WK 2 CASE 1

BBC News: Skin cancer linked to package holiday boom

Dr Ahmed takes the article and reviews it, but as he does so, notices that Mrs Gerald is looking down, with a wrinkled forehead and slightly down-turned mouth; Dr Ahmed thinks that she looks worried.

How might the GP encourage Mrs Gerald to speak about something which is worrying her?

Encouraging the patient to speak about what is their focus, helps you as the doctor build the relationship, in addition to gaining valuable information from the patient about why they have presented themselves to the doctor at that time, which may be important as you are diagnosing and formulating investigation and management plans. This forms part of the Calgary Cambridge framework, which you are familiar with.

Reference

Kurtz SM, Silverman JD, Draper J (1998) Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press (Oxford). Silverman JD, Kurtz SM, Draper J (1998) Skills for Communicating with Patients. Radcliffe Medical Press (Oxford)

Mrs Gerald admits to the GP that her brother has recently been diagnosed at the age of 90 with prostate cancer. Her brother lives in Birmingham, and so this is a journey of over two hours from where they live. She is worried about her brother as he has had a lot of hospital appointments, investigations and side effects from treatments, and she has seen him getting more and more frail. She wishes she could be there with him. Mrs Gerald thinks that her brother would have been better to not have treatment. She is hoping that Dr Ahmed tells her daughter that there is nothing to be worried about, as Mrs Gerald knows that her daughter is worried about skin cancer. She doesn’t think it is skin cancer as she has never been abroad.

Dr Ahmed acknowledges Mrs Gerald’s ideas, concerns and expectations and advises her that he hasn’t seen the article her daughter has brought in before, so will need to take it to read it carefully after the consultation. He advises that he would like to ask some more questions and examine these moles to assess them further.

Red flags

Red flags: Term used to indicate possible serious pathology. Patients may not know that these symptoms are related to the problem they are discussing, or might not know the importance of mentioning, and so it is important that these are asked about explicitly.

IN PRACTICE:

Watch your GP consulting – do you notice them asking any ‘red flags’?

IN PRACTICE:

Over the course of the block, try to compile a list of ‘red flags’ for each main body system (respiratory, cardiovascular, urological, GI (upper and lower), neurological and skin)

The GP discovers from Mrs Gerald that she has several ‘moles’ on her back, and one on her face. She admits the one on her face has been inflammed and bleeding. She put this down to being on warfarin and thinks that she must catch it when she is washing her face. It has not been oozing and there has been no change in sensation. She does not think the ones on her back have ever bled or been itchy. She does not know if any of them have changed in shape, colour or size recently, but Fiona reports that she doesn’t remember the one on her mum’s face ‘being as big as it is now’. She does not think that any of the ones on her mum’s back have changed. Mrs Gerald does not think that any have been oozing and she has not had any change in sensation or inflammation of any of the lesions.

On examination, the GP is satisfied that all the ‘moles’ on Mrs Gerald’s back are seborrhoeic warts and therefore require no further action. You can find out more about seborrhoeic warts, also known as seborrhoeic keratoses, at this link here, and try to see some on your GP placement as they are very common. They are benign, hyperkaratotic lesions which become more common wiht increasing age.

However Dr Ahmed is concerned about the appearance of the one on Mrs Gerald’s face (the scale is 1mm between the small vertical lines and 1cm between the larger vertical lines on the paper scale):

It has deep brown and light brown pigment irregularly throughout it and an irregular edge. Dr Ahmed uses the weighted 7-point checklist as outlined in the NICE guidelines for assessment and referral of suspected skin cancer to assess this mole. You will have come across or will do more about this in your dermatology block, but as a reminder or for your further knowledge, look at the link and the information below:

NICE: Skin Cancers

Weighted 7 point checklist

Major features of the lesions (scoring 2 points each):

· change in size

· irregular shape

· irregular colour.

Minor features of the lesions (scoring 1 point each):

· largest diameter 7 mm or more

· inflammation

· oozing

· change in sensation.

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for melanoma if they have a suspicious pigmented skin lesion with a weighted 7 point checklist score of 3 or more.

Dr Ahmed makes sure that all the discussions are documented in the notes, including the benefits and disadvantages of different courses of action, and the offer of another appointment if Mrs Gerald wishes to discuss things further.

Background Science – Referrals MED 35

In case FM&PH – Referrals

When the GP considers that the patient has symptoms, signs or investigation results which could indicate cancer based on these guidelines, a ‘2ww referral’ process is initiated. Once the GP has made this decision, the referral must be made within 24 hours.

It is important that this is communicated to patients, and NICE provide the following advice:

NICE: Suspected cancer: Patient information and support

CASE COMPONENT

Case Conclusion – Referrals 

In case FM&PH – Referrals

Mrs Gerald makes an appointment for the following week. This time, Mrs Gerald comes in with Fiona but asks her to wait in the waiting room. Mrs Gerald outlines that she has thought long and hard about the pros and cons for her of a referral to see a specialist. Mrs Gerald asks Dr Ahmed if he still recommends a referral, which he advises he does. He outlines that this recommendation comes from his clinical experience and national guidelines. Dr Ahmed has read the newspaper article, which he discusses with Mrs Gerald and outlines that although the article has focussed on sun exposure abroad, it is not the only sun exposure which is a risk factor for skin cancer.

Mrs Gerald says she has also spoken to her brother about things, who had echoed the point that Dr Ahmed had made the week before about how it might be easier to treat something earlier than later. She has therefore changed her mind, and decided that she would like the referral to go ahead. She again demonstrates that she has understood, weighed up the information, retained it and communicated her decision i.e. has capacity to make this decision, and Dr Ahmed is satisfied that this is her own decision.

Mrs Gerald asks if Fiona can come in to the consultation as she hadn’t told her yet of her decision, and wants her now to be fully involved again in her medical care. Dr Ahmed checks that he is able to talk about the referral with Fiona present, and Mrs Gerald says he is. Fiona comes in and Mrs Gerald outlines that she is happy now to see the specialist. Fiona is pleased to hear her decision. Dr Ahmed advises Mrs Gerald that she should have an appointment within the next 14 days. He also checks her contact information is correct to be included on the referral.

Finally, Dr Ahmed books a reminder on the computer system for a reminder for 3 weeks’ time to check that Mrs Gerald has been seen. This is an additional safety net which some GPs might use to ensure that important referral appointments such as those on a 2ww pathway are kept.

IN PRACTICE:
Ask if your GP has any additional safetynets in place regarding 2ww referrals. How much do you think is the responsibility of the patient? How much is that of the GP? You could discuss this with your tutor.

Formative Assessment – Referrals