Beneficial advice at the wrong time
Ask yourself- is it always appropriate to raise the topic of smoking cessation? Would he be in a position for a successful attempt at quitting smoking with his current levels of strain?
Consideration of the common factors behind relapse would guide the GP into the best opportunities for successful intervention.
A formulaic approach to Making Every Contact Count and lifestyle advice would not be in his best interests, either through lack of recognition of the detail within this case, to the likely prospects of successful smoking cessation.
SCA Feedback Statements
Decision-making or diagnosis was illogical incorrect or incomplete
Examiners felt that you failed to make the appropriate diagnosis and/or that the reasoning behind your conclusions did not make sense, clinically.
Making a diagnosis or reaching a decision means making a conclusion about what is likely, from the information you have available to you.
For example, did you conclude someone had psoriasis when the rash and history were those of a fungal skin infection? Did you decide someone has restless legs, despite them being vegan and have a very low B12? Could that URTI more likely be hay fever, based on the information available. Perhaps the ECG provided showed Atrial Fibrillation but you did not diagnose this.
Or did you appear to sit on the fence and avoid communicating a diagnosis that seemed obvious, for fear of getting it wrong in the examination?
Suggestions
Try to reach a decision before debriefing a patient with your supervisor and ensure you challenge yourself about the likely diagnosis. Is your decision-making in line with that of your colleagues?
Do you tend to be dogmatic or quick to jump to conclusions in your diagnoses?
Is there an area of the curriculum you are less confident in?
Consider proactively addressing this in your reading, your patient experience and your other learning opportunities.
Random case analyses and case-based discussions are also very helpful in putting your decision-making in the spotlight.
The management plan relating to investigations was inappropriate or not reflective of current practice
You are expected to show that your clinical management skills are in line with current UK best practice. You may not have suggested investigations at all, where they were needed. You may have suggested inappropriate or unjustifiable investigations. Or you may have arranged investigations when none were needed in this case.
For example, it may not be necessary to request an MRI scan for simple back pain, or a sputum sample for an URTI. If someone has symptoms of irritable bowel syndrome it may be unclear why a vitamin D level is suggested. Alternatively, after a cough worsening over several weeks, it may have been advisable to request a chest Xray.
Suggestions
Your management plan should be coherent and feasible. You should be familiar with current national guidelines such as those published by NICE (National Institute of Clinical Excellence) and SIGN (Scottish Intercollegiate Guidelines Network).
Investigations requested should be targeted and relevant, answering a specific clinical question. It should be clear why they are being chosen, based on the probability of disease and with an awareness of budgetary governance.
You may feel that it would be better to be ‘on the safe side’ by ordering a battery of tests and whilst understandable, this can make you appear indiscriminate.
Collect a list of all the investigations you have requested over a few sessions at work. Compare with others, peers or your supervisor. What was the reason for choosing those investigations? Were they helpful and/or justified? Plan a tutorial where you share and action your supervisor’s results list and vice versa.
A judgmental approach was shown to the person
Examiners felt that you conveyed judgement about the person and/or their behaviour/situation in your response to them during the consultation. This may have been implied.
There are many ways a judgement can be expressed or perceived. For example, doctors may inadvertently ‘fat shame’ someone with obesity by implying ‘we get the body we deserve’; or comment ‘what did you expect?’ when a person becomes pregnant from unprotected sex. A person who has recently left prison may experience judgement when an unnecessary line of questioning about their crime ensues. Although reasonable challenge may be appropriate, criticism of parental decisions about vaccinations, food choices or smoking in the flat may be unhelpfully judgemental and therefore alienating.
It may be that people with certain protected characteristics generate a less empathic, supportive response. For example, an undocumented migrant may be only superficially helped or even dismissed.
Suggestion
We all carry unconscious bias. Recognise which consultations may challenge your assumptions. Understand why some people may be more vulnerable, more susceptible to illness or less able to make changes that improve health. Try to consult with a diverse range of people and demonstrate empathy, compassion and partnership with them all where possible.