In what situation? Learning trigger?
John is a GP and has just seen a 52 year old patient in surgery. The patient has had diabetes for five years but the patient does not want to have any medication, despite his blood sugar continuing to rise. John is unsure whether to be more forceful in his advice to encourage the patient to start medication.
What happens? (Sequence of the main actions performed), With which tools and physical objects?, Which actors are involved?
- John is unsure of the risks /benefits of starting medication. He wants to be sure that he is giving evidence based “best” advice (information need seeking). He looks up the latest advice on the NICE website by using the practice computer before leaving surgery to go home at the end of the day. After reading the website, he is still unsure what to do.
- John remembers in the car whilst driving home that there was a recent article in the British Medical Journal (BMJ) about dilemmas in treating diabetics. He cannot remember the exact date but uses Google Scholar on his home computer to find the article. He finds the article but needs to access the full text of the article by logging onto his BMJ account. After reading the article, he is still unsure what to do.
- John is in a dilemma and decides to ask one of his partners in the practice over coffee the following morning (opinion need seeking). His partner is also uncertain. They both feel that they should be more forceful in their advice but would like to have a second opinion.
- John decides to search Google again when he arrives home that evening from his home computer but becomes frustrated since he is overwhelmed by the wide range of different information on the main medical information web sites that he frequently uses – GP Notebook, Medscape, SIGN guidelines.
- John writes an email the following morning using the NHS net email system on the practice computer to the local hospital consultant in diabetes asking for his advice. John had not been able to do this from home as he was unable to access his NHS net email account from his home computer. At the practice he has to put in a smartcard before he has access to either SystmOne (the patient record system) or NHS.net email. The consultant replies by the end of the day but the consultant does not give a definitive answer. The consultant gives the advantages and disadvantages of both starting medication or not starting medication at this moment in time.
- John decides to start medication and over coffee the following morning he tells his partner about what he has decided to do (validation seeking). His partner agrees that commencing medication appears to be the best option for the patient at this time.
- John decides to share his dilemma and the advice of the consultant at the next face to face practice meeting, since at this meeting are the rest of the partners, the registrar (Rebecca, a qualified doctor now undertaking training to specialise as a GP) and the two practice nurses that have a special interest in diabetes.
- There is a lively discussion about this case at the practice meeting, with people sharing their experiences and pointing to relevant research (both in terms of the benefits of medication and the benefits of involving patients in their treatment discussions and decisions). It is clearly seen as being a complex problem with no clear right or wrong answer. In general most people support John’s decision. No detailed notes are kept of the discussion or the esearch/experiences referred to and this discussion is not formally followed up at another meeting.
- Rebecca (the registrar) did not contribute much to the discussion but listened closely. She felt that the decision was probably right but she would have liked to see the patient more actively involved in reaching the decision with the GP. She goes home and writes a reflection on this and sets out some ways in which you could involve the patient. She puts this in her portfolio as an example of reflection and learning in practice. Next time she is in a comparable situation with another patient she tries to involve them in the reviewing of the material and the decision making process and she updates her portfolio with the outcomes of using this approach. She finds this approach very interesting and continues to record episodes like this in her portfolio. However, these reflections are only shared with her GP Trainer, not more widely across the practice. Once she qualifies as a GP she continues to take an interest in this area, ultimately working with patient and public involvement groups and undertaking research and publishing papers and giving conference presentations on effective methods of working with patients who have long-term critical illnesses in order to recognise their expertise and experience and involve them effectively in their treatment discussions and decision-making.
The final result
- John identifies a specific learning need (opinion) but first turns to an information source that does not offer opinion but is easily accessible from the consulting room.
- John is prompted to continue further learning by reflection in an informal situation. This reflection prompts recall of previously read information but cannot readily access what he had read.
- John prefers a quick response to his learning need for opinion by contacting the local consultant
- John’s discussion face to face helps to clarify his learning need to that of wanting validation of his actions.
- John has searched for information, sought an opinion, reached his own decision (based on his analysis of the general information he has been given and his understanding of the patient and their condition) and finally checked his decision with a trusted colleague. On reflection John would consider this to be a learning episode, but he has not recorded any of this in his record of continuing professional development as evidence of learning.
- There is an opportunity for others to learn from John’s experience and the wide ranging discussion at the practice meeting. But this discussion is not recorded and most of those present do not formally record this discussion as evidence of learning.
- John feels that the discussion at the practice meeting was further validation of his decision and he was pleased to see that others also considered it to be not straightforward.
- John will get further validation (or counter evidence) that his decision was right based on his observation of the patient’s condition and personal reaction following the start of the medication. Again however this is unlikely to be formally recorded anywhere as evidence of John’s learning and John may not have the time or opportunity to share this with the rest of the practice.
- Rebecca feels strongly that the discussion in the practice meeting has had a long-term impact on her practice and working life. She found the ideas raised in the discussion very interesting (and they linked to some of the ideas raised in her undergraduate medical degree which had a high patient involvement). She learned a lot not only from the discussion but from her subsequent reflections and actions and this has led to her now (4 years later) being a ardent enthusiast in the area of patient involvement.