GP Stage 3 Simulated Consultation - Patient 4
You are an FY2 working in a GP surgery and your next patient is Miss Alice Lindhoff, 43. You can see in the notes that one of the GP Partners (who is presently on holiday) had reluctantly referred her to the local minor surgery clinic (run by GPs and nurse practitioners) for a lesion on her left arm, which your colleague believed did not require any dermatology input, however Miss Alice Lindhoff insisted on having it removed. She has now attended to discuss the results of her recent skin biopsy, the summary report of which is as follows:
‘Invasive malignant melanoma with clear cell features. Breslow depth 6mm.’
Reference Information (British Association of Dermatologists): Breslow Depth >4mm = 50% Approximate 5 Year Survival
You are Miss Alice Lindhoff, a 43 year old lady who had a skin biopsy taken from your left arm recently, after insisting that the GP refer you to have it removed. You have attended the GP surgery to discuss the results, and are now seeing a different doctor.
You suspect that the lesion may be harmless, however you were very keen to have it removed as your friend was recently diagnosed with skin cancer after having a similar lesion removed. You have limited medical background knowledge, and are pleased to hear that the diagnosis is not cancer, for candidates using the medical term ‘Malignant Melanoma’ (This is a form of advanced skin cancer).
You are distraught to hear the diagnosis (if directly advised that you have cancer), and require significant consoling. You are also furious that this was potentially missed two months ago when you first came to the doctor and they decided that nothing further needed to be done. In particular, you are not sure how you will cope at home (previously independent, living alone at home), and how the cancer will affect the rest of your body as well as your work as a partner at a prestigious law farm. You also would like to know what the next step is, as well as the prognosis.
This consultation tests a candidates ability to break bad news as well as provide necessary information, in a jargon-free manner. Candidates require a sensitive, yet focused approach providing the diagnosis in a clear manner, as well as providing appropriate emotional support thereafter. Despite the ‘reference’ information provided, it is essential for candidates to demonstrate an understanding of their limitations and seek to involve senior/specialist input rather than providing specific detailed information regarding prognosis and on-going management, given that this is generally patient specific. Given, the need for urgent specialist referral, it would not be appropriate to defer/delay the biopsy results as well as need for urgent specialist input.
S – Setting up the interview (preparing yourself and the consultation setting)
P – Perception (Understanding the patient's perception of their condition and it's seriousness)
I – Invitation (Wait for the patient to invite you to deliver the bad news)
K – Knowledge (Knowledge and information transfer to the patient)
E – Empathy and emotional support
S – Summary and strategy for the future