Ethics OSCE Station Blueprint

Station Name: Sexual Impropriety

Issue:

Women's Health

Presenting Situation:

Carol Abbott is requesting a referral to a new psychiatrist. "Things didn't work out" with the one she had been seeing.

Activities:

Patient encounter.

Time Required:

10 minutes

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.

Instructions to Candidate:

You are working in a family medicine clinic. You are about to see Carol Abbott, a new patient. Your nurse tells you that Carol is depressed and wants a referral to a psychiatrist. Carol had been seeing a psychiatrist but "things didn't work out".

Carol did not have an appointment. She came as a "walk-in" patient. Your nurse was able to fit her in between some other patients.

CHECKLIST ITEMS:
^^^^^^^^^^^^^^^^

YES     NO     The Candidate:
        
               1.      inquires about how things "didn't work
                       out" and establishes that relationship
                       was sexual.
----|-----------------------------------------------------------

               2.      informs the patient that sexual contact
                       is not part of the normal doctor/patient
                       relationship.
----|-----------------------------------------------------------
               3.      informs patient that sexual contact
                       in context of doctor/patient
                       relationship is unethical.
----|-----------------------------------------------------------
               4.      asks about how patient is feeling
                       currently (e.g. depression, anxiety).
----|-----------------------------------------------------------
               5.      assures patient that she is not
                       responsible/it is not her fault.
----|-----------------------------------------------------------
               6.      tells patient that filing a report in
                       front of the College is an option.                 
----|-----------------------------------------------------------
               7.      understands that sexual impropriety
                       could lead to loss of physician's
                       licence. 
----|-----------------------------------------------------------
               8.      mentions that physician is obligated to
                       report the psychiatrist.
----|-----------------------------------------------------------
               9.      asks for name of psychiatrist.
----|-----------------------------------------------------------
               10.     offers ongoing counselling to patient
                       and/or referral to a psychiatrist.
----|-----------------------------------------------------------
               11.     recognizes that patient may feel more
                       comfortable with a female psychiatrist. 
----|-----------------------------------------------------------

=================================================================

                              
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

Instructions to Standardized Patients:

Your name is Carol Abbott. You are a woman aged 20 - 50.

Chief Complaint:

"I'd like you to refer me to a psychiatrist. I've been seeing one but I can't go back to him."

You were being treated for depression but "things got complicated"/"things didn't work out" with the psychiatrist. (Do not emphasize the depression.) It's hard for you to talk about the reason for not continuing with the psychiatrist. In order to make the scenario work it is important to HINT STRONGLY. If asked about how things "didn't work out", you can say, "I'm really not sure how to talk about this. I'm kind of upset about the whole thing. Things got physical."

History of Present Concern:

Two and a half years ago, you started seeing psychiatrist for depression. Your symptoms included anxiety, fatigue, hopelessness, no interest in sex, needing lots of extra sleep, trouble concentrating, lack of interest in life, low self-esteem, thoughts of suicide.

You think you have been somewhat depressed for most of your life, but things seemed to get more "painful" a few years ago. Things with the psychiatrist seemed to go well for the first year. Mood improved.

An attraction to the doctor began to form. It was reciprocated. Physical contact started with hugs. It progressed to kissing, petting and eventually intercourse. Although other physical contact continued, there was only one instance of intercourse. All this activity occurred in the office.

It was very confusing for you because you were still attracted to the doctor. You wanted to see the doctor outside the office. You had some trouble understanding why the doctor never wanted to see you outside the office even though he said he really cared for you. Doctor said that the physical contact was part of the therapy.

Doctor started to act cold and disinterested and almost rude. He would open mail and take phone calls while you were there for a session. You became upset and eventually left. You simply did not show up for a scheduled appointment. The doctor never called to find out why. No other appointments were scheduled. You want to continue working with a psychiatrist but will not go back to the one you were seeing. You are very confused about whether to talk about what happened. On one level you do want to talk about it but you are reluctant to give the doctor's name.

Past Health:

Unremarkable. Use own history if applicable.

Social History:

Use own history.

Family History:

Use own history.

Review of Systems:

Occasional headaches.

Patient Behaviour:

You are nervous. A little sad looking. You are confused about your feelings concerning previous psychiatrist. You can be reticent in the beginning. Can say it's hard to talk about. You're going to be confused because you still have an emotional bond to the doctor.

Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues.

PROMPT 1 (immediately):
"I need a referral to another psychiatrist. I've been seeing one but I can't go back to him."

PROMPT 2 (by 1-2 minutes):
"I'm confused. I feel guilty. I should have said 'no'."

PROMPT 3 (by 3-4 minutes):
"Is there something I should do?"

PROMPT 4 (by 5-6 minutes):
"What would happen (to him, to me) if the psychiatrist is reported?"

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