Domain – Education in general practice (case)

You are a GP in training, working in a regional group general practice. You have been asked by the GP supervisor to run a teaching session for the final year medical student on lower back pain. The one-hour session is scheduled in the following week.

Communication and consultation skills

How would you decide what to include in this session?

Deciding What to Include in the Session

• Assess Prior Knowledge:
  • Ask the student about their previous experience with patients having lower back pain.
  • Identify gaps in their understanding and tailor the session to address these areas.
• Core Topics:
  • Epidemiology and Etiology:
    • Prevalence and risk factors.
    • Common causes (muscle strain, herniated disc, degenerative changes, etc.).
  • Differential Diagnosis:
    • Mechanical vs. non-mechanical causes.
    • Referred pain from visceral organs.
    • Psychosocial factors contributing to pain.
  • Red Flags:
    • Symptoms indicating serious pathology (e.g., cauda equina syndrome, malignancy, infection).
  • Assessment Techniques:
    • Comprehensive history taking (onset, duration, nature of pain, aggravating/relieving factors).
    • Physical examination (inspection, palpation, range of motion, neurological assessment).
  • Management Strategies:
    • Non-pharmacological: Physical therapy, exercise, ergonomic advice.
    • Pharmacological: NSAIDs, muscle relaxants, analgesics.
    • Interventional: Injections, referral to specialists.
  • Patient Education:
    • Importance of activity modification, weight management, and ergonomic adjustments.
  • Safety-Netting:
    • Educating patients on when to seek further medical attention.

How would you ensure cultural safety for your learner in your teaching session? What if the student identified as Aboriginal or Torres Strait Islander?

Ensuring Cultural Safety

• Discuss how cultural beliefs and practices can influence patient care and management.
• Use culturally relevant case studies and examples.
• Encourage an open and respectful dialogue about cultural differences.
• Create a supportive atmosphere where the student feels comfortable expressing their views.
• If the student identifies as Aboriginal or Torres Strait Islander
  • incorporate indigenous health perspectives.
  • Acknowledge Country:
    • Begin by acknowledging the traditional custodians of the land. This can be done by saying, “I would like to acknowledge the Traditional Owners of the land on which we meet today, and pay my respects to Elders past, present, and emerging.”
  • Understand Cultural Protocols:
    • Familiarize yourself with local ATSI cultural protocols, which may include specific customs or traditions relevant to the community.
  • Involve ATSI Representatives:
    • Invite ATSI representatives to participate in planning the meeting. This ensures their perspectives and needs are considered from the outset.

How might role play be used as a learning activity for the student in this session?

• Simulated Consultations:
  • Organize role plays where the student acts as a GP, and you or a colleague act as the patient with lower back pain.
  • Focus on history taking, physical examination, and patient communication.
• Feedback:
  • Provide immediate, constructive feedback on their performance.
  • Highlight strengths and areas for improvement.
• Scenarios:
  • Develop diverse scenarios, including common presentations and red flag situations.
  • Include culturally sensitive scenarios to practice culturally competent care.

What techniques would you use to ensure the session is interactive?

Clinical information gathering and interpretation

What would you like to know about the student that would help you plan the session?

• Background Information:
  • Inquire about the student’s clinical rotations and any specific experiences with lower back pain cases.
• Learning Style:
  • Ask the student about their preferred learning style (visual, auditory, kinesthetic) to tailor the teaching approach.
• Specific Interests:
  • Identify any particular areas of interest they have within musculoskeletal or pain management.

On reflecting on your own clinical practice in assessing and managing back pain, what important lessons could you share?

Lessons from Clinical Practice

Common Pitfalls:

• Share examples of common diagnostic errors and how to avoid them.Discuss the importance of a thorough history and examination to avoid missing red flags.

Clinical Pearls:

• Provide practical tips, such as using a systematic approach for the physical exam.Emphasize the importance of patient education and reassurance.

Patient Communication:

• Highlight the importance of empathetic communication and building rapport with patients.Share techniques for explaining complex medical terms in simple language.

Does your supervisor have any areas they would like you to include in the session? – Noooooooooooooooooooooooo. too busy earning $$$$$

Making a diagnosis, decision making and reasoning

If the student wants to use this session to discuss a case, how could you use this to maximise their learning?

• Relevance:
  • Select cases that are common in general practice and relevant to the student’s future clinical work.
• Structured Approach:
  • Use a systematic format for case discussions, such as SOAP (Subjective, Objective, Assessment, Plan).
  • Guide the student through each step, encouraging them to think critically and apply their knowledge.
• Interactive Discussion:
  • Encourage the student to ask questions, propose differential diagnoses, and suggest management plans.
  • Provide feedback and discuss alternative approaches to management.

What are the main learning outcomes you think are important for this session?

• Knowledge:
  • Understanding the common causes and red flags of lower back pain.
  • Familiarity with evidence-based guidelines for diagnosis and management.
• Skills:
  • Proficiency in history taking and physical examination specific to lower back pain.
  • Ability to develop a differential diagnosis and management plan.
• Attitudes:
  • Developing empathy and effective communication with patients.
  • Awareness of the importance of cultural competence in patient care.

How would you approach this if these outcomes don’t align with the student’s outcomes?

• Negotiation:
  • Discuss with the student their learning objectives for the session and how they align with your planned outcomes.
  • Negotiate to find a balance between their goals and the essential topics you need to cover.
• Flexibility:
  • Be open to adapting the session to address the student’s specific interests and needs.
  • Ensure that key learning outcomes are still met, even if adjustments are made.

Clinical management and therapeutic reasoning

What resources might you use to enhance the student’s understanding of clinical reasoning?

• Guidelines: Provide access to Australian clinical guidelines (e.g., RACGP guidelines) and explain how to use them.
• Articles: Share key journal articles on the assessment and management of lower back pain.
• Textbooks: Recommend relevant chapters from medical textbooks on musculoskeletal disorders and pain management.
• Online Resources: Introduce reputable online resources, such as UpToDate, to supplement learning.

What specific teaching activities could you use to achieve optimum learning?

• Clinical Skills Practice:
  • Conduct hands-on practice sessions for physical examination techniques.
  • Use mannequins or simulated patients if available.
• Interactive Case Studies:
  • Analyze and discuss detailed case studies, encouraging the student to apply their knowledge.
• Simulations:
  • Use simulation scenarios to practice managing acute presentations and identifying red flags.
• Reflection:
  • Encourage the student to reflect on their learning experiences and clinical encounters.

Preventive and population health

In setting up the session, what would you do to create an environment conducive to teaching and learning?

Ensure a comfortable and quiet space free from distractions.

How would you approach this task differently if you were asked to run an education session for the other doctors in the practice? Or for a community group?

• Doctors:
  • Focus on advanced clinical reasoning, recent research findings, and evidence-based practice.
  • Encourage peer discussion and sharing of clinical experiences.
• Community Groups:
  • Simplify medical terminology and focus on practical advice for managing lower back pain.
  • Use relatable examples and engage the audience in discussions about their experiences.

Are there other health professionals in the community that you could suggest the student spend time with to further their knowledge of back pain management?

• Allied Health:
  • Suggest spending time with physiotherapists to learn about physical therapy techniques.
  • Recommend shadowing occupational therapists for ergonomic advice and workplace assessments.
  • Encourage observation of chiropractors or osteopaths for alternative management approaches.
• Multidisciplinary Approach:
  • Highlight the importance of a team-based approach in managing chronic lower back pain.

Professionalism

How will you know that your teaching session has been effective?

• Feedback:
  • Use formal (e.g., evaluation forms) and informal (e.g., verbal feedback) methods to gather feedback.
  • Assess whether learning objectives were met through feedback from the student and supervisor.
• Assessment:
  • Include quizzes or practical assessments to evaluate the student’s knowledge and skills.
• Reflection:
  • Encourage the student to reflect on their learning and identify areas for further improvement.

How will you ask for and receive feedback about your teaching? How could you incorporate this into your own learning plan for education?

Receiving Feedback

Direct Feedback:

• Ask the student for immediate feedback after the session.Encourage honest and constructive feedback.

Anonymous Surveys:

• Use anonymous surveys to gather candid responses and suggestions for improvement.

Incorporation:

• Reflect on the feedback and incorporate it into future teaching plans.Develop a personal learning plan to enhance your teaching skills based on the feedback.

If the student became distressed during a case discussion, how would you manage this?

• Support:
  • Provide emotional support and allow the student to take a break if needed.
  • Acknowledge their feelings and offer reassurance.
• Resources:
  • Refer to counseling services or support networks if necessary.
• Debrief:
  • Discuss the distressing issue in a supportive manner.
  • Encourage the student to express their thoughts and feelings.

What information would you share with the medical student’s supervisor about the student’s participation in the session? – again he is too busy doing GMP and TCA to notice

General practice systems and regulatory requirement

How could you ensure your teaching session covered all the domains of general practice? What organisational legal dimensions should be mentioned? If you or the student wished to discuss a patient, how would you ensure confidentiality?How would you explain to a patient and get their consent if this was a teaching session with the patient present?

Covering All Domains of General Practice

• Clinical Competence: Ensure coverage of clinical knowledge and skills.
• Communication: Include aspects of patient communication and education.
• Professionalism: Discuss ethical and professional behavior.
• Critical Thinking: Encourage clinical reasoning and problem-solving.

Organisational Legal Dimensions

Consent: Emphasize the importance of obtaining patient consent.Confidentiality: Discuss maintaining patient confidentiality.Documentation: Highlight proper documentation practices.

Ensuring Confidentiality

Anonymization: Use anonymized cases when discussing patients.Consent: Obtain explicit consent if discussing identifiable patient details.

Patient Consent for Teaching Session

Explanation: Clearly explain the purpose of the teaching session to the patient.Consent: Obtain written or verbal consent from the patient.Respect: Respect the patient’s decision if they decline to participate.

General Practice Systems and Regulatory Requirements

Compliance: Ensure adherence to local and national regulatory standards.Guidelines: Follow clinical guidelines and protocols.Documentation: Maintain accurate and detailed patient records.

Procedural skills

If the student wanted you to teach them how to instruct a patient to do back exercises, what steps would you plan for in your session? What techniques are required to ‘teach a skill’? If you decide to include examination of the back, how will you go about instructing this?

Teaching Back Exercises

• Demonstration: Show the student how to perform each exercise.
• Practice: Allow the student to practice the exercises.
• Feedback: Provide constructive feedback to ensure correct technique.

Instructing on Back Examination

• Step-by-Step: Break down the examination into clear, manageable steps.
• Demonstration: Perform the examination on a model or simulated patient.
• Practice: Supervise the student as they practice the examination.

Managing uncertainty

In general practice, there is often uncertainty. How could you work through this in the case of lower back pain? How could you help guide the medical student on managing uncertainty in low back pain?

• Acknowledgment: Recognize that uncertainty is a part of general practice.
• Guidance: Provide strategies for managing uncertainty (e.g., safety-netting, follow-up plans).
• Critical Thinking: Encourage the student to think critically and use a systematic approach.

Identifying and managing the significantly ill patient

How could you support the medical student to understand how to safety-net? Did you consider this part of your presentation? Did you include red flags in your presentation?

Teaching Safety-Netting

• Definition: Explain the concept of safety-netting and its importance.
• Examples: Provide practical examples of safety-netting in lower back pain management.
• Practice: Role play scenarios where safety-netting is used.

Including Red Flags in Presentation

• Importance:
  • Highlight the significance of recognizing red flags that may indicate serious underlying conditions.
• Examples:
  • Provide a list of red flags for serious conditions such as cauda equina syndrome, malignancy, infection, and fractures.
  • Discuss the appropriate actions to take when red flags are identified, including urgent referral and further investigations.