Problem based learning: fitness to fly, DVLA and holiday insurance”
14th Feb 2012
How to use this booklet
You will be working in small groups and should work through the scenarios one page at a time.
Most pages will involve either a consultation role play or a group task. Before moving on to the next page the group must define any learning needs prompted by the material.
The roles can be played by males or females, just alter the names!
The learning needs must be allocated to individuals who will feedback next week (21st February)
You will not get through the whole booklet on 14th but will need to scan the remaining pages at the end of the session to define all the learning needs for next week.
Scenario one.
You are consulted on Monday morning by Malcolm and his wife Judith.
Malcolm is 65 and is a retired from being a building inspector 5 years ago. Judith was a nurse at the local hospice until she retired two years ago.
You are aware that Malcolm is suffering from early vascular dementia. He also is being treated for hypertension.
Malcolm and Judith have come for a review of his blood pressure control and treatment.No changes are required. His blood pressure is well controlled and routine bloods are satisfactory.
On enquiring about his forgetfulness Judith tells you that Malcolm does is unable to remember where utensils and food are put away in the kitchen and repeatedly asks where things go. He needs prompting in a morning to help him find the correct drawers containing his clothes. He is otherwise cheerful and cooperative and enjoys walking the dog by himself.
Judith volunteers that Malcolm is still driving. This is not an area you have discussed before.
Choose volunteers to role play the doctor, Malcolm and Judith.
The information for Malcolm and Judith are in a separate envelopes
Before starting discuss what the challenges are in this consultation in terms of consultation skills ( 2 persons present), clinical decisions and ethics.
Who might help you assess Malcolm’s ability to drive?
After the consultation half the observers should give feedback based on the list derived from the above and half should use the CSA feedback overleaf.
Define learning needs for the group
CSA SCORING SHEET FOR OBSERVERS
Data Gathering and Examination Skills
PositiveNegative
Clinical Management Skills
PositiveNegative
Interpersonal Skills
PositiveNegative
Additional notes e.g. consultation structure, time management, agenda setting etc
3 things to change or try
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Scenario 2
Some weeks later you get a message from the reception staff asking you to return a call from Charles who is Malcolm’s son and who lives in Manchester.
The receptionist tells you that Charles wants to speak to you about his father’s driving.
What issues could be raised and how will you deal with them?
Elect members of the group to be the doctor and Charles.
The information for Charles is in a separate envelope
Role play the telephone conversation by sitting back to back
The rest of the group should give feedback after the consultation on the points discussed prior to the consultation.
Now define some futher learning needs.
Trevor is age 70 and is an ex-smoker. He was diagnosed as having COPD ten years ago and is treated with tiotropium, salbutamol and fluticasone/salmeterol inhalers. He is quite breathless after walking down the corridor to your room but recovers after a few minutes sitting.
He comes to see you for his review and you notice that his ‘MRC dyspnoea score’ has not been completed in his records. You are not sure quite what this means but remember that your practice needs to do better on this QOF indicator.
If you have 100 patients with COPD in your practice how many will have to have an MRC dyspnoea score recorded to meet (a) the lower QOF target (b) the higher QOF target? How much money does this represent?
Trevor tells you that he has booked to fly to Australia to visit his family. He thinks that if he doesn’t go soon he will be too frail to make the trip.
Why may air travel present problems for Trevor?
How will you assess Trevor’s fitness to fly in relation to his COPD?
What would you do if supplementary oxygen or a wheelchair is required?
Consider the implications for flying in patients having had the following:
- Laparoscopic cholecystectomy
- Drainage of a spontaneous pneumothorax
- Middle ear surgery
Define some learning needs for the group
Scenario three
Raymond has made a review appointment to see you about his diabetes.
He is 65 years old and a retired estate agent
He was diagnosed with type 2 diabetes one year ago and initially had a trial of diet.
His HbA1c remained above 8.0% despite an adequate trial of diet alone and so he was started on metformin 500 bd 6m ago.
Further assessment of his vascular risk one month ago led you to start simvastatin 40mg daily as well as rampril 5mg per day.
You have arranged to see him to review progress.
Elect a doctor to undertake the consultation
The instructions for Raymond are in a separate envelope.
After the consultation give feedback to the ‘doctor’ using the CSA sheet overleaf.
Now consider the particular challenges in this consultation and how they could be
managed.
If you were asked to fill out a form confirming Raymond’s fitness to travel would you charge him? If so how much? Why can/should you charge for this service?
Define any learning needs
CSA SCORING SHEET FOR OBSERVERS
Data Gathering and Examination Skills
PositiveNegative
Clinical Management Skills
PositiveNegative
Interpersonal Skills
PositiveNegative
Additional notes e.g. consultation structure, time management, agenda setting etc
3 things to change or try
1
2
3
Raymond and Cynthia return from their cruise having obtained cheaper insurance from another company.
Unfortunately Raymond’s glycaemic control remains poor despite increasing his metformin to 1g BD.
You decide to add gliclazide 80mg BD to his treatment regime.
You are alarmed to receive an A/E note to say that Raymond has been involved in an RTA due to a suspected hypoglycaemic episode.
What advice should you have given to Raymond at his last review? Where would this advice be found?
Define any learning needs
Describe the effects of the following on :
1. a class 1 driver
2a class 2 driver ie HGV license holder
- MI
- TIA
- Stroke
- A single epileptic fit
- Syncope of unknown cause
- Loss of vision in one eye
If your patient wants to return to class 1 driving after a stroke resulting in a mild hemiplegia how can you arrange assessment for capability and adaptations?
Define any learning needs
Info sheets for the workbook
Judith,
You are slightly worried about Malcolm’s driving but don’t want him to feel that he is ‘useless’.
He seems to drive ‘safely’ and has not had any accidents
He has not made any mistakes on junctions, traffic lights or roundabouts and has not had any accidents.
He does need constant prompting about directions as he does not recognise where he is .
If Malcolm stopped driving life would become very difficult as you do not drive yourself and you don’t live within easy reach of shops etc.
Try to divert the doctor into ‘arranging a scan’ or ‘waiting to see what the neurologist says’ at his review appointment in 6months.
Charles
You visit your parents in Ripponden every month.
Last weekend you travelled in the car driven by your father to visit Tescos. You were really alarmed by his poor driving skills and felt that he became very confused whilst trying to drive out of the car park. You felt that an accident could have occurred at any time.
You want to know what your father’s diagnosis is and ‘what stage’ has he got to?
You don’t think your father should be driving but don’t want to tell him this yourself as he would get very upset.
You wonder if the doctor could ‘call in’, whilst ‘on your rounds’ and take the car keys away.
You don’t think your mother has been telling the whole truth about Malcolm’s driving as she feels her husband would become depressed if he was told that he was incapable of driving.
Raymond
You have recently booked to a Caribbean cruise to celebrate your wife’s 65th birthday. You and Cynthia have been planning this special event for some years.
You were alarmed to find that the cost of travel insurance was increased dramatically by your diagnosis of diabetes. The insurance company also loaded your premium on the basis of the number of medications you were taking. This number has recently jumped from one to three.
You are really fed up with the doctor who keeps adding more and more medication for your diabetes. You feel perfectly well and don’t understand what all these tablets are for.
You don’t think you will be able to afford all the extra treats for Cynthia that you had planned as well as pay the new insurance premium.
You would like the doctor to take you off some or all of your medication and sign a form for the insurance company that you are on diet alone.
You have been a patient at the practice for many years and hope that the GP will help you out on this occasion. Surely he could just alter the records temporarily?
Get as angry as you like!
Make the GP explain about your medication and try to persuade you that he cannot falsify the records.
Malcolm.
You are cheerful and dismissive about any problems that might occur whilst driving.
You have ‘driven all your life’ and don’t think that you have any problems at present.
If the doctor suggests a driving assessment you would be happy to take part as you really don’t think there will be any problems.
Remain cheerful and laugh a lot!
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