Tutorial 5th. May 2011

Podcast.
Website.
We started with you being asked to write a report for the risk management committee about a patient who had a post-operative problem that was not very well managed. This is a very typical station and you can easily manufacture an example or two. The parallel obstetric station will usually be mangement prior to delivery with failure to deploy a protocol, late involvement of the consultant etc. Abeer, who joins the tutorials on-line sent her example to me wondering how best to answer it. I changed her version slightly. Send me an e-mail and I'll e-mail it to you so that you can print it off. My e-mail is on the webpage: http://www.drcog-mrcog.info/contact.htm.
You are going to be asked what information you don't have and who needs to be asked to write a summary of their involvement to provide it. You may be asked to point out areas in which care may have been deficient and how this can be assessed. You may be asked about implications for the O&G department or the whole Trust. Remember that the incident might indicate a need for an audit.
You are likely to be asked about complaints and litigation and how to lessen the chances of the patient going down this route - all stuff that we have discussed on a number of occasions. The strategy is to make sure that she is given all the facts by someone senior, total honesty being the policy. You tell her how to make a complaint and to pursue litigation. In real life, as in the exam, this tends to defuse the situation. You talk about the seriousness of the adverse clinical incident investigation procedure and the outcomes for those found negligent, including you! This ranges from re-training and restrictions on what you can do to getting the sack and being reported to the GMC.
You are usually going to have a number of issues that need you to display "senior doctor thinking" - how often have you now heard that?
Then it is about scrutinising the details of the case. The case we dealt with was a woman of 48 having hysterectomy for fibroids. Why 48? Because it raises issues about her being close to the menopause and the operation being unnecessary.The problems caused by the fibroids were not specified, nor did we know their size, number or location.
What was done by whom and were they qualified to do it? What was not done that should have been done? What was done but later than would have been good care? And so on.
These scenarios are all very similar. You will have a pre-op problem: obesity, medical disorder, penicillin allergy, bleeding disorder, history of VTE etc. You will have an operation that may be inappropriate. A failure to do a proper assessment pre-operatively e.g. the WHO check list (which we failed to work into the viva) and so on. Then the post-operative care will usually be deficient. Things like pyrexia or hypotension + tachycardia will be ignored, the consultant will be involved too late, investigations will not be asked for or the results will be misinterpreted. The records will be poor with dangerous phrases like "routine procedure" for an operation, "observations stable" or "observations normal" without saying what they observations were. I think the group covered it pretty well.
Then we discussed a patient with inoperable cancer coming to clinic for the results of the tests that showed pelvic recurrence of a cervical cancer and a lung metastasis. You had to discuss the results and her subsequent care. Unfortunately, I turned off the recording when they were writing their plans and was slow to turn it back on again, so the early part of the discussion is missing.
I'll write something tomorrow. Send me your plan and I'll send mine. My e-mail is on the webpage: http://www.drcog-mrcog.info/contact.htm.  But don't ask for mine until you have attempted to write an answer. Tackling these difficult stations is essential preparation for the exam.
My thoughts and best wishes go with all of you who are sitting the exam next week. Let me know how you get on.