The GMC states that “being able to provide good clinical care is fundamental to becoming a doctor”1. I must strive to learn and understand the concept of good clinical care so that it is put into practice throughout my future career in the medical profession. I have chosen three specific examples from this year which have helped me analysis, understand and reflect upon the importance of good clinical care in medical practice.
Example 1:
My first example occurred during a primary care consultation. I was asked by the GP to take the patient’s history, which I was really quite nervous about, as I had only done so once previously. I proceeded to take the history of the patient, asking the necessary questions. The patient complained of having episodes of shortness of breath.
After taking what I thought to be a full history, the GP took over and asked a few vital questions. She asked the patient about his psycho-social history, which I had completed overlooked during the consultation. The patient actually explained that he was recently divorced and had a very stressful job has made him anxious and stressed over the past few months. The doctor explained to the patient that it was quite likely these respiratory problems were due to his stress and anxiety. The GP then asked if there were activities he enjoyed doing in his spare time, and if he had friends and family whom he could talk to. The GP advised him about local support groups available. However, the doctor did perform a chest examination and provided the patient with a peak-flow meter to take home as an investigation measure.
Lessons learned:
This example taught me the importance of taking a full history in a consultation. The GMC states that one must “adequately assess the patient’s conditions, taking account of the history (including the symptoms, and psychological and social factors)”.1 I felt embarrassed and disappointed at myself for missing the psycho-social history. It proved to be a vital part of the diagnosis, because if it was simply overlook, the patient may have been wrongly diagnosed and managed.
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The doctor was quite sure that the problem was due to his anxiety, but still crucially performed a full chest examination, which helped to rule out other conditions, in accordance with the GMC guidance, a doctor should “where necessary, examine the patient”1. The combination of a full history and examinations/investigations, where necessary, is fundamental to provide ‘good clinical care’ for your patients. It has been noted by research that “understanding each patient’s biological, psychosocial and cultural background is the foundation of effective patient care”.2
Aims:
I recognise that various improvements are needed during my medical education. I will practice my consultation skills on a regularly, both on patients and on friends and family. I will especially try to make the most of consultation skill sessions led by the medical school throughout the course, and ask for constructive feedback for guidance in areas needing improvement. I am currently studying the Calgary-Cambridge guide3 on performing a medical interview to make sure I remember all the appropriate points needed to perform a successful consultation. My examination skills will also need to be practised vigorously. Part of building the ‘doctor-patient’ relationship is performing the appropriate examination. I will set aside 2 hours a week for revision of examination techniques, not simply to pass my OSCEs, but so that as a Doctor I will feel confident and competent to examine and treat my future patients.
Example 2:
The next case which I feel represents an important example of ‘good clinical care’ occurred on a home visit to a patient, who had been diagnosed with rheumatoid arthritis over 30 years previously. I was there to discuss her condition and ask all the relevant history which was needed to write a comprehensive logbook.
The patient explained that she regularly visited various healthcare professionals in order to control her symptoms. She visited the GP surgery each week for intravenous methotrexate injections, had check-ups with the rheumatology consultant every 6 months to discuss treatment dosage and options, and a physiotherapist every month, to aid with mobility. The patient explained she plays an active role in deciding what treatment is best for her, and had recently (after a discussion with her consultant), decided against a new biologic treatment. She had been given a full explanation about the medication she is on and sticks to her treatment vigorously as she understands the implications of not doing so. The patient felt very happy with the service she received from the NHS.
Lessons learned:
This case has taught me about the importance of on-going management and treatment of conditions. There must always be good communication between the GP, hospital and other healthcare professionals in order to provide good clinical care for the patient. The GMC state that one must keep “clear, accurate and legible records” regarding patients, to prevent confusion or mistakes being made.1 Another important issue is to understand the roles of each healthcare professional, which was highlighted in this case. The GMC states that “decisions should be arrived at through assessment and discussion with the patient”.4 The patient had an active role in decision-making regarding her medication, which she felt very happy about. Hence, it appears vital to show respect to the patient, but also be willing to listen to the patient when deciding a treatment plan. This is in accordance with the GMC guidance stating one must “respect the decisions and rights of patients”.4
In order to gain full compliance from the patient, providing adequate education is paramount. The patient felt she had been educated suitably about both her condition and treatment, and so she complies fully with her treatment plan, hence communication skills are vital. Research conducted by doctors, which has been published in the BMJ, have concluded that “when doctors use communication skills effectively, both they and their patients benefit”.5 Providing education about a condition or treatment plan for instance, will require explanation on a level which the patient can understand and follow.
Aims:
Understanding the roles of other healthcare professionals is important for providing good clinical care, which I am to improve by working hard during IPL sessions during my time at university. I will choose IPL during my third year, even though it is optional, as I can see the relevance and significance of it for providing effective health care for the patient. I will also aim to shadow not only doctors, but other healthcare professionals too. The GMC state that a doctor or medical student must “behave with courtesy”4 and “respect the decisions and rights of patients”4, which I feel is something I have always achieved, yet understand that complacency should never be allowed to creep in. The GMC also states that keeping up-to-date records1 and completing work on time4 are important aspects of good clinical care, and so I aim to be thoroughly organised during this course, making sure PBL work is completed on time, and good notes are kept, filed in organised folders. This should prepare me for the organisation levels required as a doctor.
Studying conditions very thoroughly, and speaking to as many patients as possible throughout my medical education, will gain me experience at delivering information to patients, hence better at providing education for my future patients.
Example 3:
My final example from this year occurred on my first day of primary care, and is the most memorable day of my medical education to date. The GP arranged for a patient to come in for a ‘general check-up’, simply to demonstrate some basic clinical skills. I remember a feeling of excitement and anticipation of the morning ahead. After the check-up, the patient was asked if he had been feeling fit and well recently, and he casually replied that he had been having pain urinating. The GP seemed quite concerned and asked for a complete history and a urine test, which showed up blood and infection signs. Due to his age and symptoms, the GP decided that these concerning factors needed to be investigated further by the Urologist, who she referred him onto.
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The patient wanted to know the possible implications, and the GP decided that the patient ought to know that there was a small chance that the possible diagnosis could be prostate cancer. She delivered the news in a very sensitive and empathetic fashion. I remember the patient’s face went white and he was utterly alarmed by the news. I also felt shocked, and a great deal of empathy towards him. The patient was however grateful that the doctor had decided to refer him on immediately. When the doctor left the room for a moment, the patient asked me about the implications of prostate cancer. I apologised and told the patient I was a first year medical student and therefore not informed enough to talk about any such implications.
Lessons learned:
The GMC state that one must “recognise and work within the limits of your competence” and “refer a patient to another practitioner, when this is in the patient’s best interest”1. The GP recognised the possible implications of the problem and made a decision that it needed further investigation from a specialist in the area. The GP recognised her limitations in this area of medicine, and correctly referred the patient. I should remember and employ as a basic principle working within my limits of competence throughout my future career.
Maintaining the doctor-patient relationship, which is based on mutual trust and respect, the GP decided to inform the patient that there was a possibility of prostate cancer. I feel it is very important to keep the honesty as otherwise the relationship will break down, and good clinical care will therefore suffer as a result. When asked about the implications of prostate cancer, it was important for me to “accurately represent my position or ability”4. Any advice or views given by myself could have been wrong, and therefore caused further harm and distress to patient. Also, misrepresentation of myself is a fitness-to-practice issue and I do not wish to represent myself in this way. I could have handled the situation better on reflection, and been more empathetic, but my nerves and the shock situation hindered me. Hopefully over time, I will develop the professional skills to be more confident in such situations.
Aims:
My goal during my medical education is to realise my limits. Setting time each day for work and recreation will give me a balanced life, and help me progress at a steady and attainable pace. It is imperative for me to ask more questions (to the appropriate people) and ask for help with pieces of work when I do not fully understand something. I acknowledge I currently do not do this enough, as I sometimes feel embarrassed to ask for help, but during my time as a clinician in the future, getting a second opinion, or just a piece of advice from a colleague will be essential for the provision of good clinical care. I am currently trying my best to get more actively involved in my PBL feedback sessions and ask questions on areas which I lack understanding in. I am finding this very beneficial for my education, and helpful in combating embarrassment I may feel when asking for help. Another aim is to always remember to introduce myself correctly to patients during consultation, so they understand I am a medical student, therefore causing no confusion of my position or ability.
Conclusion:
Provision of good clinical care is essential as a Doctor. My scenarios have taught me the value being aware of the GMC guidelines, and reflecting upon my performance constantly throughout both my medical education and career, ensuring good clinical care is provided as a fundamental principle of clinical practice. My experiences this year have not only improved my clinical skills, but on reflection, have made me question my approach to different tasks, which with the goals I have set, I hope to improve.
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