Medication adherence and treatment fatigue OSCE — assessment, measurement and the tailored plan

Station objectives

1. Open the adherence conversation with a non-judgemental, normalising frame and time alone. [1] [5]
2. Take a structured adherence history across initiation, implementation and persistence. [1]
3. Interpret discordance between self-report and objective data without blame. [2]
4. Build a tailored plan: shared goals, motivational interviewing, regimen simplification with the team, reminders, family-based support. [3] [5]
5. Recognise and act on red-flag consequences and the transition cliff. [4]

Candidate brief

You are the paediatric doctor in an adolescent chronic-disease clinic. You have 10 minutes for Station A (cystic fibrosis adherence assessment and plan) and 12 minutes for Station B (transplant recipient nearing transfer, subtherapeutic tacrolimus, and a disclosure you must handle safely). Examiners score the opening frame, the measurement interpretation, the barrier mapping, the quality of the tailored plan, and the safety reasoning. [1] [5]

Station A — Cystic fibrosis, perfect self-report, discordant refills

Setup: A 16-year-old with cystic fibrosis reports taking every enzyme and antibiotic dose; pharmacy refill data show the antibiotics have been collected two months late for the last three cycles. [2]

Expected actions:

• Open non-judgementally with time alone; normalise that everyone misses doses. [1]
• Take a specific behavioural history (last seven days) rather than a global question. [1]
• Treat the discordance as the conversation, not the indictment; triangulate self-report, refills and any objective data. [2]
• Map barriers across regimen burden, side-effects, family supervision and access; probe the darkest. [5]
• Offer a tailored plan: simplify where the team permits, add reminders, involve psychology, name the next contact. [3] [5]

Station B — Transplant recipient, transition, disclosure

Setup: A 17-year-old liver-transplant recipient nearing transfer to adult care has subtherapeutic tacrolimus at two visits and has missed clinic. Seen alone, they disclose skipping doses because the medicine marks them out, and they ask you not to tell the transplant team. [4]

Expected actions:

• Acknowledge the disclosure without blame; name the identity load the medicine carries. [1]
• Recognise graft-loss risk: explain what must be shared and why, involve the transplant team urgently, and screen for graft dysfunction with exit to acute care if present. [4]
• Address the transition cliff: strengthen transition readiness and arrange a warm handover. [4]
• Build a shared plan with motivational interviewing, a low-threshold way back in, and protected adolescent-only time. [3]

Marking anchors

Clear pass: secures time alone and a non-judgemental frame; structured phase-based history; treats discordance as conversation not indictment; maps barriers across domains and probes the darkest first; tailored plan with shared goals, simplification with the team, reminders and psychology; clear safety reasoning and transition plan. [1] [3] [4] Borderline: good rapport but incomplete measurement, vague barrier mapping, or a plan limited to reminders. Fail: confrontational opening; takes self-report at face value; punitive testing; ignores graft-loss or transition risk; blames the patient. [2] [5]

Debrief pearls

• Adherence is a behaviour you support, not a command you issue — agreed, not imposed. [1]
• The outcome is sustained engagement; the young person who returns after a lapse is the success case. [1]
• The transition cliff is predictable and preventable — never leave it unmanaged. [4]