Focus on the Physical
Here we see the GP applying Ideas, Concerns and Expectations in a barely successful way- in order, sequentially. This could be described as formulaic but despite the brief pauses by the patient, she just about gets away with it to recover towards making a successful summary of his symptoms against what the records and investigation results show. Summarising is a successful strategy for checking you've understood the issues, (while buying you thinking time!), before making a commitment that you have completed the Data Gathering phase of the consultation before proceeding towards sharing the management plan.
The GP successfully uses incremental exposure to broach the topic of cancer towards the 10-minute mark, and this is sensitively done given the patient is not expecting the consultation to proceed in this way.
The examiner felt you were insufficiently able to generate functional solutions for data gathering when the presentation was complex or multifactorial.
This may be about prioritisation; recognising the most pressing or important issues for this encounter and negotiating this with the patient. For example, if a patient has hay fever, longstanding headaches and bleeding on passing stool we might agree to focus on the latter today, offering time for the other issues in future.
Or this may be about seeing the bigger picture, rather than attempting an exhaustive evaluation of each of the symptoms in turn. For example, if a patient has symptoms in multiple bodily systems, might there be a unifying diagnosis? Or might exploring why all this is happening at once and what the patient is most worried about be more helpful than an exhaustive enquiry into each and every symptom, as long as this is safe?
Suggestion
Ensure you see plenty of complex patients, including those with co-morbidity. This may need triaging as new practice members often have more ‘book on the day’ single-issue consultations; complex patients may have a ‘usual doctor’ already. Discuss cases with your supervisor, as CBDs. Consider tutorials or peer study group sessions on complexity and negotiating priorities with patients.
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.’