Possible OSCE Station- HEP/ Lifestyle Station

The following is the stem we were given for our end of year OSCE last year -

You are a doctor in a GP clinic. Arif Asri, a 36-year-old sales manager, has come to your clinic because he is very concerned about his health and wants to know what he can do to improve it. He has recently been diagnosed as having diabetes mellitus. Apart from this, he has gained a lot of weight in the past two years, and also smokes about 20 cigarettes a day. On examination his BP is 130/90 mm Hg and his BMI is 30.

Tasks:

You are required to:

a) Take a brief history of his lifestyle based on the ESSENCE model (4 mins.)

b) Suggest a plan for changing any one aspect of his lifestyle (diet, exercise, or smoking), using a behaviour change strategy e.g. Prochaska Diclemente cycle of behaviour change, and a model for target setting (4 mins).

Approaching this Station -

1. Introduce yourself, consent, explain what you'll be doing -

'Hi, my name is ______, how are you? I understand that you've come in today because you're concerned about your health?'

1. Much of the information you would normally gain from a history has been provided in the stem, so don't spend too much time going over it – remember you only have 8 minutes (sounds like ages – it's not always!)
2. “So you're looking at improving your health, and that's fantastic. Acknowledging that you want to change is the first step so it's great that you've come in to see me.” Positive reinforcement is always useful and very helpful in developing rapport.
3. “Before we start discussing the changes that we would like to implement, first I'd like to find out a bit more about your current lifestyle – so tell me, are you getting much exercise at the moment?
4. Then just move systematically through the ESSENCE model – or whichever plan works best for you. Personally I find that starting with Exercise is a good question to start off with as people will expect it and (initially at least – while you're still developing rapport) it's easier to answer than “where do you get a sense of meaning from.
5. So, working through the acronym, just have a general question in mind for each aspect -

E – Education – 'what do you know about how your habits affect your health?'

S – Stress Management – 'do you ever feel stressed about work/relationships? How do you deal with this?'

S – Spirituality – 'do you get a sense of meaning from somewhere in particular? Do you attend church?'

E – Exercise – 'what sort of exercise do you do? How much would you do in a week?'

N – Nutrition – 'what would you eat for each meal in an average day?'

C – Connectedness – 'do you feel close to your friends or family? How much time do you spend with them/how often do you see them?'

E - Environment – 'who are you living with? Are you happy living with them? Do you think they would support your new lifestyle changes?'

1. And then, using BASK or Prochaska DiClemente, set up a plan for the patient to begin these lifestyle changes. Personally I find smoking to be the easiest as there is generally just the one aspect – needing to cut down as much as possible. Nutrition and Exercise are both good ones to look at though (remembering that this stem has only asked you to look at one.)

BASK model for behavior change

Behaviors

Attitudes

Skills

Knowledge

SAME model for goal setting

Specific

Attainable

Measurable

Enjoyable

Prochaska DiClemente Cycle for change

Precontemplation

Contemplation

Preparation

Action

Maintenance

Relapse (relapse is not failure)

8. For this I would probably talk to patient through Prochaska (I find it easy to explain) – although stick with whichever you are most comfortable/familiar with.

Eg - “Are you familiar with the Prochaska DiClemente cycle? It's a system that is used for helping people initiate behaviour change. Most importantly, we need to identify the stage as which you are at. The first stage is Precontemplation, but by coming in to see me I recognise that you have already begun thinking about the changes we need to make. The next stage is contemplation, and this is where you begin to weigh up the benefits of embracing a healthier lifestyle, and it's great to see that you've done that. The next phase is Preparation, and this is what I'd like to work with you to do today... Proper preparation is very important etc... You've mentioned that you'd like to cut down on smoking -

- reduce number of cigarettes

- have you ever heard of nicotine patches?

- reward yourself when you resist a cigarette

- remove yourself from/reduce the number of situations where you want to smoke – high stress, 'smoko' at work etc

When you leave today I'd like you to begin to put this into Action... After this it is important to Maintain these changes... if you do move into Relapse, where the lifestyle changes we discuss are not upheld, remember that this is not a 'failure' as such... You can try again etc...