS)
CANDIDATEINFORMATIONANDTASKS 1
You work in a general practice. You are counselling the family of a four-month-old male
infant who was rushed to the Emergency Department of the local hospital the day before
but was dead on arrival. The provisional diagnosis is sudden infant death syndrome (SIDS)
and the baby (Andrew) is to have a Coronial autopsy.
You had seen him for the first time two months previously, with his single mother, when he
was thriving and developing normally and had commenced immunisations. Two days
before his death you saw him again, this time with mild upper respiratory snuffles which
were causing minor difficulties with breastfeeding. However, over the next two days he
apparently improved, and his mother had advised you that he appeared normal and fed
well from the breast just prior to his death. You are unaware of any suspicious circum-
stances surrounding the death.
The family members have attended to seek details of why the baby died and why an
autopsy is necessary. The spokesperson for the group is the mother's sister, the aunt of the
infant. The mother is also present, but is too distressed to ask any questions herself.
YOUR TASKS ARE TO:
• Answer the questions of the aunt relating to the death of the infant.
• Counsel the aunt and family.
055

Condition 006
Hair loss in a 38-year-old man
You are a Hospital Medical Officer (HMO) working in a primary care clinic attached to a
teaching hospital. This 38-year-old male newsagent has just consulted you about recent
(2-3 weeks) hair loss from the scalp. One eyebrow is also affected. He is otherwise well
with no significant past or family history. The patient is very concerned about possible future
progression and wishes to ask you about the diagnosis and possible treatments. You have
completed an examination of the scalp. The findings are as depicted below.
YOUR TASKS ARE TO:
• Discuss the condition with the patient.
• Advise him about treatment.
CONDITION006.FIGURES1AND2.
056

Condition 007
An unusual feeling in the throat in a 30-year-old man
You are working in a general practice. Your next patient is a 30-year-old man who is
consulting you about a throat problem.
He is a previous patient of the clinic, is married with two children, parents and his siblings
are well. He smokes 10-15 cigarettes daily and takes 2-3 alcoholic drinks only at
weekends. He had a vasectomy two years ago and has had no serious illnesses.
YOUR TASKS ARE TO:
• Take a focused history about his throat problem. The examiner will then give you the
examination findings.
• Discuss the most likely causes of the problem and its nature with the patient.
• Discuss whether any investigations are necessary and if so, what is most likely to be
found. .
057

058
008-009
Condition 008
Pain in the testis following mumps in a 25-year-old man
Your next patient in a general practice is a 25-year-old man who consulted you five days ago
because of painful swellings on both sides of his face associated with fever and malaise You
made a confident diagnosis of mumps.
You had previously diagnosed mumps in the patient's five-year-old son, a little less than three
weeks beforehand. The son has now fully recovered. The patient's other child, aged three years,
is well. You are aware that the couple have contemplated having another child.
You advised the patient to rest at home, suggested paracetamol as an analgesic, and asked him
to see you in a few days time before returning to work. The patient has come to see you today
because of a relapse of his fever associated with the onset of severe pain in his left testis.
You have found the left testis to be swollen to twice the size of the right one. It is very tender. The
right testis feels normal. The patient has a temperature of 38.4 °C. His face is slightly swollen.
Apart from a tachycardia, there are no other abnormal clinical signs.
YOUR TASKS ARE TO:
• Advise the patient of the diagnosis.
• Advise him about treatment and prognosis.
• Answer any questions asked by the patient.
Condition 009
Contraceptive advice for a 24-year-old woman
You are working in a general practice. A 24-year-old woman has come to see you for advice as to
the most appropriate pill she should go on for contraception for the next two to three years. She
knows that various types of pills are available and wants to know how to decide which is the most
appropriate pill for her.
YOUR TASKS ARE TO:
• Take a further relevant and focused history.
• Ask the examiner about findings you wish to elicit on general and gynaecological
examination.
• Advise the patient of the appropriateness of oral contraceptive pill (OCP) therapy, which pill
should be given, and how it should be administered.

Condition 010
Rape of a 20-year-old woman
CANDIDATE INFORMATION AND TASKS J
You are a Hospital Medical Officer (HMO) in the Emergency Department of a metropolitan
general hospital. Your patient is a 20-year-old university student who is brought to the
Emergency Department of the hospital because she was raped by a man that she met at a
disco and who offered her a lift home. The rape occurred six hours ago after he had
stopped the car in an undeveloped area. She has decided not to involve the police as the
person concerned is known to her family. She has had no previous operations or illnesses
and no pregnancies.
YOUR TASKS ARE TO:
• Take any further relevant history you require.
• Ask the examiner about appropriate findings likely to be evident on initial general and
gynaecological examination.
• Advise the patient of the investigations required and the management you would
propose.
059

Condition 011
Cancer of the colon in a 60-year-old man
You are working in a general practice. A 60-year-old man, whose father died of colon
cancer, consults you following a screening colonoscopy. This revealed a lesion shown in
the photograph given to the patient (see illustration below). The biopsy report confirms an
adenocarcinoma of the colon. The patient insists he has no symptoms and refuses to have
any operative treatment. However, he is still concerned enough to ask you what will happen if
nothing is done. The specialist who did the colonoscopy said the lesion was on the left side
of the colon.
The patient also wishes to know what are the prospects of cure if he changes his mind and
has the lesion removed by surgery, and would the surgery ever entail having a colostomy
(which he dreads)?
YOUR TASKS ARE TO:
• Advise him what symptoms and signs may occur in the future, what complications
may develop and how they would be treated.
• Address his concerns and counsel him about surgery.
You are not required to take any further history.
Clinical notes: Biopsy of ulcerating tumour of rectosigmoid at 15 cm from anus.
Biopsy report: The specimens show numerous fragments of a moderately well
differentiated adenocarcinoma of the colon with invasion into the
submucosal tissues.'
Diagnosis: Adenocarcinoma of colon.
060

061
Condition 012
Thalassaemia minor in a 22-year-old woman
You are working in a general practice. Your next patient is a 22-year-old woman who
recently had a self-limiting febrile illness, which was suspected to be infectious
mononucleosis (IM). She is now fully recovered. Blood tests for IM were negative, but the
full blood examination showed a hypochromic microcytic anaemia of 108 g/L. The mean
corpuscular volume (MCV) was below normal (68 cubic microlitres — normal 80-101). You
followed this up but there was no evidence of chronic blood loss (other than normal
menstruation). Serum iron and ferritin estimations were also normal. You suspected
/j-Thalassaemia minor ('Mediterranean anaemia') and this has been confirmed by
electrophoresis which showed an elevated Hb H2 level (4.3%).
You are aware of her Greek descent and that she has just become engaged to be married.
Her fiance is also of Greek descent. The family history is that her mother, father and brother
are all alive and well. Her grandparents died in Greece and both were very old. One of her
father's brothers was reported to have died in childhood from an unknown cause. The
patient is very worried about being told she is anaemic, and as she is to be married shortly,
is worried about the effects on any of the children she hopes to have.
The patient has returned to discuss her results with you.
YOUR TASKS ARE TO:
• Explain the nature of the condition to the patient.
• Answer the patient's questions.
• Advise the patient what should be done now.

062
013-014
Condition 013
Pre-pregnancy advice to a 28-year-old woman with
previous thromboembolism
You are working in a general practice. Your next patient is a 28-year-old woman, who had
one pregnancy 18 months ago, which was complicated by deep vein thrombosis and a
postpartum pulmonary embolus. She has come to see you for pre-pregnancy counselling
as she wishes to conceive again. At the time of a previous assessment twelve months ago,
she had ceased warfarin. When assessed six months ago, there were no sequelae or
symptoms and she had no signs of chronic venous insufficiency in the legs. There are no
abnormalities on physical examination and she is not overweight.
YOUR TASKS ARE TO:
• Take any further relevant history you require from the patient.
• Advise the patient on the management she will require before and during the
next pregnancy.
Condition 014
Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus
You are working in the primary care facility of a teaching hospital. Your patient is a woman
aged 24 years (para 0, gravida 0), a known diabetic for 15 years and well controlled on
insulin. She has come to see you for counselling and advice about possible future
pregnancies.
YOUR TASKS ARE TO:
• Take any further relevant history you require.
• Advise the patient of the information she needs to be given for pre-pregnancy
counselling.

Condition 015
An anencephalic fetus diagnosed at 18 weeks gestation in a
25-year-old primigravida
You are a Hospital Medical Officer (HMO) working in a primary care clinic attached to a
teaching hospital. Your next patient is a 25-year-old primigravida who has just had an
ultrasound performed at 18 weeks of gestation, which has revealed an anencephalic fetus
(as shown in illustration below). A maternal serum screening (MSS) was done at 16 weeks
and this had shown elevated levels of alpha fetoprotein.
YOUR TASKS ARE TO:
• Take any further relevant history.
• Advise the patient, in lay terms, of the relevance of the diagnosis and the subsequent
management you would propose in this pregnancy.
• Advise the patient of the care you would recommend in a subsequent pregnancy.
You will not be expected to request examination findings, nor to arrange any further
investigations.
CONDITION015.FIGURE1.
Anencephalicfetusat18weeksofgestation
063

Condition 016
A duodenal ulcer found on endoscopy in a 65-year-old man
You are working in a general practice. You recently referred a 65-year-old man with a history of
self-medication for arthralgia and a subsequent six week history of epigastric pain and indigestion
to a gastroenterologist who performed an upper gastrointestinal endoscopy. The endoscopist told
the man he had detected a duodenal ulcer and gave him a photograph of the ulcer, taken during
endoscopy. The patient has come back to you seeking answers to several questions. The
photograph is as shown.
YOUR TASKS ARE TO:
• Discuss the endoscopic findings with the patient in terms of the:
~ pathogenesis of the ulcer;
~ natural history and possible complications of the condition; and
~ treatment options available to him.
064

065
017-018
Condition 017
Advice on autologous blood transfusion to a 55-year-old man
awaiting elective surgery
You are working in a general practice. Your next patient is a middle-aged man booked for a
total hip replacement. You referred him to an orthopaedic surgeon who has arranged
elective surgery for his severely osteoarthritic hip. The patient has now come back to see
you, as he has some questions and in particular, is concerned about the risks of blood
transfusion (if required) and would like to find out about using his own blood for the
operation.
The patient wishes to discuss this with you, as he did not take in everything that was
explained by the surgeon.
YOUR TASKS ARE TO:
• Explain the principles and indications for preoperative blood collection and intra
operative autologous blood transfusion.
• Answer any questions from the patient about the blood transfusion procedure.
Condition 018
Advice on stopping smoking to a 30-year-old man
You are working in a general practice. The next patient is a 30-year-old man who has
returned to your practice for followup following a recent chest infection. He is a smoker (20
cigarettes per day). On his previous visit, you had told him that the 'best thing that he could
do for his health would be to stop smoking'. You have examined his chest which is clinically
normal.
At this visit, you are expected to follow up his response to your previous advice and counsel
him further about tobacco cessation.
YOUR TASKS ARE TO:
• Assess his motivation to stop smoking.
• Counsel him appropriately.
• Discuss treatment options and general resources.
• Respond to any questions he may have.

066
Condition 019
Excessive alcohol consumption in a 45-year-old man
You are working in a general practice. You are about to review a 45-year-old businessman
who consulted you two days ago about his drinking after seeing a TV program about the
harmful effects of alcohol.
At the previous consultation you established the following:
• He is drinking excessively (at least five standard drinks every day);
• This is of long standing — at home, at work and socially;
• He has problems at work;
• He has trouble with his close family relationships;
• His sexual performance is impaired;
• He has had two minor traffic accidents in the last year;
• He has a family history (grandfather) of alcoholism; and
• On examination he is overweight (BMI 28 kg/m
2
), hypertensive 180/90 mmHg, and has
hepatomegaly.
You told him that his use of alcohol appears to be excessive and you ordered liver function
tests and a full blood examination. He is seeing you today for the results of the tests which
are as follows:
Liver Function Tests
Bilirubin Total 14 umol/L (<20)
ALP (Alkaline phosphatase) 50u/L (25-100)
AST (Aspartate transaminase) 45 u/L* (<40)
GGT (Gamma glutamyl transaminase) 63 u/L* (<50)
Serum albumin 32g/L (32-45)
Full Blood Examination
This showed a normal haemoglobin level (145 g/L) with a macrocytosis and elevated
mean corpuscular volume (MCV) of 106 fL (normal range 10-96) and some
variations in red cell size and shape (anisocytosis and poikilocytosis). Other features
were normal.
YOUR TASKS ARE TO:
• Explain the results of the tests to the patient.
• Discuss the effects of the excessive alcohol consumption.
• Counsel him about his drinking.
You do not need to take any further history, nor perform any examination. The
Performance Guidelines for Condition 019 can be found on page 121

067
020-021
Condition 020
Type 1 diabetes mellitus in a 9-year-old boy
A nine-year-old boy, Roger, is admitted to the paediatric unit to which you are the Hospital
Medical Officer (HMO). This is his first presentation of insulin-dependent Type 1 diabetes
mellitus. His general condition is satisfactory, not requiring intravenous resuscitation, and
he has already commenced insulin therapy and has stabilised with good blood sugar
control.
As the Ward HMO, his mother has asked you for further information about his ongoing care
in relation to his diabetes from now on.
YOUR TASK IS TO:
• Answer the queries the mother has, related to the ongoing care of Roger's diabetes.
Condition 021
Request for vasectomy from a 36-year-old man
You are working in a general practice. You are seeing a man aged 36 years who indicates
that he wishes to discuss vasectomy with you. You have enquired about his past medical,
family and social history (see below). He is asymptomatic across all his body systems.
Physical examination is normal, including his scrotum, testes and penis. Blood pressure is
120/70 mmHg, urinalysis normal. He is not overweight. You believe that he is in good
physical health.
You have already obtained the following patient details:
• He has been married for 12 years and has two children (a boy aged seven and a girl
aged nine years). There are no marital problems of any kind;
• He is a senior constable in the police force, does not smoke but is a moderate alcohol
drinker (three standard drinks a day);
• He has no known drug sensitivities;
• His mother, father and brother are well, as are his wife and two children; and
• He is not on any medication.
YOUR TASKS ARE TO:
• Explain the sterilisation procedure and its consequences to the patient.
• Answer the patient's questions and provide counselling accordingly.
There is no need for you to take any additional history from the patient. The
Performance Guidelines for Condition 021 can be found on page 129

1-A
Communication,
Counselling& Patient
Education
1-A Communication, Counselling and Patient Education
MCAT 002-021
2 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman
13 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism
14 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus
15 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida
17 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery
068

069
002
Condition 002
Advice on breastfeeding versus bottle-feeding for a 28-year-old
pregnant woman
AIMS OF STATION
To assess the candidate's ability to advise a young expectant mother on the advantages and
disadvantages of breastfeeding and bottle-feeding. This scenario tests the candidate's ability to
identify the conflict the young mother has in trying to respect what her mother has told her, while
knowing that this advice is contrary to her own feelings. It also tests ability to discuss logically the
advantages and disadvantages of the different feeding methods as well as testing knowledge on
safe bottle-feed preparation.
The examiner will have instructed the patient as follows:
You are a 28-year-old mother having your first baby. You now have only five weeks to go and
although you always hoped to breastfeed your infant, you have had some doubts about its value
recently when your mother mentioned that formula-fed babies grow better than babies who have
been breastfed. You have come to discuss this. You realise that you may have to defend what
the doctor says to you (about breastfeeding being advantageous), and your own previously held
ideas about breastfeeding, against the ideas of your mother with whose opinions you have to
live.
Opening statement
'My mother feels that bottle-fed babies gain more weight than breastfed babies and therefore are
more healthy. What do you think, doctor?'
Questions to ask if not already covered:
• 'What are the advantages of breastfeeding? I would have thought it is easier to breastfeed.'
• ‘Is there anything special about breast milk? I always thought there was.'
• 'Do you have to prepare bottle feeds in any special way?'
• 'Are the formula feeds safe? I thought they contained cow's milk and what if you are allergic to
cow's milk?'
The candidate should:
• Be nonjudgmental, avoiding comments like 'Where on earth did your mother get such an
idea?'; rather asking 'Why do you think your mother made such a recommendation?'
• Discuss that while breastfeeding is the optimal method of feeding the human infant, and that
the majority of mothers successfully breastfeed, a variety of reasons may prevent
breastfeeding in practice, including:
~ illness in the mother;
~ failure to establish lactation, which may be hormonally based;
~ possible illness in the baby (e.g. cleft palate);

70
002
PerformanceGuidelines
~ prematurity, which requires the mother to express regularly to maintain her supply;
~ previous extensive breast surgery in the mother; and
~ heightened anxiety in the mother.
• Explain that if for some reason breastfeeding is unsuccessful, formula-feeding is a safe
and very effective alternative.
• Discuss that formulas are designed to contain the same nutritional components as
breast milk, but that exact reproduction is difficult as the concentration and components
of breast milk change throughout each feed.
• Advise that there is no advantage of formula-feeding over breastfeeding.
• Discuss the specific advantages of breastfeeding:
~ the practical advantages of being able to feed almost whenever and wherever the
baby wants it without having to prepare formula, carry bottles around and without
problems with sterility;
~ increased resistance of the baby to infection, from immunological constituents in
breast milk including lymphocytes and antibodies; and
~ satisfaction derived from feeding the infant as well as the development of a close
relationship with the infant.
• In response to her mother's comment, advise that weight gain is not the only criterion for
success as excess weight gain in the first 12 months of life may in fact be detrimental in
later life.
The candidate should stress the importance of optimal formula-feeding as follows:
~ sterility in preparing the bottle feeds is essential;
~ bottles need to be washed clean with a bottlebrush to ensure that all milk residue is
removed;
~ bottles and teats need to stored in solution (e.g. Milton®), to ensure continuing
sterility, but the bottles need to be rinsed free of this solution prior to use;
~ the fluid used to make the formula and to rinse the bottles should be cooled boiled
water;
~ each can of formula has explicit makeup instructions on the side of the can or packet;
if followed these will produce the exact required concentration;
~ there is no place for any added scoops, which can be harmful;
~ the day's requirements are best made up at the one time, although each feed can be
made separately. If the former, the day's feed should be stored in the refrigerator;
~ only one day's feed at a time should be prepared in advance; and
~ each feed should contain approximately 30 ml more than it is anticipated the baby
may take, and any excess discarded at the end of the feed.
KEY ISSUES
• Empathic answering of this young mother-to-be's questions.
• Recognition that she is uncomfortable with what her mother has told her but is seeking
reassurance and support for her own view which she feels is accurate.
• Satisfactory explanation of the advantages and disadvantages of the different methods
of feeding.
• Candidates should know how formula feeds are prepared.

071
002
CRITICAL ERROR - none defined
COMMENTARY
Ability to discuss impartially and accurately the relative merits, indications,
contraindications and techniques of infant feeding by breastfeeding and by
formula-feeding is a requisite for all medical graduates as outlined and is an area where
good communication skills are paramount.

072
003
PerformanceGuidelines
Condition 003
Advice on neonatal circumcision for a couple expecting their first child
AIMS OF STATION
To assess the candidate's ability to give impartial advice about neonatal circumcision.
The examiner will have instructed the parents as follows:
You are a couple who are expecting your first baby. Your family members have suggested
that if the baby is a boy he should be circumcised. You are very unsure about this, as you
cannot see any reason why circumcision is essential. You have no religious beliefs that
dictate that circumcision must be done. You have therefore come to discuss the process
and learn what the advantages and disadvantages of the procedure are before making
your own decision on the matter.
Opening statement
‘We have come to discuss with you whether to have our baby circumcised.'
Questions to ask unless already covered:
• ‘What does the procedure involve?'
• 'What are the complications that can happen?'
• ‘What are the advantages of having it done?'
• 'Are there any times when it definitely should or shouldn't be done?'
• 'Has anyone looked into this in detail and come to any conclusions about it?'
The candidate should:
• give an impartial but informed explanation to the parents on the advantages and risks
involved in routine neonatal circumcision;
• indicate that when religious grounds are stated as the reason for the procedure, these
are generally respected; and
• realise that many are unaware of the actual process of circumcision and may ask for the
procedure more as a ritual; and stress that the parents should consider the advantages
and disadvantages of the procedure before making a decision.
During the discussion, the candidate would be expected to advise along the following
lines:
• The perceived advantages of routine neonatal circumcision commonly quoted are:
~ Reduced incidence of urinary tract infections (UTIs) in circumcised boys. While
circumcision may assist the uncircumcised boy who is suffering recurrent UTIs,
routine general circumcision of all boys is not indicated to achieve this, but can be
selectively applied at a later age if this situation exists.
~ Reduction in the incidence of sexually transmitted infections (STIs) and HIV infection.
This remains a controversial point. The literature currently is divided on this issue, but
some evidence suggests the risk of HIV infection is lessened by circumcision.

073
003
~ Circumcision is indicated for phimosis or its prevention. This is true only if all
conservative methods of treatment have failed. Often, phimosis, developing after
birth, is secondary to inappropriate foreskin care and subsequent trauma and
scarring. If asked, the candidate should indicate the appropriate care of the foreskin,
which is minimal, until the foreskin can be retracted easily, which is usually by about
five years of age.
~ Neonatal circumcision minimises the risk of subsequent development of carcinoma
of the penis. But poor penile hygiene associated with human papilloma virus infection
is the major contributor in adults, cancer being rarely seen in men who can retract
and clean the foreskin.
• The recognised complications and disadvantages of routine neonatal circumcision
should also be discussed and include:
~ haemorrhage;
~ infection, including septicaemia/meningitis (rare);
~ ulceration of the glans;
~ inadvertent injury to the urethra;
~ too much skin removed leading to unsatisfactory cosmetic appearance;
- anaesthetic complications; and
~ secondary phimosis.
The complication rate has been estimated to occur with an incidence of between 1-5%
(range 0.2%—10%); but these are figures at all ages, not just in the neonatal age range. The
skill of the operator is obviously of paramount importance. The most common complication
is haemorrhage.
• The candidate should also discuss the absolute contraindications to routine neonatal
circumcision explaining each in turn:
~ hypospadias and other congenital anomalies of the penis (e.g. epispadias);
~ chordee;
~ buried penis;
~ sick infants, including jaundiced infants;
~ family history of a bleeding disorder or known recognised familial bleeding disorder
possibility (e.g. haemophilia A); and
~ inadequate expertise and facilities.
• The candidate should be able to explain the procedure of circumcision and indicate
that:
~ it is usually done under local anaesthesia; and
~ if performed after six months of age, it is done under general anaesthesia.
KEY ISSUES
• The ability to discuss in an unbiased manner the perceived advantages and
disadvantages of routine neonatal circumcision.
• Capacity to summarise that the recommendations of various national and international
paediatric and paediatric surgical associations, who have extensively reviewed the
literature on the subject, do not support routine neonatal circumcision.

074
003
CRITICAL ERROR - none defined
COMMENTARY
This topic is one that has been controversial for many years. While circumcision for religious
reasons has been done for many centuries, the issue in the scenario is related to the secular
trend towards routine neonatal circumcision of all males soon after birth. This has become more
of a ritual rather than for any recognised medical indication, although this tendency has reduced
in recent times. In fact there are many recognised complications of circumcision, not just routine
neonatal circumcision, but circumcision at any age. However there are recognised medical
indications for the procedure (e.g. established phimosis in boys and men).
CONDITION 003.FIGURES 1AND 2.
Circumcision in ancient Egypt Phimosis
Many young parents are unaware of the issues involved and are often ill-informed by family
members who recommend that their infant should have the procedure performed without any
explanation as to why. They then request circumcision without any information about the
procedure and hence the need for informed discussion to allow them to make a rational decision
in the interests of their baby.
This scenario illustrates that medical practitioners are obliged to provide accurate information on
the risks and benefits of routine neonatal circumcision and should attempt to avoid any personal
bias. The decision should be left to the parents after a full and accurate discussion.
Unbiased up-to-date written material summarising the evidence should be made available to the
parents.
The review of the literature in relation to risks and benefits shows there is no evidence of
benefit outweighing harm for neonatal circumcision as a routine procedure.
The Policy Statement on Circumcision from the Paediatric and Child Health Division of the Royal
Australasian College of Physicians (September 2004) is recommended as an excellent summary
with 78 references to the evidence for and against circumcision. This is available on the open
website of the Royal Australasian College of Physicians under Policies (http://www.racp.edu.au).

Amc handbook of clinical assessment 2007

Amc handbook of clinical assessment 2007

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Amc handbook of clinical assessment 2007