RCA Calibration Tool: How to Use the Cases

Case 8

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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 a change in bowel habit.

Analysis

Summary

The doctor doesn’t introduce themselves nor check patient identity (this may be confirmed elsewhere, but as the video is not recorded via FourteenFish it’s important to clarify).

The opportunity to follow the narrative using what the patient thinks is wrong to introduce the concept that this could be something more serious is missed.There is a lot of summarizing which wastes time. Psychosocial history is asked almost as an afterthought and not really used.

Examination is offered without a chaperone and no PR is done (or its absence explained).

Whilst referral to exclude a tumour would be needed there is no discussion of other potential diagnoses nor negotiation of a potential diagnostic work up with bloods and FIT testing prior to that referral which could be done very quickly afterwards.

In that discussion the possibility of cancer is given without any softening of the blow and the doctor spends nearly 2 minutes digging themselves out of the hole it creates.

Timeline

0.00  Asks what is wrong

No introduction or checking of identity

0.10 The patient volunteers loose stool “messing with life” and that has reduced gluten as worried Coeliac without effect, and thinks needs tests for gluten allergy and to see a dietician.

1.00 The doctor asks how long; states 3 months and reiterates dietary changes haven’t helped and hoping for better on prescription which the doctor says can do.

1.50 First summary: 3 months and change of bowel habit

1.55 Closed question re consistency (i.e. “Is it loose?”) when could have used open question (i.e. “tell me about your bowel habit”)

2.10 Establishes frequency bowel opening

2.30 Series of closed questions establishing that there is no blood in stool, no anal pain and that wind/bloating has increased

2.50 Second summar, then closed questions re. weight and appetite which are ok.  

3.35 Asks perceptive question “Do you think your symptoms fit coeliac?” Patients says yes except dietary changes haven’t helped.

3.50 Establishes hasn’t had anything like this before

4.00 Establishes effect on life and need to be near the toilet. Then follows direct question re IDEAS CONCERNS EXPECTATIONS

4.25 What did you think was going on? Patient interjects thinking of coeliac.

4.30 Asks worries and again patient volunteers coeliac and knows there are tests. The doctor doesn’t follow the narrative and says can talk about later.

4.48 Asks what patient expects: again the patient has already mentioned tests and dietician. The doctor did clarify what the patient expected from the bloods and dietician referral

On the whole the doctor asked a reasonable history listening reflecting and clarifying the presenting history

However the ICE felt clumsy the patient had already volunteered what they wanted and better questions would have been “besides the coeliac screen was there anything else”  showing they were listening following the narrative and saving time

At the point above where the doctor asked did the symptoms fit coeliac, the narrative could easily have moved on to “anything else you were thinking” and even that the doctor, whilst acknowledging the patients worry, raise the idea that they were thinking differently.

5.22 For first time asks patient if patient had thought of anything else

Patient says no, but the doctor doesn’t use opportunity to verbalise own ideas or prepare the patient for bad news. It could have been very simple; eg ‘let me have a good look at you to see if there are signs of anything else going on’

5.35 Examines abdomen off camera

No chaperone offered and no PR discussed so omitted. Very difficult to assess what actually happens as isn’t vocalized and is fairly brief. The doctor does say examination fine couldn’t feel anything there. Its hard to criticise what you cant see but it would not appear to be an adequate assessment. 

6.00 Asks re effect on job, alcohol and smoking

Had already asked about effect on life earliers so could have raised then, this felt a little like going back to history taking as an after thought when should have been moving to verbalizing diagnostic thinking.

Whilst alcohol was relevant, credit is given when its used or the relevance made clear; eg.” alcohol can sometimes upset the bowels does that apply to you?

6.40 Third summary

Summarising to clarify not missed anything is good, three summaries of the same information here is wasting time.

7.05 Doctor says could be more serious and thinks this could be bowel cancer despite patients reaction moves on to saying will need to be seen in the clinic.

7.10 Verbalises rationale re change of bowel habit being a potential marker for cancer. Once again plunges on with need to go to hospital clinic and have a camera test

Well at least they were direct however there was no preparing the patient for news they probably didn’t want to hear eg I know you thought this was coeliac have you considered it could be something else etc etc

Verbal and non verbal cues of shock at the news are ignored. The doctor needed to take time at each step; i.e. the potential diagnosis (and any likely  differentials which weren’t given), the reaction to the potential cancer diagnosis, the need for referral, the need for a colonoscopy.

7.35 Patient asks for clarification of what camera test will involve

7.45 Patient comes back to ask about seriousness of what the doctor is thinking

Doctor does what they should have done earlier, explaining that it may not be cancer but cancer needs excluding and the rational for that. However, it feels very much that the doctor is trying to extract themselves from a difficult hole.

8.50 Rather than negotiating the management the patient is told they need to be referred and asked how they feel about that which isn’t negotiation

Despite the need for a 2ww referral, negotiating along the lines of “how would you feel about me involving my hospital colleagues…

9.10 Discusses will be 2ww

9.20 Patient alarmed at urgency which the doctor acknowledges

9.55 Suggest bloods if patient wants and uses technical language ‘anaemia’

Felt like an afterthought; poor explanation of why needed and what looking for. Didn’t do a FIT test.

10.05 Says hospital doctor will give explanation of what going to do had earlier said would give leaflet about clinic

Giving information in this way ie. via other people or leaflets doesn’t gain much credit if vital information the patient needs isn’t given in the consultation.  Its better to ask what the patient wants to know today then its perfectly acceptable to explain there isn’t enough time to explain everything in detail in this consultation and arrange to see again/ to get others to see /or if you must give what you can in written form. Its likely they were so shocked by the mention of cancer that they would take little else in.

10.20 Says “can have sedation for camera test” if worried rather than asking about worries about test

10.39 end

RCA Assessment

RCA assessment Overall: Borderline

Data Gathering: Pass

A reasonable history testing differentials . Exam was performed no PR. Bloods were offered but no FIT test Psychosocial was asked but not really used.

Management: Pass

A working diagnosis was made, referral was appropriate , no firm arrangements to see again after the hospital appointment were made

Interpersonal: Fail

Didn’t introduce. An attempt to explore ICE was made. No chaperone offered for examination. Shared management plan was missing. The opportunity to explore the patients’ reaction to the potential diagnosis was missed.

I’ve given a Fail rather than Clear Fail as there were moments where the doctor showed they could respond to the patient and that they could verbalise their thinking to help the patient understand but it was close.

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