Asking about complementary and traditional medicines — OSCE

Station overview

A communication station testing whether the candidate can take a respectful, non-judgemental complementary and alternative medicine (CAM) history from a parent, recognise the herb-drug interaction risk, counsel honestly without dismissing the family's beliefs, and build a shared safety plan. The station is not about the pharmacology of St John's wort per se; it is about the disclosure gap, the interaction risk, the shared decision and the documentation. [4]

Candidate instructions

You are the general paediatric registrar. You have eight minutes. The boy's epilepsy is well controlled on sodium valproate and lamotrigine. During the routine medication review, the mother mentions — almost in passing — that she has started giving him a herbal product "for his mood" that she bought online. Your task is to take a respectful CAM history, assess whether the product could interact with his antiseizure medicines, counsel the mother honestly, and agree a shared plan. The mother (played by an examiner or actor) is worried about her son's low mood and is defensive about being judged for trying a herbal remedy. [1]

Encounter structure

1. Establish rapport and normalise the question first. Use open, non-judgemental wording — "Lots of families try herbs or natural remedies alongside prescribed medicines, and I always like to know about everything so I can make sure it's safe together. Tell me about what you've been giving him." Do not judge or dismiss. [4]
2. Take a full CAM history. Establish the product name, the ingredients (ask to see the bottle or the website listing), the dose, how long he has been taking it, who recommended it, and whether anything else — vitamins, other herbs, traditional remedies — is being given. [1]
3. Identify the specific interaction risk. If the product contains St John's wort (Hypericum perforatum), explain that it is a potent inducer of the CYP3A4 enzyme and P-glycoprotein, which can lower the blood levels of several antiseizure medicines and increase the risk of breakthrough seizures. Name the mechanism in plain language. [5]
4. Counsel honestly and collaboratively. Acknowledge the mother's concern about her son's mood — it is a real and important problem — and do not dismiss the wish to help. Explain that the mood problem itself needs proper assessment and that the herbal product, by interacting with his epilepsy medicines, could do more harm than good. Frame stopping the St John's wort as protecting his seizure control, not as punishing her. [4]
5. Build a shared plan. Agree to stop the St John's wort (and check the antiseizure levels if there is any concern), arrange a proper assessment of the low mood (paediatric psychology or child and adolescent mental health), invite her to bring any future CAM product to you first for a safety check, and offer to document everything so nothing is hidden. [4]
6. Document. Tell the mother you will record the CAM product, the discussion, and the plan in the notes, and that you will follow up. [4]

Marking domains

• Communication and rapport — normalises the question, uses plain language, checks understanding, acknowledges the mother's concern without dismissing it. (High-weight domain.) [4]
• Accuracy of the CAM history — establishes name, ingredients, dose, duration, source and recommender; identifies whether the product contains St John's wort. [1]
• Interaction risk assessment — correctly identifies St John's wort as a CYP3A4 and P-glycoprotein inducer that can lower antiseizure medicine levels; does not claim all CAM is dangerous. [5]
• Honest, collaborative counselling — respects the family's beliefs, frames the plan as protecting the child rather than judging the parent, and addresses the underlying mood problem. [4]
• Safety plan and documentation — stops the interacting product, arranges mood assessment, invites future safety checks, and commits to documenting the CAM history and the plan. [4]

Common pitfalls (what loses marks)

• Dismissing the herbal product or the mother's concern about mood, which destroys trust and drives future non-disclosure. [4]
• Failing to establish the specific ingredients, so the interaction is missed. [5]
• Claiming all CAM is dangerous, or conversely reassuring without checking the interaction. [4]
• Forgetting to address the underlying mood problem, which is the reason the family reached for the product. [4]
• Not documenting the CAM history or the plan. [4]

Actor notes (for the examiner)

• If the candidate avoids asking about CAM specifically, prompt: "I wasn't sure whether to mention it — is it a problem that I've been giving him a herbal remedy?" [1]
• If the candidate is dismissive or judgemental, push back: "I only wanted to help him — are you saying I've done something wrong?" [4]
• If the candidate does not name the interaction, ask: "Will it actually affect his epilepsy medicines?" [5]
• If the candidate forgets the mood problem, ask: "So what do I do about his low mood, then?" [4]