Tutorial 4 - Risk + Uncertainty

Question 1

What is an example of a consultation model used during consultations?

Answer 1

Calgary Cambridge Model

Question 2

What are the steps of the Calgary Cambridge Model?

Answer 2

1) Initiating the Session
2) Gathering Information
3) Providing Structure
4) Building Relationship
5) Explanation and Planning
6) Closing the Session

IISRE+PC

Question 3

What are the tasks of a consultation? (Roger Neighbour - purely from a doctors point of view)

Answer 3

1) To Connect with the patient
2) To Summarise and Verbally Check that the reasons for attendance are clear
3) To Hand Over and bring the consultation to a close
4) To ensure that a Safety Net exists in that no serious possibilities have been missed
5) To deal with the Housekeeping of recovery and reflection

CSCSH

Question 4

What does Neighbours model start to include?

Answer 4

Concepts of risk management

- tries to minimise risk and uncertainty

Question 5

Definition of risk

Answer 5

Chance of (or of bad) consequences, loss etc

Question 6

Definition of uncertain

Answer 6

Not able to be relied on; not known or definite

Question 7

Definition of uncertainty

Answer 7

State of being not completely confident or sure of something

Question 8

What is an example of where risk and uncertainty should be considered?

Answer 8

The patient will need help in understanding what the risk or likelihood of an illness affecting them is.

A medical student might be uncertain due to lack of knowledge or experience.

A GP might be concerned that even if they take the correct decision and formulate a good management plan, there remains some uncertainty.

Question 9

Does everyone perceive risk the same?

Answer 9

No

For example - doctors, patients, government and astronauts all perceive risk in different ways

Question 10

What does individualising care mean?

Answer 10

Take into account their health beliefs, and their educational, social, cultural and economic backgrounds - so for identical problems you might give differing advice in order to minimise risk and uncertainty

Question 11

How might different social backgrounds affect the outcome?

Answer 11

The different social settings might mean the difference between needing admission versus being able to cope and recover at home, for the same individual with the same medical problems

Imagine for example you have a elderly female patient who develops a pneumonia and requires antibiotics.
One scenario, for example, might be someone who lives in social isolation with some mild memory impairment, and you might not be sure if she will be able to take the tablets on time herself, if at all.
A patient of the same age, with the same conditions might be living in a retirement complex, with a warden who can check the medicine box, and ask if she has taken the tablets daily. They might also check she has been able to eat and drink enough.

Question 12

What does constantly asking yourself “have I done the right thing?” lead to?

Answer 12

Lack of skills for dealing with uncertainty can lead to burn out and depression - personal growth and control often result from getting through uncertainty

Question 13

What does uncertainty come from?

Answer 13

Comes from not only the medical issues, but also from interpersonal aspects and interactions

Question 14

What does stress mean?

Answer 14

Imbalance between demands and resources

Occurring when pressure exceeds ones perceived ability to cope

Question 15

What is useful for the times when it appears that one is likely to be unable to cope with a situation?

Answer 15

Strategies to cope

Question 16

What is an example of a coping strategy?

Answer 16

Taking through problems with a colleague or with someone outside medicine = helpful coping strategy

Question 17

What is the problem with this coping strategy though?

Answer 17

Doctors workload often makes it difficult for them to find the time for such discussions - it is therefore useful to have some personal coping strategies for coping with uncertainty

Question 18

What may be critical in a consultation and is part of Neighbours techniques for minimising risk?

Answer 18

Safety netting

Question 19

What are the points of safety netting?

Answer 19

1) If uncertainty remains, that should be communicated to the patient
2) They must know what to look out for and be told how exactly to seek help for given outcomes or clinical features - they should know exactly how to seek help if needed
3) It may be important to arrange follow up face to face or by phone
4) They should know what to expect about time course
5) However, it should be made clear that if a patient has concerns they should not delay seeking further medical advice

Question 20

What are the sources of guidance that might help you deal with Risk and Uncertainty?

Answer 20

National
Local
Immediate
Colleagues
Peer group
Reflection

Question 21

What is national based evidence?

Answer 21

SIGN guidance = Scotland
NICE guidance = UK
The provide peer reviewed guidelines for specific conditions

Question 22

What is an example of local guidance?

Answer 22

Scottish Referral Guidelines for Suspected Cancer - referral or management pathways have been developed (useful when there is clinical uncertainty about which step to take next or who to refer to, they can also be useful in enabling the appropriate provision of services in secondary care also)

Question 23

What is an example of immediate guidance/protocol and why is it important?

Answer 23

The emergency management of anaphylaxis (severe and potentially life threatening allergy)
- helpful in the management of an acute condition (these situations can be highly stressful for the professionals involved and a protocol to follow can be extremely helpful)

Question 24

How might GP’s discuss things with colleagues?

Answer 24

1) Formally - write specifically to a haematology consultant for advice about a single patient
2) Informally - discussing problems with a patient with your GP colleagues (even in a small practice team there are likely to be relative experts e.g. in Diabetes or in interpreting heart tracings)
3) Some GP’s arrange peer group sessions for ongoing education, taking along cases to discuss

Question 25

What is the aim of reflective practice?

Answer 25

To continue to improve over time - all GP’s reflect on their own decisions and performance, it is normal and human to make errors or to have gaps in knowledge

Question 26

How does Neighbour minimise risk in a GP consultation?

Answer 26

He ensures that both the doctor and the patient are agreeing what the issue is today by summarising and verbally checking - often a patient will add or correct information

He hands over to the patient at the end to cake all issues have been addressed - “does that cover it”

He safety nets - do they know who to contact if that happens? have I advised them which symptoms would be concerning if they were to arise?

He housekeeps - have I documented it well? have I dictated the referral I promised? do I need to pause and allow myself to focus for the next consultation?

Question 27

What is a strategy for managing risk and uncertainty?

Answer 27

1) Developing a good doctor-patient relationship
2) Consider each patient as an individual and take their background into consideration - support, social network and education
3) Use external evidence (guidelines) and respect the internal (doctors and patients) evidence
4) Checklist for diagnosis
5) Good organisation + note keeping (includes documentation of safety netting)
6) Be aware of your feelings and acknowledge them
7) Apply reflective practice
8) Peer group discussions

Question 28

What is used in primary care instead of a systemic enquiry?

Answer 28

Hypothetico-Deductive Reasoning

Question 29

What is Hypothetico-Deductive Reasoning?

Answer 29

There are many possible things that it child be but you should follow the most probable theory - however, you might be wrong, you didn’t look into the other suspected theory and you assumed there was no other cause

Question 30

What is important points about Hypothetico-Deductive Reasoning?

Answer 30

Some causes are more probable than others

Some pieces of information are more important/valuable than others

Question 31

What is the Hypothetico-Deductive Reasoning process?

Answer 31

Maybe four or five diagnostic hypotheses (differential diagnosis) - think what’s most likely!

Rare but not immediately concerning diagnoses excluded at this stage

Strengthen case for diagnoses through brief history and examination

Extend the search thereafter if no diagnosis identified (if no diagnosis at this stage extend search and focus on other differentials)

Not about common diagnoses, rather about likely diagnoses