Posted in ARCP, eportfolio, ESR, MRCGP

Learning logs, capabilities and self-rating

Lets talk learning logs. The fourteen fish platform allows you to enter learning logs of varying types and keeps a tally of the number entered and how it compared to the expected number of entries. But how shall we use the learning log in the most effective way?

Lets think about what the learning log is aiming to achieve. What is it’s use. It’s clear aim is to allow you a place to store evidence of your development. It is there to allow you to evidence your capabilities and how you are covering the curriculum. When it comes to an Educational Supervisors report (ESR), you will use these entries to support your self-rating and your educational supervisor (ES) will use them to evidence their rating. Or, in the case of an interim ESR, to support your own self-rating. So in this respect the entries need to clearly demonstrate your level of competency.

The entries allow for reflection. Lets be honest – not everything you add to the learning log is going to create deep reflection. Attending mandatory BLS training is unlikely to leave you with a profound reflection. But the case reviews certainly should give you something to reflect on. But what this reflection is might vary.

I’m not going to discuss reflection any further in this post. You can see my earlier post on reflection here. What I’d like to do is think about the smart ways of using the portfolio to demonstrate evidence, and allow you to plan what you might need to add into the learning log.

So with each entry you are able to allocate both curriculum statements and capability statements. With respect to the curriculum statements you are aiming to show a well rounded coverage of these. Though the curriculum we cover will likely be influenced by the jobs we are in at that time. So to some extent you can plan which jobs will allow you work on which curriculum statements. Within general practice we will find that all areas can be covered. But medicine for the elderly and paediatrics will show some limitation, unless we are adding entries regarding weekly teaching sessions, revision for exams or other learning you undertake outside of the position you currently hold. By the end of ST3 though, we want to see a broad coverage of all the areas in fairly equal amounts.

Again, with each entry you are able to link it to up to 3 of the 13 capabilities. The trainee and their supervisor are then able to provide justification for demonstrating this capability. This is where I think the word descriptors should come into play. Below, after the example log entry, are some of the word descriptors for clinical management.

So when you’re recording this entry jump forwards to undertaking your self-rating and thinking about how to rate yourself. Make it easy on yourself. Look at the word descriptors as you record the entry. Copy and paste the descriptor that applies to what you are demonstrating and justify it. By doing this you are making it clear as to why you feel you achieve this self-rating and you are putting it on a plate for your ES to see and support your rating.

Lets take an example. I have a case where a patient came to me about their knee and was keen to get a referral for a knee replacement. I decided to examine them and as I was doing Lets take a made up example. A patient came to me to discuss their knee pain. They wanted a referral for a knee replacement. I asked if I could examine his knee. Whilst I was doing this I noticed he had a lesion on his shin. I asked a couple of questions about it and found out it had only been present for a couple of months but had grown quite a bit. The patient hadn’t been too worried about it and was more bothered about their knee pain. I was worried it could be an SCC. An SCC would warrant a 2ww referral. I therefore decided to acknowledge the knee issue but explained I was actually more worried right now about the lesion on their leg. I negotiated with the patient that I would organize a follow up call to talk further about their knee such that I could fully explain and discuss my worries about the lesion on the leg and what a 2ww referral entails. The patient was frustrated that I hadn’t sorted the knee out today but understood the importance of their referral.

So what capability is being demonstrated here? I looked over the word descriptors and think I have demonstrated and circled the ones I feel this case shows. So you can see that I have clearly covered NFD and competent word descriptors.

Perhaps if I had given the patient some more autonomy over when the follow up for the knee would be this would have also added a further competent area. I could also follow up with another entry from when I spoke the man again regarding his knee. Though he is showing signs of wear and tear he hasn’t gone down the physiotherapy route yet so he doesn’t meet local criteria for referral for knee replacement. It was a hard conversation to have and he asked me about how much I thought it would cost to have this done privately. After a further conversation we agreed that he would seek private physiotherapy to speed up the process and once this was completed I would refer him for consideration of a knee replacement. This then allows me to circle some of the word descriptors that come under excellent. I felt happy to consider myself ‘competent’ in my self-rating.

Regularly reviewing your capability areas and the evidence you have available in your portfolio will allow you to look for gaps and work out what you need to add to your log so that your entries are smart and relevant.

Also be aware that a case you log doesn’t have to always be something highly interesting/different/unusual. It just needs to provide evidence of what you are demonstrating in both capability and curriculum learning.

I addition I also urge you to think beyond this particular case/episode when reflecting. How does this case apply to your wider practice? Another example is:

You work in the endocrine department. You see a 23 year old who is suffering with DKA. You, alongside your seniors, initiate the correct management and her DKA resolves. You decide to enter a learning log and the reflection is that you now know how to manage DKA. So you link it to the clinical management and making a diagnosis capabilities. But in General Practice do we manage DKA? No. We need to recognize it but we will admit them to hospital. But what will we do as a GP? We will look after the long term management of this patient and her diabetes. We can provide education to prevent this from recurring, we can work with her to gain optimal control of her diabetes, monitor for complications and manage her emotional wellbeing. Was this something that was impacting upon her at the time of her DKA or subsequently. We could in fact draw upon the capability of practicing holistically because we are reflecting about how health beliefs can impact upon management of conditions, facilitating long term support, utilizing the community diabetes team or dieticians for support, for example. See where this is going? Think about the reflection more widely than “I was nervous because I didn’t know how to manage DKA but I do now and so in future I will not be nervous as I will know how to initiate treatment for DKA”

I hope this helps to think about how to use the learning log is a smart way that leaves you feeling like it has a purpose other than just extra work to complete!

Posted in Cardiovascular system, Chronic disease management, Diagnosis, Heart Failure, Uncategorized

Heart Failure – the need to knows

Heart failure is a condition we are increasingly seeing as the population ages. According to figures there are approximately 900,000 people in the UK with a diagnosis of heart failure. It is likely many more remain undiagnosed.

Why is it important to a GP? Because it is often our doors that patients arrive at with symptoms of undiagnosed heart failure, or for management of their already diagnosed heart failure. So we need to remember to consider it as a diagnosis, know what other points in their medical history are relevant, how to investigate and how to manage heart failure.

An important learning point – from prior experience – keep heart failure as a differential diagnosis in all patients presenting with symptoms of breathlessness, regardless of age or lack of other risk factors. It is not difficult to include it in your investigations so keep it on the list until you’ve excluded it via tests.

Firstly, we need to think of the way people might present with heart failure. I am not going to cover an exhaustive list of all of the symptoms because you should know this by now. But people often come to see their GP with symptoms of breathlessness ( to differing degrees), fatigue, or very commonly – ankle swelling. All of these symptoms have multiple potential diagnoses, and it is through further questioning and consideration that you are going to consider whether heart failure is on your list of differentials. If it is then your first step is going to be the trusty BNP or NTproBNP blood test.


These peptides are sensitive enough to use as a diagnostic tool for detecting heart failure. But they are not quite as specific. Carrying out a blood test to check the levels of either of these peptides is going to help you both diagnose or exclude heart failure.

But what other factors or conditions can affect the BNP result?

Falsely lower Falsely higher
Obesity Tachycardia
Diuretics LVH
ACE Inhibitors Hypoxaemia
ARBs eGFR < 60
Beta- blockers COPD
> 70 years

Note the above features – this is going to influence the other elements of your assessment. In order to help you interpret the result you need further information. You need their medical history, medication list and some examination findings.

Notably you might need to weigh your patient to look for their BMI. You need to know what their pulse is and the regularity of it. In addition, an ECG isn’t going to go amiss. From that you can look for SVTs, LV strain and signs suggestive of ischaemia.

In addition to the BNP you want to get some additional blood results:

  • Renal function
  • Liver function
  • Thyroid function
  • Lipids
  • HbA1c

*An off-track learning point – I am pretty tough on trainees at times when it comes to requesting bloods and tests. Why? Because they are expensive and you need to interpret them! When I undertook my emergency medicine rotation I worked in a hospital where the pathology lab was off site. During the induction they told us that we shouldn’t be ordering bloods unless we were planning to admit the patient, because the chances were that the results would not be available before the 4 hour see and treat time was up. Unless you’ve experienced this you will not appreciate how liberating it is to go back to using a history and examination to diagnose a patient. General practice has very much the same ethos. It can be really tempting when requesting a blood test to tick a load of other boxes ‘whilst we are at it’. Don’t. Have a rationale for each test you undertake – what are you looking for and why is it relevant. I’m not going to spell it out for you for the above tests but have a think why they might be relevant!

Interpreting the result

We now have a patient with some symptoms suggestive of heart failure and a positive BNP. What do we do now?

Well we need to look for the cause, unless it is glaringly obvious. The chances are we need an ECHO to help us with this. But how urgently do we need an ECHO? We are going to split our patients into three different categories (as suggested by NICE guidance), and this is going to help us treat our patient within an appropriate time frame:

  1. A very raised BNP (> 400pg/ml) or NTpro BNP (>2000pg/ml) – levels like this carry a poor prognosis so refer urgently to the heart failure clinic for further assessment.
  2. past medical history of a myocardial infarction (MI) – refer for an ECHO and specialist assessment within two weeks.
  3. Other patients – need an ECHO within 6 weeks of the abnormal BNP result.

The result of the ECHO is going to split our treat versus refer patients even further. Who will we refer?

  • Patients with a preserved ejection fraction
  • Valve disease – I think there is some scope to be rational with this group of patients. Read the ECHO report and refer sensibly. A very mild aortic stenosis in an 80 something year old may not necessarily require immediate referral.

So the other patients, i.e. those with left ventricular systolic dysfunction, are the ones we are going to get on and treat.

Mangement principles

  • Effective communication regarding the diagnosis
  • Lifestyle measures
  • Drug treatment
  • Consider the psychological impact of the disease

Communication – You need to explain the diagnosis clearly and carefully. Heart failure is probably a scary diagnosis to a patient. They are being told their heart is failing. We need a heart to live, and theirs is failing! You need to turn this into a less scary situation with a very good explanation and reassurance that there are ways of helping them. Think about how you might explain this diagnosis, and perhaps try your explanation out in a role play setting.

Lifestyle measures – There are a number of changes patients can make that could help to improve their symptoms and outcomes. Increasing exercise as best they can, stopping smoking, reducing alcohol intake and receiving their annual influenza vaccine.

Drug treatments – Keep this simple in your mind.

  • First line:
    • ACE Inhibitors & Beta-blockers – titrate your ACE inhibitors every two weeks (keeping an eye on the renal function) and start with a low dose and gradually increase (perhaps alongside the ACE inhibitor). Make sure you keep an eye on the heart rate when titrating the beta-blocker. If your patient has a home BP monitor then it is worth suggesting the patient check their blood pressure and pulse if they are feeling dizzy or unwell. An ARB is a suitable alternative if the ACE inhibitor is not tolerated.
  • Second line:
    • At this stage you might wish to consider seeking specialist advice but the following medications can be used in the management of heart failure:
      • Aldosterone antagonist (Spironolactone) – for moderate to severe heart failure, or oedema in congestive heart failure.
      • ARB (Candesartan and Valsartan) – mild to moderate heart failure.
      • Hydralazine + Isosorbide dinitrate – moderate – severe heart failure.
      • Digoxin – will improve the symptoms but will not improve mortality. Use in worsening or severe heart failure where patients are already taking maximal treatment with the above mentioned medications.
  • Diuretics:
    • Use for the relief of congestive symptoms and fluid overload.
    • They can be titrated up and down as required.
    • If a patient is requiring greater than 80mg Furosemide daily then you should refer them onwards.
    • Whilst using diuretics you should monitor every six months via a blood test and medication review.

As with all chronic diseases it is important to consider the psychological impact upon the patient. You should address this at their reviews, and manage as required. Locally in Peterborough the psychological wellbeing service has capacity to provide support to individuals who are suffering from chronic disease such as COPD and heart failure. This part of the management shouldn’t be under-estimated. You can spend your days treating disease and illness, but you can’t lose sight of your patient as a whole.

I hope this has been a helpful summary of how to work up a patient for heart failure, and the basic management approach.

Posted in Consultation skills, Diagnosis, Men's health, Uncategorized

Male lower urinary tract symptoms (LUTS)

This topic seems to crop up fairly regularly as a tutorial request. It’s funny because whenever we go through it I think it actually seems very straightforward. Yet there seems to be this tendency to over think the subject. So I have put together my approach to the male LUTS consultation. My suggested reading for this topic is the hyperlinked BMJ article and the NICE guidance.

A good way to approach male LUTS are to consider the symptoms as storage versus voiding symptoms. Having this in the back of your mind is helpful for data gathering but also gives you information from which to consider the most appropriate management options.

  Storage Voiding
Symptoms Frequency

Urgency (and urge incontinence)



Poor stream

Terminal dribbling

Double voiding

Causes Overactive bladder (if isolated) Benign prostatic hypertrophy

Urethral stricture

Meatal stenosis


Management options Anticholinergics Alpha blockers

5-alpha reductase inhibitors

A mixed picture of symptoms would suggest bladder outlet obstruction, most commonly cause by benign prostatic hypertrophy (BPH).

I take a history of the above symptoms in a systematic manner. I go through all the steps of passing urine to clarify what symptoms they have. It is also important to consider the duration of these symptoms. If these symptoms are acute then you should be considering whether this might be a urine infection, or potentially a bladder cancer.

The other important information you need to know are whether they have (or could have) any other medical conditions that may be causing their symptoms. E.g. is this a presentation of diabetes if they have increased frequency of micturition. Also, the medications that they take for other medical conditions could cause side effects that mimic LUTS. So check with them and check their medication list. You also need to consider taking a sexual history if they have any dysuria or penile discharge.

One of the important questions to ask, as with all consultations:

Why is this man presenting now? What are his concerns?

This is the golden question because it is going to guide your management plan. I often see men who wish to discuss their urinary symptoms because they are concerned about the possibility of prostate cancer. But once this is discussed and investigated they don’t feel the need to take medication for their symptoms. So ask them about expectations – it might save an unwanted prescription!

You need to examine your patient:

  • Abdominal examination
  • Genital examination
  • Digital rectal examination (DRE)
  • Look for peripheral oedema
  • Neurological examination – if there is anything in the history that creates suspicion

A note about DRE and Prostate specific antigen (PSA). You need to undertake a DRE at some point during your assessment of the patient presenting with LUTS. Unless the patient is having their blood test very soon after the DRE it is unlikely to impact upon the PSA results. However, you could undertake the PSA testing, advise them they will need this examination at their follow up consultation and then perform it at the review. That is down to your preference. As long as it is completed in good time.


  • Urinalysis – can look for infection, diabetes, or possibility of malignancy.
  • An input/output diary – if they have storage symptoms or nocturia. Make sure they note caffeine intake.
  • PSA – You need to counsel the patient prior to offering a PSA test. I really like this website for providing a man with information about PSA testing.

It is also very helpful to ask the man to complete the international prostate symptom score (IPSS) questionnaire. The man’s scoring on this questionnaire can direct the management plan put in place.


First line should be information. About their condition and the lifestyle measures they can make that may improve their symptoms e.g. fluid modification. I really like this patient information leaflet from BAUS

Drug treatments. This is where the IPSS can be helpful.

Mild LUTS (IPSS <8)

Enlarged prostate

5 Alpha reductase inhibitor
Moderate – Severe LUTS (IPSS >7)

Normal sized prostate

Alpha blocker
Moderate – Severe LUTS (IPSS >7)

Enlarged prostate

Alpha blocker +

5 Aplha reductase inhibitor

Overactive bladder (isolated storage symptoms) Anticholinergics

(if fails or not tolerated Beta 3 agonist)

Consider the common side-effects of these medications when explaining them to patients:

  • Alpha blockers (e.g. Tamsulosin) – reduced ejaculation, postural hypotension (it is advisable to suggest the patient takes these last thing at night)
  • 5 Alpha reductase inhibitors (e.g. Finasteride or Duasteride) – Reduced libido, Erectile dysfunction, gynaecomastia. With this treatment it may take several months for it’s benefit is seen. It is worth explaining this to the patient up front.
  • Anticholinergics (e.g. Oxybutynin) – dry eyes, dry mouth, constipation, confusion (in the elderly).
  • Beta 3 agonist (e.g. Mirabegron) – Tachycardia

Organise follow-up:

It is useful to review they patient at 4-6 weeks post initiation of treatment. They you can review at 6-12 month intervals. If it is Finasteride only that you have initiated then you may wish to lengthen the first review to around 3-6 months to allow time for it’s effects to have been seen.

Who to refer?

  • Failure of medical treatment after a couple of reviews
  • Severe LUTS (IPSS 20+)
  • DRE suggests malignancy
  • Elevated age-specific PSA
  • Recurrent UTIs
  • Persistent non-visible haematuria or any visible haematuria
  • Urinary retention

This is the British Association of Urological Surgeons (BAUS) age adjusted PSA guide:

Age Maximum PSA (ng/ml)
40-49 years 2.7
50-59 years 3.9
60 – 69 years 5.0
70-79 years 7.2
80-84 years 10
85+ years 20

If your patient has a raised PSA then this is a really nice web page to direct them to or print off to explain what this means and what might happen next.

I really hope this has shown you how straightforward a male LUTS consultation can be. If you have any questions then just as and I will answer as best I can.

Posted in CSA, MRCGP, Uncategorized

Getting stressed about your CSA?


Yes that is much easier said than done. But try not to because it will hamper your preparation. And remember that everyone prepares in different ways and everyone is ready at different times. You might be sitting your CSA on the same day as one of your colleagues and be stressing about the fact that they’re so much better prepared than you are. However, does it really matter? As long as you are ready by the day of the CSA it doesn’t matter if you’ve been ready one month, one week or one day before it. Yes we may feel more confident if we have been ready for a month but the flip side to this argument is that you could just have a really bad exam day and struggle. You wont though because you’re going to consult like you do every day, and you’re going to be great! That is rule one – believe in yourself. If you are doing the day job well (I would hope your trainer has talked to you if you aren’t) then it should be just fine.

How can you prepare for the CSA other than do your day to day consultations? There are many ways:

Role play with your trainer, your fellow trainees and even your family.

Video your consultations and show then to your trainers. Watch them yourself too.

Joint surgeries.

Don’t forget your clinical knowledge – make sure you know your red flags, your guidelines, your management plans.

You can create opportunities every day to incorporate these forms of preparation. Set rules for feedback – you don’t want your confidence to be knocked by lots of negative feedback, but continually sharing only positive feedback, or saying ‘it was fine’ isn’t going to help you get better. My trainees’ might describe me a bit tough and honest where feedback is concerned. Here’s my thinking – I’m going to tell you if it was fine and you might manage a pass. But I’m going to be a bit fussy and excessive too. Why? Because my principle is that when you are preparing you should be aiming for that ‘perfect’ consultation. You know – the one where it all comes together and you send the patient away with an amazing plan! For what reason am I doing this, rather than just making sure you can pass each consultation? For two reasons – the first is that I want my trainee to be a great GP, and I want their patients to see just how good they are. The second is more CSA focussed. There are very few of us who do not suffer from some degree of nerves when we are faced with a pressurised situation. The CSA is just that – it’s the last big hurdle in our training, it’s really expensive so we don’t want to pay for it a second time, it’s a foreign environment (to most of us) and we know that people can fail it. What happens when we are nervous? We are potentially not on our top form. So lets aim for perfection when preparing so that when the nerves hit we perhaps drop a little but not below the pass/fail threshold. So whoever you’re preparing with – ask them to judge you to perfection.

If you’re role playing a patient for a colleague then make it a bit tricky every now and again. Put your peers under a bit of pressure. Again it makes facing the CSA that little easier. From experience I really didn’t find there was a patient there to trip me up, and no one was really terrible to me! But if your colleagues have been a bit tough on you here and there then you won’t be phased if you have a consultation that’s a bit trickier, and most of the consultations will feel like a breeze compared to the practice you’ve been doing.

It may seem a bit odd to suggest practicing with your non-medical family and friends. But it can be really helpful. I recall practicing telephone consultations with my sister who lives 100 miles away. I gave her a rough brief on a topic she might have some idea of what kind of symptoms to have – thyroid, an ill child, etc. Then we would undertake the consultation in ten minutes, and I’d see how she felt it went. Non-medics are also great for practicing your explanations and planning with. However good at role playing you are it is always hard to put your medical knowledge out of your mind. So the explanation might seem fine to a fellow medic, but not so clear to someone with no prior knowledge. So try explaining CKD3 to your partner, or the two week wait to your friend. Genetics is a really good topic to role play with someone non-medical, because you will soon see that you can’t drop into a full description of mendelian inheritance in a ten minute consultation – you have to keep it simple and concise.

Don’t let your theoretical knowledge slip away. This is a really good reason for getting tied up in knots in the exam. When observing, I can tell when someone is starting to question their plan because they can’t quite remember what the guidelines suggest, or they don’t recall the cut off values for this and that. The consultation then just slowly falls apart because the trainee isn’t confident in what they are doing, and they are running out of time to complete the consultation. So know your stuff. The consultation skills get you a long way, but to go the whole way you need to back it up with knowledge.

Be yourself. I remember watching some videos back when I was about 4 months away from the CSA and cringing. I realised that I was consulting completely differently to normal in a bid to undertake the perfect consultation structure. The consultations went terribly and didn’t reflect my usual practice. Once this was highlighted to me I took a step back and started trying to improve my consultation structure rather than start from scratch. You need to be yourself otherwise it will awkward for you, the patient and the examiner. The use of stock phrases just doesn’t work. If this phrase is new to you and doesn’t fit your style or personality then it wont work with the effect it is hoped to. But, by all means take feedback on board and try out new techniques or phrases. Just don’t do it all at the same time! I do advocate being conscious of any words or things you do that you might want to work hard to wipe out of your consultations. Apparently my phrase was ‘I think’. I’m pretty sure I have erased this from my consultations but I know that I use phrase too much in day to day life because my toddler went through a phrase of adding ‘I think’ to the end of most sentences! So just be cautious of repeated words and phrases you use, or those that might make an examiner or patient (who does not know you and will have one encounter with you) think that you are not confident in what you are saying or doing.

I really hope this post has given you some pointers as to how to approach CSA preparation. There really isn’t a one size fits all preparation guide because we all learn differently. If I can answer any questions then please get in touch.

Posted in Consultation skills, Diagnosis, Malignant disease, Uncategorized

Referring for suspected cancer

This is written following some CSA preparation with a trainee. Let me start with a usual disclaimer – I am no expert in breaking bad news or discussing this topic! I have spent a number of years trialling different methods of approaching this with patients. I’m still not sure I have it right but I wanted to share some thoughts to help you build on your skills.

I don’t know if there are many people out there who do not know of cancer. I would say the vast majority, if not all, have heard of the word. It may be that they don’t fully understand what that means though. But how good are you at using the word in your consultations and saying it with ease? It’s an easy word to stumble over and turn in to the most awkward conversation you’ve had that day. Even with those patients who have a diagnosis of cancer. So practice saying it aloud regularly. Normalise the word.

Here’s where I think the problem lies. Most of us are all a bit too nervous to say the word aloud to someone who doesn’t already have a diagnosis. So when we sit there worried that their symptoms suggest cancer, and we want to refer them, we try to think of every other way of saying it without using the word. We talk about the need to exclude serious, sinister or worrying causes. But none of these words define cancer. They could define any illness that may be more than something minor, or something that someone may have to live with or need an operation for. Some people may not even be sure what sinister means. So here’s the issue – we tell someone we need to refer them to clinic to rule out something serious (or sinister; or worrying) but we don’t tell them we need to exclude cancer. We then send them via a clinic that is specifically to exclude this, where there’s a reasonable chance someone else is going to use this word. Imagine being the patient at this point in time. You’ve trundled along to the hospital, on your own having taken the bus, thinking you might have something wrong that that the GP can’t quite sort out. You’re then faced with someone telling you that you’re in this clinic to look for cancer. Yep, I’d feel pretty stressed too. What if I’ve got cancer? Am I going to have to get home by myself and hold it together? Especially, if they decide you need further investigations to rule it out.

So this is what we need to do – we need to find a clear, yet sensitive, way of breaking this news to the patient. I would like to hope that somewhere along the way in your medical training you’ve been given some guidance on breaking bad news, and had the opportunity to practice this. (I wish someone would have given some guidance in medical school on how to tell a relative their loved one is dying or has already passed away – it would have made my days a junior doctor a little less painful).

We need to model this explanation and planning upon the breaking bad news methods. Because that’s what we are kind of doing. We are introducing the possibility of cancer to a patient, who may not have even considered this as the cause for their symptoms.

Firstly – have you gathered the patient’s ICE (ideas, concerns and expectations)? If you have then you may have already garnered that they are a) worried they have cancer or b) have a completely different agenda. A good example is the consultation regarding a breast lump. On the whole a woman thinks a breast lump = cancer. They want you to tell them it’s not. So they are still a little surprised when you explain you’d like to refer them onwards, but they understand why from the get go. The opposite is bowel or urinary symptoms I find. They think there’s probably something wrong but they haven’t often considered it might be cancer. They just want you to stop them from opening their bowels several times per day for example. So ICE is your starting point for knowing what your opener needs to be.

Use the above knowledge to start the explanation. Here’s the important part – I really think you need to use the word cancer at some point during this stage of the consultation. How you do it is something to work out for yourself, via practice. If I am not truly convinced it’s cancer but they sit within the criteria for a two week referral I usually say something along these lines:

” From everything you’ve told me I think you fit within the criteria for us to refer you urgently to rule out cancer as a cause. I’m not entirely convinced this is the case, however I think it would be wrong not to consider this”

Or if you’re really nervous about telling them you could try:

“For each area of the body there are set symptoms and time frames that have been listed as a reason to refer someone to rule out cancer. From what you have told be you fit into one of these categories so I really think it would be a good idea to send you to the hospital clinic”

If you’ve examined them and you are really worried because you’ve found a mass for example then tell them:

“When I examined your tummy I could feel a lump there. There are many causes for feeling a lump in the tummy. However, when taking the symptoms you told me you have into consideration, I’m worried this could be a cancer. So I think we need to get this looked at urgently”

The same goes for discussing a result that is highly suggestive, or confirmatory for cancer. Speak the whole truth.

Whichever way you decide to drop the word cancer in. Follow it up with a ‘would that be ok?’ and a ‘do you understand?’ or a how do you feel about that?’ You know roughly the answers to these questions but asking them out loud rather than assuming allows you to open up the discussion about how they are feeling and to do some (metaphorical) hand holding. Acknowledge that you understand this may be worrying, stressful, etc.

Discuss the next steps. Confirm that two week wait means they will be seen within the next fortnight. If it’s such they may have investigations first then explain this. If they’re going to the breast clinic or neck lump clinic then tell them it might be a long day and they might want to take a book. Suggest they may wish to go along with someone for company.

When closing the consultation and planning suggest some follow up so they know they can come back to you. If they don’t have cancer then they will still have the symptoms that need to be managed, and if they do then they might want to talk to you about it. In addition, if appropriate, make sure you offer some management for the symptoms they have in the meantime.

You might have noticed that I have dropped the word cancer into this narrative many time – because it’s an actual word with a definition and we shouldn’t be afraid of it.

It’d be great if anyone else has any good tips to share on how they broach the subject of a two week wait referral.

Posted in Administration, Uncategorized

Writing a referral letter

This topic came up in conversation at the practice recently. Disclaimer – I am not the world’s best letter writer, and English was not my favourite topic at school!

This post is perhaps more an opener to think about how you are currently constructing your referrals, and how you can improve on this. Some people take the mail merge literally, and mail merge their last consultation, whereas some people like to write a life story of their patient. I must admit, I have been guilty of both of these in the past.

The most important point when considering referral letters is what are you asking the person on the end of the referral for. This should be the very first sentence of the referral. For example, if you think someone needs surgery then that’s what the referrer needs to know. Plus, you might wish to explain why you think the patient needs the procedure. An example might be “I would be grateful if you would see this 48 year old woman, who has been suffering recurrent episodes of cholecystitis, for consideration of a cholecystectomy”. Thus, the reader knows exactly what you’re thinking, and hopefully what the patient is expecting.

Leading on to the second point – make sure the referral reflects the conversation you had with the patient. If you’ve told the patient you’re referring them for one reason, and the letter makes it sound like it’s for something totally different, it is going to lead to a difficult consultation between the patient and whoever they have been referred to. So keep the story consistent. For example, if there are strict criteria in your area for knee replacements, and you know the patient doesn’t meet them, it is not helpful to tell them you are referring them for this. In reality, you are referring them to a specialist since you’ve exhausted the options, and you need to see if there’s anything available in secondary care that they can try whilst they don’t meet the threshold for replacement. It works in the opposite direction too – why are you referring someone with a hernia to a surgeon, if they don’t want to have surgery? You need to be clear what your patient’s agenda is, and clarify to them what your agenda is when referring.

The above is by far the most important part of writing a referral. The rest is just details, and, in some ways, is shaped by the referral processes local to you. Examples locally are the virtual gastroenterology and neurology clinics. They have been set up to manage the demand for these services locally. The process is simple – you refer to the clinic, they read the letters, they may provide some advice and not see the patient, they may book patients in for investigations first prior to review, or they might see the patient in clinic initially. As such, giving a good history is essential to them making the right decisions. So thats what you need to do. Go back to the days of having to present patients on the post-take ward round, or back in medical school, and present your patient. For example if there is pain – describe the pain. You need to describe the associated symptoms, and the duration of them. You need to include any relevant medical history or medication history. You don’t need to talk about their broken toenail back in 1984! Think about what you’d like to know if you could give patients forms to describe their symptoms in advance of your appointment. Imagine how much easier the consultation may be if you had a nice outline of everything before you saw the patient. (Remember we do have a rough outline as we at least have their medical history, current medications, etc. in front of us)

You don’t want to bore the reader, and you don’t want them to be digging through your letter to make sense of why a patient is being referred. This is why mail merge letters from the relevant consultation are not the most helpful. Your consultation notes are just that – your consultation notes – not you discussing the case with someone else. We often use abbreviations and incomplete sentences, and flit from one part of the history to another. Read the last consultation in the next patient’s notes you open and see if you feel that you know exactly what the writer was thinking, and whether it was an easy read! The other factor here, is a lot of surgeries undertake referral audits, and/or review referrals before they leave the building, which is another reason to make clear why you are making a referral and whether it lives up to peer scrutiny.

Another reason for writing a concise, clear referral is because it helps you. Writing or dictating the referral may prompt you to undertake some further investigation, or ask a few further questions prior to sending the referral off. I like to write my referral as soon as I have wound up the consultation, where possible, as all of the information is fresh in my mind, and I just find it a lot quicker.

Remember I said you don’t need to tell the patient’s life story? You really don’t! I know this because I have, once or twice, received a response thanking me for my ‘comprehensive’ history. Which I am pretty certain means they stopped reading it halfway through! Just give the relevant points!

I hope this is of use when you write your next referral!

Posted in Consultation skills, CSA, Diagnosis, MRCGP

CSA – What’s clinical management all about?

I went to the autumn seminar at the end of September, and I saw a session on clinical management in the CSA. So I circled it and made sure to attend. Having sat the CSA myself I really couldn’t say with certainty exactly what they were looking for. I have also found this with trainees I have helped prepare since. I think the data gathering section is obvious (because you need to take a thorough yet relevant history), and interpersonal skills are also pretty straightforward. But with the clinical management it’s hard to be sure whether we are supposed to have a clear diagnosis, whether we need to show the examiner we know everything there is to know about a topic, give 10 options to the patient, or completely cure them in one consultation!

In addition, the commonest CSA feedback statements are related to clinical management, and this is where trainees are most likely to lose marks.

This session was, by far, the most useful I have attended to date. So I thought I would share some of my learning from it. It was led by Dr Roger Tisi, who is the Associate Postgraduate Dean for Health Education East of England. All credit is to him for making things clearer, and being a great presenter! In addition, this information is from his session so I must also credit him for the knowledge I pass on.

The first point that was made clear is that we should consider that we aren’t just getting 3 marks for the clinical management section. We should assume that half the marks for each station are related to clinical management since interpersonal skills run throughout, and are linked in with a good management plan.

The commonest pitfalls in the CSA are what we all know they are – running out of time, missing the point and managing a condition but not managing the patient who has the condition.

A lot of people in this session noted they would see a clear drop in energy levels as a trainee reaches the second half of the consultation. So you need to think about how you might keep that energy up, and provide a great management plan. Some suggestions included repositioning yourself and straightening your posture, taking a deep breath, etc. The clinical management section begins at the time that you put a possible diagnosis on the table. One possible way to ease in to the clinical management section is to repeat their ideas, concerns and expectations back to them. You might want to think about how you phrase this, but if you can achieve this then you know that you’ve got to the bottom of this consultations, and are on the right tracks. In addition, it means you are more likely to manage the patient and the psychosocial context rather than just the condition in general.

What I took away that is very important is that the CSA doesn’t require you to have a diagnosis in every case. You may be creating a differential diagnosis, or dealing with a dilemma, or providing something else such as advice or support. Remember this – how many times per session do you sit and listen to a history and make a definitive diagnosis at the first appointment? I know that I often come up with some differentials, and have to undertake some further investigations to create a diagnosis and an appropriate management plan. So if it’s ok in real life, it’s ok in the CSA!

You need to provide your explanations in such a way that both the patient and the examiner can understand. You may wish to refer back to any concerns the patient has raised here. Something I like to do, and that we discussed in this session, is thinking out loud (We’ll call it the Em Sheerham technique). Sometimes you have a lot of thought running through your head ‘it could be this or it could be that’, ‘to decided I think I need to do this or that’, ‘normally we’d do this but this patient is that’. If you sit in silence having those thoughts it looks awkward, and also no-one knows why you then come up with the plan you have made. In addition, if you’ve thought it all through in your head then there’s a good chance that when you verbalise it you do it in such a way that you don’t give the full information. Instead, say it out loud – confidently. If you do this then both the examiner and patient see where you’re coming from and understand your rationale. They are more likely to get on board if you make it clear what your thinking is.

Just to reiterate – you must put it into the context of the patient you have sat in front of you. E.g. the lady that’s had a funny turn (possible seizure) who drives for a living, the contraceptive advice for the 15 year old who’s boyfriend is 19. It might be when doing this that you realise you’ve missed a crucial piece of information. If you have then signpost that you hadn’t asked a question that may be of relevance and then ask it. The examiner might realise for the first time that you’ve missed something here so be careful!

Options, options, options! Guess what – sometimes it’s ok to give few or non-options. On the basis that you keep it patient centred, and explain your rationale. E.g. the patient who is worried he may have cancer, and you’re worried he has cancer. The only real option is 2WW referral – so that’s what you’re going to offer – just explain why! You need to inform the patient to allow them to be involved in the decision process, whether there are lots of options or none. Again, this is whether thinking aloud helps, and remembering that the consultation is a dialogue or a conversation – not a presentation!

But whatever you do – do something! A really good point that Dr Tisi made was that the examiner might ask himself at the end of the consultation ‘Is this patient better off for having seen this doctor today?’ They want to be able to say yes, and if you do nothing at all then the answer will be no. So make a plan that the patient is happy with and go with it. Do not run out of time before you’ve done this.

Make sure the patient knows what the plan is, agrees with it, knows how it is to be executed, and there is follow up to ensure patient safety. Be clear on it. E.g. if you say you’ll get in touch with them then tell them how e.g. telephone, writing to them or face to face.

Last crucial point – DO NOT AVOID THE ELEPHANT IN THE ROOM! It is in the CSA for a reason. However painful you might think it will be to address the 14 year old with the 20 year old boyfriend, the drug addict, the patient with back pain who probably has bone metastases, etc. You must address this, otherwise chances are you will fail!

Few little pointers:

  • Video consultations – watch some of your own and check whether you are a serial word user. This can be annoying to an observer so just be careful! I remember I used to say ‘I think’ a lot, and my supervisor pointed out that I sound unconfident, even when I knew I was doing the right thing.
  • Stock phrases such as ‘what were you hoping I could do for you today?’ need to be used carefully, and in the appropriate context. Otherwise they just sound wrong, patronising, ridiculous. If a phrase is completely out of your comfort zone then don’t bother with it.
  • Patient preference doesn’t always take preference. It’s Ok if you don’t give the drug addict more fentanyl patches.
  • Consultations don’t necessarily have to end on a positive note – e.g. as with the above scenario. But this shouldn’t be due to an inappropriate management plan or lack of consultation skills!

You just need to practice all of this, and with time it will just flow. Remember if you need to practice explaining diagnoses or treatments then the best person you can find is a non medical friend or relative. You can easily work on a jargon free explanation with said individual!


Posted in Consultation skills, Depression, Diagnosis, Mental health

Consultation skills – Tackling low mood and depression

One of the commonest consultations we have in primary care is for low mood and depression. It’s also picked up during consultations where a patient may not have come specifically regarding their mood. As such it’s really important that we have the skills required to tackle this type of consultation.

With experience each of you will develop your own way of working your way through this type of consultation, and setting up your own schedule for reviewing, and providing ongoing care to this cohort of patients. But in the early days of training it can be helpful to hear about how others undertake such consultations, and shape this to fit your own style.

So I will talk through how I approach this type of consultation. I’m not planning to cover all the detail regarding diagnosing depression, and specific management protocols. You can find the most recent NICE guidance on the recognition and management of depression here

NICE uses the DSM-IV criteria for diagnosis of depression. It’s important to know this since this is how you are going to diagnose someone with depression, and recognise the different grades of depression from ‘sub-threshold’ to severe. By understanding the diagnostic criteria you will a) know what you need to ask your patient and b) be able to ascertain what type of treatment you may wish to offer to your patient.

DSM-IV criteria for major depression:

5 or more symptoms

  • Depressed mood for more than 2 weeks
  • Anhedonia
  • Poor appetite/ Weight loss > 5%
  • Insomnia/ Hypersomnia
  • Agitation / Psychomotor retardation
  • Reduced Libido
  • Loss of energy
  • Poor concentration
  • Thoughts of life not worth living / Suicidal ideation

Categorisation of depression:

  • Sub-threshold = < 5 of the above symptoms
  • Mild = only 5 (or not many more) of the above symptoms, resulting in only minor functional impairment
  • Moderate = Symptoms or functional impairment is between mild and severe
  • Severe = Most symptoms, and they have left a major functional impairment.

With the above knowledge we should be able to come up with a diagnosis, and a severity, of depression. However, the important part is how to gather that information. Sure, we could go through each of these symptoms very robotically, but is the person sat in front of us going to open up and be honest if you are undertaking a tick-box exercise? The answer is no!

It is this type of consultation where I find that a golden minute, or possibly two, is the most useful of any type of consultation. Because in that time you can get an idea of what’s going on, to what extent, and you get to look for all the verbal, and non-verbal cues, that will help you interpret what they are saying, and give you ideas of further questions you need to ask. I’m not going to teach you to undertake a mental state examination (I found a really nice summary here if you need to brush up on your skills), but during this opening minute or two you can start to cover some of the areas of the mental state examination. This is really important for considering the impact of symptoms upon the persons level of functioning.

I like to try and gather information regarding their other symptoms by turning the consultation into more of a ‘chat’ than an ‘interview’. I find this makes it more personal, and tends to develop a greater rapport with the patient.

In my head I am trying to be as nosy as possible, and painting a picture of this person’s life. By doing this I can work out what’s going on, why they might be in this position and the amount of support they have. In turn, this is going to help me offer them the best options for management.

What do I tend to ask about?

  • One of the big questions I ask is what triggered them to come and see me today in particular – this gives a really useful insight in to their situation.
  • I want to know when they last remember being themselves/happy/’normal’
  • Have they ever felt like this before? If so what happened at that time
  • Can they put a finger on what triggered this episode? Is that ‘something’ still happening?
  • Whats their home set up like – Who do they live with? Do they have children? Is home happy or are there stresses? Are their financial or marital concerns?
  • What do they do for work? How is their mood impacting upon work, and how does work impact upon their mood? Have they had any time off recently? If so, did things improve?
  • What makes them happy normally – Do they have any interests? Do they get time for themselves? Are they still enjoying those things they used to?
  • How is their sleep? If they are not sleeping well is it because they struggle to get to sleep, or are they waking. If they struggle to get to sleep – why? What are they thinking/worrying about?
  • Are they eating? Do they enjoy mealtimes as before?
  • Do they smoke, drink, take drugs?
  • Who is in their support network locally – do they have one? Have they got family and good friends locally? Have they talked to any of these people about how they are feeling? Is there any history in the family of low mood/depression/other psychiatric illness?
  • Have they got to the point where they’ve felt so low that they have thought about harming themselves in any way? Or thought about ending their own life? If they answer yes to these questions then I am going to ask for more information (I will chat about this more below)
  • In anticipation of this appointment, have they thought about what might help them get better? Are there any specific treatments they wanted to talk about? What are their views on taking tablets? Have they taken any medications for mood in the past, or undergone any psychological therapies?

By the end of this questioning I feel like I have a really good grip of whats going on, what it might be sensible to offer, and what my follow up plan will be.

If they answered yes to the question regarding self harm and/or suicidal ideation then I need to talk about this in a bit more depth. I acknowledge that this might be difficult for them to talk about, but that it’s important for them to be as open as they can so that I can help to the best of my ability.

If they express that they have thought about taking their life I ask about what those thoughts have involved? How often they’ve occurred? Do they have any intention of acting upon them? What would stop them from doing so? Have they ever had thoughts like this in the past and have they ever attempted suicide in the past?

Asking these questions allows me to generate a degree of risk. Again, this will alter my management plan. Someone who has clear plans, and no clear support or inhibitive factors is going to make me question whether I ought to make a same day referral to the crisis team. Those with thoughts but no active intention I am going to follow up sooner than those with no thoughts of self harm. At this point I also take into account the demographics of the person sat before me. Male suicides are more common than female, and middle-aged males more likely to commit suicide than anyone else.

Only you can decide what your follow-up consultation interval will be for each patient. You are making your own risk assessment, and often this is affected by our personal level of risk. For me, it might be between 2 days to 4 weeks. I might even follow someone up by telephone the following day if I’m particularly worried, but I don’t feel there’s anything specific that warrants a crisis team referral. Bear in mind that some crisis team referrals are bounced back pretty quickly so even if you do refer, you need to continue with your own follow up plans.

What are the management options?

This will be tailored to the patient in front of you but can range from no treatment if they have sub-threshold depression, or there’s a specific incident driving their mood that they just need to be supported through. It may require low intensity psychological therapies such as self guided or computerised CBT, or medications.

Medication ought to be reserved for those with moderate or severe depression, or where they have a past history of moderate or severe depression. It may be considered if they have had sub-clinical or mild depression that has persisted for a couple of years, or where low intensity psychological therapy has failed.

It is important to consider patients ideas and choice. However, I often make it clear that medication may help the symptoms, but if there is a clear trigger then it is most helpful to address this. Hence why psychological therapies can be very useful. Sometimes it’s the conversation you have that breaks down their barriers and opens them up to trying such therapies. If they are not keen initially I will ask them to think about it and discuss it more next time.


  1. Patients can self – refer for psychological therapies. In those who I  feel a re low risk with sub-clinical and mild depression I advocate this. It gives the patient some ownership of their symptoms, and there is less likely to be a non-adherence to treatment if they have chosen to refer themselves.
  2. We have 111 option 2. By calling 111 and selection option 2 they are put through to a first responder from the mental health trust. They are trained to talk to patients over the phone, with the aim of avoiding A+E attendances. They are also working with Mind (a mental health charity) to provide ‘safe havens’ where people can go out of hours if they are experiencing a crisis.

Please feel free to use the comments section to share your ideas, or ask questions related to the above. Also, would it be helpful for me to post a video of a simulated consultation for this topic?

Posted in Book review, Palliative care, Uncategorized

Book recommendation – Being Mortal by Atul Gawande

This post is not going to teach you anything – it’s a book recommendation. I know you might be thinking ‘when do I have time to read a (non textbook) book?’ but stick with me.

I came to read this book, not through selecting it myself but it was gifted to myself, along with a copy for all the doctors in our practice, by a patient. So, I added it to my growing pile of books to read. I tend to save books for holidays because I am an avid reader – one that struggles to read just a few pages at a time. But I knew I would read it. If someone has taken the time to gift you a book then it’s got to be worth a read.

I wasn’t entirely sure what the book would cover, since I hadn’t read the Amazon synopsis in advance. So to convince you it’s worth your time I will give you a rough idea, and place it into the context of why it was a great read for me.

The book covers the issue of death, and how we get there. Atul Gawande is a surgeon in the USA, and he wrote this book after reflecting on his experience of caring for older people – professionally and personally, and looking after those with terminal diagnoses. It is a personal reflection of his journey to improving the care of those people in the later stages of their life, and in the terminal phase. He looks at ageing (briefly), and how that impacts upon physical ability. Then puts this into the context of care of older people – in hospital and beyond. He looks at how modern medicine impacts upon mortality, and the choices available to people of all ages when they are given an end of life diagnosis. Finally, then looking at the change from managing at home to needing nursing home care, and how this has changed with time. He has spoken to palliative care specialists, those who have worked within the social care setting, colleagues, and most importantly patients.

All of the above is why I urge you to read this. How many of you have spent much time in your medical education and work, to date, dealing with end of life care directly? I recall my time as a trainee in the hospital recognising that people were moving into the terminal phase of my life, but not having the seniority to ‘make the call’. Sometimes I’d be given the responsibility of having discussions with relatives, to pass on the decisions made by senior colleagues. Sometimes I would watch as colleagues made seemingly unfathomable decisions that we must continue aggressive treatment of patients. I actually found some of my hospital shifts extremely upsetting as a result of this. I felt helpless watching management plans unfold, and being complicit in seemingly irrational management plans. The hospital is a busy place, and often understaffed at weekends. This could lead to a more senior doctor not having time to review your patient, and thus see in reality their situation. As such this sometimes seemed to prompt them to make management plans that would serve as a ‘holding plan’ until they could get to see the patient. My issue with this process was that by undertaking and ABG, or a portable CXR, you are suggesting to the family members who are watching their relative get sicker, that there is a way back from this. Yes, sometimes this is the case, but in one particular experience (I recall the scenario vividly – it happened 7 years ago) I knew that they would make no difference, but I followed orders. I remember thinking at the time I would rather spend my time talking to the family, and making this death something they wouldn’t remember as traumatic in any way. I didn’t get to do that. I felt really unsatisfied with my job when I got home that day.

This book, didn’t solve anything for me, but it made me think of how it could help hospital colleagues. It made me consider how I could potentially help my patients avoid being in this position when they reach the hospital. It opened up the idea of very frank and honest discussions. I thought I was trying to do that already, but this book gave me some tips on how to refine this.

It didn’t take too long to read. I also found there was no part of the book that I felt the urge to skim read. It was all interesting, and pertinent to the role of a GP. I encourage you to read this book, because I think it will improve your care of those patients reaching the later phase of their life, and making that time a positive experience for themselves and their family.

You can find a link to the authors website, and more information on the book here


Posted in ARCP, eportfolio, ESR, MRCGP

Reflective learning

This entry has come about through a chat with one of our trainee’s. He felt that it was difficult to get to grips with reflection. He told me that he got to know about Gibbs (1988) reflective cycle, and that this had improved his ability to reflect. I also recalled this was the model my sister was encouraged to use during her midwifery degree.

So I went back to my theory from my Postgraduate Certificate of Medical Education, did a bit more reading, and thought I’d share the salient features. Having looked through numerous theories of learning and reflection I do agree that Gibbs’ method fits the GP e-portfolio learning log well.

It’s important to note that reflection is a very personal experience. It can give an insight to your personality, and can reveal how you are feeling at a point in time. It’s useful to be open when writing a reflection, and feeling comfortable that whoever reads your entries will treat this information as confidential, and be supportive and developmental in their feedback. Though, it is sometimes easy to fall into doing a lot of description, and sharing of feelings, but less about how this has impacted upon your learning, and any changes you might make. Hence, why having some models to frame your reflection upon can help.

One of the earliest theorists to consider reflective learning was Dewey. His thoughts were that reflection was potentially very useful when making sense of situations that we may have found difficult. To learn from it required a description of the event and questioning ourselves to analyse why it occurred in that way, and considering ways to change the outcome of the event. (Dewey, 1933)

One of the most common theorists to come up in discussion of reflection is Kolb. His learning cycle (1984):Kolb learning cycle

It’s a very simple model. But what I don’t like about it is that one of the stages is to ‘reflect’ and I find that it doesn’t help with structuring the reflection. Instead, I would use this model in association with another model, that discusses the reflection in greater depth.

So we come to Gibbs Reflective cycle (1988).

Gibbs reflective cycle

Gibbs’ model of learning is what we call iterative – learning through repetition. The aims of his model are to:

  • Challenge assumptions
  • Explore different ways of doing things
  • Promote self-improvement
  • Link practice with theory
  • Thinking about the positive as well as the negative

I’m going to give an example of a reflection using this structure

Description – I saw a man in his 30’s who presented with haematospermia. It had happened on 2 occasions. As soon as he told me what the problem was I realised I knew nothing about the topic.

Feelings – I felt myself getting stressed because I didn’t know what I was going to do. I really had no idea whether this was something to be concerned about or not. I think, looking back, I must have looked disinterested because my mind was wandering trying to think what I was going to do, whilst he was still telling me about the problem.

Evaluation – Actually, I don’t know if he noticed just how stressed I was, as I managed to keep calm on the outside which was good. I explained a need to check some guidelines so I could quickly look on GP notebook to work out what to do! He seemed satisfied with the consultation, though I was quite worried that I’d missed something else during the time I wasn’t fully listening.

Analysis – I think my worry that I knew absolutely nothing about the topic hindered my ability to listen to the patient, and thus my consultation skills were not up to scratch. If I had been able to keep calm, and think ‘I can look this up’ earlier on, it would have facilitated a better consultation.

Conclusion – I could have been completely open with the man and said I wasn’t sure and needed to have a look/ask a colleague. I could have done this during the consultation or afterwards and followed this up with a call. I also think that I need to separate my concern about a lack of knowledge from the consultation structure. It hampered the consultation, and added extra stress.

Action plan – I will read up on haematospermia more thoroughly, and this might lead on to other men’s health topics I have less knowledge about. I will also try and role play some consultations where I really don’t know the answer, and try to focus on what I can do. I can also try out different ways to signpost that I need to look up some information.


  • Dewey, J. (1933) How We Think. A restatement of the relation of reflective thinking to the educative process (Revised edn.), Boston: D. C. Heath.
  • Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.
  • Gibbs G (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.