A fallacy of choice? One hormone or another.
Focus on the pharmaceutical
The GP is more directive in style here and as part of this deviation from sharing the decision she falls into a trap of pursuing her own agenda of increasing the Oestrogen dose in a way that doesn't reflect best practice.
There are no discussions regarding wider aspects of the relationship or Genito-Urinary Symptoms.
The decision is made to increase the Oestrogen and write to the consultant with a view to Testosterone, leaving the patient feeling dismissed even though changes have been made.
We're left feeling that this has been a transactional encounter and not a sense of mutual understanding of the issues. For some this might be perceived as an efficient process of the medication request, but do you think she will turn up for the next review? Difficult to say, but the opportunity for a greater connection and a more satisfied patient has been missed.
The checking-in aspects of sharing the management choices helps to enable this connection and build the series of consultations if the safe prescribing of Testosterone within the GP's competence is to be the patient's preferred approach.
SCA Feedback Statements
Relevant psychological or social information insufficiently recognised/responded to
Examiners felt that you needed to explore the patient’s social or psychological situation further, to establish context. Or that this contextual information was not sufficiently conveyed in your discussion or decision-making. Often patients present with a physical problem, but its effect may be provoked, magnified or complicated by their social or psychological situation.
This is about seeing and valuing the whole person, rather than simply their symptom. Recognising that no two patients’ experience of an illness are the same.
For example, a diagnosis of “tennis elbow / lateral epicondylitis” might appear to be relatively straightforward. However, if the patient is self-employed, currently out of work with a newly pregnant partner, suggesting a Fit Note or time away from the factors exacerbating the elbow pain might be unhelpful. A different approach to a cough or rash will be needed for someone about to take a flight to start a gap year abroad, from someone who is street homeless or someone who is a current star of musical theatre. Without establishing the psycho-social context, it is harder to produce a management plan that is appropriate and acceptable to the individual patient.
Suggestions
Be curious about your patients and their experiences. Establish the impact of an illness on their lives. Recognise and value their needs and priorities. This is not a tick box exercise, but a demonstration of wishing to understand how to make this consultation relevant, responsive and unique for the individual concerned.
Ask for feedback from your supervisor on this aspect of your consulting; role play cases you have encountered with your peers, with you ‘role reversing’ by playing the part of the patient.
The management plan relating to prescribing of medication was inappropriate or not reflective of current practice
You are expected to show that your clinical management skills are in line with current UK best practice, making safe prescribing decisions, considering relevant drug interactions, dosing, and side effects. You may not have developed a plan at all, where a prescription was needed. You may have prescribed or failed to stop an inappropriate medication; or issued an incorrect dose. Or you may have prescribed when no prescription was necessary in this case.
This may also refer to the suggestion of over the counter (non-prescription) medication. For example, perhaps tamsulosin rather than finasteride would have been more suitable for a gentleman with LUTS, first line. Or when prescribing alendronic acid, advice about side effects and how to take should have been given, enhancing patient safety.
Suggestions
Your management plan should be coherent and feasible. You should be familiar with current national guidelines such as those published by NICE (National Institute of Clinical Excellence) and SIGN (Scottish Intercollegiate Guidelines Network).
Make a habit of referring to prescribing guidelines and/or the BNF after you have seen each patient at work. Where appropriate, consider other options before prescribing and be aware of the risks of polypharmacy and the need to deprescribe, too.
Get involved with the work of repeat prescribing in your surgery, complete your Prescribing Assessment for WPBA. Attend prescribing meetings at work with your team and community pharmacist.