Chronic disease self-management in young people — branching viva

Stem

The examiner will test whether you can assess and support a young person's self-management under pressure. [2] [1]

Branch 1 — Principles and definitions

Examiner: Distinguish adherence from compliance, and name the self-management task-domains. [2]

Strong answer: Adherence is an active, agreed collaboration; compliance implies passive obedience. Self-management has three task-domains — medical management (the regimen), role management (fitting the condition into life), and emotional management (coping with stigma and mood). All three must be addressed. [2]

Examiner: Why is self-management a developmental process rather than a switch? [7]

Strong answer: Responsibility hands over in a graded arc — parent-led, then shared, then young-person-led, with a safety net throughout. Where a young person sits is what you assess at the bedside, and it is not the same as their age, diagnosis, or readiness score. [7]

Branch 2 — Objective adherence assessment

Examiner: A 16-year-old with type 1 diabetes has had two DKA admissions. How do you assess adherence? [2] [5]

Strong answer: Never trust self-report alone. Pair it with objective markers — insulin pump or pen downloads, continuous-glucose time-in-range, and pharmacy refill data. Use a multimethod approach because no single measure is enough, and re-assess the diagnosis if the picture is confusing. [5] [2]

Examiner: How would you use the TRAQ here, and what are its limits? [3]

Strong answer: Use the TRAQ to map the specific self-care gaps in domains such as managing medications and keeping appointments. Its limit is that no readiness score alone justifies or blocks transfer; readiness remains a clinical judgement. [3]

Branch 3 — Motivational interviewing encounter

Examiner: Show me how you open with this ambivalent 16-year-old using motivational interviewing. [4]

Strong answer: Use OARS — Open questions ("what would make this worth doing for you?"), Affirmations (name effort, not just outcomes), Reflective listening (mirror the meaning back), and Summaries (collect the thread and roll with resistance). The aim is to draw out change talk, the young person's own reasons to manage their condition. [4]

Examiner: What does the evidence show for MI in this group? [4]

Strong answer: A systematic review found motivational interviewing improves adherence and symptom severity in adolescents and young adults with chronic illness. It is the behavioural tool to name and demonstrate. [4]

Branch 4 — The acute non-adherence crisis

Examiner: A 17-year-old transplant recipient presents with falling tacrolimus and rising creatinine, and refill data confirm non-adherence. Walk me through your priorities. [7] [5]

Strong answer: First, treat the acute problem — graft function, hydration, and infection risk by protocol. Hold the self-management conversation for the recovery phase, non-judgementally. Build a tighter safety-net: closer follow-up, objective graft-function monitoring, a simplified regimen, and wrap-around supports. A punitive stance destroys the relationship and worsens future engagement. [7] [2]

Examiner: What is the leading modifiable driver of graft loss here? [7]

Strong answer: Immunosuppression non-adherence is the leading modifiable driver of graft loss in adolescent transplant recipients, which is why it must be monitored proactively with drug levels and refill data. [7]

Branch 5 — The transfer cliff and transition

Examiner: A 19-year-old with cystic fibrosis is lost to follow-up for two years after leaving paediatric care, then re-presents in crisis. What failed, and how do you prevent it? [1] [6]

Strong answer: This is the transfer cliff — a system failure, not a patient failure. Prevention is a structured, early, person-centred transition with a named coordinator, a handover summary, and a warm link to the adult team. Telehealth and eHealth tools can support continuity, though the evidence base is still maturing. [1] [6]

Examiner: What does the Campbell 2016 Cochrane review actually conclude about transition? [1]

Strong answer: Interventions are diverse, study quality is variable, and the certainty of evidence is limited. Structured, coordinated, early transition with a coordinator shows promise but is not yet proven superior. Name the honest limitation; do not overclaim. [1]

Examiner extras

• The adherence dip deepens around the transfer years and partly recovers in the mid-twenties — a deteriorating 18-year-old is passing through, not lost. [2]
• Simplify the regimen before escalating the drug — fewest doses, combination devices, once-daily options where possible. [2]
• Name the regional transition tool: Ready Steady Go (UK), Got Transition Six Core Elements (US), RACP position statement (ANZ). [1] [3]
• Technology can widen inequity when device and app access follow socioeconomic lines — watch for it. [6]