Improving learning log entries in GP training: a clinical encounter

This first article in a three-part series 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 is provided along with the trainer’s comment.

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 learning log entry

Subject title: My GP clinical supervisor observes my consultation

What happened?
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.

I took a history about pain scale, aggravating and relieving factors and ruled out red flags. I examined him, confirming mechanical LBP (not sciatica); advised on 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. 

What, if anything, happened subsequently?
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’.  

What did you learn?
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. 

What will you do differently in future?
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. 

What further learning needs did you identify?
My trainer asked me to read about GP fit notes and how GPs can suggest amended duties in the workplace. He asked me if I knew what ‘reasonable adjustments’ meant and how employers could be advised to make ‘reasonable’ adjustments. I need to look this up. 

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?

Had the trainee reflected more deeply in his LLE, he would have shown good evidence for the following domains:

  • Communication and consultation skills – elicits psychological and social information to place the patient’s problem in context.
  • Practising holistically – recognises the impact of the problem on the patient, their family and/or carers.

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

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