'Antibiotic Request'
Doctor Information
Jenny Snow (60)
You can see from her record that: Mrs Snow was fast tracked to Neurology to exclude brain cancer. She was seen and sent for a CT head with contrast. The most recent letter from neurology states that: 'The consultant has informed Mrs Snow of the diagnosis which is SOL (meningioma). He Suggested she be booked back in to see his surgical colleague to discuss the possibility of surgery. She has refused. She wants no further treatment. Other options were discussed, but Mrs Snow doesn't wish to undergo any surgery nor chemotherapy - She has also explicitly asked that her family not be informed of the diagnosis
You can see from her record that: Mrs Snow was fast tracked to Neurology to exclude brain cancer. She was seen and sent for a CT head with contrast. The most recent letter from neurology states that: 'The consultant has informed Mrs Snow of the diagnosis which is SOL (meningioma). He Suggested she be booked back in to see his surgical colleague to discuss the possibility of surgery. She has refused. She wants no further treatment. Other options were discussed, but Mrs Snow doesn't wish to undergo any surgery nor chemotherapy - She has also explicitly asked that her family not be informed of the diagnosis
Patient Information
John Snow: Aged 40 - coming in to discuss about his Mother: Jenny Snow (78)
Opening Sentence: Your Mum has been having wobbly episodes, where she was unbalanced, forgetful and she was dropping things. She had an appointment to see a consultant with the you. The consultant said that he was concerned and wanted an Urgent CT head. Your mum went back to see the consultant alone, and keeps saying everything was ok.
Further information if asked: You are worried that your mum lacks capacity and is confused and therefore unable to make sensible decision about her future medical care. You therefore feel that you need to be kept up to date with the results, but there is no lasting power of attorney in place. You do not have any power or attorney.
You are 48, divorced, two teenage children that live with your ex, you carer for your mum, you go in three times per week to help with laundry, meals and organising her medications. You feel that you are the only one looking out for her now that your dad passed away a few years ago.
You are still currently working, but have had to take part time hours, and this is placing a financial burden on you and your payments for your teenage children. All this stress is stopping you from sleeping. Your mood is ok, you’re not anxious, and you have no suicidal ideations. You don’t smoke or drink at all.
You feel that you are her carer and you are being cut out of this vital step in her care. She is the last real family you have and you obviously care for her a lot. If the Doctor just keeps telling you that they can’t tell you anything you are just going to get increasingly angry and keep telling them that how would they feel if it were their mum, and keep saying that you don’t think she has capacity.
Ideas: Your mum lacks capacity to make any decisions
Concerns: You are worried that your mum is not making a sensible decision
Expectations: You want to know the results of the scan and you want some input into her care. You will accept a visit for assessing capacity.
How to respond: If the Doctor is not empathic, does not enquire about your situation, or attempt to understand where you are coming from you will get annoyed. Especially if they just keep saying "we can't tell you anything", and offer little else in terms of help. You will keep telling them "how would they feel if it was their mother, and threaten to make formal complaints against them to the GMC".
If the Doctor is empathetic however, and empathises with you, and works with you to get a shared solution, you will accept a home visit - even if you're not there - for the GP to assess your mothers capacity.
Opening Sentence: Your Mum has been having wobbly episodes, where she was unbalanced, forgetful and she was dropping things. She had an appointment to see a consultant with the you. The consultant said that he was concerned and wanted an Urgent CT head. Your mum went back to see the consultant alone, and keeps saying everything was ok.
Further information if asked: You are worried that your mum lacks capacity and is confused and therefore unable to make sensible decision about her future medical care. You therefore feel that you need to be kept up to date with the results, but there is no lasting power of attorney in place. You do not have any power or attorney.
You are 48, divorced, two teenage children that live with your ex, you carer for your mum, you go in three times per week to help with laundry, meals and organising her medications. You feel that you are the only one looking out for her now that your dad passed away a few years ago.
You are still currently working, but have had to take part time hours, and this is placing a financial burden on you and your payments for your teenage children. All this stress is stopping you from sleeping. Your mood is ok, you’re not anxious, and you have no suicidal ideations. You don’t smoke or drink at all.
You feel that you are her carer and you are being cut out of this vital step in her care. She is the last real family you have and you obviously care for her a lot. If the Doctor just keeps telling you that they can’t tell you anything you are just going to get increasingly angry and keep telling them that how would they feel if it were their mum, and keep saying that you don’t think she has capacity.
Ideas: Your mum lacks capacity to make any decisions
Concerns: You are worried that your mum is not making a sensible decision
Expectations: You want to know the results of the scan and you want some input into her care. You will accept a visit for assessing capacity.
How to respond: If the Doctor is not empathic, does not enquire about your situation, or attempt to understand where you are coming from you will get annoyed. Especially if they just keep saying "we can't tell you anything", and offer little else in terms of help. You will keep telling them "how would they feel if it was their mother, and threaten to make formal complaints against them to the GMC".
If the Doctor is empathetic however, and empathises with you, and works with you to get a shared solution, you will accept a home visit - even if you're not there - for the GP to assess your mothers capacity.
Examination Findings
Examination
No examination in this station
No examination in this station
Mark scheme
Data Gathering
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POSITIVE INDICATORS
Organised and systematic in gathering information Asks questions about the mother, what happened during the consultation, and how Jenny is doing now. Explores patients knowledge / understanding of why she was referred, the CT scan results. Asks about past medical history, birth history, any developmental concerns and immunisation history. Asks about how John is coping, his medical health, his situation at home, his mums care needs, and for evidence that may support the notion of Jenny lacking capacity Asks about Johns mood and stress levels |
NEGATIVE INDICATORS
Data gathering is unorganised and not systematic. Fails to enquire about what happened at the consultaiton, and how Jenny is doing now. Fails to ask about patient's current knowledge / understanding about the referral / CT scan Fails to enquire about John, his medical health, stress levels, mood etc... |
Clinical Management Skills
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POSITIVE INDICATORS
Develops a management plan that is appropriate and in line with current best practice Does not divulge personal information regarding Jenny's diagnosis Explains why you are unable to breach confidentiality Offers alternative options to ease patient concern- such as arranging a joint visit or an individual visit Manages risk effectively, safety netting appropriately |
NEGATIVE INDICATORS
Colludes with the patient - divulges personal information without consent Does not work with John to find a solution to the problem Does not explain why the Dr is unable to say what's going on Management does not reflect an appropriate assessment of risk |
Inter Personal Skills
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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 Responds to needs & concerns with interest & understanding Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation Is not judgemental towards patient's situation Works hard to find out more about John, his situation, how he feels, any carer strain? |
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 appears judgemental towards patient's situation Doesn't enquire about John's welfare, nor home situation. |
Management
Management:
This would not be an easy case to manage in real life, but can be something that we often come across as GPs Firstly: you can not tell the son about the diagnosis, it is not his right to know, regardless of his status / relationship to the patient.
However, one must remember that the patient in this case is NOT about the mother, it is the son sat in front of you. Therefore the focus, is to listen to him, find out about his ideas, his concerns and what he was hoping to happen and address these. If the patient feels listened to, and feels his concerns have been heard and are being addressed, then he will leave happy. If he feels that the GP is being obstructive, and simply re-iterates “i’m sorry, but we can’t tell you this” then he will get angry.
To complete this station successfully and candidate should try to work with the patient (the son) to come up with a way forward that satisfies the patient, without breaking confidentiality. So instead of saying “i’m sorry but we can’t give you this information”, one could try an alternative route; “as you may be aware, I’m not allowed to give you any confidential information about your mother, however I’m more than happy to listen to your concerns, and to see if we can agree a way forward to help her.”
There are a few genuine concerns raised in this case. The mum could very well have memory problems, may not have understood what was said to her in the specialist clinic when she attended alone, or may not have capacity to make a decision that was in her best interest.
Therefore one option would be that you would agree to go out and independently assess the mother’s memory and capacity. You could also discuss with the mother why she doesn’t want any family to know.
The GMC has very clear guidelines on when personal information can be disclosed: Link here
This would not be an easy case to manage in real life, but can be something that we often come across as GPs Firstly: you can not tell the son about the diagnosis, it is not his right to know, regardless of his status / relationship to the patient.
However, one must remember that the patient in this case is NOT about the mother, it is the son sat in front of you. Therefore the focus, is to listen to him, find out about his ideas, his concerns and what he was hoping to happen and address these. If the patient feels listened to, and feels his concerns have been heard and are being addressed, then he will leave happy. If he feels that the GP is being obstructive, and simply re-iterates “i’m sorry, but we can’t tell you this” then he will get angry.
To complete this station successfully and candidate should try to work with the patient (the son) to come up with a way forward that satisfies the patient, without breaking confidentiality. So instead of saying “i’m sorry but we can’t give you this information”, one could try an alternative route; “as you may be aware, I’m not allowed to give you any confidential information about your mother, however I’m more than happy to listen to your concerns, and to see if we can agree a way forward to help her.”
There are a few genuine concerns raised in this case. The mum could very well have memory problems, may not have understood what was said to her in the specialist clinic when she attended alone, or may not have capacity to make a decision that was in her best interest.
Therefore one option would be that you would agree to go out and independently assess the mother’s memory and capacity. You could also discuss with the mother why she doesn’t want any family to know.
The GMC has very clear guidelines on when personal information can be disclosed: Link here
GMC on disclosing personal information:
Confidentiality is an important ethical and legal duty but it is not absolute. You may disclose personal information without breaching duties of confidentiality when any of the following circumstances applies.
1) The patient consents, whether implicitly for the sake of their own care or for local clinical audit, or explicitly for other purposes (see paragraphs 13–15).
2) The disclosure is of overall benefit4 to a patient who lacks the capacity to consent (see paragraphs 41–49).
3) The disclosure is required by law (see paragraphs 17–19), or the disclosure is permitted or has been approved under a statutory process that sets aside the common law duty of confidentiality (see paragraphs 20–21).
4) The disclosure can be justified in the public interest (see paragraphs 22–23).
When disclosing information about a patient you must:
1) use anonymised information if it is practicable to do so and if it will serve the purpose
2) be satisfied the patient:
i. has ready access to information explaining how their information will be used for their direct care or local clinical audit, and that they have the right to object.
ii. has not objected
3) get the patient’s explicit consent if identifiable information is to be disclosed for purposes other than their direct care or local clinical audit, unless the disclosure is required by law or can be justified in the public interest
4) keep disclosures to the minimum necessary for the purpose
5) follow all relevant legal requirements, including the common law and data protection law