RCA Calibration Tool: How to Use the Cases

Case 5

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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 presents with depression.

Analysis

Summary

Overall, quite a superficial history, with serveral opportunities to follow-upon cues missed or ignored, culminating in a management plan that is not very patient-centred.

Timeline

0.10 Patient volunteers feeling flat and doctor asks at 22 seconds how is mood patient says bit down

The doctor must mentally think depression and rather than an open question “tell me more” goes on to ask

0.32 open question re sleep

1.10 closed question re “last time had fun”

1.35 open question what else has changed immediately shut down with three combined closed questions re eating drinking appetite

The golden minute is lost with the early interruption. The doctor falls into the trap of qualifying open with closed questions and asking multiple questions together

1.55 Two closed questions combined re tiredness and energy levels Patient says impacting on work and needs to get sorted : both cues ignored The Doctor asks if anxious which patient says no panic attacks or worries

More combined closed questions and missed cues re work

2.25 Doctor says tell me more about home life 28 lives parents mum is also worried another missed cue (why is mum worried?). You mentioned about work what do you do says doctor (again opportunity to use cue about how affecting work missed) Doctor ploughs on with psychosocial do you smoke or drink.

More missed cues re work and mothers concerns. Robotic asking of job smoking alcohol rather than how is this affecting your life. People who feel like this can drink a little more….

The doctor has explored symptoms of depression but hasn’t tried to uncover any precipitating causes eg work home life events nor any potential physical causes eg hypothyroidism

3.23 Doctor questions re illicit drugs

3.37 Doctor checks not already on medicines and has no other medical problems

4.00 Doctor asks if any dark thoughts re harming self, patient says thoughts but no intent and Doctor says parents protective

Done ok his safety is established

4.40 Doctor asks for patients’ thoughts about what is going on Patient says probably depressed and that his mum thought same and should get help

The opportunity to follow the narrative cues and into expectation (Did your mum have anything in mind?) is missed, as Doctor asks about Concerns in a formulaic way

5.03 Patient says doesn’t want to feel like this brings up affecting work again

Cue ignored

5.20 Expectation asked and patient asks if tablets needed

5.32 Doctor says good suggestion and goes on to use technical explanation of neurotransmitters and how sertraline will help with list potential side effects this lasts 61 seconds

6.33 Patient asks if addictive (doctor doesn’t ask why asks) says no.

6.55 Doctor asks if ok patient says doesn’t want anything addictive that will affect mind (again cue not followed)

7.20 Patient asks how long on for. Doctor explains check in 4 w and then up to 6m treatment

It feels that the doctor is simply being led by the patient I’d like tablets ok here they are

No overview is given eg people who find themselves in your situation can benefit from tablets for mood like you say and this is sometimes combined with talking therapies … then a discussion of pros and cons.. then what do you think would be best for you?

Instead this sounded like a lecture everything I know about neurotransmitters The patient had to ask for information rather than the doctor outlining course of treatment and or asking what else the patient wanted to know

8.05 Asks patient for thoughts on that and patient says something should do

Once again this isn’t true negotiation saying “is that ok?” and “glad we’ve come to agreement” isn’t negotiation. Giving pros and cons and patient deciding is. It’s ok to weight the choices eg normally the first thing we would do in your situation is or “the advantages of doing this first would be”.

8.15 follow up arranged

Follow up is arranged but no safety netting ie if you were to feel worse what would you do…? and potentially give crisis numbers etc

8.38 End

RCA Assessment

RCA assessment Overall: Clear Fail

Data Gathering: Fail

The history is limited to symptoms of depression and other than questions about alcohol and drugs other causes both psychological and physical are missed He asks about work but not the effect on work Safety is just about established

Management: Clear Fail

The patient asked for antidepressants and got them. The doctor didn’t outline alternative treatments nor the pros and cons of those approaches. The follow up didn’t include what to do if things got worse.

Interpersonal: Clear Fail

The doctor didn’t seem interested in finding out about the patients’ life. Once the decision to prescribe was made a physiology lecture was given which almost certainly went over the patients head The examiner knows that information and doesn’t need to be told it. Information about follow up and side effects and duration had to be asked for by the patient. The patient wasn’t involved in making a management plan

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