Practice Station DSH

Instructions to Candidates:

You are a Foundation Doctor in Psychiatry.

Jo Beig was admitted yesterday following a deliberate

paracetamol overdose.

Please take a history and establish Jo's risk of further self-harm.

At 7 minutes, the examiner will ask you questions.

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Practice Station DSH

Station Information
Station Reference Practice Station DSH

Station Title Practice Station DSH

Student Description none

Author no author

Year Group Practice 1Med Stations

Clinical Domain Mental Health

Clinical Competency Patient Assessment (History Taking)

Information for Site Organisers

Type of patient required:
Simulated patient (history only).

Patient information:
SP any gender and age 20-35

Resources and equipment needed:

Alcogel

Candidate pink notepaper, black pens and clipboard in case the candidate wishes to make notes

Chairs x 3

Setting up the station:

The examiner’s chair should be positioned so that he/she can observe faces of both candidate and
patient/relative/colleague.

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Practice Station DSH

Information for the Examiner

What is the overall aim of this station?
This station tests the candidate's ability to take a history relating to deliberate self harm and in doing so, risk-
assess the patient for future potential for self-harm.

Examiner’s role:
• 0 minutes: candidate enters station. Check their ID card, then observe & assess the candidate.
• 7 minutes: ask the candidate:
1. What do you perceive to be the patient's current suicide risk level, and why?
• 8 minutes: politely ask the candidate to move on to the next station. Complete marking.

Standardisation is important. Whilst you may clarify the candidate’s responses to the questions above, please
do not ask supplementary questions of your own.

What is expected of the candidate?

The candidate should:
• Make attempts to build rapport
• Pre-admission history - prior symptoms, screen for depressive symptoms: mood, interest,
enjoyment, sleep, appetite, attention/concentration, libido. Any previous self harm.
• Explore events leading to admission -
o Precipitating factors to self harm
o Details of overdose itself: impulsive, use of alcohol, number & type of tablets, when and
where taken, alone when took tablets, intent, final acts
• Current mental state, insight, outlook
• Any ongoing ideation / plans re self-harm including exploring patient risk factors for self-harm
• Social history: family, housing, alcohol/drug use etc
• Briefly clarify past medical history, drug history, family history

Marking Guidance: if you award a global judgement below 'Excellent', it is

extremely important you provide constructive feedback on key areas the candidate
should develop further i.e feedback which justifies the grade awarded.
The excellent / good candidate typically…
• Will take a structured & clinically reasoned history and explore the events around the overdose,
quickly exploring key symptoms and assessing risk
• Will explore all or almost all of the key risk factors for self-harm, including assessment for depression
and alcohol/substance misuse/dependence
• Will, in the time allocated, complete the history including asking about past medical history, drug
history, family history, social history, etc.
• Will consider the impact of the condition on the patient/family and elicit and address the patient's
ideas, concerns, feelings and expectations.
• Will demonstrate excellent communication skills, using a structured but sensitive approach and
avoiding jargon.
• Will be able to describe the current risk accurately
The satisfactory candidate typically …

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Practice Station DSH

• Will take a structured history, although may not explore all of the events around the overdose, or
may not fully assess for depression or alcohol/substance misuse.
• Will, at times, be unstructured in their approach but generally will have a sensitive and patient-
centred manner.
• May not fully cover all aspects of the history in the allocated time.
• Will still identify some of the likely differentials and be able to describe some of the required next
steps.
• Will demonstrate good communication skills, using a largely sensitive and structured approach, and
using minimal jargon
• Will be able to describe the risk accurately
The failing candidate typically …
• Will have a disorganised manner throughout with an unstructured & unsystematic approach to
history-taking and assessing DSH risk
• Will demonstrate cognitive biases that influence their clinical reasoning
• Will fail to identify the events around the overdose or important risk factors
• Will not assess for depression or alcohol/substance misuse/dependence
• Will adopt a doctor-centred, disjointed approach, or show lack of compassion/sensitivity.
• Will demonstrate poor or limited communication skills, without a structured approach and using
frequent jargon.
• Will not ask about current intent and will not be able to assess current risk accurately

As this station involves a patient (simulated or real), the candidate should follow standard infection control
practices (e.g. clean hands with alcogel upon entering AND before leaving / clean stethoscope if used / bare
below elbows etc).If the candidate is in breach of any OR multiple infection control measures, then their
global judgement should be no more than 'GOOD', and remind them of the importance of this in their
written feedback.

Clinical information relevant to the station:

Deliberate self harm (DSH) attempts can have a range of causes and contributing factors including
maladaptive reactions to distress, communication to significant others (eg anger, despair) and a genuine
suicidal intent – i.e. desire to die driven by hopelessness or helplessness. Common psychiatric disorders
involved are depression, alcohol/substance misuse and personality disorder. Impulsive attempts are often
precipitated by acute distress compounded by loss of inhibition through the use of alcohol. Management of
DSH depends on an accurate assessment of:
• seriousness of the attempt (more serious indicated by planning, final acts, hiding the attempt and
avoiding detection, greater medical seriousness/violence)
• presence of risk factors such as psychiatric illness, alcohol/substance misuse and personality
disorder, intractable social situation, social isolation, physical illness
• current risk including ongoing distress, DSH/suicidal intent, lack or resolution of precipitating events.

The patient's suicide risk level is low for the following reasons:
• They hadn’t had suicidal ideas in the period leading up to the overdose
• They had no plans to kill themself before impulsively taking the overdose – they hadn’t deliberately
bought the paracetamol
• They hadn’t made a will or made any ‘final arrangements’
• They hadn’t tried to hide the overdose
• They hadn’t thought about whether the tablets were enough to kill themselves
• They had felt somewhat helpless but not generally hopeless about the future
• They do not have any future plans or intent to kill or harm themselves.
• No thoughts to harm others.

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Practice Station DSH

Information for the Simulated Patient

Opening statement for the patient:
Can I be discharged home now?

About you:
Jo Beig, age as per SP.
You are living with your partner and in the second year of university studying Art and Design.
You have been in a relationship for the past twelve months and are living with your partner. Your relationship
is generally okay but there are arguments about your partner being unfaithful.

Current health problem:

You were admitted to hospital yesterday following after an overdose of Paracetamol.
Yesterday morning you had an argument with your partner and there were concerns that your relationship
might end. After your partner left the house for lectures, you were feeling very fed up so you drank some
alcohol (a bottle of wine) and decided that life was no longer worth living and that people would be better off
if you were dead. At 2.00pm the same day you took sixteen paracetamol tablets. You did not write a suicide
note. You had not planned on doing what you did until the argument occured
Although you wanted to die, after taking the tablets you were frightened your partner would not forgive you
and you rang your partner who phoned for an ambulance.
At the Emergency Department, your blood test showed that the paracetamol levels were below the level
needing any treatment and the doctors reassured you that your physical health was good. Because this was
your third overdose over the past two years you were advised to remain in hospital for psychiatric review the
following day. You regret your overdose now. You have no plans to try anythng like this again.
You have taken one previous overdoses in similar circumstances after having had arguments with previous
partners.
Your mood is generally good and overall life is worth living. Your sleep and appetite are satisfactory. You get
pleasure from your hobbies and friends. Your energy levels are good, you can concentrate on your studies
and your libido is fine.
You have not had the feeling anyone wants to harm you, nor experienced voices or anything else unusual.

Your ideas, concerns, feelings and expectations:

You now feel foolish about what you did and blame the fact that you had too much to drink and feeling sorry
for yourself. You don’t want to die or take another overdose. You do not think you have a mental illness.

Questions:
Nil

Previous medical history:

You have hayfever which only troubles you in spring/summer.

Medical problems in the family:

Nil

Medication:
Antihistamines when your hayfever flares up. Otherwise nil else regular. Nil OTC.
No known drug allergies.

How to play the role:

You are slightly reluctant to discuss what went on as you feel embarassed now about it. You will however
answer the questions posed. Eye contact slightly reduced

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Practice Station DSH

Marking Domains
01. Overall conduct of the consultation with patient/relative/carer
Introduces self, states own role and checks identity of patient/ relative/ carer
Explains and agrees the purpose of consultation
Establishes and maintains rapport
Attends to the comfort, safety and dignity of the patient if applicable
Demonstrates empathy and sensitivity
Discusses patient information sensitively and with awareness of confidentiality if applicable
Maintains a fluent, coherent and competent approach
Manages time, completes task and closes appropriately
Follows appropriate infection control measures throughout

02. History Taking Skills

Appropriately uses a combination of open, probing and closed questions
Adopts a clinically reasoned approach, demonstrating the ability to differentiate relevant from irrelevant
information in order to narrow the differential diagnosis
Enquires about red flag features in order to rule in and rule out serious/ significant pathology
Uses a patient-centred and structured approach throughout
Appropriately elicits and acknowledges the patient’s feelings, ideas, concerns and expectations
Explores the impact on the patient’s life
Clarifies and summarises as appropriate
Avoids inappropriate reassurance
Demonstrates responsiveness to the social, cultural and ethnic background of the patient, and their
abilities and disabilities

04. Non-verbal Communication

Maintains appropriate body language and eye contact
Maintains a calm and composed demeanour
Demonstrates active listening (e.g. remaining focused on the patient)
Uses or offers visual methods for conveying information e.g. diagrams
Uses appropriate seating position

13. Clinical Knowledge

Identifies the underlying problem(s)
Demonstrates an appropriate depth of understanding of the clinical condition/pathology
Applies clinical reasoning skills to interpret information in the clinical context
Applies knowledge to the patient’s current problem
Comes to appropriate conclusion(s)

15. Providing information to the examiner

Communicates findings clearly, if applicable
Summarises accurately and concisely if applicable
Answers examiner questions clearly and competently
Provides and prioritises answers that are reflective of routine clinical practice
Justifies answers in context of the patient’s problem

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