Improving learning log entries in GP training: a clinical encounter

Dr Prashini Naidoo looks at a typical e-portfolio learning log entry (LLE) and discusses how the trainee could improve its quality.

(Photo: iStock.com/PeopleImages)
(Photo: iStock.com/PeopleImages)

E-portfolio learning log entries should show serious thinking (reflection) about an aspect of a GP trainee’s professional experience to demonstrate how they learnt from it.

This article focuses on what an ST1 trainee learnt from a clinical encounter. An example reflective log, using the new FourteenFish template, is provided along with the trainer’s comments.

The patient the trainee saw had mechanical low back pain (LBP). The trainee discusses what he learnt about making holistic assessments and how this contributes to empathetic interactions.  

After reading the reflection below, answer the questions that follow, which will help you understand how the reflection could be improved.  

Example clinical case review

Subject title: My GP clinical supervisor observes my consultation
Setting: General practice - scheduled care

Brief decsription
I saw a 30-year-old telecommunications engineer who presented with a three-day history of low back pain (LBP). He described the pain starting as ‘something going’ in his lower back on dead lifting 140kg in the gym (less than usual weight for him to dead lift) and he felt ‘something give’. He was concerned about a ‘tingling’ sensation in his lower back. He wanted advice about analgesia. I had elicited his ICE.

Clinical experience groups (max 2):

  • Clinical problems not linked to a specific clinical experience group

Capabilities that this entry provides evidence for (you can only add 3 capabilities)

  • Data gathering and interpretation
  • Making a diagnosis/decisions
  • Clinical management

Capability: Data gathering and interpretation
Justification [describe how your actions and approach link to the capability]:
I linked to data gathering because I took a history about pain scale, aggravating and relieving factors and ruled out red flags. I examined him, confirming mechanical LBP (not sciatica).

Supervisor: You have evidence of a structured approach to history taking. Your choice of examination was appropriately targeted. You interpret your examination findings.

Capability:  Making a diagnosis/decisions
Justification [describe how your actions and approach link to the capability]:
Once he had a normal neurological examination, I made a diagnosis of mechanical LBP. 

Supervisor: Your differential diagnosis for LBP included sciatica and neurological problems. You also used your knowledge of prevalence, probability and natural history to make a diagnosis of mechanical LBP.

Capability: Clinical management
Justification [describe how your actions and approach link to the capability]:
I advised on OTC analgesia; gave a leaflet on ‘caring for your back’ and asked him to return if symptoms did not resolve in three weeks or if ‘red flags’ developed.

Supervisor: The treatment options you advised were appropriate and reasonable. 

Reflection: what will I maintain, improve or stop?
Before the patient left, my trainer asked him how the pain was affecting his work and home life. The patient said he had to cancel or re-arrange meetings because he could not sit or drive for longer than 20-30 minutes. He had a three-month-old baby and he couldn’t lift or carry baby stuff as he would normally do. This was ‘frustrating’ him and he was worried about ‘permanent damage’. 

When my trainer asked about the effect of the LBP, the impact of his ‘simple’ clinical condition suddenly became more real to me. I felt for the guy and I’m sure my body language changed from detached clinical to more empathetic.

As it was my first ‘observed’ consultation in GP, I was intent on showing that I knew how to take a succinct history, perform a good examination, and manage according to NICE guidance. I could be more holistic in future consultations and find out what impact the problem is having on the patient’s life, and empathise with the difficulties. 

Learning needs identified from this event
I need to discuss with patients how the illness affects home and work life.  Also, if the patient had asked for a referral to physiotherapy, I’m not sure how I would refer and what the waiting times are. I need to speak to the referrals clerk.

Supervisor comments:
Over the next few weeks, while we work on communication and consultation skills, I would like to see you elicit psychological and social information to place the patient’s problem in context. I agree that it is important for GPs to practise holistically, so it is good to acknowledge the impact of the problem on the patient and their family.

Questions for GP trainees to consider

  1. What learning does this LLE demonstrate?
  2. What main concepts are discussed? How well are they discussed?
  3. Did the trainee discuss being able to apply this learning in future to solve problems in a different way?
  4. What conclusions did the trainee draw about the main concepts?
  5. What key ideas about holistic assessments and empathy have contributed to our understanding (as GPs) on patient communication and consultation models?

A trainer’s comment

This LLE was written by an ST1. I would have been disappointed to see this from an ST3. By ST3 stage, I would expect less description of what happened in the consultation. It could be summarised as:

‘I consulted with a 30-year-old male telecommunications engineer, a new parent, who presented with signs and symptoms of suggestive simple mechanical LBP. I managed as per NICE guidance with PILs on activity, simple analgesia and deferred physiotherapy.

‘What I learnt, from observing my trainer consult, was the importance of making a holistic assessment. By finding out how the patient’s LBP impacted on his work and family life, I was able to react with empathy, which builds my relationship with the patient and contributes to the therapeutic nature of a consultation.’

This doctor could have explored the concepts of ‘holistic assessment’ and ‘empathy’ more deeply:

  • What is holistic assessment’ and ‘empathy’?
  • Why are these skills important to GPs?
  • What happens if patients are not assessed holistically? 
  • What happens if GPs do not display empathy?
  • Are empathetic GPs better clinically or is it just patient satisfaction that is improved?

Dr Prashini Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP was published in January 2016.

Background reading

More advice for GP trainees

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