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“You have been asked to see Sarah Canning, aged 40-years, who has had a confirmed segmental, non-severe pulmonary embolus on CT scanning after a long-haul flight from South Africa. Please counsel her for the suitability of and cautions for treatment with warfarin and answer any of her questions.”
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This case centres around the confirmation of a diagnosis of pulmonary embolus (PE) after a long haul flight and the need for warfarin treatment, as per the National Institute of Clinical Excellence (NICE) guidelines.
There are other oral options for anti-coagulation, but also, injectable, depending upon the clinical situation. We are going to go through warfarin treatment, as there are a number of issues which have to be dealt with when counselling someone for warfarin treatment.
The doctor here introduces herself and ensures she has the correct name and age. She then launches into the confirmation of the diagnosis. The history this patient has can be watched here. However, in the exam, you will not have the luxury of having taken a history from the condition you are communicating about, and therefore you should obtain a brief history of the the patient’s presentation.
DO NOT TAKE A FULL HISTORY
This is a communication skills station and as such, the history should be focused to help determine the best treatment options and appropriate counselling.
It is also useful here to ask, before you provide the confirmation of the diagnosis of pulmonary embolus (PE), of what the patient’s thoughts are of their diagnosis. For example, if they have cancer, and they have no idea, then this will mean you should be careful in explaining the diagnosis. If however, they straight away say, ‘I think I have cancer’, then this allows you to approach the subject more directly.
At 00:28, after telling the patient the diagnosis, her shock is audible and can be seen, and the doctor wisely allows her some moments of silence to take the information in. This is important – do not be afraid to say nothing for a few moments. Often, in our desire to help reassure a patient, we want to talk, and we talk a lot. However, it is important to allow the patient to listen and then take in the information before being given more.
00:42, the doctor now tries to reassure her of the availability of treatments and their success. Note how she does not use percentages or averages, but gives general information currently, as the patient would not be in a position, yet, to take in numbers and so on.
00:55, the family history for thrombo-embolic phenonema is important, as currently, we are treating this as a provoked PE which currently requires 3-months of treatment. If however, as in this case, there is a family history, this might require further investigations.
In addition, it allows the patient to talk about her fears which can be addressed.
01:20, the doctor provides her condolences and acknowledges that the patient is concerned. She then reassures her again, which is required.
The doctor then goes through, in lay language, how PE can be life threatening, or not of significant concern. As the doctor was not involved in the patient’s family care, it would not be appropriate for her to comment on the case. However, by talking about PE spectrum of disease in general, she recognises that it can be life-threatening, but also that the patient does not have a life-threatening PE.
01:50, the patient has been concerned, but the doctor, does not launch into treatment, but checks with the patient that she would like to have this discussion. Do not be afraid to ask the patient what they want to know.
02:00, she checks about her other risk factors and lifestyle and medication issues that might affect warfarin/anticoagulation treatment. In particular alcohol intake and her plans for pregnancy.
03:24, the doctor checks she does not have any further questions about what she has talked about before she carries on. This allows you to ensure you have explained everything up until then.
03:40, the doctor gives reassurance about warfarin and does it in a non-judgemental manner.
The doctor explains everything in lay language, not using medical jargon and ensures that information is given slowly and hence understood.
The doctor keeps checking that the patient does not have any questions, and allows opportunities for the patient to clarify.
When talking about the foods that need to be avoided, instead of giving a long list of foods, and for you, the doctor, having to remember these, the doctor instead says she will provide a leaflet, which the patient can then use in her own time. She does specify alcohol, because this is key.
Near the end, she asks the patient to feedback the information to ensure the information has been understood.
At the end she does check if there are any questions, before going through into the need for further investigations required after she completes treatment.