Case 3

Back to Case List

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 has come for a result of their HbA1c

Analysis

Summary

A good case for long term condition as the opportunity to take a good history to work out why control has deteriorated is needed and usually negotiated management can be shared.

Timeline

Doctor Introduces himself and patient says has come for results.

0.10 Asks patient if knows why had tests done.

0.15 Patient asks if will just give him results.

Doctor says looks anxious and Patient says he is as never rung up before to come in.

0.30 Patient asks what they show and is it serious?

Doctor says results show sugars have gone up the patient knows it’s the HbA1c

  • Dr says has gone up to 78 and patient expresses surprise says it’s a lot.

Slightly awkward start my advice would be unless it’s really bad news to get on and give result because a patient won’t think of anything else until you do So here eg ‘as you know we’ve called you in to discuss the test that looks at diabetes control and that has gone up a bit.’  Instead of that the patient has to ask for result and express frustration at not being told

1.00 Dr asks if he has any idea what may have caused the rise.

1.06 Patient says not looking after himself as well increased snacks and reduced exercise.

1.22 Doctor asks if anything happened in life to cause that and patient says not been as active as churchwarden, lots of deaths covid quite stressful and need to get (diabetes) sorted.

This but is done well reflective questions and the patient is very knowledgeable and forthcoming.

What the doctor doesn’t do is assess physical symptoms thirst fatigue blurred vision weight gain/loss thrush etc to get an idea of how much the rise is affecting the patient

2.02 Dr says sounds like struggling – patient says reduced support.

This was just about ok however I think imposing how you would feel in a situation on a patient isn’t a good idea it’s better to ask them open questions how have you coped? How did you feel? (Listen to some Desert Island Discs as the presenter Lauren Laverne is excellent at this!)

2.15 Asks how diet has changed Patient repeats that snacking.

2.35 Dr reflects back about exercise and asks what does: Patient says reduced walking.

3.00 asks re alcohol patient says no and also volunteers doesn’t smoke.

3.19 Dr asks what thinks and patient volunteers simply needs to change diet.

Little bit of repetition here however we do get that alcohol isn’t involved. We don’t get much of a sense of the patient’s home life. Does he cook or not is that why he snacks? Who else is at home?

3.35 Dr asks if that will be enough? Patient says yes and will also get back to exercise.

Good reflective question.

3.50 Dr suggests there are other options but then asks if will be able to stick to diet.

Again quite reflective and signposts might not be enough.

4.10 Dr highlights other options eg medications and Patient says are they needed?

4.34 Dr says when levels ‘serious’ risk of stroke heart attack increases Patient says doesn’t really want to go on tablets.

The issue here is that in someone who has been well controlled one abnormal HBa1c isn’t going to cause them to have a stroke or lose their feet. Such shock tactics isn’t appropriate it needs to be put in context. Using words like serious is emotive and frightening. Also studies have shown that tight control later in life isn’t as effective in stopping problems as tight control early so the explanation isn’t correct.

5.10 Patient explores reluctance and patient says on life once started, and doctor asks patient to explain who says he doesn’t feel dr will stop.

5.35 Dr says that possible if gets lifestyle sorted then may be able to stop.

I think the real opportunity to negotiate is missed. What would be wrong with offering the choice to try what he thinks he can do for 3 months and then revisiting tablets if control isn’t achieved?  That could be set against starting tablets now. The pros and cons having been discussed the patient can make a decision?

5.50 Patient expresses surprise might be able to stop medication in the future.

6.00 Dr refers to guidance that tablets needed now.

Guidance is guidance not gospel. A reluctant patient who looks well doesn’t need to be forced onto tablets which is what this feels like.

6.10 Patient asks a searching question about how many patients have had their tablets stopped. Dr says every patient different and doesn’t answer question or ask patient why asks. Says if get sugars under control then no reason for long term use.

Take the opportunity to ask patients why they are asking you the questions. Sometimes you will find out what they are thinking other times you will need to answer as here.

6.50 Patient asks if needs to start medication. Dr says its an option and patient quickly interrupts to ask what doctor would do?  The doctor starts to suggest the lifestyle changes but the patient interrupts what would you do if it was your dad?

7.24 The Dr answers start the tablets..

An interesting exchange where the patient puts the doctor on the spot. The doctor does answer eventually. Personally I think if the options to try diet/exercise alone had been on the table vs tablets now, the patient (not the doctor) would have made the decision but all credit for saying what would do.

7.35 Patient says doesn’t want to but probably has to. Doctor says will support in process and discuss the tablets.

8.05 Talks about metformin starting dose side effects then increasing dose Patient says three a day is a lot.

9.03 Dr explores the reluctance re the three a day and goes on to say will check HbA1c again in 3 months.

9.55 Patient says sounds like have to do it. Dr answers question rather than asking why patient asking. Reiterates diet and exercise and mentions health trainer.

The support system is only briefly touched on. At the start of the management the doctor could have set the scene. ‘There are things you can do like the diet and exercise. There are things I can do like using some medicines which I’ll explain in a moment, and there are people who can help us like the health trainer We can do all or some of these things What do you think would work for you?’

10.41 Arranges review in 3 months

A safety net isn’t really needed however it would have been reasonable to say if the tablets don’t suit get back to me, or if you get thirsty etc  despite the tablets please get in touch.

RCA Assessment

RCA assessment Overall: Borderline

Data Gathering: Fail

Unfortunately, the doctor doesn’t do much in this area. Current symptoms aren’t assessed The patient’s home situation isn’t enquired about especially around shopping diet and meal preparation

Management: Pass

He does follow the guideline and explain metformin He does encourage lifestyle changes with diet and exercise. he does involve another member of the team in the health care assistant He does arrange to see again after a repeat blood test. It’s all a little superficial though and there are no reasons to reattend

Interpersonal: Pass

I think this just creeps into pass but only just by virtue of some of the questions like do you think will that be enough However some of the explanations and words used could have shocked rather than got the patient on board The management whilst talked about at length didn’t give the patient the option of trying diet and exercise alone for 3 months so it was imposed rather than negotiated. Having said that the patient asked the doctors opinion he gave it and the patient followed it

Back to Case List