This station was developed by Dr. Peter A. Singer (Centre for Bioethics and Department of Medicine, University of Toronto), and Anja Robb (Department of Family and Community Medicine, University of Toronto. It is part of the Ethics OSCE Project which is funded by Educating Future Physicians for Ontario (EFPO). There is an accompanying videotape. This material can be used for teaching or evaluation. It is not copyrighted and may be freely reproduced for educational purposes.
You are about to see Beverley Carter, who has been Dr. Hardy's patient for several years. Her 16 year old daughter, Linda, is also a patient of Dr. Hardy. A few months ago, Dr. Hardy prescribed the birth control pill for Linda because she was sexually active. Linda asked several informed questions and was fully aware of the risks and benefits of taking the pill. Dr. Hardy wrote in his notes that he felt she was fully competent to make that decision. Linda told Dr. Hardy in no uncertain terms that she did not want her mother to know she was on the pill or why she was being prescribed the pill. Last week you saw Linda to renew her prescription for the pill. You agree with Dr. Hardy's assessment of her competence.
The mother, Beverley, has subsequently become suspicious about Linda's visits to the doctor's office and has made this appointment to discuss the issue. You have a very busy office today and only have 10 minutes to see her.
CHECKLIST ITEMS:
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YES NO The Candidate:
1. refuses to discuss nature of daughter's
visit.
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2. states that information about daughter's
medical condition is confidential.
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3. states that nature of present visit
between mother and doctor is also
confidential.
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4. checks if mother has asked daughter
about reason for visit.
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5. addresses nature of mother-daughter
communication.
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6. offers practical strategies for
improving communication with daughter
(e.g. counsel them together).
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7. states that competent people (like
Linda) are treated like adults and
allowed to make their own medical
decisions.
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8. addresses consequences of breaking
confidentiality: e.g. patients will lose
trust or not discuss personal matters
which may have bearing on physical
health.
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RATE FROM 1-5:
+------------------------------------------------------------+
| | | | VERY | |
| POOR | FAIR | GOOD | GOOD | EXCELLENT |
| 1 | 2 | 3 | 4 | 5 |
+------------------------------------------------------------+
1. How would you rate the candidate's communication skills?
1 2 3 4 5
2. How would you rate the candidate's ability to address the
ethical issue in this case?
1 2 3 4 5
Last week while preparing clothes to take to the cleaners, you found an appointment card from the doctor's office in the pocket of Linda's jacket. It listed 2 appointments about which you knew nothing. You worry that Linda may be sexually active and suspect that the appointments were for getting "the pill".
You are now at the doctor's office expecting to find out the reason for Linda's visits. You think you have a right to know about your child's health and medications because Linda is only a child. You are very worried about her best interests. Linda has no idea that you are after this information.
You are particularly concerned because Linda has been running around with a "rough" crowd that you don't approve of. You suspect that Linda may also be smoking and drinking. You don't think she is making very responsible decisions lately (because of the smoking, drinking, and staying out late). You think that Linda may have "fooled" the doctor into thinking she was mature and responsible. You are afraid that Linda is not grown up enough to know what she's doing. If she's sexually active, you don't believe she's doing it with full knowledge. You don't think she has considered the consequences of her actions (e.g. STDs or pregnancy). You have a hard time thinking of her as anything other than your little girl and you don't want your little girl to come to any harm. Linda's recent change in behaviour has you very concerned.
Your relationship with Linda is somewhat strained. Whenever you ask about her activities she accuses you of prying and most attempts at conversation end in an argument. Linda's relationship with her father appears smoother, but they only see each other during summer holidays as he lives in another city. You fear that if your daughter gets pregnant or gets infected with a sexually transmitted disease and your ex-husband finds out, he may challenge your capability as a responsible parent and you may lose custody of Linda. This prospect frightens you because you don't think your ex-husband is a fit parent.
You really don't expect to meet with any resistance in obtaining information about Linda's visits. If challenged you might say: "You're not the parent, I am. Legally she's still my child. I'm the person who's responsible. I'll have to bear the consequences."
Part of your anxiety may be because when you were a teenager, you became pregnant and had an abortion. You came to regret this. Your own parents had not known about the pregnancy or abortion. (Perhaps on some level you think if your parents had known, they might have guided you to another decision.)
You conduct yourself as though you expect no resistance to your request. When you get it, you act with some level of disbelief. You are surprised and want to know why. You think you have several good reasons for getting the information about Linda.
Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues.
PROMPT 1 (almost immediately):
I'm concerned about my daughter. I want to know why she
came in to see you. Is she sexually active? Is she on the
pill?
PROMPT 2 (by 2-3 minutes):
I need to know what you talked about. Are you going to tell
me?
PROMPT 3 (by 3-4 minutes):
WHY can't you tell me? (repeat the "WHY" if necessary)
PROMPT 4 (by 4-5 minutes):
Is that a law?
PROMPT 5 (by 5-6 minutes):
How am I going to find out?