RCA Calibration Tool: How to Use the Cases

Case 6

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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 calls with asking for a prescription of omeprazole, who turns out to have chest pain requiring assessment.

Analysis

Summary

Timeline

Introduces and checks identity

0.24 Asks for tablets for indigestion gaviscon usually helps but wants omeprazole

0.53 “Tell me about symptoms…” Doctor listens whilst explains worst pain ever had last night. Gaviscon helped and pain lasted an hour. Felt nauseated and sweaty

1.26 Doctor confirms history and asks if ever had before

1.52 Doctor confirms that pain different and checks if has had any more episodes. The patient does say feels well now.

2.40 Doctor asks if thinking that the pain is due to indigestion the patient confirms and volunteers that working hard and been drinking a little more than normal. The patient does say feels well now.

Good open questions and good use of summarising Doctor follows the narrative. However there is very little history to establish severity eg radiation of pain palpitation breathlessness, or alternative diagnoses eg PE cough haemoptysis

2.55 Asks about job as a cleaner and whether indigestion has been affected, About his wife who is a florist and checks on alcohol intake

This felt like psychosocial history for psychosocial sake. The patient had already given cues about alcohol and these weren’t used. Crucially no smoking or family history taken

3.40 Asks about whether the pain worried him and the patient brings up that did wonder if was his heart but on balance still thinks its indigestion that would be helped by different medication

This was done very well and in the narrative style this doctor has showed so far

4.10 Doctor uses patient language to explain that this could be something a little more serious that his indigestion and it could be his heart. Raises possibility that the pain last night could have been a heart attack

Again really well done narrative style and well explained

4.45 Doctor responds to patient’s surprise by explaining thinking again and checking the patients knowledge and understanding of what might be going on

5.35 In a very nice drip drip fashion the Doctor explains that further tests are needed and that these would need to be done in hospital

5.40 Patient asks if they can be done at the surgery Doctor explains that the tests can be done at the surgery but the rationale behind them being done at the hospital ie speed of getting back and starting treatment.

Continues the giving of information simply and in chunks each chunk leading to the next. The doctor is a little doctor centred Having explained why they would prefer hospital admission they could have asked what the patient thought about that now versus being seen at the surgery first.

6.25 Asks if can get to hospital patient says will drive, Doctor asks if wife can take patient says he is fine to drive himself. Doctor says not safe as risk of losing consciousness and persuades him to ask his wife.

Whilst the patient needs to get to hospital and it wouldn’t be safe to drive, the rationale for not using an ambulance isn’t explained. Often these days the ambulance can take directly to a specialist heart centre (for primary PCI) and a 999 would have been safer and probably quicker had the patient had an abnormal ECG in the ambulance

8.20 Doctor confirms that Doris is taking him. Asks if ok which patient says isn’t. Explains that it could be severe indigestion but that a heart attack needs checking out.

Asking is that ok having told the patient what to do isn’t a substitute for negotiation. Having left the patient to find his own way to hospital the doctor doesn’t make arrangements to check that he actually gets there safely, and doesn’t offer to see after discharge to either follow up treatment or investigate alternative diagnoses should that be the case

9.06 End

RCA Assessment

RCA assessment Overall: Borderline

Data Gathering: Pass

The doctor listens and establishes that likely cardiac but doesn’t explore the degree of symptoms accepting the patient saying feels well now, or other possible diagnoses. The psychosocial history misses smoking and Family History. A pass but only just.

Management: Fail

Deciding to admit is effectively the main decision taken which any person with medical knowledge could have come to. The doctor also needed to show that they were safe ie mode of admission as commented on above, and that they would arrange to see again as commented on above.  A fail but only just.

Interpersonal: Pass

I liked the narrative style. The way information was given in small amounts The explanations used the patient’s ideas. The doctor effectively told the patient what was happening ie Doctor led management but in a very nice way!

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