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 patient who presents with back pain.
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 case looks at a case around back pain in patient for whom the implications are important
Timeline
0.00 Doctor Introduces and asks how getting on how can help.
0.18 Patient gardener lifted bag rubble and done back pain and needs to get sorted and losing money.
Cue “get sorted” was opportunity to ask expectation
0.50 Doctor says sounds stressed and patients interjects with “stress is wrong word… keen to get sorted”.
Doctor puts own emotion onto patient who rejects – I would avoid. It’s better to say “how has that affected you” or made you feel .Patient repeats “get sorted”, presumably because thinks doctor hasn’t listened.
1.00 Doctor says we can discuss it, tell me more. Patient says in low back right side, worse shooting down leg, tingling behind knee and can’t function.
Doctor puts off discussing and goes back to history.
1.23 Doctor says “ok its having significant impact.” Patient agrees and says happened end last week and hasn’t worked since.
1.38 Doctor says “you said going down leg… which one?”. Patient says right.
1.42 Doctor asks open question: “noticed anything else?” and closes down straight away with closed questions re red flags numbness and a combined question regarding bowels and bladder function.
If you can leave an open question open, close it down if patient doesn’t answer or clarification needed. Ask closed questions singularly so get specific answers
1.55 Doctor says tell me more and summarises not able to work, and asks combined closed questions: “are you active/able to do much round house?”. Patient says able to get out but struggling with pain at night.
2.38 Doctor asks if straightening leg makes pain worse, patient says yes
The narrative is broken again; instead of asking what has done for pain and what wants doing, carries on with history.
2.46 Doctor says has affected work and asks how has affected home, said lives with wife. Patient says wife has pushed to come and concerned that her dad died prostate cancer which started with back pain. Patient says that isn’t his concern
We know the pain is affecting work and home but doctor repeats this and strikes lucky in that patient volunteers wife’s concerns
3.45 Doctor says can ask more questions to rule out other things; re weight, night sweats, asks more water work questions regarding urinary stream
Unlikely symptoms given history so far but completes picture of an acute back strain.
4.32 Doctor asks expectation and patient says strong pain killers. Doctor asks what tried patient says ibuprofen.
Now a direct question, re expectation the patient has alluded to this many times already ‘get sorted’ ‘affecting sleep’
5.15 Doctor says he thinks has sciatica and there are options for treatment.
Makes a diagnosis, that’s good, however, I’m not certain that without examination he could be certain it’s not just musculoskeletal strain.
5.50 Doctor says unlikely prostate issue patient concurs.
Good that links explanation to patients‘ wife’s worry.
6.15 Doctor mentions for third time there are options for treatment and then suggests first line anti-inflammatory naproxen discusses using PPI (proton-pump inhibitor) as well. Patient asks if anything else anything stronger,like diazepam that a friend had. Doctor says used for muscle spasm. Doctor discusses that can make drowsy and dissuades from having.
I think this is slightly disingenuous in that naproxen is pushed as a stronger nsaid but its still an nsaid and this wasn’t explained.
8.15 Doctor says has he thought about long term to strengthen back
The doctor misses the opportunity to talk about prognosis and to put the various management ‘options’ into perspective. If it was just a back strain, the patient would be better before any physio was obtained. If its a disc, a proper explanation of prognosis was needed, including what happens if didn’t settle spontaneously. This could be broken down into “what you can do, what I can do and what others can do”. An overview would make the patient realise there isn’t a quick fix, which was never properly explained.
8.23 Patient says wasn’t sure about whether should take time off, Doctor says keep as active as can.
The patient misunderstands about time off. Keeping active and labouring as a gardener are two different things and this isn’t addressed and no prognostic information is given
9.00 Doctor talks about involving physio in practice or NHS 6 week wait.
9.25 Patient reiterates wants quick fix and that’s too long to wait and Doctor suggests private if wants faster.
10.20 Patient asks for private costs and doctor says patient needs to research himself.
The doctor seems to be trying not to upset patient by saying this will take time and you might not be able to do your work short term. Instead we end up talking about private physio which some might consider inappropriate if the patient hasn’t suggested
10.55 Patient asks how long Doctor says could take 6 weeks. If pain killers aren’t working then says are more options.
Patient finally pins doctor down options mentioned but doctor doesn’t say what they are
11.25 Safety nets re urinary and bowel problems or legs funny to seek help asap Patient asks re script and doctor says will sort.
RCA Assessment
RCA assessment Overall: Borderline
Data Gathering: Pass
Takes history around what caused symptoms now. Excludes cauda equina over phone. Gets some social history. Thinks around potential differential diagnoses. Doesn’t offer examination to differentiate sciatica from a more likely muscle strain from lifting. Relatively simple case as patient almost gives diagnosis at outset.
Management: Pass
Makes a working diagnosis of sciatica and discusses treatment in terms of a different NSAID (although this isn’t explained to patient) and physio. Safety nets for cauda equina but doesn’t put in context of history given that unlikely to happen. Vague about prognosis and timelines for treatment which the patient has to push for. Although mentioned options for treatment if didn’t settle we didn’t hear them.
Interpersonal: Fail
I think this fell down on explanations and negotiation. The doctor didn’t explain that naproxen is another ibuprofen. He didn’t really discuss natural history of his diagnosis sciatica. It was quite clunky with lots of repetition of what patient had said which broke the narrative. The ICE was clunky in that he didn’t use what the patient had already told him to explore further. The patient was told what was going to happen rather than being able to choose. Some would question pushing a private route unless the patient brought it up.
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