A SIX POINT PLAN FOR 
EXPLORING PROBLEM CASES 

A plan for leaders when exploring problem cases with trainees

It could also be used in  one - to - one  teaching with trainees.

 This plan came to one of us, the course organiser,  when  faced with trying to find a constructive and well-intentioned method of exploring a trainee‘s problem case, and having to think on her feet quickly when she became aware not only of the strong feelings of the trainee in relation to the particular patient he was describing, but also her own feelings about the case.

So, when as a trainer you are feeling “blocked” by your feelings about a trainee’s handling of a patient which you find difficult or overwhelming, try this plan which amongst other things gives you a bit of thinking time!  You could use it as a format for exploring any problem case. 

Scenario

The trainee described his case of a brilliant young scientist with ME whom he encountered in his first week in practice.

The patient was eccentrically dressed, came in and sat down and asked for his usual monthly sick certificate.  He had not worked for five years, and rarely went out.  His own doctor had recently retired.

The trainee refused to give him one and attempted to find out about his illness and why he was unable to work.

The patient left the consultation abruptly, and instead of coming back to see the trainee in a weeks time to discuss the problem, made an appointment with a partner and obtained his certificate.

The trainee was angry, and felt undermined.  He also felt that he should not be signing sick certificates for such illnesses, and that the patient should be on unemployment benefit. 

PLAN

 1.         DOCTOR’S FEELINGS AND THOUGHTS

            Ask the doctor to describe his feelings and thoughts about the case, and then     ask the group    to describe their feelings and what comes into their minds.

            Flip chart them.

            Anger, frustration, “not my job to sign certificates for this condition, and is it        legal?”,” Is this what general practice is all about?” Loss of control,            impotence.

2.         PATIENT’S FEELINGS AND THOUGHTS

            Ask the group to sink themselves into the role of the patient and try to work       out what the patient might have been feeling and thinking.          

            They may find it easier to do this in pairs.

            Again flip chart the feelings

            anxiety, frustration, anger, “will this new doctor give me a certificate?”,”I            wish my doctor hadn’t retired”, “What does he think of ME?”, “will he           believe my symptoms are real?”, etc

 ·        Allow brief discussion.

 3.         CLARIFY THE FACTS

            Clarify and share any facts that might help the group.

             Eg  Trainees’ and leader’s views on ME

            Sick certification rules

            Current research into ME

4.         OBJECTIVES/ WHAT ARE YOU TRYING TO ACHIEVE?

            List the objectives / what you want to achieve in this consultation.

            Facilitating trust in the patient, helping the patient to “move on”, negotiating       change in patient behaviour, constructive discussion of sick certificates.

            Confrontation with “care” about  what has happened to him over the last five      years.

5.         HOW TO GET THERE

            Work out the skills and strategies which you would need to use in order to         achieve your objectives.

            Listen, acknowledge the patient’s problem and feelings and concerns,        

            be empathic, information giving, offer support etc

            You can contribute here as a member of the group. “I’d like to make a suggestion here.......”

6.         GENERALISING AWAY TO SIMILAR PROBLEMS

            Summarise the plan and work out how it might be useful with other problem       patients.

 ·        This plan allows the group to air their feelings and look at the blocks to being patient-centred.

·        It also facilitates finding effective strategies for problem solving, and allows you as the group leader to contribute your experience and what “works for you” in similar situations, without appearing to be too expert or critical.

·        It allows you some space to acknowledge any difficult feelings that you may have about this trainee’s handling of the patient so that you can be constructive and helpful.

·        It gives you and the rest of the group some thinking time to work out a structured problem solving approach, as well as facilitating respectfulness and sensitivity and support amongst group members.

·        It takes the focus off the trainee who initially brought up the case, and allows you to generalise away to similar problems which the trainees may have. 

Juliet Draper, Course Organiser,    Mark Pummell, trainee  Cambridge VTS

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