Problem based learning “disability and benefits” 6th ...



Problem based learning “problems in practice” 16th Oct 12

How to use this booklet

You will be working in small groups and should work through the scenarios one page at a time.

Most pages will involve either a consultation role play or a group task. Before moving on to the next page the group must define any learning needs prompted by the material.

The learning needs must be allocated to individuals who will feedback next week (23rd October)

You will not get through the whole booklet on 16th but will need to scan the remaining pages at the end of the session to define all the learning needs for next week.

Lee has registered with your practice yesterday. He has moved from Runcorn to live in an area of council housing in your practice that seems to have a high prevalence of social problems.

Choose one member of your group to be Lee and one to be the doctor.

The instructions for the GPST role playing Lee are

You have registered with the practice today having moved from Runcorn to come to live in Slagtown with your partner Sharon.

You have previously taken both cocaine and heroin but make great play of the fact that you are now ‘only taking diazepam’.

You are currently using approx 30mg of diazepam per day which your GP was providing by posting scripts to you in Slagtown even though he knew you had moved out of the area.

You need another prescription today.

You should be initially calm and pleasant but will soon become loud and aggressive if the prescription is not forthcoming.

You might state that if you don’t get enough diazepam then you could end up back on cocaine or heroin.

You have been told that you have a ‘personality disorder’ and feel that it is unreasonable to expect anyone with this diagnosis to manage without a supply of medication to use prn.

You may wish to disclose that you have recently finished a prison sentence for assault.

You may wish to suggest that you know where the GP lives ….

By the end of the consultation you might reluctantly go along with the suggested management plan as long as you can see that your supply of diazepam will not be cut off abruptly.

After the consultation feedback to the consulter using the sheet on the next page

Brain storm the options available to the doctor.

Discuss in the group issues that are raised

Define any learning needs.

CSA SCORING SHEET FOR OBSERVERS

Data Gathering and Examination Skills

Positive Negative

Clinical Management Skills

Positive Negative

Interpersonal Skills

Positive Negative

Additional notes e.g. consultation structure, time management, agenda setting etc

3 things to change or try

1

2

3

It is a Friday morning and your practice manager finished work yesterday to start her well-earned skiing holiday in a luxury Alpine resort.

Two weeks prior to her holiday the practice manager appointed Sheila to work as a part-time receptionist. Sheila is a patient of yours and you are aware that she had treatment for breast carcinoma two years ago and is currently taking citalopram for chronic anxiety.

Sheila previously worked as a hairdresser but the practice manager was impressed by her ‘people skills’. The practice was desperately short of reception staff and Sheila seemed an ideal candidate. Sheila is the sister of your Practice Nurse.

It is reported to you that Sheila has been overheard in the local post office as describing the running of the practice to be ‘like Toy Town’ and the reception manager to be ‘as much use as a chocolate tea pot’.

What issues are raised?

What exactly would you do?

Define any learning needs.

At the end of your Monday morning surgery you are contacted by your practice manager to say that she has had to deal with complaint that probably needs your attention.

The parents of David, a four year old boy, wish to complain about the care given on the preceding Friday afternoon by your registrar Mary.

Mary finished work on Friday evening to start her well earned break in a luxury hotel in the Maldives to celebrate her CSA pass.

Review of Mary’s exemplary records suggests that David had presented with a one day history of malaise and pyrexia without focal signs. He was not particularly unwell and a presumptive diagnosis of ‘viral illness’ was made. The final comment is ‘to return if worse or parents concerned’

It would appear that David became more unwell during Friday night and was found to have a non-blanching rash on his legs by Saturday morning. His parents rang 999 and he is now on the paediatric ward being treated for meningococcal septicaemia.

One of the junior doctors on the ward had said to his parents that ‘he just got to the hospital in the nick of time’

Discuss the issues raised.

What would you do?

You decide to ring Terry and June, David’s parents who say that they would like to come in to see you to discuss their concerns.

Discuss in the group what that doctor should try to do in this meeting.

The meeting is with two ‘patients’, what consultation skills are going to be needed?

What protocols should be in place in the practice for dealing with this complaint?

If the patient does not want to complain to the practice what alternative routes are available?

Elect one member of your group to be the Doctor and two members to be Terry and June.

The instructions for Terry and June are

You are both very upset and anxious as David is still very ill and there is some risk that he might loose one or more toes.

Initially attempt to sit so the doctor cannot see you both at the same time.

You should try to talk over the top of each other to force the doctor to try to manage the consultation.

Your main concern is that David was seen by an “inexperienced young female doctor” who missed a serious diagnosis.

You can’t understand how such a serious illness could not have been detected on Friday evening.

You have always been very happy with the care given by the practice before but this has come as a terrible blow and your confidence in the practice is shaken.

You want to know how much supervision Dr Mary was under and how this sort of error will be prevented in the future.

You do not want compensation nor will you take legal action but do not want ‘anyone else to have to go through what you are going through’

After the consultation ‘Terry and June’ should provide feedback and the group should provide feedback using the sheet on the next page as a template.

Define learning needs.

CSA SCORING SHEET FOR OBSERVERS

Data Gathering and Examination Skills

Positive Negative

Clinical Management Skills

Positive Negative

Interpersonal Skills

Positive Negative

Additional notes e.g. consultation structure, time management, agenda setting etc

3 things to change or try

1

2

3

Now put yourselves in Mary’s shoes.

She returns, tanned and relaxed, from her holiday to find out from the first member of staff that she meets in the kitchen that David was admitted to hospital seriously ill.

What are Mary’s needs?

Discuss how Mary and her trainer should deal with this situation.

Mary, your GP registrar, (still tanned but not so relaxed after her holiday) asks if she can talk to you about some concerns that she has about the surgery debriefs that she has on a Monday evening with Jim the senior partner in the practice.

She understands that Jim does a short Monday evening surgery as he attends the Rotary club dinner over lunchtime.

Mary is concerned that Jim regularly smells of alcohol which is obvious to her and must be noticeable to patients as well. She is also concerned that Jim’s manner sometimes makes her feel uncomfortable with occasional inappropriate pats on the back and odd discussions unrelated to medicine.

You are also aware that Jim drives back from the Rotary meeting in town to do his surgery.

What issues are raised?

What are your options?

Where could you go for help?

You arrange for several of the partners to meet to discuss the problem.

Choose 2 members of the group to take part in this meeting. The rest of the group should consider the arguments being put forward and decide with whom they agree.

The instructions for ‘partner 1 and partner 2’ are

You are an evangelist!

Put forward the following arguments in any order adding any more that you can think of!

• Jim is bringing the practice into disrepute, we should report him to the PCT and GMC

• The partnership agreement states that he could be removed from the partnership

• We should get the police to breathalyse him in the surgery car park

• We should start a review of his notes to see if his care is satisfactory

• You always thought he was a bit sleazy and he was always a liability at the practice Xmas party

• We should have this out with him straight away and ask him to resign.

• We should inform the Deanery as trainees could be at risk

• All GPs should retire at 60 before they become a danger to the public

You are a pragmatist!

Put forward the following arguments in any order adding any more that you can think of!

• Jim is a very experienced GP who still has amazing clinical acumen

• He has successfully lead the practice through challenging times

• He is due to retire next year and this confrontation is unnecessary and cruel

• We only have the registrar’s word for the fact that he smells of alcohol.

• Jim is old enough to be Mary’s father. It’s not surprising that he puts his arm round her shoulders in an avuncular way.

• Registrars can learn a lot from experienced GPs like Jim

• We need to exclude some sort of medical problem that is causing him to drink more

• I can have a quiet word with him and explain that there has been a misunderstanding. Perhaps he could have less to drink at the Rotary lunch.

• I hope that when I get near retirement I am not hounded out of the practice by the ‘goody two shoes’ brigade.

Following your successful passage through the prestigious Pennine training scheme you are pleased to be offered a years salaried post in your uncle’s practice, Drs Duffer, Scuffer and Hapless in Gurning-by-Sea. The practice is assisted by two elderly ‘practice nurses’ , sisters Vague and Woolly.

The previous salaried doctor seems to have left under mysterious circumstances…….

You are interested to hear from Uncle Duffer that the partners’ annual income is “about £75K, which is quite good for these days.” You wonder if their income could support the sort of life in the fast lane that you have become accustomed to whilst a GP registrar.

Uncle Duffer also tells you that the partnership “doesn’t get on with QOF very well as it interferes with our clinical freedom”. One of the jobs that they would like you to do as part of your salaried contract is to “help sort out our QOF points”.

You learn that their QOF achievement last year was 850/1000.

You decide to make a presentation to the partners at a clinical governance afternoon held after a sumptuous Indian meal at the Shigella Star restaurant in town. You want to provide a balanced argument on the pros and cons of the QOF system of payment, how it works in practice and how much it contributes to practice income compared with the other main income streams.

Brain storm some learning needs and choose one of your group to present next week to the (postprandial) partners

The presentation seems to do the trick and the partners find a new enthusiasm for all things QOF-ish.

You soon receive news that a new QOF indicator will be introduced in March 2013 which relates to erectile dysfunction.

The total number of points on offer will be 15 and these will be divided up as follows.

Eligible target group males age 40 to 70.

1. Percentage of men with a record of being questioned about erectile problems in the past 24 months 5 points . (minimum threshold 30%, max threshold 70%)

2. percentage of men with erectile dysfunction who have been screened for cardiovascular risk factors 5 points (50-80%)

3. percentage of men with erectile dysfunction who have been offered pharmacological treatment or referred. 5 points (50-80%)

You realise that you now have three problems. The first is to work out how to organise the practice to meet this QOF target. The second is to convince the partners that the effort is financially worthwhile. The third is how to organise and effect change in a practice to achieve this and other QOF targets.

Brain storm some learning needs and bring back some ideas for getting Drs Duffer, Scuffer and Hapless up to speed.

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