RCA Calibration Tool: How to Use the Cases

Case 10

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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 video recording looks at a patient who presnts with a headache.

Analysis

Summary

Good data gathering is sadly let down by a failure togather important psychosocial context and develop a management plan. Opportunities to follow the patient’s own narrative, naturally revealing their ideas, concerns and expectations are missed.

Leaving a case “open” pending further investigation may be realistic, but doesn’t demonstrate that the doctor is able to diagnose and manage the condition. Remember that the aim of the MRCGP examinations is to demonstrate competency to work as as an independant practitioner; a good physician associate will gather data and present to a doctor to formulate a plan, but a GP needs to be able to do it all.

Timeline

0.00 Introduces and asks how can help

0.18 Patient says horrible headaches wants tests and a scan if that is possible

First opportunity to explore ICE overloooked

0.30 Doctor says tell me more Patient says had for 6 weeks and “really bad pressure” to head

0.54 Doctor says tell me more whereabouts? Patient says dull annoying ache front head

1.10 Doctor asks how long; patient repeats 6 weeks, comes on in morning worsens during day and really worried and would like something done about them.

Second opportunity to explore ICE overlooked

1.35 Doctor says sorry worried and can he have more information. Asks two closed questions together re funny sensations and changes vision. Patient says no re visual upset, although spends a lot time on the computer at work.

Asking double questions means sometimes only one is answered as here.

2.05 Doctor asks re nausea and vomiting, says sickly. Asks if woken up in the night patient says no but has been under some stress so not slept as well.

2.38 Doctor reflects mentioned stress and work and if she thinks connected with headache. Patient says manager in call centre and has been under pressure but because 6 weeks although thought might be stress but not sure.

Good pick up on stress cue and reflected question. Cue re “not sure” could have led to ICE again

3.06 Doctor breaks narrative re stress and asks if anything else changed Patient says no.

3.18 Doctor asks re lifestyle alcohol and smoking. Doctor suggests should reduce smoking but patient says doesn’t want to stop. Doctor asks about caffeine and she volunteers an intake of 6 to 7 cups.

4.10 Patient comes back to asking re scan. Doctor says can talk about it but needs more information but acknowledges has heard that’s what she wants.

The two agendas are clashing the doctor wants to get a history the patient wants to know she can be scanned.  Credit to the doctor for acknowledging patient agenda, however, following the patient narrative would have relieved the patient and sounded better

4.25 Goes back to saying caffeine intake high and whether she thinks headache related to caffeine; she says drunk that much for a long time

Once again good reflective question ‘do you think’

4.51 Asks specifically about red flags weakness arms legs, fever stiff neck, bright lights again asked as combined closed questions

Good exclusion of other causes would have been better as single questions

5.10 Goes back to scan and asks what worried about. Patient says pressure in head and brain tumour worry and that scan and tests would help.

Finally get to ICE

5.50 Doctor acknowledges worry and not unreasonable to be worried.

6.00 Doctor says doesn’t sound like symptoms linked to brain tumour and more likely stress related and also caffeine induced. Patient says ok what would she do about that.

Good reassuring dialogue leading the patient along a line of thought so that she asks what she can do

6.22 Doctor says needs plan to reassure you; think about examination to make sure nothing worrying and check she is ok with that. Then brings up bloods and says will decide on management when comes

So good that sets stall with plan and describes examination well; but doesn’t state what bloods or how they will help. Unfortunately doesn’t describe any potential management (see below)

RCA Assessment

RCA assessment Overall: Borderline

Data Gathering: Clear Pass

The doctor takes a good history arranges to examine and describes what will do tests differentials and finds out the psychosocial background which he uses He doesn’t say what blood tests or how they will help

Management: Clear Fail

We are left in suspense management will be decided after he has seen her. Real life yes but the exam needs some discussion of management choices for the potential diagnosis/differential

Interpersonal: Pass

A good doctor who leads the patient through his thinking however in the early stages he ignores cues finally acknowledging her expectation and exploring it. He does a good explanation of what he thinks is going on. We don’t get a shared management plan as there is no management which is a shame and prevents a Clear Pass in this domain

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