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.
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.
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.
Trainee's learning log
Subject title: A patient with psychological distress
What was the subject and aims of the tutorial?
The topic was what GPs can 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.
What led to this particular subject being chose?
I found myself thinking in a recent consultation 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 realised that I didn’t know what more experienced GPs do.
What did you learn?
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.’
What will you do differently in future?
Instead of feeling inadequate at the end of the consultation, I could explore local 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?’
What further learning needs did you identify?
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.
A trainer's conclusion
This LLE is a good example of how an ST1 trainee is approaching learning the skills he needs to become a competent GP. It tells me the trainee learnt about local resources for mental health problems and a few specific consultation skills. I hope that he gets an opportunity in future consultations to practise some of these specific techniques and gain confidence in these skills.
- 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