{"id":2697,"date":"2022-03-02T18:34:18","date_gmt":"2022-03-02T18:34:18","guid":{"rendered":"https:\/\/gp-training.hee.nhs.uk\/bolton\/?page_id=2697"},"modified":"2022-07-26T21:21:19","modified_gmt":"2022-07-26T20:21:19","slug":"case-8","status":"publish","type":"page","link":"https:\/\/gp-training.hee.nhs.uk\/bolton\/mrcgp-examinations\/rca-calibration-tool\/case-list\/case-8\/","title":{"rendered":"Case 8"},"content":{"rendered":"\n<a href=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/mrcgp-examinations\/rca-calibration-tool\/case-list\/\" class=\"wp-block-nhsblocks-nhsbutton nhsuk-button\">Back to Case List<\/a>\n\n\n\n<p class=\"has-text-align-center has-white-color has-emergency-red-background-color has-text-color has-background\" style=\"font-style:normal;font-weight:700\">Remember, before reading the analysis, ensure you have listened to the recording, made your own notes and completed your own assessment of the case.<\/p>\n\n\n\n<p>This video recording looks at a patient who presents with a change in bowel habit.<\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-vimeo wp-block-embed-vimeo wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Case 8 - Change in Bowel Habit\" src=\"https:\/\/player.vimeo.com\/video\/672322766?dnt=1&amp;app_id=122963\" width=\"640\" height=\"360\" frameborder=\"0\" allow=\"autoplay; fullscreen; picture-in-picture; clipboard-write\"><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"has-white-color has-nhs-blue-background-color has-text-color has-background wp-block-heading\" style=\"font-style:normal;font-weight:700\">Analysis<\/h2>\n\n\n\n<p class=\"has-text-align-center has-white-color has-emergency-red-background-color has-text-color has-background\"><strong>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.<\/strong><\/p>\n\n\n\n<h3 class=\"has-nhs-blue-color has-text-color wp-block-heading\">Summary<\/h3>\n\n\n\n<p>The doctor doesn\u2019t introduce themselves nor check patient identity (this may be confirmed elsewhere, but as the video is not recorded via FourteenFish it&#8217;s important to clarify).<\/p>\n\n\n\n<p>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.<\/p>\n\n\n\n<p>Examination is offered without a chaperone and no PR is done (or its absence explained).<\/p>\n\n\n\n<p>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.<\/p>\n\n\n\n<p>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.<\/p>\n\n\n\n<h3 class=\"has-nhs-blue-color has-text-color wp-block-heading\">Timeline<\/h3>\n\n\n\n<p>0.00&nbsp; Asks what is wrong<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>No introduction or checking of identity<\/em><\/p>\n\n\n\n<p>0.10 The patient volunteers loose stool \u201cmessing with life\u201d and that has reduced gluten as worried Coeliac without effect, and thinks needs tests for gluten allergy and to see a dietician.<\/p>\n\n\n\n<p>1.00 The doctor asks how long; states 3 months and reiterates dietary changes haven\u2019t helped and hoping for better on prescription which the doctor says can do.<\/p>\n\n\n\n<p>1.50 First summary: 3 months and change of bowel habit<\/p>\n\n\n\n<p>1.55 Closed question re consistency (i.e. &#8220;Is it loose?&#8221;) when could have used open question (i.e. &#8220;tell me about your bowel habit&#8221;)<\/p>\n\n\n\n<p>2.10 Establishes frequency bowel opening<\/p>\n\n\n\n<p>2.30 Series of closed questions establishing that there is no blood in stool, no anal pain and that wind\/bloating has increased<\/p>\n\n\n\n<p>2.50 Second summar,  then closed questions re. weight and appetite which are ok. &nbsp;<\/p>\n\n\n\n<p>3.35 Asks perceptive question \u201cDo you think your symptoms fit coeliac?\u201d Patients says yes except dietary changes haven\u2019t helped.<\/p>\n\n\n\n<p>3.50 Establishes hasn\u2019t had anything like this before<\/p>\n\n\n\n<p>4.00 Establishes effect on life and need to be near the toilet. Then follows direct question re IDEAS CONCERNS EXPECTATIONS<\/p>\n\n\n\n<p>4.25 What did you think was going on? Patient interjects thinking of coeliac.<\/p>\n\n\n\n<p>4.30 Asks worries and again patient volunteers coeliac and knows there are tests. The doctor doesn\u2019t follow the narrative and says can talk about later.<\/p>\n\n\n\n<p>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<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>On the whole the doctor asked a reasonable history listening reflecting and clarifying the presenting history<\/em><\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>However the ICE felt clumsy the patient had already volunteered what they wanted and better questions would have been \u201cbesides the coeliac screen was there anything else\u201d&nbsp; showing they were listening following the narrative and saving time<\/em><\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>At the point above where the doctor asked did the symptoms fit coeliac, the narrative could easily have moved on to &#8220;anything else you were thinking&#8221; and even that the doctor, whilst acknowledging the patients worry, raise the idea that they were thinking differently<\/em>.<\/p>\n\n\n\n<p>5.22 For first time asks patient if patient had thought of anything else<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Patient says no, but&nbsp;the doctor doesn\u2019t use opportunity to verbalise own ideas or prepare the patient for bad news. It could have been very simple; eg \u2018let me have a good look at you to see if there are signs of anything else going on\u2019<\/em><\/p>\n\n\n\n<p>5.35 Examines abdomen off camera<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>No chaperone offered and no PR discussed so omitted. Very difficult to assess what actually happens as isn\u2019t vocalized and is fairly brief.&nbsp;The doctor does say examination fine couldn\u2019t feel anything there. Its hard to criticise what you cant see but it would not appear to be an adequate assessment.&nbsp;<\/em><\/p>\n\n\n\n<p>6.00 Asks re effect on job, alcohol and smoking<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>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<\/em>.<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Whilst alcohol was relevant, credit is given when its used or the relevance made clear; eg.&#8221; alcohol can sometimes upset the bowels does that apply to you?<\/em>&#8220;<\/p>\n\n\n\n<p>6.40 Third summary<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Summarising to clarify not missed anything is good, three summaries of the same information here is wasting time<\/em>.<\/p>\n\n\n\n<p>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. <\/p>\n\n\n\n<p>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<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Well at least they were direct however there was no preparing the patient for news they probably didn\u2019t want to hear eg I know you thought this was coeliac have you considered it could be something else etc etc<\/em><\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>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 &nbsp;differentials which weren\u2019t given), the reaction to the potential cancer diagnosis, the need for referral, the need for a colonoscopy<\/em>.<\/p>\n\n\n\n<p>7.35 Patient asks for clarification of what camera test will involve<\/p>\n\n\n\n<p>7.45 Patient comes back to ask about seriousness of what the doctor is thinking<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>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<\/em>.<\/p>\n\n\n\n<p>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\u2019t negotiation<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Despite the need for a 2ww referral, negotiating along the lines of &#8220;how would you feel about me involving my hospital colleagues\u2026<\/em>&#8220;<\/p>\n\n\n\n<p>9.10 Discusses will be 2ww<\/p>\n\n\n\n<p>9.20 Patient alarmed at urgency which the doctor acknowledges<\/p>\n\n\n\n<p>9.55 Suggest bloods if patient wants and uses technical language \u2018anaemia\u2019<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Felt like an afterthought; poor explanation of why needed and what looking for. Didn\u2019t do a FIT test<\/em>.<\/p>\n\n\n\n<p>10.05 Says hospital doctor will give explanation of what going to do had earlier said would give leaflet about clinic<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Giving information in this way ie. via other people or leaflets doesn\u2019t gain much credit if vital information the patient needs isn\u2019t given in the consultation.&nbsp; Its better to ask what the patient wants to know today then its perfectly acceptable to explain there isn\u2019t 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<\/em>.<\/p>\n\n\n\n<p>10.20 Says &#8220;can have sedation for camera test&#8221; if worried rather than asking about worries about test<\/p>\n\n\n\n<p>10.39 end<\/p>\n\n\n\n<h2 class=\"has-white-color has-nhs-blue-background-color has-text-color has-background wp-block-heading\" style=\"font-style:normal;font-weight:600\">RCA Assessment <\/h2>\n\n\n\n<p class=\"has-text-align-center has-nhs-black-color has-nhs-warm-yellow-background-color has-text-color has-background\">RCA assessment Overall: <strong>Borderline<\/strong><\/p>\n\n\n\n<p class=\"has-nhs-black-color has-nhs-yellow-background-color has-text-color has-background\">Data Gathering: <strong>Pass<\/strong><\/p>\n\n\n\n<p>A reasonable history testing differentials . Exam was performed no PR. Bloods were offered but no FIT test Psychosocial was asked but not really used.<\/p>\n\n\n\n<p class=\"has-nhs-black-color has-nhs-yellow-background-color has-text-color has-background\">Management: <strong> Pass<\/strong><\/p>\n\n\n\n<p>A working diagnosis was made, referral was appropriate , no firm arrangements to see again after the hospital appointment were made<\/p>\n\n\n\n<p class=\"has-white-color has-emergency-red-background-color has-text-color has-background\">Interpersonal: <strong>Fail<\/strong><\/p>\n\n\n\n<p>Didn\u2019t introduce. An attempt to explore ICE was made. No chaperone offered for examination. Shared management plan was missing. The opportunity to explore the patients\u2019 reaction to the potential diagnosis was missed.<\/p>\n\n\n\n<p>I\u2019ve 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.<\/p>\n\n\n\n<div data-wp-interactive=\"core\/file\" class=\"wp-block-file\"><object data-wp-bind--hidden=\"!state.hasPdfPreview\" hidden class=\"wp-block-file__embed\" data=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/wp-content\/uploads\/sites\/52\/2022\/03\/CASE-8-COBH.pdf\" type=\"application\/pdf\" style=\"width:100%;height:600px\" aria-label=\"Embed of Embed of CASE-8-COBH..\"><\/object><a id=\"wp-block-file--media-bed12419-39f7-450e-8643-0ac04d64392c\" href=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/wp-content\/uploads\/sites\/52\/2022\/03\/CASE-8-COBH.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">CASE-8-COBH<\/a><a href=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/wp-content\/uploads\/sites\/52\/2022\/03\/CASE-8-COBH.pdf\" class=\"wp-block-file__button\" download aria-describedby=\"wp-block-file--media-bed12419-39f7-450e-8643-0ac04d64392c\">Download PDF<\/a><\/div>\n\n\n\n<a href=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/mrcgp-examinations\/rca-calibration-tool\/case-list\/\" class=\"wp-block-nhsblocks-nhsbutton nhsuk-button\">Back to Case List<\/a>\n","protected":false},"excerpt":{"rendered":"<p class=\"nhsuk-card__description\">Remember, before reading the analysis, ensure you have listened to the recording, made your own notes and completed your own [&hellip;]<\/p>\n","protected":false},"author":107,"featured_media":0,"parent":2724,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2697","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.0 - 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