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OR14.1-4 | Counselling and Rehabilitation Skills — Assignment
CLINICAL SCENARIO
This assignment develops your ability to plan and communicate orthopaedic counselling across the full spectrum of the competency — from prognosis disclosure and informed consent to recognition of warning signals requiring referral and amputation rehabilitation. You will analyse a structured case and produce a written counselling plan that demonstrates clinical depth, ethical soundness, and patient-centred communication.
Instructions
- Read the case scenario carefully.
- Using the SPIKES protocol as your framework, plan how you would counsel this patient about prognosis and the proposed surgical intervention.
- Identify all elements required for valid informed consent for below-knee amputation, and describe how you would address this patient's specific concerns.
- Identify at least THREE warning signals present in the case and explain how you would communicate each to persuade the patient/family of the urgency of definitive management.
- Describe the rehabilitation journey for this patient post-amputation, covering: (a) ideal stump properties you would aim for, (b) the PTB socket and its weight-bearing mechanics, (c) phantom limb pain — its nature, counselling approach, and first-line treatments, and (d) realistic functional outcome expectations.
- Write your response in structured sections (headings provided in the scaffold). Aim for 600–900 words total.
Case Scenario:
Mr. Suresh Kumar, 55 years old, a farmer from rural Tamil Nadu, presents to a district hospital with a 3-week history of fever, left leg swelling, and an open wound over the left foot with visible bone, foul-smelling discharge, and surrounding cellulitis. He has poorly controlled diabetes (HbA1c 11.2%). Doppler shows absent flow in the anterior tibial artery; foot ABI is 0.3. X-ray shows osteomyelitis of the left second and third metatarsals with gas in the soft tissues. His right-handed son insists his father 'will not agree to amputation' and asks the surgical team to 'just tell him he has no choice.' The surgical team recommends urgent below-knee amputation with external fixation. Mr. Kumar is conscious, oriented, and anxious.
Length: 600–900 words
What to Submit
1. Prognosis Counselling (SPIKES Framework)
Guidance: Using the SPIKES steps (Setting, Perception, Invitation, Knowledge, Emotions, Strategy), outline how you would conduct the prognosis counselling conversation with Mr. Kumar. Address the clinical reality honestly while maintaining patient dignity and hope. Discuss how you handle the son's request to withhold information.
2. Informed Consent for Below-Knee Amputation
Guidance: List and explain each component of valid informed consent as applied to this case (capacity, information, comprehension, voluntariness). Identify which component is most at risk here and how you would safeguard it. Address language barriers, health literacy, and the family pressure issue.
3. Warning Signals and Referral Justification
Guidance: Identify at least three warning signals present in this case (e.g., vascular compromise with absent Doppler flow, gas gangrene signs, uncontrolled DM with osteomyelitis). For each, explain in patient-friendly language why it justifies urgent definitive surgery and what happens if treatment is delayed. Describe how you would convince the patient (not just the family) to accept the procedure.
4. Amputation Rehabilitation Plan and Counselling
Guidance: Describe the ideal stump you would aim to create and why each property matters for PTB socket fitting. Explain the mechanics of the PTB socket to the patient (how weight is distributed, what areas bear load). Counsel Mr. Kumar on phantom limb pain — validate it, explain the mechanism, and outline first-line management. Describe realistic functional outcome expectations (ambulation level, return to modified farm activities, driving potential).
Grading Rubric — Counselling and Rehabilitation Skills Assignment Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Prognosis Counselling Quality (SPIKES application, patient-centredness, handling family coercion) | 10 pts | SPIKES applied fluently; Perception and Invitation steps explicitly addressed before Knowledge delivery; family coercion correctly managed by prioritising patient autonomy while including family respectfully; empathic language throughout |
| Informed Consent Elements (capacity, information, comprehension, voluntariness — all four addressed with case specificity) | 10 pts | All four consent elements explicitly addressed with case-specific detail; comprehension verified via teach-back; voluntariness documented and family pressure addressed; language/literacy barriers acknowledged and mitigated |
| Warning Signal Identification and Communication (clinical accuracy + persuasive patient communication) | 10 pts | Three or more accurate warning signals identified (e.g. absent Doppler flow with ABI 0.3, gas in soft tissues indicating gas gangrene, osteomyelitis with uncontrolled DM); each explained in accessible language with clear consequence of delay; persuasive patient-directed arguments |
| Amputation Rehabilitation Knowledge (stump properties, PTB socket, phantom pain, functional outcomes) | 10 pts | Ideal stump described accurately (12–15 cm tibial length, cylindrical, posterior scar, muscle cover, pain-free); PTB socket weight-bearing mechanics correctly explained to patient; phantom limb pain validated as neurobiological, mechanism explained accessibly, mirror therapy + gabapentinoids mentioned; realistic K2–K3 functional outcome with modified occupation discussed |
| Communication Quality and Professional Tone (clarity, empathy, structure, appropriate terminology) | 10 pts | Writing is clear, structured, and appropriately professional; medical terminology is accurate and patient-facing language is accessible; empathic tone consistent; word count within guidance (600–900 words) |
PEER REVIEW
Review your peer's submission against each rubric criterion. For each criterion: (1) note one specific strength with a quote or reference from their text, (2) identify one gap or improvement, and (3) assign a score. Provide a 3–5 sentence overall comment addressing what was most persuasive in their patient counselling approach and what clinical information could be strengthened. Be constructive and evidence-based in your feedback.