Explain a perplexing presentation and a safety-netted plan to an exhausted family — OSCE

Candidate instructions

You are the paediatric registrar. The parents of a seven-year-old boy — two years of recurrent vomiting, fainting and fatigue, seen at four hospitals, no diagnosis, school attendance under 30% — have ten minutes with you. They are exhausted, frightened and frustrated. They want to understand, in plain language: (1) why you will not arrange a feeding tube today when the previous team was considering one; (2) whether you think their son has a rare disease the other doctors have missed; and (3) what your plan actually is, and who is in charge of it. Explain with empathy and honesty, do not accuse, hold the balanced differential openly, check understanding throughout, and agree a clear, named, dated plan. [5]

Encounter

Mother: "We have been doing this for two years. Nobody can tell us what is wrong. The last doctor said a feeding tube might help. Now you are saying no. Are you giving up on him?" [5]

Registrar: "I can hear how exhausting and frightening this has been for you both, and I am sorry it has felt like nobody is in charge. I am not giving up on your son — quite the opposite. I want to explain what I think is happening, why I am pausing before a feeding tube, and what my plan is. Can I take a moment to lay it out, and then please ask me anything?" [5]

Father: "Please. Because right now we feel like we are falling through the cracks." [6]

Registrar: "I think that is exactly what has been happening — not through anyone's fault, but because your son has been seen by many teams in many hospitals, and no one person has been holding the whole picture. That fragmentation is itself part of the problem. So the first thing I am going to do is become the one doctor who holds all of his records, all of his results, and the plan. I am going to gather everything from every hospital — every test, every note — and look at it as a whole, because that is often where the answer is, and it is the step that gets missed when care is scattered." [6]

Mother: "But why no feeding tube? He is losing weight." [5]

Registrar: "I want to be honest with you about my thinking. A feeding tube is a significant intervention, and right now I do not have a clear medical reason that would justify it. When we add interventions without a clear reason, sometimes the treatment itself becomes part of the problem — more procedures, more hospital time, more time away from school and friends. I am not saying never. I am saying let me first pull together everything that has been done, examine him carefully, and meet with the team, so that if a tube is needed, it is needed for the right reason — and if it is not, we do not add a burden that does not help. Does that make sense?" [5] [7]

Father: "Do you think he has something rare that the others missed?" [4]

Registrar: "That is one of three possibilities I am holding in my mind, and I want to be open with you about all three. The first is yes — there may be a rare or complex medical condition that the tests so far have not captured, and if so, I will find it; I will get a genetics and metabolism opinion to look at the whole picture rather than testing one system at a time. The second is that some of his symptoms may be what we call functional — real symptoms, real distress, where the nervous system is overwhelmed, that are not caused by a disease in the usual sense but are nonetheless disabling and treatable. The third is that the situation itself — the years of tests, the lost school, the worry — may now be part of what is keeping him unwell, regardless of where it started. All three can overlap, and my job is to keep all three in mind and not close the door on any of them too early." [4] [3]

Mother: "So what happens next, and who do we call?" [5]

Registrar: "Here is the plan. I am the named doctor — you call me, and if I am not here, my team knows your son. This week I will request every record from every hospital. Next week I will examine him thoroughly and meet with the genetics and psychology teams. Within two weeks I will sit down with you both and go through everything I have found and what I recommend. In the meantime, here is what to watch for and when to come back straight away — a written safety-net. And I want us to start thinking about school, because getting him back to his friends and his routine is part of his recovery, not something we wait to do until we have a label. What worries you most about that plan?" [5]

Father: "That you will do all this and still not find anything." [6]

Registrar: "I understand that fear, and I will not pretend I have an answer today. What I can promise is that you will not be bounced between teams anymore — one plan, one doctor, one record — and that we will review the plan together at a fixed date, not leave you waiting indefinitely. If something changes or worsens before then, you come straight back. Uncertainty is hard, but you will not face it alone, and you will not face it without a plan." [6]

Marking domains

• Communication (25%): plain language, empathy, checks understanding, invites questions, avoids jargon and does not accuse or dismiss. [5]
• Clinical content (30%): explains the three-limb balanced differential in plain language, the rationale for pausing further intervention, the strategy of gathering prior records, and the role of a single named consultant and multidisciplinary team. [5] [6]
• Honesty and shared decision-making (20%): is truthful about uncertainty, refuses harmful intervention without being dismissive, frames the plan as protective and collaborative, and agrees a clear next-step plan with the family. [7]
• Safety (15%): gives an explicit written safety-net with what to watch for, when to return, and a fixed review date; names who the family can contact. [5]
• Professionalism and global (10%): maintains a calm, non-judgemental, collaborative stance; acknowledges the structural problem of care fragmentation and names the structural solution. [6]