Remember, before reading the analysis, ensure you have listened to the recording, made your own notes and completed your own assessment of the case.
This audio recording looks at a contraceptive Pill Check.
Analysis
It is important to note that the expert analysis is to be used as a guide only. These cases have not gone through the same rigorous approach used in the marking of the real RCA examination. However, the analyses provide an indication of how a typical assessor might review and grade a case.
Summary
This is a difficult case as its in an area that GPs are unlikely to deal with on a regular basis. The doctor does well to pick up on the hidden agenda. I suspect that he will also need to read up on what services are available and what can be done whilst waiting for the referral. As a result the management feels a little superficial. How far has the patient actually thought this through regarding treatment that could lead to transition eg testosterone treatment and surgery? The doctor is empathic and supportive.
Timeline
Doctor Introduces and asks how can help
0.15 Patient says told needs pill review
0.20 Doctor says can see on POP and how finding it?
0.28 Patient says fine and stops periods.
0.35 Doctor says that’s why people like it whether using for that or contraception. Patient says to stop periods. Doctor asks if any problems patient says fine.
1.00 Doctor asks why wants to stop periods. Patient says finds distressing so pill great as just stops periods.
1.18 Doctor asks what means by distressing and patient reveals that identifies as male.
1.50 Doctor asks if knew that when started pill patient says no.
A good start within 2 minutes we are into the real agenda which the doctor has picked up by following the narrative and being inquisitive about the reasons for not wanting periods
2.10 Summary by doctor that takes to stop period. Asks what sees as long term, is stopping period enough or other things eg gender.
2.35 Patient says looking things up ?other options ?transgender clinic.
3.14 Doctor says can do referral. Asks what patient wants out of referral.
3.35 Patient says has thought about taking hormones and would want to transition. Hasn’t spoken to family nor what they would think and would want to find out more re support and thinking.
Again the doctor is following the narrative and is asking open questions re expectation They could then have been a little more specific regarding treatments. Has the patient though about the treatments that could be involved eg hormonal and surgical and pros and cons of that .
4.17 Doctor says considered and asks if spoken to the friend mentioned earlier which she has.
4.55 Doctor asks if found difficult. Patient says yes and asks again for referral.
5.28 Doctor asks permission to ask questions to understand better and patient says yes. Asks re job – student in English and whether people on course know – answer no.
6.00 Doctor asks how she feels about them not knowing. Patient says wants referral for support so can work that out.
Doctor doesnt need to ask permission to ask questions This line of enquiry is a little one dimensional in that it only looks at her relationship with college acquaintances. Perhaps more open questions regarding when did she start feeling like this Relationships within family would also have been relevant.
6.39 Doctor asks practical things about pill ie smoking, other drugs and alcohol. States from records has no other medical problems.
This felt like they were being asked for asking sake, rather than relating to current problem. The details weren’t used and certainly weren’t needed for pill prescription.
7.10 Doctor asks about mental health and patient says has had low points but mood generally ok just wants referral and doctor invites her to come to him if mood changes.
Good that the doctor touched on this area and also signposts can come back to him.
7.50 Doctor says for today need to do repeat pill and look at referral options. Asks if knows how works. Doctor states are regional centres and long waiting times. Signposts on line resource Gender Kit she can look at and come back to him. Then meet up again to discuss.
I suspect the doctor also has some homework to do however as mentioned above some consideration of involved treatments both physical and psychological that might be needed for gender transition could have been mentioned so that this part felt less woolly
9.15 Doctor says if have covered what wanted to cover and that have only just started conversation.
Again. Good signposting that this is just the start of a journey.
9.50 Arranges follow up after she has looked at information.
10.05 Patient brings up friend has done blood pressure which doctor says doesn’t need and ends consultation.
Safety net is seeing again nothing more is needed I’m not certain if there was something behind offering the BP but doctor could have asked rather than dismissing as not needed
RCA Assessment
RCA Assessment Overall: Pass
Data Gathering: Pass
A reasonable history Some areas were covered superficially eg psychosocial and the history of how long had felt like this wasn’t fully explored. Explored mood which was good
Clinical Management : Pass
A hard case and needs to be assessed as to how the average GP would cope. I suspect most would need to do some research and come back to the patient as here maybe the GP should have vocalised that. However, treatment would potentially involve hormonal and or surgical. Asking what the patients attitude to that might be would have been reasonable and showed some insight into what would be involved. It was good the doctor signposted this was the start of a journey.
Note: Had the case just been a pill repeat or dealt with as such then it would been hard to get good marks in any domain so credit for taking it to a different level.
Interpersonal: Clear Pass
I thought the doctor facilitated this patient journey. They did well to pick up ICE early and go with the narrative. They weren’t judgmental and sounded empathic. They did try and explore what her feelings to undergoing any treatment might be.
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