Listing the options
Is the list enough?
The GP may well feel she has presented all the various options of support, and it is indeed comprehensive, from the Age Concern Worker, the practice Carers Group, the Social Prescriber, the specifics of support- all of this knowledge is adequately demonstrated, but the effort to present the list has ignored the risk of fracture apparent for a patient on long-term steroids who has persisting bony pain.
Shared Decision Making must be conducted within clinical safety and not miss the warning signs.
Was the offer of support really how Jane needed it or was this unfurling of a list done in an impersonal way?Notice what Jane says and what she really means at 11:08 when asked about seeing the GP again!
Are there other examples of mixed signals you've noticed in consultations?
The clash of agendas continues with the GP discussing seeing again about blood test and home BP readings, but Jane feeling the appointment would be required for pain control- unless this is verbally acknowledged by the GP, the patient will remain at odds to the recommended long-term plans as they are left imposed rather than agreed, without incorporating Jane's priorities.
SCA Feedback Statements
Differential diagnoses or hypotheses were inadequately generated or tested
Examiners felt that you did not consider relevant conditions in the differential diagnosis. Perhaps you should have considered and explored a broader range of possibilities, before narrowing your diagnosis. Or perhaps the examiners felt it was impossible or unnecessary to make a single diagnosis during the consultation and that different options should be explored further.
For example, although the patient may appear anxious, before concluding she has anxiety disorder, might it be helpful to consider ADHD, might she use cocaine, or might she have issues with her thyroid gland?
Suggestions
Try to consider and test a range of possible diagnoses. Avoid assumptions about patients. Notice if you employ confirmation bias, where you favour new information that confirms previous beliefs, disregarding other evidence that may not align.
Sharing insight into your diagnostic reasoning with the patient (and thereby the examiner) is helpful too. For example, ‘I had thought about X but as your Y is not painful this is less likely, however if Z happens, we will need to reconsider this next time.’
The plan relating to the medical management of risk was inadequate or inappropriate
Medical management of risk means ‘the forecasting and evaluation of risks together with identification of procedures to avoid or minimise their impact’. Risk management prioritises patient safety and ensures an appropriate response to preventing risk or managing error.
Examiners did not feel that you managed risk appropriately. This could mean either that you failed to identify the potential risks or that having done so you did not respond in an appropriate way. Perhaps you didn't seem aware of the responsibility for a systems' response, for example significant event analysis or the complaints process.
Alternatively, you may have been too risk-averse in an otherwise safe encounter.
For example, was the risk of a patient falling, or the impact on their eGFR, greater than the risk of their slightly raised blood pressure? Should those risks have been prioritised before following a BP guideline?
Was the risk of overdose greater than the convenience of issuing three months’ of medication?
Did a temporary patient with no records receive care without reference to his registered GP in a way that created risk?
Did a concerned daughter who identified a problem with her cognitively impaired father’s care fail to receive supportive signposting to the complaints procedure and a willingness to investigate via a significant event analysis with the team?
Were documents shared without consideration of data protection?
Suggestions
Be aware of NHS guidelines around medical risk management. Engage in partners’ meetings and significant event / complaints analyses in the practice to become familiar with the practical applications of risk management in the workplace. Discuss risk with your supervisor and consider risk management as a priority in your patient encounters.