DECISION MADE:
You have chosen:
A consultation that unravels
All the right notes, but not necessarily in the right order...
Here's an example of a candidate getting into a bit of a chaotic conclusion, flipping from management choices to further bits of history, giving the impression that the plan is coming to him mid-sentence. It doesn't give the imrpession of a considered or structured approach. Often in an exam situation the nerves can result in this 'by the way' or 'did I mention' pattern of loosely-linked issues that the patient comments as "all over the place".
Signposting is a successful means of clarifying your structure- 'Moving on to management choices now...'
A Summarising statement also helps to buy you thinking time, make sense of the data gathered and check you've understood the gist of the problem. By making this summary you are drawing a line in the sand to signal to yourself that you're moving into the shared part of the consultation where you will discuss management rather than return to either the patient's part of doctor's part gathering diagnostic information. Here the GP uses a Summarising Statement after 10:30, but true to form, goes back to asking questions about smoking and alcohol that didn't influence further management.
SCA Feedback Statements
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.
Data gathering was unsystematic and or disorganised
Examiners did not feel that the consultation had a logical structure.
Consultations are not scripted or linear, it is often necessary to return to aspects of data gathering or test new hypotheses as information comes to light. The consultation is a conversation between two people and as such, may be unpredictable.
However, your data gathering may have appeared disjointed, your questioning failing to show a reasoned way of thinking. The consultation may have appeared disorganised or even chaotic, with some elements apparently occurring at random. This gives the impression of a doctor who may miss important clinical issues because he/she is not systematic; or one who is at a loss for what to ask.
For example, for a patient with long COVID, a systematic approach to their symptoms, rather than a ‘scattergun’ enquiry of irrelevant, disjointed questions may be more helpful both diagnostically and therapeutically. It may seem topsy-turvy or presumptuous to give a diagnosis before data has been gathered. Or to agree to a prescription prior to establishing safety.
Aim for a stepwise approach to systematically gather information, focus your enquiry and target questions to the problem.
Suggestions
Consider the various GP consultation models (such as Neighbour, Pendleton or Cambridge-Calgary). Ask a colleague or your supervisor to critique the structure or organisation of your consulting.
Using open questions to explore the presenting features, before focussing on specific detail with closed questions, is often helpful.
Try signposting, where you signal to the patient what you are about to do. For example, ‘I would like to ask you some questions about your health in the past.’ If you should need to return to aspects of data gathering later in the consultation, consider saying, ‘I realise I need to return to some other questions now…’
Summarising also demonstrates that you are collating and processing the collected information; and is useful in allowing the patient to clarify anything misunderstood.