Explain an anomalous coronary and exercise restriction to a young athlete — OSCE

Candidate instructions

You are the paediatric registrar. You have seven minutes to speak with Liam, a fourteen-year-old who plays competitive football, and his mother Mrs Chen. During a match two days ago Liam felt central chest pain and became dizzy, and he sat down just before he felt he might faint. An echocardiogram in the emergency department suggested that his left coronary artery arises from the right coronary sinus, and he has been told not to train until he is reviewed. Explain what this finding means in plain language, why he must stop competitive sport for now, what further tests and a possible operation involve, and what the outlook is — honestly and without overpromising. Answer their questions, check their understanding, and agree a plan. [1] [2]

Actor brief (athlete — Liam)

You are fourteen, sport is the centre of your life, and you are frightened and angry that you have been told to stop. You want to know: (1) What does it mean that a heart artery is in the wrong place — are you going to die? (2) Why can you not just play, since you have felt fine before and after? (3) Will you need an operation, and will surgery end your football career? (4) Is this your fault, or from something you did in training? (5) If you have the surgery, can you play again? Push back if the candidate is vague, dismissive of your worry about your career, or overpromises. You engage when the candidate is honest, respects how much sport matters to you, and gives you a clear plan. [2]

Actor brief (parent — Mrs Chen)

You are frightened because you have read that this can cause sudden death, and you are worried it was missed. You want the candidate to be honest about the risk, to explain what the next tests are, and to be clear about whether surgery is needed. You support Liam but want to make sure he is safe. Ask about the timing of the tests and surgery, and about whether the family needs to be checked. Calm when the candidate is honest and gives a clear, structured plan. [1] [3]

Exemplar candidate approach

Open and acknowledge. "Liam, Mrs Chen, please come in and sit down. I can see this has been a frightening couple of days — collapsing on the pitch was terrifying, and then being told to stop the sport you love is hard. You are in the right place, and we are going to work through this together. Let me explain clearly what we have found, why we are being careful, and what happens next, and please interrupt me at any point." [1]

Explain the finding in plain language. "The heart is supplied by two coronary arteries, which are the pipes that carry blood to the heart muscle. Normally the left one comes from the left side of the main artery, the aorta. The heart scan suggested that Liam's left coronary artery comes from the right side instead, and we think it may run between the two big arteries as it travels to the heart muscle. That matters because when the heart is working very hard, as it does in a match, that artery can get squeezed and the heart muscle can be short of blood — and that is almost certainly what caused the chest pain and dizziness on the pitch." [1] [3]

Be honest about the risk and the reason for rest. "I want to be straight with you. This kind of problem can, in some people, cause a dangerous heart rhythm during hard exercise — and that is why we are taking it seriously and why Liam cannot train or play competitively until we have finished the tests. It is not your fault at all — this is something you were born with, and nothing you did in training caused it. I am not going to pretend it is nothing, because it is not, but there is a great deal we can do, and most young people with this who are properly assessed and treated do very well." [1] [3]

Explain the next tests and the possible operation. "The next step is a more detailed heart scan called a CT coronary angiogram, which will show us exactly where the artery goes and how tight the course is, and an exercise test to see how the heart copes with effort. With those results, the congenital heart team will decide whether Liam needs an operation. The operation, if it is needed, is called an unroofing or reimplantation procedure, where the surgeon reshapes the artery's origin so blood flows freely. It is major heart surgery, but it is well established, and the teams who do it are very experienced." [1] [2]

Address the return-to-play and outlook honestly. "I know the question that matters most to you, Liam, is whether you can play again. I cannot promise that today, and I will not pretend otherwise. What I can tell you is that after successful surgery, many young athletes do return to competitive sport under a careful, supervised plan — but the decision depends on the anatomy and the operation, and it is made with the specialists over the coming weeks. Either way, you will have lifelong check-ups with the heart team, and you will not be on your own making that decision." [2]

Check understanding and agree a plan. "Can I check — what is your biggest worry right now, and has anything I have said been unclear? Here is the plan: Liam stops all competitive training from today, we arrange the CT coronary angiogram and exercise test this week, and you see the congenital heart team within the next one to two weeks to decide on surgery. We will also talk about checking close family members, because that is good practice after a finding like this. You can reach me or the team at any time, and nothing happens without you understanding why." [1] [2]

Mark scheme (10 marks)

• Empathy and relationship (2): acknowledges fear and the importance of sport, sits and listens, plain language, does not dismiss the career worry or overpromise. [1]
• Explains the finding clearly (2): coronary from the wrong sinus running a tight course, squeezed on exertion, not the patient's fault. [1] [3]
• Explains the risk and the reason for rest honestly (2): danger of dangerous rhythm with exercise, why competitive sport is stopped, honest without being bleak. [3] [4]
• Explains the tests and the possible operation (2): CT coronary angiogram and exercise test, unroofing or reimplantation, experienced congenital team. [1] [2]
• Addresses return to play and agrees a plan (2): honest about uncertainty, supervised return possible after surgery, structured next steps, family screening, ongoing availability. [2] [1]