Drawn into a diagnostic chase
Emotional resonance influencing management
Anchoring bias is focussing on the first item and paying undue attention to this- the lady's understandably prominent worry about the condition that resulted in losing her husband to Sepsis during COVID means that mintues are spent excluding this diagnosis when the history really doesn't fit a likely diverticulitis picture- see https://www.whatsupwithmygut.org.uk/ for helpful information on differentiating gut symptoms.
When further examination findings also fail to support the idea of diverticulitis, the GP pivots to another referral pathway when the patient symptoms don't yet meet the diagnostic criteria- it's a management plan of extremes, even though a clinical suspicion of cancer is perfectly appropriate.
All of this focus on one diagnosis and then onto the next leaves the GP with little headspace to remember the renal implications of the symptoms.
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 implications of comorbidity were insufficiently considered
You are expected to recognise the inevitable conflicts that arise when managing patients with multiple problems and takes steps to adjust care appropriately.
It is also important to simultaneously manage the patient’s health problems, both acute and chronic.
For example, although a guideline for managing one chronic disease may indicate best practice for prescribing for that single condition, sometimes the other conditions a patient is living with may mean it is necessary to alter or even avoid prescribing. This may be particularly true for frail older adults and in the case of polypharmacy.
Or a patient with hands affected by rheumatoid arthritis, who has CKD may not be able to open bottles of ibuprofen during a flare, nor be safe to take them, given their eGFR.
Suggestion
Ensure you regularly consult with people experiencing multiple illnesses or chronic disease. This may mean pro-actively triaging your cases or taking over the care of frail vulnerable adults. Participate in team meetings for example where housebound patients are discussed with district/palliative nurses. Use self-directed learning time to attend community falls clinics, or care of the older adult outpatients. Be aware of the literature surrounding over-medicalisation and the downsides of polypharmacy.
Uncertainty including that experienced by the patient was managed ineffectively
Examiners felt that clinical uncertainty and/or that experienced by the patient was ineffectively managed.
It may be that time as a diagnostic aid was not used appropriately. Or that you were unable to tolerate or ‘hold’ uncertainty effectively. Or that management strategies used to respond to the patient’s uncertainty were not helpful.
For example: Another scan may not be helpful for a patient with medically unexplained symptoms. It might be reasonable to wait a week or so before prescribing for, or investigating a symptom that is likely to be self-limiting. On the other hand, someone who declines antenatal testing for Down Syndrome may need additional support and information while she completes her pregnancy.
Suggestion
Be aware of the literature surrounding over-medicalisation. Plan a tutorial or peer study group session on uncertainty in General Practice. Consider how uncertainty might be safely tolerated or responded to.