There's a little bit of Anchoring bias here, focusing on the first item of information, which leads the GP down the wrong path by focusing on Mental Health and ultimately missing the crux of the case.
Anchoring bias is an important concept to be aware of- it's the first bit of information that can lead you off on an unhelpful tangent, and bias your further questions and discussion. What other cognitive biases have you explored?
A danger of undifferentiated cases can be that we could miss what seems innocuous and not tune into what we know about risk, interpretation of clinical symptoms and signs alongside current guidance.
Key elements here are the observed issues of a patient over 60 years old, unintentionally losing weight with a likely raised HbA1c given the 'weeing for England' symptom.
If you'd like to see this played out differently, go back and make a new choice.
Did you notice how satisfied the patient was with the consultation?
Be careful to avoid inappropriate collusion!
When you set off on the wrong path
SCA Feedback Statements
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.
Suggestions
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.
Inappropriate or inadequate arrangements for follow-up continuity and or safety netting
Examiners felt that your follow-up arrangements were not adequate or that you did not ensure that there was an appropriate safety net.
Making arrangements for follow-up demonstrates your commitment to the continuity of care of patients. It shows that you are prepared to take responsibility for managing the ongoing presentation of the condition until the problem has been resolved. However, inappropriate or unrealistic follow-up is unhelpful both for the index patient and for other patients who may be unable to access their GP, with limited appointment availability.
Safety-netting describes the information you should be giving to each patient about what to expect, including a time scale if appropriate, and what to do if symptoms get worse or develop in some unexpected way. However, safety-netting may cause unnecessary alarm if performed without care.
For example, having diagnosed upper abdominal pain as simple indigestion, consider how a safety net that suggests going to A&E if it recurs ‘in case it is your heart’ might be received.
Suggestions
Consider how you end your consultations. Is it always with a safety net and if so, is that appropriately tailored to the consultation? Be aware of the literature surrounding the benefits of continuity of care in GP and discuss the systems that enable this in your practice, with the team. Notice if you are booking a follow-up and consider if this is necessary or practical.
Communication skills, including the nonverbal, responding to cues and or active listening were insufficiently demonstrated
The examiner felt you did not demonstrate sufficient communication skills for independent practice. This may include responding to cues that could have enhanced your understanding. They may have felt your listening skills were poor, for example you may have asked questions, but not listened to or responded to the answers. Or that your consulting was ‘formulaic’, meaning it felt rigid or even scripted: Perhaps you used phrases that did not seem relevant or helpful to the person, or did not appear to acknowledge their reply appropriately.
For example, if you repeat a stock phrase such as ‘I am sorry to hear that’ too frequently it loses its impact. Perhaps when a patient says ‘I am not sociable these days’ you should have been curious as to what that means, or why. Perhaps when a patient tells you they are worried about a breast lump there is a better response than ‘OK, is there anything else you’d like to discuss today?’
Suggestions
Active listening includes paying attention and responding appropriately. It is essential for building a relationship of trust with the patient. It is helped by clarifying and summarising what has been shared to demonstrate understanding.
Cues can include non-verbal gestures, pauses in speech or facial expressions. Cues are moments in the patient’s account that indicate there are additional areas to explore.
To avoid ‘formulaic’ consulting, try to avoid rigidly applying a set consulting ‘model’ to the consultation that does not respond to the individual patient.
Watch videos of your consultations, seeking feedback from your supervisor. Notice how you demonstrate you are listening, how you facilitate the consultation and the timing of your interruptions.
Practice different phrases to respond authentically to the patient’s contribution. Watch your colleagues consult and write down every possible cue you notice.