How to use this book

This book is designed to help medical students and doctors practise clinical cases likely to be seen by general practitioners in Australia. Each case consists of instructions for the doctor and role-playing patient, a suggested approach, case commentary and references, or recommended further reading. The cases are written in note form as is usual practice in clinical records.

It is based on my experience of facilitating case-based learning groups for medical students and general practice registrars. Trial and error helped establish what worked and what did not, but everyone is different, so if you find a new way of practising please let me know.

You will learn more by using this book rather than reading it from cover to cover. Come to each case fresh, so that you can test your knowledge and skills in general practice and identify your learning needs. If you read through the book when you practise cases you will distract yourself with trying to remember the suggested approach. This would test your recall rather than the application of your knowledge and clinical skills to a particular context.

The easiest way to fail a clinical exam is to ignore the instructions as marks are pre-allocated according to the instructions. Time management is crucial to ensure you cover the requirements. For example, you need to take a ‘good enough’, safe history before moving on to the clinical examination and planning management, if all three elements are requested in the scenario. Taking eight minutes to do a complete history will lead to a fail if the examination and management are omitted.

Most people find it is easier to study with a group rather than in isolation. A group motivates you to persevere and learning from your mistakes in a safe environment is far better than learning from making mistakes with patients.

If you are in isolated practice you can still join a group. I have run practice consultation groups over the phone, via Skype or video-conference. It presents some challenges but can be done. I do not know of any technology for remote physical examination, but all other aspects of the consultation can be practised. If you have not been observed conducting physical examinations you could videorecord consultations with patients (with their written consent), friends or relatives. Send password-protected copies to your group and ask them for constructive feedback. Your physical examination of each system and body part must be so automatic that you can focus and interpret what you find.

Groups work better if group rules have been agreed to. The group needs to develop trust so that ignorance leads to learning rather than embarrassment. Confidentiality is an important issue. Participants will learn more if learning is derived from and related to their own clinical practice, so everyone needs to know that they can safely share their experiences.

Allocate the roles to the role-players ahead of the session if possible. This lets the role-players familiarise themselves with the scenario and search out more information about the clinical problem, which adds to their learning. Props can help role-players give a more authentic look and mimic the sorts of clues that prompt GPs in clinical practice.

These scenarios are about common problems; at some stage one of the scenarios could be about a condition that the role-player, or a friend or relative, suffers from. This may enhance their performance but equally it could create a tense situation. By allocating roles in advance, the role-player can decline the case before major issues develop.

Observers of the role-play will learn more if they see only the ‘Instructions for the doctor’. Encourage observers to make notes on how they would approach the case, which helps them to be active learners rather than passive observers. They can also give constructive feedback to the role-playing doctor and patient.

ONE PERSON CAN facilitate the case and have access to all the information. The checklists are designed for the facilitator to tick off as the doctor deals with a particular aspect of the case.

Please give the doctor the examination findings only on specific request. Doctors should demonstrate their reasoning by asking for the findings that will confirm or refute the diagnosis. For example ‘what are the neurological findings’ is too broad a question to ask about a patient with a suspected stroke. Instead questions should be asked about the expected changes in tone, power, sensation, coordination and reflexes in the affected limbs.

Allocate a timekeeper for each scenario. Students and junior general practice registrars may decide to use the material without a time limit but more experienced doctors should complete the short cases in eight minutes and the long cases in nineteen minutes, following three minutes to read through the case scenario.

Allow time for discussion after each scenario: usually twenty minutes for short cases and thirty minutes for long cases is adequate.

Set up the room like a consulting room, with chairs for the patient and doctor, a desk, examination couch and standard consultation equipment. The patient should be sitting on the chair at the beginning of the consultation even if they will need to be examined. It gives too big a clue if the doctor walks in and finds the patient dressed ready for a physical examination! Role-playing patients may prefer to wear bathers or shorts under their clothes to ease their potential embarrassment at being examined BUT remember that this is about learning, not humiliation. If the patient role-player does not wish to be examined, please accommodate this.

In physical examination cases you should demonstrate in a deliberate way that you are performing the examination correctly. Talking yourself through the examination, making a running commentary of your actions and findings, can increase your awareness of what you are doing and why, and demonstrate your clinical reasoning to observers.

One component of the Australian College of Rural and Remote Medicine (ACRRM) assessment is ‘StAMPS’: structured assessment using multiple patient scenarios. This is an examination via video-conference where each scenario lasts for ten minutes. Doctors are asked questions in a viva or role-play format. Physical examination and practical skills are assessed separately from StAMPS.

The cases in this book were primarily designed for doctors preparing for the Royal Australian College of General Practitioners (RACGP) Clinical Examination but doctors preparing for the ACRRM Fellowship may find them a useful resource to practise via video-conference or webcam (see Introduction on page xv).

The suggested approach to each case includes the essential elements of medical consultations as outlined in the Kalamazoo Consensus Statement¹ but does not exhaust all the possibilities. When you are reading this section you will probably think of your own additions, but for each addition you need to remove an item to avoid the cases becoming impossibly long for the time available. You will find that additions are easy but taking something out is not; discuss these issues with your group—the process of considering what to do in each case greatly improves your clinical reasoning. If your group does agree on a significant addition, please let me know.

Mnemonics pose a particular risk. They help us to remember what to ask but are best used as a framework for a conversation. Too often a doctor is working hard to remember the mnemonic rather than focusing on the patient’s response to the questions. While this is understandable we must be more than questionnaires on legs! There is no point asking the right questions if you don’t listen and respond to the answers.

There is a commentary on the relevant issues in each case as well as references and suggestions for further reading.

Doctors will usually learn more from the scenario if it runs for the allotted eight or nineteen minutes. However, maintaining someone’s self-esteem may be more important. The response to a doctor getting stuck or suffering from stage fright mid-consultation will depend on their level of experience. For doctors early in training, you can ask for volunteers to take over the consultation. For more experienced doctors, the facilitator can make suggestions such as, ‘Try reading through the scenario again; it might prompt you on how to proceed,’ or ‘If this happened in your surgery, what would you do?’

This gives the doctor a framework for what to do if they get stuck in either an exam situation or in clinical practice.

If the role-playing patient is disturbed or upset, the scenario may need to be stopped.

Giving feedback constructively is a skill that will be useful for all general practitioners. Confidence can quickly evaporate in someone who has done badly in a scenario and it helps to have guidelines to avoid feedback being perceived as judgemental and destructive. It may feel contrived but it is safe. Once the group has grown and is learning well together you can focus more quickly on the aspects for improvement.

• Briefly clarify matters of fact

• The doctor says what was done well, and how

• The rest of the group says what was done well, and how

• The doctor says what could be done differently, and how

• The rest of the group says what could be done differently, and how.

I follow Pendleton’s guide and ask the doctor to start the discussion by outlining what they did well.² Doctors invariably focus on their mistakes and fail to notice what worked well. I have waited on occasion for several minutes for some doctors to say just one good thing about their consultations. This is important, so that learning builds on what is already good and gives practitioners a realistic framework for self-reflection throughout their career.

Once the positives have been recognised I ask the doctor to outline what they might do differently if they had another chance. This gives me insight into their perceptions of their performance, and allows them to self-correct before group members comment. I know that I am facing a major teaching challenge when someone is unaware that they have performed poorly.

If there is time and the doctor has noticed an error, you can re-run the role-play and allow them to practise their new learning. Once they have shared their ideas on how to improve their consultations, the observers can join in. Again, it is a good principle to ensure that feedback is balanced. Descriptive feedback should reduce defensiveness and promote learning. It is:³

• non-judgemental

• specific

• directed towards behaviour rather than personality

• checked with the recipient

• outcome-based

• problem-solving

• in the form of suggestions rather than prescriptive comments.

Let me give you an example. You have just watched a colleague’s consultation. During the consultation the doctor wrote a script for an anti-hypertensive, asking the patient about her exercise regime at the same time. You observed the patient go red in the face and mumble an answer. The doctor did not raise the issue of exercise again and did not notice the patient blush.

Judgemental feedback might be something like this:

Facilitator: ‘You missed your chance to hear about her exercise. It is bad practice to ask questions while you are writing scripts. You’ll never make a decent doctor. Don’t they teach you anything at medical school?’

The alternative descriptive feedback might be:

Facilitator: ‘Well done for asking about exercise. She did not say very much. Why do you think that might be?’

Doctor: ‘Maybe she was embarrassed because she does so little. Why do you ask?’

Facilitator: ‘I noticed that you asked about exercise while you were writing the script. When you asked the question she blushed, looked embarrassed and mumbled an answer. What do you think that was about?’

Doctor: ‘I guess asking about exercise is a delicate issue. Maybe I gave the impression that I wasn’t interested in the answer when I asked her at the same time as writing the script. No wonder she didn’t say much. In future I’ll try to give patients my full attention when I ask important questions.’

Facilitator: ‘Would you like to re-run the scenario?’

Role-play has an established place in facilitating learning in general practice and in assessing the competency of practitioners in Australia.⁴ However, many students and doctors are reluctant to participate. This is understandable. Consulting is central to our effectiveness as practitioners but it is also very personal.

International medical schools may have different approaches to teaching consultation skills. Several doctors that I have taught had not been observed consulting during their training. When they moved to Australia they found this method of learning new and frightening—an added challenge was consulting in English. My tip for this situation is to suggest that international medical graduates come to groups and just watch at first. When they are more familiar with the process they may be prepared to role-play as patients. Once confident in this, they can be invited to play the doctor.

Lastly, do enjoy your practice sessions. This is NOT about ritual humiliation. I learn something new each session about clinical practice, which improves the quality of care I give as a GP and increases my interest in the profession.