When does respect become collusion?
Depending on your previous experience of shared decision making, you may be so hesitant to put forward your own perspective and defer to the professional with greater experience or knowledge- here Philomena presents the case in a knowledgeable and confident way, and it would be easy to go along with each suggestion.
Think about Transactional Analysis- Parent, Adult and Child states in the dynamics of the conversation:
Discuss with your Trainer what transaction this version of the consultation represents.
Adult-Adult? Parent-Child?
For Shared Decision Making to be effective, we need to facilitate Adult-Adult interactions, between professionals as in this case, and enabling patients who may present in a passive, child-like or dependent state, to take ownership in the shared decision and become active in generating their way forward through the problem.
SCA Feedback Statements
The plan relating to the medical management of risk was inadequate or inappropriate
Medical management of risk means ‘the forecasting and evaluation of risks together with identification of procedures to avoid or minimise their impact’. Risk management prioritises patient safety and ensures an appropriate response to preventing risk or managing error.
Examiners did not feel that you managed risk appropriately. This could mean either that you failed to identify the potential risks or that having done so you did not respond in an appropriate way. Perhaps you didn't seem aware of the responsibility for a systems' response, for example significant event analysis or the complaints process.
Alternatively, you may have been too risk-averse in an otherwise safe encounter.
For example, was the risk of a patient falling, or the impact on their eGFR, greater than the risk of their slightly raised blood pressure? Should those risks have been prioritised before following a BP guideline?
Was the risk of overdose greater than the convenience of issuing three months’ of medication?
Did a temporary patient with no records receive care without reference to his registered GP in a way that created risk?
Did a concerned daughter who identified a problem with her cognitively impaired father’s care fail to receive supportive signposting to the complaints procedure and a willingness to investigate via a significant event analysis with the team?
Were documents shared without consideration of data protection?
Suggestions
Be aware of NHS guidelines around medical risk management. Engage in partners’ meetings and significant event / complaints analyses in the practice to become familiar with the practical applications of risk management in the workplace. Discuss risk with your supervisor and consider risk management as a priority in your patient encounters.
Ownership or responsibility for decision making was inadequate or inappropriate
The examiners felt that you did not take adequate ownership or responsibility for your decision-making. It may have appeared you were overly risk-averse, or unsure how to manage a simple situation without unnecessary input from other sources.
For example, this may involve suggesting you will ‘Run this past my colleagues’ or ‘Drop an email to Advice and Guidance from the specialist’ or arrange a physio opinion ‘just in case’ where it was not needed or warranted.
It is clearly important, safe and good practice for GPs to share decisions, refer to literature and involve others. Nevertheless, sometimes a simple decision is robust, defensible and adequate, without need for additional input. This is partly about the gate-keeping role we hold in GP, but also the message we convey to patients (including raising anxiety or expectations) when it is reasonable and safe for the GP to be the only clinician involved, because in this situation the answer is straightforward or clear.
Suggestions
Try to make decisions before debriefing a patient with your supervisor, even if you do not implement the decision until discussed. Develop confidence in recognising when your decision-making is good enough. Watch experienced GPs and notice what a good enough GP will do, too.