FCM WK1 CASE 4

In Year 4 PCC, you have had opportunity to consult with a person using a translator.

The GMC in Good Medical Practice (2013) state the importance of effective communication:

“You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.”

In a systematic review by Flores (2005), 36 articles were found looking at how interpreting impacted on quality of health care. Good quality interpreting improves patient satisfaction and better care that they receive. There is a negative impact on care when there are no interpreters or poorly trained interpreters. This particularly affects patients with mental health conditions.

The barriers to good utilisation of interpreters that Flores (2005) cites include a lack of information on the cost of interpreters, lack of doctor awareness of the work of interpreters, and potential errors by interpreters. There is also a potential increase in the consultation time.

In Year 4 PCC, you have had opportunity to consult with a person using a translator.

The GMC in Good Medical Practice (2013) state the importance of effective communication:

“You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.”

In a systematic review by Flores (2005), 36 articles were found looking at how interpreting impacted on quality of health care. Good quality interpreting improves patient satisfaction and better care that they receive. There is a negative impact on care when there are no interpreters or poorly trained interpreters. This particularly affects patients with mental health conditions.

The barriers to good utilisation of interpreters that Flores (2005) cites include a lack of information on the cost of interpreters, lack of doctor awareness of the work of interpreters, and potential errors by interpreters. There is also a potential increase in the consultation time.

There are several potential barriers to using a family member to interpret for a patient (Huang et al 2009):

· Confidentiality issues

· Reluctance to discuss medical problems with family present

· Family member not understanding medical terms and therefore translating wrongly

· Poor interpreting skills from interpreter, so misunderstanding the doctor’s questions

· Longer consultations as questions need to be repeated

Helpful guidance for medical students created by the Division of Medical Education. Please take a look at this and this can be applied in future similar consultations.

As seen in the document, there needs to be preparation before a student arrives at the practice, further clarification during induction and specific tasks undertaken during the consultation. There should also be opportunities for feedback after the consultation.

·          Insulin

.Consider alternative tablets. Insulin is a later consideration in type 2 diabetes management.

·          Gliclazide

.Correct answer.

Gliclazide, a sulphonylurea is selected as an alternative medication to manage his diabetes.

·          Alogliptin

.Not licensed for monotherapy.

Helpful guidance for medical students created by the Division of Medical Education. Please take a look at this and this can be applied in future similar consultations.

As seen in the document, there needs to be preparation before a student arrives at the practice, further clarification during induction and specific tasks undertaken during the consultation. There should also be opportunities for feedback after the consultation.

Dogra et al (2003) provide a good summary of Cultural Sensibility. Sensibility refers to being able to understand the reason for something or why someone’s actions. Cultural sensibility applies this sensitivity to situations where culture is a factor. The aim is to improve medical student self-awareness, and to question their ideas on cultural issues, in order to deliver healthcare more fairly. This removes assumptions and therefore allows a student to explore issues more objectively and without bias. They also need to see a patient as an individual, and not be biased by preconceived ideas of a particular group or community.

Students should consider that Mr Khan is from Iran, but not to have any preconceived ideas about his lifestyle and diet. An example is that he likes steak and chips, rather than a traditional Iranian meal. Another example is that he enjoys Pilates classes, again not something a student may associate with a patient from the Middle East. This information would only be elicited if a student had a culturally sensible approach to the consultation.

Primary prevention in diabetes is not relevant as Mr Khan already has diabetes. Secondary care measures to prevent diabetic complications include the bloods and urine outlined, to assess glycaemic control, renal function , BP and BMI. Mr Khan will also have annual retinal screening to ensure adequate health of the eye. Tertiary measures would look at managing established complications of diabetes. This could include management of common complications, such as coronary heart disease, chronic kidney disease, glaucoma and leg ulcers.

·          Alogliptin

.Alogliptin dosage needs to be reduced given CKD and this will affect how well it works to reduce HBA1c.

·          Gliclazide

.Correct answer.

Gliclazide is the best option as it is cheaper and can be given to patients irrespective of heart failure and CKD.

·          Pioglitazone

.Pioglitazone is contraindicated in heart failure.

·          Chest radiograph

.Correct answer.

·          HIV blood test

.Assuming that someone has underlying HIV is not culturally sensible, as it is assuming that symptoms are based on the ethnic origin of the patient. Basic tests such as chest radiograph and sputum culture can help explore the differential diagnosis, but to consider co existing HIV with T.B is an assumption too far.

·          Sputum culture

.Correct answer.

·          An 80-year-old patient with diabetic nephropathy coming in to have their U+E checked

.This patient is tertiary prevention. 

·          A 48-year-old non diabetic man who comes in to have his HBA1C checked

.This patient is primary prevention.

·          A 72-year-old patient with diabetes coming in to have their HBA1C checked

.Correct answer.

This patient is secondary prevention.