Complaint / Back Pain
Doctor Information
James Landis, age 45
Past Medical History
Asthma
Eczema
Low back pain
Medication
Clenil modulate 50 microgram 2 puffs bd
Salbutamol 100 microgram 2 puffs prn
MRI scan report from 3 weeks ago
Request details4 Month history of right sided neurological symptoms, no weakness or saddle anaesthesia.
Scan Report:Possible cause for sciatica symptoms found: There is a degenerate broad-based posterior bulge of the L5/S1 disc which impinges the traversing S1 nerve root. There is no evidence of compression. Normal appearances of remainder of intervertebral discs.
Filing notes: Filed by locum GP: Nerve impingement caused by wear and tear/arthritis - satisfactory - to return if necessary
Past Medical History
Asthma
Eczema
Low back pain
Medication
Clenil modulate 50 microgram 2 puffs bd
Salbutamol 100 microgram 2 puffs prn
MRI scan report from 3 weeks ago
Request details4 Month history of right sided neurological symptoms, no weakness or saddle anaesthesia.
Scan Report:Possible cause for sciatica symptoms found: There is a degenerate broad-based posterior bulge of the L5/S1 disc which impinges the traversing S1 nerve root. There is no evidence of compression. Normal appearances of remainder of intervertebral discs.
Filing notes: Filed by locum GP: Nerve impingement caused by wear and tear/arthritis - satisfactory - to return if necessary
Patient Information
James Landis, age 45
You want to make a complaint. You had a scan on your back three weeks ago. Last week you rang reception to get the results and the woman told you it was “wear and tear / arthritis”. So you went on the internet and found some exercises for arthritis on the arthritis research UK website, but things have not improved. This morning you were sent home from work because your pain was so severe, so you rang the surgery and spoke to the on-call doctor. She said that the MRI shows a ‘slipped disc’ and you need to come in straight away to discuss it. This frightened you, so you’ve googled up slipped disc, and seen that an operation is needed to fix it! You are angry because the receptionist shouldn’t be telling you wrong diagnosis over the phone – she’s not a doctor and now it means that the operation that you need has been delayed by a week!
If asked: thigh pain is on the right and started about 4 months ago. It never gives you numbness or tingling in your leg, and you have no trouble going to the toilet. You have been taking dihydrocodeine tablets that your girlfriend gave you from her shoulder operation, and they take the edge off (you are taking them sporadically, roughly 8 a day). You sporadically notice shooting pains running down the length of your right leg, you notice no perineal numbness, you have no weakness in your lower limbs. You have no night sweats, no weight loss, and no thoracic pain.
You work in a manual job fabricating doors. The doors are about 20kg to lift, and you have to deliver up to 200 miles away. You do find work hard but you have only been there 3 months and you are still on a trial period so you haven’t had any time off. You also do weights at the gym, usually 3-4 times per week, although you have not been in at least 2 weeks. You don’t smoke, and you have been drinking a couple of lagers on a night to help you get to sleep. You live with your girlfriend. You have asthma but it doesn’t really bother you, and you had an episode of low back pain 2 years ago that settled with physiotherapy.
Ideas: you are furious that the receptionist told you the wrong diagnosis and you might be suffering more as a result.
Concerns: That the incorrect results given to you over the phone has resulted in you doing exercises that may have worsened the problem, and that your treatment has been delayed by a week.
Expectations: to now be referred to the surgeons for an operation to “fix” your back.
When you enter the room, you ask to stand because it is less painful for you. You start off quite angry and demand to make a complaint. If the doctor apologises and offers to go through things with you, you calm down and allow him/her to continue. If you get a good explanation of a slipped disc, how it relates to ‘sciatica’, and a good management plan (Initially you want an operation, but if explained that this has risks and often physic can help it go away on its own) then you will accept this. If you feel the doctor has pacified the situation well, you agree that you will listen to their advice, but would like to make a complaint to the surgery anyway about the way telephone calls are handled for giving out results – mainly so it doesn’t happen again.
You want to make a complaint. You had a scan on your back three weeks ago. Last week you rang reception to get the results and the woman told you it was “wear and tear / arthritis”. So you went on the internet and found some exercises for arthritis on the arthritis research UK website, but things have not improved. This morning you were sent home from work because your pain was so severe, so you rang the surgery and spoke to the on-call doctor. She said that the MRI shows a ‘slipped disc’ and you need to come in straight away to discuss it. This frightened you, so you’ve googled up slipped disc, and seen that an operation is needed to fix it! You are angry because the receptionist shouldn’t be telling you wrong diagnosis over the phone – she’s not a doctor and now it means that the operation that you need has been delayed by a week!
If asked: thigh pain is on the right and started about 4 months ago. It never gives you numbness or tingling in your leg, and you have no trouble going to the toilet. You have been taking dihydrocodeine tablets that your girlfriend gave you from her shoulder operation, and they take the edge off (you are taking them sporadically, roughly 8 a day). You sporadically notice shooting pains running down the length of your right leg, you notice no perineal numbness, you have no weakness in your lower limbs. You have no night sweats, no weight loss, and no thoracic pain.
You work in a manual job fabricating doors. The doors are about 20kg to lift, and you have to deliver up to 200 miles away. You do find work hard but you have only been there 3 months and you are still on a trial period so you haven’t had any time off. You also do weights at the gym, usually 3-4 times per week, although you have not been in at least 2 weeks. You don’t smoke, and you have been drinking a couple of lagers on a night to help you get to sleep. You live with your girlfriend. You have asthma but it doesn’t really bother you, and you had an episode of low back pain 2 years ago that settled with physiotherapy.
Ideas: you are furious that the receptionist told you the wrong diagnosis and you might be suffering more as a result.
Concerns: That the incorrect results given to you over the phone has resulted in you doing exercises that may have worsened the problem, and that your treatment has been delayed by a week.
Expectations: to now be referred to the surgeons for an operation to “fix” your back.
When you enter the room, you ask to stand because it is less painful for you. You start off quite angry and demand to make a complaint. If the doctor apologises and offers to go through things with you, you calm down and allow him/her to continue. If you get a good explanation of a slipped disc, how it relates to ‘sciatica’, and a good management plan (Initially you want an operation, but if explained that this has risks and often physic can help it go away on its own) then you will accept this. If you feel the doctor has pacified the situation well, you agree that you will listen to their advice, but would like to make a complaint to the surgery anyway about the way telephone calls are handled for giving out results – mainly so it doesn’t happen again.
Examination Findings
Examination
Pulse 86
No tenderness over spine or paraspinal muscles
Restricted forward flexion of spine to 30 degrees, normal extension and lateral flexion
Straight leg raise left leg NAD
Straight leg raise right leg painful and restricted to 45 degrees, worse on foot dorsiflexion
Normal tone, power and reflexes in both legs
Normal peri-anal sensation
PR refused.
Neuro lower limb: NAD.
Pulse 86
No tenderness over spine or paraspinal muscles
Restricted forward flexion of spine to 30 degrees, normal extension and lateral flexion
Straight leg raise left leg NAD
Straight leg raise right leg painful and restricted to 45 degrees, worse on foot dorsiflexion
Normal tone, power and reflexes in both legs
Normal peri-anal sensation
PR refused.
Neuro lower limb: NAD.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently Asks about complaint and explores patients understanding of the condition |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Refers appropriately to physiotherapy, doesn't refer to surgeons as unnecessary Manages risk effectively, safety netting appropriately Discusses how to make a complaint, what the procedure involves, and how long before he receives a response. |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Fails to take account of related issues or of co-morbidity Does not suggest to patient how they may make a complaint. Or what the complaint procedure involves. Does not discuss impact of current condition on work, and suggest options to help. |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Explores patients concerns around the back pain and his occupation. Is empathetic towards the mistake made by the practice Offers apology for the situation, and works well to calm the patient down. |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Is not empathetic towards problem Refuses to apologise for practice mistake, or refuses to accept practice responsibility for said mistake |
Management
Explanation: Your MRI scan shows something called a disc prolapse, or slipped disc. Nothing actually slips, but the inside part of the disc which is soft, bulges out through the harder outside part and can press down on the nerve that runs past it. This can give you back pain, leg pain, numbness and pins and needles depending on which part of the nerve is squashed. We call this ‘Sciatica’. The main treatments for this condition are painkillers and physiotherapy. It is important to keep going and not have too much bed rest. Sometimes the symptoms can get worse and affect the nerves that go to your bladder or bowel. This is a rare and is an emergency, should it occur you should be seen urgently. Whilst is is true that some people may need an operation to solve this problem, for most physiotherapy, time and rest from heavy lifting is all that is needed.
Despite having an MRI report, you should still data gather as you normally would – you still need to establish the symptom history and exclude the red flags of back pain
Despite having an MRI report, you should still data gather as you normally would – you still need to establish the symptom history and exclude the red flags of back pain
Symptoms:
Thoracic Pain
Night Pain
Progressive worsening symptoms
Systemic symptoms ( fever, night sweats, weight loss)
Previous Cancers
Loss of bowel / bladder control
Age <16 or >50 with NEW onset back pain.
Signs:
Saddle anaesthesia
Bilateral neurological involvement
loss of perianal tone
The treatment options follow the same pattern as for chronic low back pain:
Simple analgesia, adding in weak opioids to NSAIDS/paracetamol as required. Beyond this a trial of a tricyclic antidepressant or gabapentin is recommended. Encourage the patient to keep active, use heat and massage, and try physiotherapy. If your patient would prefer to try some home exercises, then refer them to the Arthritis Research UK website, that has an excellent collection of patient information leaflets for many musculoskeletal conditions, with exercises that they can try. Persistent or worsening pain, or any red flag symptoms should be referred onwards to the appropriate speciality. If those red flags include any suggestion of spinal stenosis then admission is usually required.
Simple analgesia, adding in weak opioids to NSAIDS/paracetamol as required. Beyond this a trial of a tricyclic antidepressant or gabapentin is recommended. Encourage the patient to keep active, use heat and massage, and try physiotherapy. If your patient would prefer to try some home exercises, then refer them to the Arthritis Research UK website, that has an excellent collection of patient information leaflets for many musculoskeletal conditions, with exercises that they can try. Persistent or worsening pain, or any red flag symptoms should be referred onwards to the appropriate speciality. If those red flags include any suggestion of spinal stenosis then admission is usually required.
Dealing with complaint:
The next part of this scenario is dealing effectively with a complaint. The first thing to do is acknowledge the complaint and discuss exactly what the patient takes issue with. Complaints can be often resolved during the consultation by making an apology (for the situation, or apologise for your error if this is what has happened), and making an effort to resolve things. In this situation, even if you manage to pacify the patient and he is content with your management plan, he will still want to complain about the receptionist. He has the right to do this, and you should not discourage him. Instead, talk him through the complaints procedure (usually a complaint is made in writing - preferable - or by telephone to the practice manager, who will acknowledge it within 48 hours, and provide a written response within 10 days). The usual situation will involve speaking to the individual in question, discussing the situation at the practice meeting, and making amendments if appropriate to the way results are handed out by telephone. If the complaint falls under the category of a significant event, then it should be dealt as such.
Here are a few helpful hints on dealing with an angry patient:
- 1. Avoid confrontation or argument
- 2. Listen patiently initially, let the patient finish their narrative
- 3. If the patient is angry about a missed diagnosis or incorrect management of an individual, ask about them early on (i.e. a missed diagnosis of appendicitis in a child, ask about the child early in the consultation)
- 4. Reassure the patient that the course of action they have taken is the correct one: in this case, coming in to speak to someone about this.
- 5. Try to show you understand how distressing the situation must be for the patient.
- 6. However never say "I understand" as this is simply fuel for an angry patient (who will typically reply with; "Oh no you don't!!")
- 7. If you say "I'm sorry" be clear on what you are apologising for, is this an admission of responsibility or not. i.e. "I'm sorry that this has happened", vs "I'm sorry I did something wrong."
- 8. Don't criticise other health care professionals
- 9. Above all, stay calm, stay seated, and listen.