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Office of Postgraduate Education Centre for Addiction & Mental Health, College St. Site 250 College Street, Suite 828 • Toronto ON M5T 1R9 Canada Tel: 416-979-6911 Fax: 416-979-6928 PGY 2 – PGY 5 MOCK ORAL EVALUATION FORM (Resident must complete 3 Mock Oral Examinations during each 6-month rotation) The Mock Oral Evaluation form covers several domains including the psychiatric interview, case presentation, differential diagnosis, formulation and management. For each item listed on the evaluation tool, we ask that you use the following scoring-system: Score of 1 - 4 Score of 5 - 6 Score of 7 - 8 Performs below the level of a PGY2 resident Performs at a Junior Resident level (PGY2 & PGY3) Performs at a Senior Resident level (PGY4 & PGY5) The resident’s overall performance on the mock oral should be determined by the examiner’s global impression of the examinee’s performance. This means that residents may score below their expected level on selected items but may excel in a majority of areas resulting in an “acceptable” score overall. Items that are bolded relate to domains that are expected of Senior residents. These items should still be scored for Junior residents for the purpose of feedback but should not be factored into the global overall evaluation of the junior resident’s performance. Resident Name: Year of Training: Date/Time: Day/Month/Year Interview Start Time Evaluator Name: Interview End Time Hospital: Your performance on today’s evaluation based on your level of training was: Pass Fail Patient Description A snap shot of the patient that includes, age, gender, likely diagnosis and other relevant identifying factors. Patient Difficulty Specify here any unique patient characteristics (e.g., language issues, disabilities, psychopathology) that clearly makes establishing and maintaining the doctor-patient relationship and/or interviewing the patient more difficult: 1.0 Physician-Patient Relationship (Total) 1 2 3 4 5 6 7 8 1.1 Introduces self, role and circumstances 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 1.2 Maintains appropriate eye-contact Comment: Page 1 of 9 Mock Oral Evaluation Form 1.3 Appears genuinely interested 1 2 3 4 5 6 7 8 Comment: 1.4 Remains supportive throughout 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 1.5 Body language suggests active listening Comment: 1.6 Responds appropriately to patient Comment: 1.7 Develops rapport with patient Comment: 1.8 Sustains rapport with patient Comment: 1.9 Engages patient in a culturally appropriate manner Comment: 1.10 Smoothly closes the interview Comment: 1.11 Provides a pertinent closing statement Comment: 2.0 Interview and MSE (Total) 1 2 3 4 5 6 7 8 2.1 Appears confident 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 2.2 Maintains control of the interview Comment: 2.3 Non-verbal behaviour encourages patient to tell his/her story Comment: 2.4 Verbal behaviour encourages patient to tell his/her story Comment: 2.5 Listens attentively Comment: Page 2 of 9 Mock Oral Evaluation Form 2.6 Reframes when required 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 5 6 7 8 5 6 7 8 Comment: 2.7 Note-taking is inconspicuous Comment: 2.8 Asks clear questions in plain language Comment: 2.9 Avoids leading questions Comment: 2.10 Avoids stacked (multiple) questions Comment: 2.11 Moves appropriately between open and closed questions Comment: 2.12 Maintains a logical sequence to questions Comment: 2.13 Pursues detail and seeks appropriate clarification required Comment: 2.14 Bridges between the different sections of the interview Comment: 2.15 Comfortably allows silence to facilitate further expression Comment: 2.16 Facilitates expression of emotions 1 2 3 4 Comment: 2.17 Acknowledges patient’s distress with empathic responses 1 2 3 4 Comment: 2.18 Appropriately utilizes patient’s non-verbal communication 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 2.19 Appropriately responds to affective cues Comment: Page 3 of 9 Mock Oral Evaluation Form 2.20 Appropriately responds to informational cues 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 2.21 Appropriately deals with unusual, difficult or distressing content Comment: 2.22 Appropriately adapts the interview and MSE to be cultural competent Comment: 2.23 Supportively confronts inconsistencies Comment: 2.24 Summarizes when appropriate Comment: 2.25 Attends to timing Comment: 2.26 Interview Content Obtains demographic information Comment: 2.27 Obtains data on presenting problem(s) Comment: 2.28 Obtains History of Presenting Illness Comment: 2.29 Assesses pre-morbid state Comment: 2.30 Assesses stressors related to presenting illness Comment: 2.31 Identifies social and cultural stressors and systemic inequities Comment: 2.32 For episodic illnesses, identifies number of previous episodes Comment: 2.33 For episodic illnesses, identifies differences/similarities with this episode Comment: Page 4 of 9 Mock Oral Evaluation Form 2.34 Identifies treatment interventions for this illness episode 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 2.35 Reviews ‘A’ criteria for symptoms of illnesses in the differential diagnosis Comment: 2.36 Reviews ‘A’ criteria for symptoms of likely comorbid diagnoses Comment: 2.37 Explores patient’s explanatory model of illness Comment: 2.38 Completes an appropriate risk assessment (selfharm, aggression, self-care, competency) Comment: 2.39 Reviews current medications and over-thecounter products quantifying dose, side-effects and effectiveness Comment: 2.40 Reviews complementary and alternative treatments 1 2 3 4 5 6 7 8 2.41 Defines allergic status 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 2.42 Reviews substance use/abuse Comment: 2.43 Reviews Medical History Comment: 2.44 Reviews Psychiatric History Comment: 2.45 Reviews Forensic History Comment: 2.46 Reviews Family History Comment: Page 5 of 9 Mock Oral Evaluation Form 2.47 Reviews Developmental History i) Childhood 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 2.48 ii) Adolescence Comment: 2.49 iii) Adult Comment: 2.50 iv) Reviews relevant cultural identities, migration history/trauma/stress, acculturative strategies, and spirituality 1 2 3 4 5 6 7 8 2.51 v) Identifies social and cultural supports including family, kin networks, and communities 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 2.52 vi) Relationship History Comment: 2.53 vii) Occupational History Comment: 2.54 Conducts formal Mental Status Examination as indicated Comment: 3.0 3.1 Case Presentation (Total) Presents case in an orderly and systematic manner 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 3.2 Accurately presents relevant social and cultural issues and their impact on presentation and diagnosis Comment: 3.3 Accurately reports the Mental State Examination Comment: 3.4 Presents case in a concise manner yet includes relevant details Comment: 3.5 Presentation includes the necessary information to support the chosen preferred diagnosis Comment: Page 6 of 9 Mock Oral Evaluation Form 3.6 Presentation enhances understanding of the person with the illness 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 3.7 Accurately summarizes the risk assessment (self-harm, aggression, self-care, competency) Comment: 3.8 Accurately identifies deficits in the completed history, their relevance to the case and provides strategies for correcting those deficits Comment: 3.9 Provides a realistic, multi-axial working diagnosis supported by evidence from the interview Comment: 3.10 Identifies relevant comorbidities Comment: 3.11 Provides a brief, differential diagnosis supported by evidence from the interview Comment: 3.12 Defends the differential diagnosis and outlines strategies to further clarify the diagnosis when asked Comment: 4.0 Formulation (Total) 4.1 Identifies the major factors affecting the patient’s health (protecting; predisposing; precipitating and perpetuating factors) 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 4.2 Accurately identifies biological components of the patient’s illness Comment: 4.3 Accurately identifies psychological components of the patient’s illness Comment: 4.4 Accurately identifies social and cultural components of the patient’s illness Comment: 4.5 Able to identify prominent internal conflicts and/or cognitive distortions that influence the patient’s presentation Comment: Page 7 of 9 Mock Oral Evaluation Form 4.6 Able to identify problematic ways of relating to others that influence the patient’s presentation 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 Comment: 4.7 Able to provide an integrated and accurate formulation that enhances the understanding of the patient with the illness. Comment: 5.0 Treatment Plan (Total) 5.1 Identifies further bio-psycho-social-cultural investigations immediately required to consolidate the diagnosis or provide optimal care of the patient 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Comment: 5.2 Provides a realistic treatment plan covering immediate, short term, and long term goals Comment: 5.3 Able to recommend and defend appropriate, specific pharmacotherapies with an appraisal of the risks and benefits for the patient. Comment: 5.4 Able to consider social and cultural factors in all aspects of treatment planning Comment: 5.5 Able to recommend and defend appropriate collaborations with family, community, or other service providers Comment: 5.6 Able to recommend and defend appropriate, specific psychotherapies with an appraisal of the risks and benefits for the patient. Comment: 5.7 Able to address issues that may impact recovery beyond symptom reduction Comment: Page 8 of 9 Mock Oral Evaluation Form COMMENTS: STRENGTHS. The following behaviors contributed to your effectiveness: 1. 2. 3. WEAKNESSES. You should consider decreasing or stopping the following behaviors: 1. 2. 3. RECOMMENDATIONS. To increase your effectiveness, you may wish to consider beginning or doing more of the following: 1. 2. 3. Resident Signature: Evaluator Signature: Thank you… Please return the completed form to your hospital Postgraduate Coordinator Please Fax To: 416-979-6928 ATTN: Sue Eccles Page 9 of 9 Mock Oral Evaluation Form