In an otherwise un-overwhlemed individual potentially with vulnerability or disability, there is some suspicion of concern, ensure one seeks timely advice to avoid unmitigated risk progression
Friday, 5 April 2024
Not Good
What does it mean to seek urgent medical are?
There will be an underlying disoncertion, a sense that some physical manifestation of a disease is really an issue which need immediate attention by a professional trained in the relevant competencies of the speciifc presentation.
WELLNESS
What does it mean to be well?
There is a feeling that things are ok, there a no worries about physical or mental illness, though there may be some social struggles within ones narrative
There is a feeling that things are ok, there a no worries about physical or mental illness, though there may be some social struggles within ones narrative
Thursday, 21 February 2013
Of Sound Mind
From Oxford Textbook of Old Age psychiatry
Chapter on Will and Capacity: Harvey D Posner and Robin Jacoby
Worse than physical disablement is the dementia of not remembering ones children or who one has dined with the previous evening; by cruel testament he forbids his own flesh and blood to be his heirs. Juvenal Satire 10, C.AD 125 (Paraphrasing)
Testamentary capacity or being of sound disposing mind is the capacity to make a legally binding will. IT is a legal, and not a medical test.
In England and Wales, the execution of Wills (signing them as required in the presence of a witness) is governed by various Acts of Parliament, such as the Wills Acts (1837, 1861, 1963, and 1968) and in some instances the mental health act 1983.These are augmented by much case Law (see Vol 1 Chpt 4 of eight edition of Williams on Wills (Sherring et al, 2002).
In 1870 Banks vs. goodfellow; he left his estate (15 houses) to his neice (will made in 1863, admitted as a lunatic due to persecutory delusions of molestation by a man long dead and by evil spirits whom he believed to be visibly present nb these existed form 1841 to death in 1865). The Lord Chief Justice Cockburn (Paraphrasing):
Essential… the testator (or testatrix for females) shall understand the nature of the act and its effects; understand the extent of property he is disposing; no insane delusion shall influence his will such that had his mind been sound he would not have made the same decision.
Three elements
1) The testator must understand the nature of the act (content of the will) and its effects
2) The testator must be aware of the extent of the property being disposed of
3) The testator must know the nature and extent (doesn’t need to to know exact value) of those whom have a claim upon him of those whom he is both including and excluding in the Will.
In moderate Dementia e.g. MMSE of 15 (folstein et al, 1975) a will could still be made (but more severe dementia this is unlikely) as they may be unsure as to the exact date and location, fail seriel subtraction and fail to copy interlocking pentagons accurately but pass Banks vs. Goodfellows test. Conversely in Korsakovs syndrome has such impaired memory that he fails to retain or recall the information his son has died and that he has grandchildren who can make a claim on his bounty.
Hoff and others vs. Atherton – Lord Justice Peter Gibson in court of appeal on the case agreed patient had testamentary capacity despite moderate dementia.
http://www.thefreelibrary.com/Alzheimer's+sufferer's+pounds+1m+will+valid+-+judge.-a0125012768
Capacity has four components
1) Understand relevant information including nature and purpose of the information not just recall. Should be able to identify the choices available and paraphrase them.
2) Manipulate information rationally: shold understand benefits and risks of the choices. Focus on an internally coherent decision process rather than the actual outcome of the decision.
3) Appreciate the situation and the consequences in the context of their own emotions/position and family – assigning a value to the risks and benefits.
4) Communicating the choice – the ability to maintain consistent choice; if persons frequently change their choices they are unliekyl to be deemed competent.
Chapter on Will and Capacity: Harvey D Posner and Robin Jacoby
Worse than physical disablement is the dementia of not remembering ones children or who one has dined with the previous evening; by cruel testament he forbids his own flesh and blood to be his heirs. Juvenal Satire 10, C.AD 125 (Paraphrasing)
Testamentary capacity or being of sound disposing mind is the capacity to make a legally binding will. IT is a legal, and not a medical test.
In England and Wales, the execution of Wills (signing them as required in the presence of a witness) is governed by various Acts of Parliament, such as the Wills Acts (1837, 1861, 1963, and 1968) and in some instances the mental health act 1983.These are augmented by much case Law (see Vol 1 Chpt 4 of eight edition of Williams on Wills (Sherring et al, 2002).
In 1870 Banks vs. goodfellow; he left his estate (15 houses) to his neice (will made in 1863, admitted as a lunatic due to persecutory delusions of molestation by a man long dead and by evil spirits whom he believed to be visibly present nb these existed form 1841 to death in 1865). The Lord Chief Justice Cockburn (Paraphrasing):
Essential… the testator (or testatrix for females) shall understand the nature of the act and its effects; understand the extent of property he is disposing; no insane delusion shall influence his will such that had his mind been sound he would not have made the same decision.
Three elements
1) The testator must understand the nature of the act (content of the will) and its effects
2) The testator must be aware of the extent of the property being disposed of
3) The testator must know the nature and extent (doesn’t need to to know exact value) of those whom have a claim upon him of those whom he is both including and excluding in the Will.
In moderate Dementia e.g. MMSE of 15 (folstein et al, 1975) a will could still be made (but more severe dementia this is unlikely) as they may be unsure as to the exact date and location, fail seriel subtraction and fail to copy interlocking pentagons accurately but pass Banks vs. Goodfellows test. Conversely in Korsakovs syndrome has such impaired memory that he fails to retain or recall the information his son has died and that he has grandchildren who can make a claim on his bounty.
Hoff and others vs. Atherton – Lord Justice Peter Gibson in court of appeal on the case agreed patient had testamentary capacity despite moderate dementia.
http://www.thefreelibrary.com/Alzheimer's+sufferer's+pounds+1m+will+valid+-+judge.-a0125012768
Capacity has four components
1) Understand relevant information including nature and purpose of the information not just recall. Should be able to identify the choices available and paraphrase them.
2) Manipulate information rationally: shold understand benefits and risks of the choices. Focus on an internally coherent decision process rather than the actual outcome of the decision.
3) Appreciate the situation and the consequences in the context of their own emotions/position and family – assigning a value to the risks and benefits.
4) Communicating the choice – the ability to maintain consistent choice; if persons frequently change their choices they are unliekyl to be deemed competent.
Thursday, 18 October 2012
Educational Supervisor Review
Having recently had a supervisor review there are some really important features of how to use the RCGP ePortfolio that I wished I had been more mindful of. One of the GP ST2 had mentioned these in our induction lectures but some where along the line I must have taken my eye of the ball.
So what is the aim of the ESR? It is to evidence the trainee has covered the breadth of the curricullum as well as evidence the attainment of particular competencies. It isn't looking at the clinical skills (which the clinical supervisor looks at in terms of the particular rotation) but more about how a trainee applies themselves to the situation.
For example I had a palliative care patient which referenced nicely to the curricullum statment for palliative care. However it was also used as evidence for working in teams (with McMillan/Marie Curie), communication skills, and practicing holistically. So the first thing to remember is to make sure that each entry has an easy reference "HEADLINE" e.g. "22.6.12A Palliative Care *Comm skills *holistic practice" implying the date, this is Case A on that date, and that it is evidence towards those competencies aplying reflective practice as talked of before in order to generate a learning need to add to the personal development plan (PDP) - of which 1 or 2 should be met a month bearining in mind that the closer you complete them to the learning event the more chance of the experience cementing the knowledge being assimilated. The aim is for about three cases a week like this.
One of the mistakes I made was listing a whole bunch of cases e.g. a morning theatre list or a ward round and this really made it hard to use these entries as evidence as it was laborious to identify clearly the specific evidence used to meet a competency. A further mistake was that sometimes in my entries it was unclear who had made "the decision" e.g. a senior or myslef which is useful in order for the evidence to be considered robust enough. One tip was that when discussing a case e.g. in a professional conversation I could have highlighted the medical complexity of the case and been clear what my plans had been and how the senior colleuges had felt about/engaged with them. A further mistake I made was simply recording subtely different cases with the view that it was their subtle differences which implied complexity but actually medical complexity relates only to one particular patients management. Including this, there were 4 competency areas that really shocked me as to what they had been trying to ask for and what I had delivered so it is vital to really get to know these different competencies.
So when evidencing medical complexity one must look to the competency definition which includes managing co-morbidity, uncertainty and risk as well as having an approach to health and not just illness. At a basic level this means being positive about a patients health, prioritising managment based on risk, and drawing conclusions managing health problems seperately. The competency begins to be met when the trainee identifies the implications of co-morbidity, managing both acute and chronic conditions of a patient, explaining risk to the patient to enable them to engage in its managment, and finally encourages recovery and rehabilitation as well as health promotion and disease prevention strategy. To excell on this one, the trainee has to be able to manage the acute and chronic issues over time, co-ordinating a team based approach to rehabilitation, care, cure, palliation or health promotion, and finally anticipates and uses strategies to manage risk/uncertainty such as monitoring, outcomes assessment and feedback to minimise risk. Interestingly the way GP's are being paid is changing to reflect this ability to create health through quality.
The second interesting competency was practicing holistically - which I thought meant taking into accoun their social and psychological situations. However it also means more than this in the sense that it is important to utilise other community services and supports and not just yourself. It also means recognising how the condition will impact carers and family and hence involving them in the discussions and plans (not just informing them of the outcomes of plans) and then organising this care recognising the doctors limited ability to intervene in these matters. When making plans it is key to understand the influence of the cultural and socio-economic backgrounds and use this to generate practical solutions to the problems.
Ethics shows us the difference between a curriculumm (a broad scope of an educational programme including content, processes and experiences) and a syllabus (a list of topics to cover). The reason it shows this is because of the tension in that there is inherent conflict e.g. in providing a person centred approach i.e. a consultation looking at treament vs. a community approach i.e. telephone triaging at the time. Social expectation and political influence challenges the curricullum and creates tension by changing how refferals could be authorised to happen, aiming to prescibe cheaper generic medications, and serving different agendas. In my own competency assesment I noted how in one situation I felt something was wrong but did not have the skill and knowledge to affirm the feeling and expertly debate the case with a senior. In the competency itself it suggests not only identifying the conflict - which I sort of recognised inmyself but also take action to discuss them.
The fourth and final competency area of interest was communication skills which I will address later.
Suffisive to say that the competency are the core of the eportfolio which shouldn't just be seen as a way of revising for the AKT/CSA - IT IS a different beast!
THe Best way of seeing how the curriculum relates to the competencies is http://www.rcgp.org.uk/GP-training-and-exams/~/media/Files/GP-training-and-exams/Curriculum-2012/RCGP-Curriculum-Introduction-and-User-Guide-2012.ashx
So what is the aim of the ESR? It is to evidence the trainee has covered the breadth of the curricullum as well as evidence the attainment of particular competencies. It isn't looking at the clinical skills (which the clinical supervisor looks at in terms of the particular rotation) but more about how a trainee applies themselves to the situation.
For example I had a palliative care patient which referenced nicely to the curricullum statment for palliative care. However it was also used as evidence for working in teams (with McMillan/Marie Curie), communication skills, and practicing holistically. So the first thing to remember is to make sure that each entry has an easy reference "HEADLINE" e.g. "22.6.12A Palliative Care *Comm skills *holistic practice" implying the date, this is Case A on that date, and that it is evidence towards those competencies aplying reflective practice as talked of before in order to generate a learning need to add to the personal development plan (PDP) - of which 1 or 2 should be met a month bearining in mind that the closer you complete them to the learning event the more chance of the experience cementing the knowledge being assimilated. The aim is for about three cases a week like this.
One of the mistakes I made was listing a whole bunch of cases e.g. a morning theatre list or a ward round and this really made it hard to use these entries as evidence as it was laborious to identify clearly the specific evidence used to meet a competency. A further mistake was that sometimes in my entries it was unclear who had made "the decision" e.g. a senior or myslef which is useful in order for the evidence to be considered robust enough. One tip was that when discussing a case e.g. in a professional conversation I could have highlighted the medical complexity of the case and been clear what my plans had been and how the senior colleuges had felt about/engaged with them. A further mistake I made was simply recording subtely different cases with the view that it was their subtle differences which implied complexity but actually medical complexity relates only to one particular patients management. Including this, there were 4 competency areas that really shocked me as to what they had been trying to ask for and what I had delivered so it is vital to really get to know these different competencies.
So when evidencing medical complexity one must look to the competency definition which includes managing co-morbidity, uncertainty and risk as well as having an approach to health and not just illness. At a basic level this means being positive about a patients health, prioritising managment based on risk, and drawing conclusions managing health problems seperately. The competency begins to be met when the trainee identifies the implications of co-morbidity, managing both acute and chronic conditions of a patient, explaining risk to the patient to enable them to engage in its managment, and finally encourages recovery and rehabilitation as well as health promotion and disease prevention strategy. To excell on this one, the trainee has to be able to manage the acute and chronic issues over time, co-ordinating a team based approach to rehabilitation, care, cure, palliation or health promotion, and finally anticipates and uses strategies to manage risk/uncertainty such as monitoring, outcomes assessment and feedback to minimise risk. Interestingly the way GP's are being paid is changing to reflect this ability to create health through quality.
The second interesting competency was practicing holistically - which I thought meant taking into accoun their social and psychological situations. However it also means more than this in the sense that it is important to utilise other community services and supports and not just yourself. It also means recognising how the condition will impact carers and family and hence involving them in the discussions and plans (not just informing them of the outcomes of plans) and then organising this care recognising the doctors limited ability to intervene in these matters. When making plans it is key to understand the influence of the cultural and socio-economic backgrounds and use this to generate practical solutions to the problems.
Ethics shows us the difference between a curriculumm (a broad scope of an educational programme including content, processes and experiences) and a syllabus (a list of topics to cover). The reason it shows this is because of the tension in that there is inherent conflict e.g. in providing a person centred approach i.e. a consultation looking at treament vs. a community approach i.e. telephone triaging at the time. Social expectation and political influence challenges the curricullum and creates tension by changing how refferals could be authorised to happen, aiming to prescibe cheaper generic medications, and serving different agendas. In my own competency assesment I noted how in one situation I felt something was wrong but did not have the skill and knowledge to affirm the feeling and expertly debate the case with a senior. In the competency itself it suggests not only identifying the conflict - which I sort of recognised inmyself but also take action to discuss them.
The fourth and final competency area of interest was communication skills which I will address later.
Suffisive to say that the competency are the core of the eportfolio which shouldn't just be seen as a way of revising for the AKT/CSA - IT IS a different beast!
THe Best way of seeing how the curriculum relates to the competencies is http://www.rcgp.org.uk/GP-training-and-exams/~/media/Files/GP-training-and-exams/Curriculum-2012/RCGP-Curriculum-Introduction-and-User-Guide-2012.ashx
Monday, 8 October 2012
Clear, Caring and Convincing - a novice guide to the CSA
As per the RCGP website the Clinical Skills Assessment (CSA) is a summative assessment of a doctor’s ability to integrate and apply clinical, professional, communication and practical skills appropriate for general practice. Simulating a typical NHS surgery clinic the CSA assesses a range of scenarios from general practice relevant to most parts of the curriculum which can also target particular aspects of clinical care and expertise.
Lets not forget its got to be done in 10 minutes!
There is cummalative pass mark (clear fail to clear pass - 0-3 marks) of 13 cases; with the threshold depednign on the days mix of cases. There are feedback statements which higlgiht areas for improvement for future exams. And the reason I am so interested in when I had been on the A&E locum circuit I met many people who had failed this exam and came out of GP land (you get 4 hances to sit the exam) and I dont want to be back there because in A&E you dont get to follow patients through and become the smae doctor a patient sees because the shift nature of the job. So it is important and ifficult to pass.
We recently had a practice session on doing a CSA style OSCE - I even volunteered for one of the cases - and it was the first taste of taking the examination to the next level. We watched 4 caes being attempted twice each - fatigue, depression and nitts as well as a staff complaint. In the CSA the cases are done stratified according to difficulty, age, type (telephone/visit/surgery) and type (psychological, preventative, acute/chronic/undifferentiated, examination) - so dont forget your doctors bag!
As a Gp trainee one can start on 30 minute consultations but the aim is to get down to 5-10 minutes mark (including checking and requesting investigation then initiating or modifying managment plans). The CSA however is focused on the history taking element and even if one does not know the complete in's and out's of the managment of a condition (tested in the applied knowledge test) one can still achieve some degree of success by demonstrating efficient and relevant data gathering [proficient exam/investigation choice and interpretation], good interpersonal skills [recognised communication technniques to understand patients illness exprience whilst ethiically developing a shared approach to management], and developing a safe managment plan (which may include looking up the condition, having a chat with a partner/senior, organising/instigating a critical event analysis, writing to or calling a patient back, or organising follow up with good safety netting e.g. if A happens do X or if B happens do Y) [structured and flexible approach to decision making; ability to deal with multiple complaints and comordbidites; ability to promote a positive approach to health].
When I saw other people do their consultations (I was one of the GP ST1's in a group dominated by the skiled ST3's with the CSA around the corner) I was impressed by their ability to appear very calm, and provide tangible managment plans. I also found, after doing my own consultation where I only got to the beginning of management before my 10 minutes were up, that they had time managed very well.
So what were the key lessons I drew from the day?
1. Time managment and consultation style influence the score more than the clinical knowledge for this exam so therefore I need to become aware of how to maximise these skills and demonstrate them. This is what the rest of the blog will devlop as a theme.
2. Some times nothing is wrong with the patient and they need to be reassured e.g. a patient with tiredness who had a new family and recently returned to work was tired - nothing was found to be clinically wrong on the tests so it was all about how you "sold" the management plan.
For example one trainer suggested that to inspire patients and reassure them he had metaphors to help the patient to visualise their situation in order to understand and relate to it. for example with the patient above he would say that she has differen pieces to her unique puzzle such as her children, her job and her inability currently to enjoy the hobbies which she previously used to keep fit with such as swimming at lunch time but that they way the pieces fitted together at the moment meant she was tired. He suggested she could go away and think how these pieces could better fit tgether e.g. part time work etc. and discuss this with her family. He would make her an appointment in 3 months to see how things are going but otherwise she could come back and seem him if anything else worried her.
I love this analogy and find it a really good tool.
3. A very insteresting point that an ST3 raised was that he had to constantly kick himself to ask the patient what they wanted to do - he was so used to hospital work where the patient is told what to do that he found it a struggle to just take that bit of extra time and negotiate. Funily enough one of the participants used the phrase at the end of his consultation (at least he got there unliek me!) "here's what we are going to do..."
A different trainer chared another excellent analgoy - the doctors job is only to offer the right menu to the patient a highlighting the benefits and risks of the different options but not to pick the dish :)
4. A fourth general point fomr the practice was that it was important to quickly "get to it" e.g. you sound depressed would you like help with this? Rather than talk around the topic. However the danger of this too early means you may come across as rushing the patient. Equally it may be too hasty to say too early on "is there anything else?" (often patients come with 2 or 3 agendas they want to deal with and the risk is that if you say this question at the end you may find a another problem you dont have time to help solve) as it may appear as if the condition they have presented is not worthy of your time or not big/impressive anugh to be seen with or again that you are uncaring as if you want to move off the topic.
The other important learning points from the day were drawn from the brilliant professional actors:
1. They suggested that some people were unclear as to what was being communicated. These difficulties in them recieving the message came from simple things such as doctors speaking to fast or not giving the patient enough time to process information and feel comfortable to ask questions and check they've understood, ranging to more difficult communication errors such as an unclear thought (one doctor asked a patient to comb the knits onto "the paper" as if he had already reffered to one but hadn't made clear that it could be any paper and the relevance of doing it was so no live knits could be seen) or a shaky unclear managment plan (one doctor suggested that the mother of child with knitts brought her in but then said she may not need to).
The trainer explained that the key here was to sign post clearly what was being done. So in the example above the doctor should have made clear exactly which was it - does he want to see the daughter or not; bearing in mind as long as he can explain the reaosning there is no wrong answer - and emphasise this in his closing summary of the plan.
2. They suggested that the doctors came across as cold and uncaring - too focused on gathering the clinical (biological) data and in too much of a rush to provide the cold information on the managment options. Interestingly - when in the above case of nits the doctor asked to see the daughter the mother had felt reasured the doctor cared and this was important to her. Being talked "at" - rather than "to" for example when being told about how depression can be treated where as it may have been better to ask what the patient felt like she would like or what options she knew about (however avoiding asking two or more questions or then quickly answering with ones own response before the patient has a chance to reply.
So bringing all of this together using the flanagans and Dr ross model from http://www.pennine-gp-training.co.uk/csa-case-scenarios-written-by-our-gpsts-for-their-csa-work-groups.htm combined I think the following is useful:
1. Welcome patient and introduce yourself
2. Start with big open question and fascilitate golden minute (cue handling)
3. Explore psychosocial (Social Hx:Work, family, driving, alcohol, smoking)
- mindful that in the second half of the consultation later you should relate the patients;
> ideas to your explanation of diagnosis and differentials
> concerns to the prognosis
> expectations to mangement (investigation, watchful wait, lifestyle change, medication, refferal)
4. Focussed questions & Red Flags Focused systemic enquiry, Red flags, PMH, DH, FH
7. Examination (focused /2 minutes)
8. Explanation & Rx option sharing +/- safety netting (no later than 8 mins into the consultation)
9. Shared decision making/management plan
10. Closure – checking understanding -/+safety net /follow up
And smile, be nice, be beliveable.
Indicators of good performance
Data Gathering
1. Organised and systematic in gathering information from history taking, examination and investigation
2. Identifies abnormal findings or results and/or recognises their implications
3. Data gathering does appears to be guided by the probabilities of disease
4. Undertakes physical examination competently, or use instruments proficiently
Clinical management
1. Makes appropriate diagnosis
2. Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice
3. Follow-up arrangements and safety netting are adequate
4. Demonstrates an awareness of management of risk and health promotion
Interpersonal skills
1. Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues.
2. Develops a shared management plan or clarify the roles of doctor and patient
3. Uses explanations that are relevant and understandable to the patient
4. Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination
So there you have it - a true beginners interpretation of the exam!
Lets not forget its got to be done in 10 minutes!
There is cummalative pass mark (clear fail to clear pass - 0-3 marks) of 13 cases; with the threshold depednign on the days mix of cases. There are feedback statements which higlgiht areas for improvement for future exams. And the reason I am so interested in when I had been on the A&E locum circuit I met many people who had failed this exam and came out of GP land (you get 4 hances to sit the exam) and I dont want to be back there because in A&E you dont get to follow patients through and become the smae doctor a patient sees because the shift nature of the job. So it is important and ifficult to pass.
We recently had a practice session on doing a CSA style OSCE - I even volunteered for one of the cases - and it was the first taste of taking the examination to the next level. We watched 4 caes being attempted twice each - fatigue, depression and nitts as well as a staff complaint. In the CSA the cases are done stratified according to difficulty, age, type (telephone/visit/surgery) and type (psychological, preventative, acute/chronic/undifferentiated, examination) - so dont forget your doctors bag!
As a Gp trainee one can start on 30 minute consultations but the aim is to get down to 5-10 minutes mark (including checking and requesting investigation then initiating or modifying managment plans). The CSA however is focused on the history taking element and even if one does not know the complete in's and out's of the managment of a condition (tested in the applied knowledge test) one can still achieve some degree of success by demonstrating efficient and relevant data gathering [proficient exam/investigation choice and interpretation], good interpersonal skills [recognised communication technniques to understand patients illness exprience whilst ethiically developing a shared approach to management], and developing a safe managment plan (which may include looking up the condition, having a chat with a partner/senior, organising/instigating a critical event analysis, writing to or calling a patient back, or organising follow up with good safety netting e.g. if A happens do X or if B happens do Y) [structured and flexible approach to decision making; ability to deal with multiple complaints and comordbidites; ability to promote a positive approach to health].
When I saw other people do their consultations (I was one of the GP ST1's in a group dominated by the skiled ST3's with the CSA around the corner) I was impressed by their ability to appear very calm, and provide tangible managment plans. I also found, after doing my own consultation where I only got to the beginning of management before my 10 minutes were up, that they had time managed very well.
So what were the key lessons I drew from the day?
1. Time managment and consultation style influence the score more than the clinical knowledge for this exam so therefore I need to become aware of how to maximise these skills and demonstrate them. This is what the rest of the blog will devlop as a theme.
2. Some times nothing is wrong with the patient and they need to be reassured e.g. a patient with tiredness who had a new family and recently returned to work was tired - nothing was found to be clinically wrong on the tests so it was all about how you "sold" the management plan.
For example one trainer suggested that to inspire patients and reassure them he had metaphors to help the patient to visualise their situation in order to understand and relate to it. for example with the patient above he would say that she has differen pieces to her unique puzzle such as her children, her job and her inability currently to enjoy the hobbies which she previously used to keep fit with such as swimming at lunch time but that they way the pieces fitted together at the moment meant she was tired. He suggested she could go away and think how these pieces could better fit tgether e.g. part time work etc. and discuss this with her family. He would make her an appointment in 3 months to see how things are going but otherwise she could come back and seem him if anything else worried her.
I love this analogy and find it a really good tool.
3. A very insteresting point that an ST3 raised was that he had to constantly kick himself to ask the patient what they wanted to do - he was so used to hospital work where the patient is told what to do that he found it a struggle to just take that bit of extra time and negotiate. Funily enough one of the participants used the phrase at the end of his consultation (at least he got there unliek me!) "here's what we are going to do..."
A different trainer chared another excellent analgoy - the doctors job is only to offer the right menu to the patient a highlighting the benefits and risks of the different options but not to pick the dish :)
4. A fourth general point fomr the practice was that it was important to quickly "get to it" e.g. you sound depressed would you like help with this? Rather than talk around the topic. However the danger of this too early means you may come across as rushing the patient. Equally it may be too hasty to say too early on "is there anything else?" (often patients come with 2 or 3 agendas they want to deal with and the risk is that if you say this question at the end you may find a another problem you dont have time to help solve) as it may appear as if the condition they have presented is not worthy of your time or not big/impressive anugh to be seen with or again that you are uncaring as if you want to move off the topic.
The other important learning points from the day were drawn from the brilliant professional actors:
1. They suggested that some people were unclear as to what was being communicated. These difficulties in them recieving the message came from simple things such as doctors speaking to fast or not giving the patient enough time to process information and feel comfortable to ask questions and check they've understood, ranging to more difficult communication errors such as an unclear thought (one doctor asked a patient to comb the knits onto "the paper" as if he had already reffered to one but hadn't made clear that it could be any paper and the relevance of doing it was so no live knits could be seen) or a shaky unclear managment plan (one doctor suggested that the mother of child with knitts brought her in but then said she may not need to).
The trainer explained that the key here was to sign post clearly what was being done. So in the example above the doctor should have made clear exactly which was it - does he want to see the daughter or not; bearing in mind as long as he can explain the reaosning there is no wrong answer - and emphasise this in his closing summary of the plan.
2. They suggested that the doctors came across as cold and uncaring - too focused on gathering the clinical (biological) data and in too much of a rush to provide the cold information on the managment options. Interestingly - when in the above case of nits the doctor asked to see the daughter the mother had felt reasured the doctor cared and this was important to her. Being talked "at" - rather than "to" for example when being told about how depression can be treated where as it may have been better to ask what the patient felt like she would like or what options she knew about (however avoiding asking two or more questions or then quickly answering with ones own response before the patient has a chance to reply.
So bringing all of this together using the flanagans and Dr ross model from http://www.pennine-gp-training.co.uk/csa-case-scenarios-written-by-our-gpsts-for-their-csa-work-groups.htm combined I think the following is useful:
1. Welcome patient and introduce yourself
2. Start with big open question and fascilitate golden minute (cue handling)
3. Explore psychosocial (Social Hx:Work, family, driving, alcohol, smoking)
- mindful that in the second half of the consultation later you should relate the patients;
> ideas to your explanation of diagnosis and differentials
> concerns to the prognosis
> expectations to mangement (investigation, watchful wait, lifestyle change, medication, refferal)
4. Focussed questions & Red Flags Focused systemic enquiry, Red flags, PMH, DH, FH
7. Examination (focused /2 minutes)
8. Explanation & Rx option sharing +/- safety netting (no later than 8 mins into the consultation)
9. Shared decision making/management plan
10. Closure – checking understanding -/+safety net /follow up
And smile, be nice, be beliveable.
Indicators of good performance
Data Gathering
1. Organised and systematic in gathering information from history taking, examination and investigation
2. Identifies abnormal findings or results and/or recognises their implications
3. Data gathering does appears to be guided by the probabilities of disease
4. Undertakes physical examination competently, or use instruments proficiently
Clinical management
1. Makes appropriate diagnosis
2. Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice
3. Follow-up arrangements and safety netting are adequate
4. Demonstrates an awareness of management of risk and health promotion
Interpersonal skills
1. Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues.
2. Develops a shared management plan or clarify the roles of doctor and patient
3. Uses explanations that are relevant and understandable to the patient
4. Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination
So there you have it - a true beginners interpretation of the exam!
Tuesday, 14 August 2012
Becoming a Reflecting General Practitioner
At the GPST induction today it was highlighted that "doing reflection" and "being reflecting" were the key skills to being a successful, safe and self-aware practitioner. The deputy dean suggested during the day we would talk about it Ad nauseam (WIKIPEDIA: A latin term used to describe something unpleasurable which has continued "to [the point of] nausea"). It was outlined we should reflect on what we were doing, what we had learned, and how we could evidence we were achieving the 12 GP competencies. It was also told to us that the whole of the practice could be surmised in Cum Scientia Caritas which means to applying contextualised scientific data and knowledge with altruism and compassion.
One of the other tutors mentioned the idea of a penny dropping - in that when we write up a clinical encounter we should pick the thing which captures the imagination. Not just write a description of a case mechanistically but let the experience simmer and then perhaps the key thing for the learner may come into focus and both learning experiences and needs can be more effectively articulated. A further tutor explained the ultimate aim of the electronic portfolio was not just to reflect on practice but that the ultimate aim was to reflect in practice.
This didn't really come clear to me until I was reading this blog for my Curation - and I came across the comment by justin locke December 13th, 2011 at 8:31 pm saying that the most elite practitioners do the boring bits - the drills and scales for a large volume of time and therefore assimilate these skills. Then the penny really dropped and I felt that the practice of doing the reflection on encounters, readings/journals, seminars/tutorials and so on was vital and would lead to me being a natural "professional/structured" reflector within consultations and that some how this was key to my progress.
So armed with the knowledge that this was the thing to do and would make me such a great doctor my only difficulty remained was that I still wasn't sure what reflection was.
From Chart 2 of the ARCP check list from the EOE Deanery site I am pretty sure (as these are marked NOT ACCEPTABLE) that the learning log is not a descriptive list of events. They suggest you may just pass if you use a wider variety of evidence gathering tools for a competency and also reflect on what you have learnt and how you can professionally developed however though you may contextually apply some knowledge and evidence it is limited as is reflection on feedback you have gained.
Finally you are competent if using an extensive range of log entries and discriminating tools to evidence competence; use feed back to critically assess developmental needs; critically reflect on significant events and develop PDP in response to these; and further contextually apply whilst critically appraising evidence to justify decisions and develop.
Unfortunately this didn't really tell me what the reflection actually was though it did add the other interesting word of "critically" which I didn't understand. ONe thing I did learn was that a good learning log was not just that one entry but that each entry was a window on your practice both for yourself and your supervisors and that a key element was action - showing you had done something/doing something i.e. making a reasoned and real change to your practice. Because I now had an extra question and still not enough answers I looked to the luton and dunstable team for the critical appraisal and bradford for reflection. This all made more sense when put into the context of the short GP curriculum statements as well as this helpful guide on how to get the most form the eportfolio again by the awesome bradford team. This last document suggests that the ARCP panel will look for general points to cover competencies but having specific learning points e.g. I will look for X rad flags and may consider Y treatment for some specific Dx; it also says that your feelings are key e.g. anxious about a situation and how reacted, what you did, how you have discussed it and what has changed. For example part of your PDP may be then to go and read about a topic (though I understand the trainer needs to have read the topic first before it gives you the chance to put it into the PDP.
From medical mind maps comes a pivotal map of the competencies and this video explains that it is important to cover the breadth of curriculum while being mindful of the competencies and assign own coverage of competence.
Reading the Bradford VTS explanation of reflection was a good move forwards for the actual reflection - it suggests that learning happens with reflections and drawing on different theoretical models of reflection or previous experiences can lead to different insights. It involves analysis and evaluation as well as an action plan for the future. Another interesting development was its articulation that there are two types of reflection in-action (i.e. on your feet in a unique encounter where previous formal education cannot be called upon to make the decision) and on-action (i.e. retrospectively). It suggests trying to write a mix of both types of reflection i.e. what went on in your head at the time and then "separately" a reflection on the overall encounter and distinguishes this from the depth of that reflection. When looking at the depth of learning it highlights several key areas.
The RCGP how to produce a good learning log clarified further. I will just bullet point how I think their case study of a clinical encounter (hollow bullet points) fits into their own criteria (filled bullet points) and high light some words/phrases.
So by this time I had a fair understanding of the different elements of the learning log to make it reflective. One final document I read to bring it all together was the Being a Reflective GP by Arthur Hibble from the EOE website.
In this I learnt that it was important to not be journalistic but also reflective so observe and note the less obvious about the situation - question the situation and find the unfamiliar. Take responsibility and own your sensations and feelings about the experience (self-awareness). Self regulate by being mindful of when experiences/behaviours sit in relation to competence. Note the internal conversation of how the feelings relate to these perceptions. Seek feedback against standards by being open and honest about performance. Clarify what needs to be learnt and why you need to take it on through statements of learning and planned impact on performance and then plans for review.
This document suggest printing out an log and practicing with others to get feed back on how to improve. It offers some other general concepts:
Being reflective enlables the transitions from knowing, knowing how, being shown how and doing.
Some more specific advice of the types of things to improve upon would be (e.g. of a ?child abuse case you didn't confront with the mother behaving oddly providing an explanation for a bruise "too quickly":
So some potential questions to ask are:
A conclusive nice poem which has put me at ease again that I can relax and not get too hyped by the whole thing:
One of the other tutors mentioned the idea of a penny dropping - in that when we write up a clinical encounter we should pick the thing which captures the imagination. Not just write a description of a case mechanistically but let the experience simmer and then perhaps the key thing for the learner may come into focus and both learning experiences and needs can be more effectively articulated. A further tutor explained the ultimate aim of the electronic portfolio was not just to reflect on practice but that the ultimate aim was to reflect in practice.
This didn't really come clear to me until I was reading this blog for my Curation - and I came across the comment by justin locke December 13th, 2011 at 8:31 pm saying that the most elite practitioners do the boring bits - the drills and scales for a large volume of time and therefore assimilate these skills. Then the penny really dropped and I felt that the practice of doing the reflection on encounters, readings/journals, seminars/tutorials and so on was vital and would lead to me being a natural "professional/structured" reflector within consultations and that some how this was key to my progress.
So armed with the knowledge that this was the thing to do and would make me such a great doctor my only difficulty remained was that I still wasn't sure what reflection was.
From Chart 2 of the ARCP check list from the EOE Deanery site I am pretty sure (as these are marked NOT ACCEPTABLE) that the learning log is not a descriptive list of events. They suggest you may just pass if you use a wider variety of evidence gathering tools for a competency and also reflect on what you have learnt and how you can professionally developed however though you may contextually apply some knowledge and evidence it is limited as is reflection on feedback you have gained.
Finally you are competent if using an extensive range of log entries and discriminating tools to evidence competence; use feed back to critically assess developmental needs; critically reflect on significant events and develop PDP in response to these; and further contextually apply whilst critically appraising evidence to justify decisions and develop.
Unfortunately this didn't really tell me what the reflection actually was though it did add the other interesting word of "critically" which I didn't understand. ONe thing I did learn was that a good learning log was not just that one entry but that each entry was a window on your practice both for yourself and your supervisors and that a key element was action - showing you had done something/doing something i.e. making a reasoned and real change to your practice. Because I now had an extra question and still not enough answers I looked to the luton and dunstable team for the critical appraisal and bradford for reflection. This all made more sense when put into the context of the short GP curriculum statements as well as this helpful guide on how to get the most form the eportfolio again by the awesome bradford team. This last document suggests that the ARCP panel will look for general points to cover competencies but having specific learning points e.g. I will look for X rad flags and may consider Y treatment for some specific Dx; it also says that your feelings are key e.g. anxious about a situation and how reacted, what you did, how you have discussed it and what has changed. For example part of your PDP may be then to go and read about a topic (though I understand the trainer needs to have read the topic first before it gives you the chance to put it into the PDP.
From medical mind maps comes a pivotal map of the competencies and this video explains that it is important to cover the breadth of curriculum while being mindful of the competencies and assign own coverage of competence.
Reading the Bradford VTS explanation of reflection was a good move forwards for the actual reflection - it suggests that learning happens with reflections and drawing on different theoretical models of reflection or previous experiences can lead to different insights. It involves analysis and evaluation as well as an action plan for the future. Another interesting development was its articulation that there are two types of reflection in-action (i.e. on your feet in a unique encounter where previous formal education cannot be called upon to make the decision) and on-action (i.e. retrospectively). It suggests trying to write a mix of both types of reflection i.e. what went on in your head at the time and then "separately" a reflection on the overall encounter and distinguishes this from the depth of that reflection. When looking at the depth of learning it highlights several key areas.
- Use a range of sources to clarify thoughts and feelings as well as other sources of information to put the event into context
- Use well developed analysis of critically thought about evidence to justify or change behaviour whilst describing and trying to make sense of own perceptions, thoughts and emotions
- Demonstrate openness and honesty about performance and consideration of feelings generated. Have insight and seeing performance in relation to what might be expected of doctors. Consideration of thoughts and feelings of others as well as one self.
- Evidence that their is clarification of what needs to be learnt, why and how along side prioritisation and planning of learning.
The RCGP how to produce a good learning log clarified further. I will just bullet point how I think their case study of a clinical encounter (hollow bullet points) fits into their own criteria (filled bullet points) and high light some words/phrases.
- A good quality log entry is one that shows good reflection, which means that it demonstrates your insight into how you are performing and how you are learning from your everyday experiences.
- I felt this baby needed to be assessed as she was not well and eventually the paeds registrar agreed to see the child
- On reflection, the baby arrested while she was in the CED. The parents took her there by car. I could have arranged a blue light ambulance to take her to hospital
- evidence of critical thinking and analysis, describing your own thought processes
- To be aware that accurate assessment of a baby is vital as they can be seriously unwell and only display non-specific symptoms.
- however, although I thought she was unwell, I did not expect such a serious underlying problem and she was certainly not looking like a baby that was about to arrest.
- self-awareness demonstrating openness and honesty about performance along with some consideration of your own feelings
- I am very glad that I insisted on sending the baby to hospital despite the objections of the paediatric registrar.
- It felt very awkward at the time, but it has taught me to trust my judgement and I will find it easier to be more assertive next time.
- evidence of learning, appropriately describing what needs to be learned, why and how
- Need to refresh my memory re: congenital heart disease & its presentation in neonates. GP notebook & paediatric textbook, in the next couple of weeks.
- learnt to be aware that accurate assessment of a baby is vital as they can be seriously unwell and only display non-specific symptoms
So by this time I had a fair understanding of the different elements of the learning log to make it reflective. One final document I read to bring it all together was the Being a Reflective GP by Arthur Hibble from the EOE website.
In this I learnt that it was important to not be journalistic but also reflective so observe and note the less obvious about the situation - question the situation and find the unfamiliar. Take responsibility and own your sensations and feelings about the experience (self-awareness). Self regulate by being mindful of when experiences/behaviours sit in relation to competence. Note the internal conversation of how the feelings relate to these perceptions. Seek feedback against standards by being open and honest about performance. Clarify what needs to be learnt and why you need to take it on through statements of learning and planned impact on performance and then plans for review.
This document suggest printing out an log and practicing with others to get feed back on how to improve. It offers some other general concepts:
Being reflective enlables the transitions from knowing, knowing how, being shown how and doing.
The success of techno-rational science has been in the revelation of detail; the success of humanities has been to reveal the complexity of the whole. The language of reflexivity has as much to do with the humanistic as the scientific traditions. Medicine as a discipline bestrides both of them.
The Data, Information, Knowledge, Wisdom (DIKW) theory of knowledge starts with facts or data as a raw element that is fashioned into information. Individuals take information and transform it into knowledge. Knowledge is then synthesised and analysed through experience into wisdom. In this model knowledge does not exist outside of a person, it is either data or information until it is internalised by the individual and processed so that it has an impact on performance. Reflection is part of the processing, it is the iterative reviewing element that enables the individual to incorporate good practice, build on good practice and discard obsolete practice.
Some more specific advice of the types of things to improve upon would be (e.g. of a ?child abuse case you didn't confront with the mother behaving oddly providing an explanation for a bruise "too quickly":
- What happened
- include descriptors e.g. anxious single mum
- include awareness of others e.g. she felt her son was XYZ, she was reluctant to show me XYZ, claimed XYZ
- include what you did e.g. refer to Health visitor
- Subsequently happened
- Spoke with X they have arranged Y
- Once established plan of action is undertaken we will do Z e.g. joint visit
- Spoke with trainer
- What was learnt?
- Felt unprepared
- Uncomfortable with particular consultation skill e.g. of raising issue
- Managed medical difficulty using time and referral to gather more information
- Found out about local champion on particular issue
- Not just - learnt how to refer a case
- Do differently?
- Involve trainer, champion, HV at time of consultation e.g. not just refer earlier
- Further learning needs:
- not generic e.g. find out about huge topic
- find out about local referral process and people, case meetings and review
- ask tutors to have group based discussion on half day release
- use learning time to go to social services for half a day
- Addressing them
- read protocols in the next month
- volunteer to lead a GPST xx on topic
- make appointment to see social services in next two weeks.
So some potential questions to ask are:
What could I have done better?
What did I do well? Some people would like you to answer this one first, experience usually works the other way around.
How do I feel?
Why do I feel this way?
What is the feeling telling me?
What words can I use to describe the feeling?
Who should I speak to?
What are the boundaries of my competence?
What have I leant, been made aware of?
How can I develop my competencies?
How will I put them into practice?
How will I know that I am developing?
A conclusive nice poem which has put me at ease again that I can relax and not get too hyped by the whole thing:
I KEEP six honest serving-men (They taught me all I knew); Their names are What and Why and When And How and Where and Who.
I send them over land and sea, I send them east and west; But after they have worked for me, I give them all a rest.
I let them rest from nine till five, For I am busy then, As well as breakfast, lunch, and tea, For they are hungry men.
But different folk have different views; I know a person small- She keeps ten million serving-men, Who get no rest at all!
She sends'em abroad on her own affairs, From the second she opens her eyes- One million Hows, two million Wheres, And seven million Whys!
The Elephant's Child
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