Avoiding difficult conversations
Focus on the Physical
The GP focuses on the task at hand: Identifying the cause of the deranged LFTs and putting a plan in place. It addresses the physical health issues and nothing more.
Each of the times the patient raises the topic of Terry, it is not explored sufficiently. When a patient makes a reference to an issue on more than one occasion, it's because it's really significant to them and an attempt to bring the conversation round to what's important.
Such cues need to be acknowledged - sometimes as they arise, at other times parked to bring up further into the conversation.
For consultations as in life, grief cannot be ignored and cannot be avoided- the impact is as strong as the emotional connection that is no longer physically present.
How would you handle conversations about death and grief? What phrases help you acknowledge Jennifer's loss?
SCA Feedback Statements
Relevant psychological/social information insufficiently recognised or 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.
Practice being curious about the person, their social or psychological situation and how this might affect their experience of symptoms, or their preferences for management/next steps.
The management plan relating to prevention, health promotional or rehabilitation was inadequate or inappropriate
You are expected to encourage prevention of illness, offer health promotion and rehabilitation strategies, where needed. These may include issuing a sick note, encouraging patient autonomy and self-care, prioritising ‘lifestyle’ advice. Sometimes this might include recognising the ‘gatekeeper’ role of the GP in prioritising NHS resources and/or reducing dependency on healthcare.
For example, a patient with COPD would benefit from pulmonary rehabilitation, smoking cessation and flu vaccination. Did you focus mainly on which inhaler to provide?
Another patient may need a sick note due to their psoriasis flare. Did you refuse this unnecessarily? Or grant one that may be unhelpfully long in duration, when self-certification may be a good first step?
Someone with threadworms might be gently signposted to the pharmacist for simple over the counter medications in future, assuming they can afford this.
Suggestion
Consider whether there are important areas of prevention, health promotion or rehabilitation you might encourage. For example, do you know some simple exercises for mild knee pain? Or understand how to support someone locally with smoking cessation or weight loss? Are you aware of NHS screening programs? How do you respond to requests for housing letters or fit notes?
Think about the different types of NHS resource that GPs are ‘gatekeepers’ for, and how reference to these emerge in our consultations. This does not mean that you are expected to refuse access to services, new medications or ‘fit notes’, but that you show your awareness of the issues and responsible use of resources.