When to manage in Primary Care
But I managed it appropriately...
The GP demonstrates a perfectly reasonable process of managing dyspepsia as a suspected cause of the abdominal pain drawn from the context of the carer strain the patient is going through.
Unfortunately he just doesn't 'get' the nub of the case and the risks represented by his symptoms, smoking status and the borderline set of results that suggest an underlying cause needs to be rapidly excluded. This differential doesn't seem to have been considered.
Do you think this could be related to their established relationship? Does building continuity mean that we don't want to see the potential risks risk colluding in ignorance of a collection of low-level concerns that could add up to something more?
SCA Feedback Statements
Data gathering was insufficient to enable safe assessment of the condition/situation
Examiners felt that the history taken was insufficient in terms of breadth or depth to enable you to safely assess the condition and its severity.
Suggestions
Ensure you consider the presence or absence of relevant ‘red flags’.
An exhaustive enquiry into a list of all possible symptoms is unnecessary and impractical; but ask enough to demonstrate you have considered the relevant serious possibilities.
Be curious and interested in the severity of the patient’s presentation and how the symptoms are affecting them.
Watch videos of your consultations, or role play scenarios with your supervisor or peer study group.
Have you enough information to form a differential diagnosis and distinguish significant illness from something more minor or self-limiting? For example, if you decide a patient has mechanical back pain, have you excluded cauda equina? If they are bleeding PV, have you considered pregnancy, or if their smear is up-to-date? With each consultation consider, what else could this be? What do I need to exclude?
Create short lists to prompt red flags for common presentations in GP.
Watching other more experienced colleagues consult will help.
The implications of relevant findings identified during the data gathering were insufficiently recognised or understood
Examiners felt that you did not demonstrate an ability to identify or recognise significant findings in the consultation. Some findings may have been identified but not acted upon appropriately, so that examiners conclude you did not recognise their significance. This skill requires you to correctly recognise and respond to the significance of information in the consultation. The abnormal findings will often relate to common or important conditions.
A patient who you find to be cognitively impaired may not be able to follow complex management instructions without additional support. Or perhaps a patient experiencing unilateral headache was diagnosed as migraine rather than temporal arteritis, despite tenderness on brushing their hair.
A newly confused patient who takes DOACs may need an urgent CT head to exclude a subdural.
Suggestions
Consider how you pick up on abnormal findings and respond safely and appropriately. Discuss your consultations with colleagues, asking them to comment, particularly on your response to abnormal findings that emerge in the consultation.
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.’