Cultural Competence and Indigenous Health — DCE Clinical Case

DCE long-case clinical station: comprehensive assessment of a 48-year-old Aboriginal woman from a remote community admitted with decompensated rheumatic heart disease, type 2 diabetes, chronic kidney disease, chronic otitis media, depression, suboptimal secondary prophylaxis, and a social context of isolation and system disengagement — covering the cultural safety framework, the integrated management of multisystem disease, the approach to the Aboriginal Health Worker and community-controlled health service, the culturally safe communication and discharge planning, and the physician's role in Closing the Gap — structured for FRACP DCE and MRCP PACES.

Prompt

Station scenario

Setting. General medical ward of a metropolitan teaching hospital, 800 km from the patient's remote community. ^[1]

Patient. Mrs K is a 48-year-old Aboriginal woman from a remote community in the Northern Territory, admitted overnight with a 5-day history of progressive breathlessness, orthopnoea and bilateral leg swelling. ^[1]

Admission data.

Blood pressure 104/68, heart rate 112 and irregularly irregular (atrial fibrillation), respiratory rate 24, oxygen saturation 90 per cent on room air
Bilateral basal crackles, raised JVP, bipedal oedema
Echocardiogram: severe rheumatic mitral stenosis (valve area 0.9 cm2), moderate mitral regurgitation, mild aortic regurgitation, left atrial dilatation, no left atrial thrombus
HbA1c 84 mmol/mol, eGFR 38, ACR 65 mg/mmol, total cholesterol 5.8
INR 1.1 (not anticoagulated)
Chronic right ear discharge on otoscopy with central tympanic membrane perforation
History of ARF at age 12, on secondary prophylaxis (benzathine penicillin G every 28 days) but has missed 4 of last 6 injections
800 km from home, 14-year-old son is her primary carer, no Aboriginal Health Worker has been involved
Nursing notes describe her as 'non-compliant'
Known depression, not currently engaged with mental health services ^[1]

Task. The candidate has 25 minutes to assess the patient, take the history, consider the investigations, formulate a prioritised problem list and an integrated management plan, and be prepared to present to the examiner and answer probing questions. ^[1]

References2Show

[1]Hardy BJ, Filipenko S, Smylie D, et al. Systematic review of Indigenous cultural safety training interventions for healthcare professionals in Australia, Canada, New Zealand and the United States BMJ Open, 2023.PMID 37793931
[2]Wyber R, Ralph AP, Bowen AC, et al. Improving primary care for Aboriginal and Torres Strait Islander people with rheumatic heart disease: What can I do? Aust J Gen Pract, 2022.PMID 36451330

Cultural Competence and Indigenous Health — DCE Clinical Case

Station scenario

Setting. General medical ward of a metropolitan teaching hospital, 800 km from the patient's remote community. ^[1]

Admission data.

Blood pressure 104/68, heart rate 112 and irregularly irregular (atrial fibrillation), respiratory rate 24, oxygen saturation 90 per cent on room air

Bilateral basal crackles, raised JVP, bipedal oedema

Echocardiogram: severe rheumatic mitral stenosis (valve area 0.9 cm2), moderate mitral regurgitation, mild aortic regurgitation, left atrial dilatation, no left atrial thrombus

HbA1c 84 mmol/mol, eGFR 38, ACR 65 mg/mmol, total cholesterol 5.8

INR 1.1 (not anticoagulated)

Chronic right ear discharge on otoscopy with central tympanic membrane perforation

History of ARF at age 12, on secondary prophylaxis (benzathine penicillin G every 28 days) but has missed 4 of last 6 injections

800 km from home, 14-year-old son is her primary carer, no Aboriginal Health Worker has been involved

Nursing notes describe her as 'non-compliant'

Known depression, not currently engaged with mental health services ^[1]

References2Show

[1]Hardy BJ, Filipenko S, Smylie D, et al. Systematic review of Indigenous cultural safety training interventions for healthcare professionals in Australia, Canada, New Zealand and the United States BMJ Open, 2023.PMID 37793931
[2]Wyber R, Ralph AP, Bowen AC, et al. Improving primary care for Aboriginal and Torres Strait Islander people with rheumatic heart disease: What can I do? Aust J Gen Pract, 2022.PMID 36451330