This article, written in the form of a trainee's reflective learning log entry (LLE), focuses on patients who present to GP with psychological distress. The new FourteenFish Supporting Evidence/CPD template is used.
In this case the ST1 trainee assessed a patient and found that they did not have depression or anxiety and that medication or referral was not required. However, he felt he did not have the skills to terminate the consultation well.
The trainee discusses how he learned about three specific consultation skills, namely reframing, psychoeducation and challenging cognitions.
When reading the reflection, ask yourself if the trainee had considered what went well and why; if the trainee discussed his emotional needs; if you understand from the narrative why he chose to maintain, improve or stop certain professional behaviours.
After reading the reflection, ask yourself how you explain the physical symptoms of panic to patients; what questions you use to shift your patients' perspective to help their mood; and how you get patients to recognise and challenge their negative cognitions.
Supporting document/CPD evidence
Title: A tutorial about a patient with psychological distress
Briefly describe your key learning from this event?
The topic of the tutorial with my trainer was what GPs do for patients with stress or unhappiness who do not need referral to counselling or mental health services and who do not require prescription of psychotropic medication.
I chose this subject because in a recent consultation, I found myself thinking that I did not know how to politely end the discussion. I couldn’t say: ‘You don’t need tablets or counselling. You are not anxious or depressed. There’s nothing I can do for you. Please leave.’
I wanted to discuss with my trainer what more experienced GPs do. My trainer shared her list of useful local resources. I am familiar with Mind, Relate, Cruse but it was useful to see other resources:
- For sleep (Max Richter – sleep music on YouTube). This worked for me and I will speak to patients about this.
- Leaflets from online sources - www.ntw.nhs.uk is good. I will use this.
- Online CBT can be accessed from http://www.llttf.com/ or https://moodgym.anu.edu.au/welcome.
We discussed three specific consultation skills, namely reframing, psychoeducation and challenging cognitions, using examples to illustrate these concepts.
When we practised reframing self-defeating thoughts, I found a sentence that works for me: ‘If your friend were having these thoughts, what would you say to him/her?’
Psychoeducation about the physical symptoms of anxiety can be useful. I think speaking about the effect of adrenaline may help a patient to understand what is happening to them.
Cognitions are thoughts - I could help patients to challenge those unhelpful thoughts that lead to excessive worry. For example, I need to gently challenge comments such as: ‘If something is going to mess up, it will happen to me.’
Reflection: what will I maintain, improve or stop?
I need to maintain the consultation skills I do well: building rapport; active listening; summarising and offering treatment options.
I need to address my feelings of inadequacy at the end of the consultation, by developing a new 'mental-health tool-box'. I could explore local MH resources and online self-help options with the patient. I could set up a list of favourite resources on my computer and bring them up for discussion.
For patients with panic and anxiety I could ask them about their physical symptoms and discuss adrenaline.
I intend to use this question more: ‘If your friend were having these thoughts, what would you say to him/her?’
I need to stop feeling irritated with these patients. I think the irritation stems from not knowing how to help them. My trainer commented that talking is helpful but I feel more in control when I prescribe or refer. Perhaps I will feel more in control as I develop my style of ‘therapeutic’ conversations.
What learning needs have you identified??
I feel I do not know enough about ‘challenging cognitions’ for me to successfully use this technique at present. I need to read more about CBT first. There’s a good InnovAit article I should read. There are two podcasts in the September issue that are good.
Clinical experience groups (max 2) :
- Mental health (including addiction, alcohol and substance misuse)
Capabilities that this entry provides evidence for (you can only add 3 capabilities)
- Communication and consultation skills
- Clinical management
- Maintaining performance, learning and teaching
Capability - Communication and consultation skills
Justification: I linked to communication because I practised very specific communication techniques in this tutorial - reframing, psychoeducation and challenging cognitions.
Supervisor comments: You have evidence of active listening skills; you adapted your language to the patient in front of you; and you practised how you would ask your ‘new reframing questions’ in the tutorial.
Capability - Clinical management
Justification: I knew in this case neither a prescription nor referral was needed. I worked on developing my therapeutic conversation.
Supervisor comments: You have evidence of varying your management plan appropriately.
Capability - Maintaining performance, learning and teaching
Justification]: I identified I had a personal learning need, which I addressed in the tutorial. I engaged in the tutorial discussion.
Supervisor comments: You showed a commitment to learning by reflecting on a case, which is a common GP case, and identifying that your current skills did not allow you to deal with the case as well as an experienced GP may. You discussed the case with a view to addressing these DENs (doctors’ educational needs). You took away the resources you felt will help you and your practised some consultation techniques that I hope you will apply to future therapeutic conversations.
Overal supervisor's comments
I like this reflection because it tells me how you approach learning the skills you identify you need to become a competent GP. It tells me you learnt about local resources for mental health problems and a few specific consultation skills. I hope that you get an opportunity in future consultations to practise some of these specific techniques and gain confidence in these skills. Well done.
- Dr Prashini Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA, including CSA Practice Cases for the MRCGP
Further reading
- Fourteen Fish - Learning Logs - what is a supporting document?
