Human health + wellbeing GP SESSION 5 - Thursday 18th March 2021
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Human health + wellbeing GP SESSION 5 – Thursday 18th March 2021
This guide starts with the background to the students’ learning. The busy GP teacher will find all you
need to know for the session in the first 6 pages. This includes learning objectives for clinical contact, a
session plan, and practical guidance for managing the students’ patient contact activities.
This will be your third session with the first group of 6 students so hopefully everyone will be familiar
with the session plans and technologies used. The aim, as before, is for each student to meet a patient
either online via MS teams or by observing accuRx consultations, with the opportunity to present cases,
debrief and discuss at the end.
The students’ current case involves the urinary system so parts of this session are linked to this. This
week they will have covered “activating self-care” in their Effective Consulting session— thinking about
how patients' lifestyles contribute to their health, and how we, as doctors, motivate patients to make
lifestyle changes and manage their health and wellbeing. It’s helpful if you can share the resources you
most frequently give to patients to help them to manage their own health e.g. websites, charities, local
support groups.
Exploring sensitive topics and remote examination of the urinary/GI system are included again so that
this cohort can consider and discuss these important topics. There are some notes on all this this from
page 7 onwards, including background information on activating. There is some info the students are
given about the wellbeing wheel to support self-care and also some brief information about the creative
assignment which your students may base on a patient they met in in primary care.
All year 1 student teaching remains online and this is their only opportunity to have any authentic patient
contact which they really value and is essential for their training. We appreciate your ongoing enthusiasm
and support, and efforts delivering these complicated and busy sessions online.
Overview of the urinary case
The urinary case explores fluid balance. Two students are training for a marathon and
debate whether it is better to drink regular amounts of water or drink when thirst is
experienced. They experiment by measuring body weight before and after a one hour
run and measuring amount of water consumed. They also wonder if there is any
evidence about type of fluid consumed during exercise e.g. water vs isotonic sports drinks. The case
considers overhydration resulting in hyponatraemia, and dehydration leading to a raised haematocrit. The
case also considers a post-operative patient on IV fluids. How do doctors work out how much or how little
fluids patients need to receive whilst they are nil by mouth and cannot drink to prevent dehydration? And
whether too much fluid may result in post-operative complications?
Lectures Practicals
Introduction: fluid balance, fever, hyperventilation, sweating and diarrhoea. Daily Urinary Physiology:
requirements of fluid, sodium and potassium. Symptoms of dehydration incl. urinalysis test
Structure and function of the Urinary Tract Applied Urinary
Glomerular filtration/Tubular reabsorption and secretion anatomy and histology
Control of blood osmolarity/osmolality /Control of blood volume
Acid base balance/ Renal function tests / Nitrogen metabolism and excretion
Effective consulting lab: Small group practice with actors looking at activating people to make lifestyle
changes, thinking about the cycle of change, and briefly introducing motivational interviewing.
Secondary care: Online: assessment of the urinary system delivered by N and S Bristol academies.
1
GP SESSION 5 - Thursday 18th March 2021
Themes: Urinary
Cons skills: Activating
Session time: 2.5 hours
Start 0930 – 1200 (AM students) or 1400 – 1630 (PM students)
GP advance preparation: read this session plan. Arrange 1 patient with a urinary or renal problem to ‘meet’ the
students online. Think about how you will find the patients for the accuRx consultations
0900 – 0930 GP prep Read through these notes if not already done
1330 – 1400 time Plan for 3 consultations via accuRx – for 2 students to observe. These may be
taken randomly from your list or planned in advance. See below for details.
Start the meeting and send link to expert patient.
0930- 0950 Check in Whole group on MS Teams
1400 - 1420 (20 min) Pastoral – check in. Offer support and one-to-one chat if needed.
Run through session plan and learning objectives/tasks
Brainstorm asking sensitive questions when gathering a history
Discuss if the urinary/abdominal system can be examined remotely. Can remote
urine testing help?
Briefing on plan/important info to meet patients/observe remote consultations.
Prepare students to observe for activating within the consultation to discuss in
the debrief
0950 Pair C Pair A Pair B
1420 Leave main Teams meeting
0950- 1020 Patient GP teacher leaves Teams Meet with expert patient on MS teams.
1420 - 1450 contact once expert patient (stay in same MS Teams meeting)
(30 min) meeting started
Consult on accuRx Patient leaves when finished: then students can
debrief and practice presentations.
1020 – 1050 Patient Consult on accuRx
1450 - 1520 contact Comfort break when suits (10 min)
(30 min)
1050 – 1100 Comfort break (10 min) Watch and reflect on assigned consultation(s) on
1520 - 1530 Virtual Primary care (to present/discuss in
1100 – 1130 Patient Consult on accuRx debrief if time)
1530 - 1600 contact
(30 min)
1130- 1200 Debrief, Whole group back on teams in the original meeting
1600 - 1630 discussion Students present cases and discuss which comm skills and questions worked
and well in the patient encounters with specific focus on gathering info and ICEIE.
feedback Discuss activating:
(30 min) • What? When? How? Did you see any examples today where a GP tried
to engage a patient in self-care and behaviour change?
• What resources/apps/charities help patients manage the conditions
they live with?
Possibly other topics to discuss considering the patient/s you have encountered
Close, wrap up, draw out learning points
Remind the students to complete their reflective learning log
GP tasks after the session
• Make own reflective notes on the session if you wish
• Complete attendance data online at:
https://forms.office.com/Pages/ResponsePage.aspx?id=MH_ksn3NTkql2rGM8aQVG28R5cnu9NZOvF
whXTW-HuRUQkI5S1VWNE9FQzRHREI0WTNVVldIWTQ3Ni4u
Any questions/feedback/student concerns, contact phc-teaching@bristol.ac.uk or lucy.jenkins@bristol.ac.uk
2
Resources
Please use this session guide in conjunction with the GP teacher guide if needed. All resources are
available at: https://www.bristol.ac.uk/primaryhealthcare/teaching/teaching-in-practice-by-
year/years-1-and-2/ This includes IT guides – one to MS teams, how to start the meeting and how to
use accuRx and breakout rooms for buzz groups. Please do get in touch with PHC on 0117 42 82987
or via email if you are having problems.
Effective consulting learning outcomes
(includes EC labs and clinical contact in primary and secondary care (bold for primary care focus))
EC focus of the fortnight: Activating. Describe how clinicians can work collaboratively with patients,
to activate patients' own resources, and motivate change from within
Global EC ILOs
• Describe how the underlying anatomy of the abdomen and urinary tract can be assessed
clinically
• Outline how the underlying physiological processes of the gastrointestinal and urinary tracts
can be assessed clinically
• Describe the importance of activating patients’ self-care in the clinical encounter
• Describe how health professionals can activate their own self-care to maintain wellbeing
Clinical communication ILOs
• Describe an approach to asking sensitive questions (e.g. bowel and bladder function)
• Practise using motivational interviewing skills in a clinical encounter, building on active
listening and counselling skills.
• Describe the factors involved in the assessment of patients’ lifestyle and resilience, and
how this can be used to facilitate and activate patients’ self-care
Patient Perspective ILOs
• Describe the importance of eliciting the patient’s understanding, ideas and concern for
engaging patients in self-care and behaviour change
Specific tasks given to students
• Continue to build on your skills of talking to patients.
• Consider the anatomical and physiological processes of the gastrointestinal/urinary systems
that can be assessed clinically e.g. pulse, skin pigmentation, bowel habit, urine, hydration?
Think about the patients you meet and the consultations you observe.
• Were there any topics that felt difficult or sensitive to raise with the patient?
• Observe and note how you or your GP approached any sensitive topics e.g. weight or bowel
habit.
• How did you (or the doctor if you were observing) find out about the patient’s lifestyle?
• Were there any opportunities to Activate patient self-care in today’s session?
• Do you think there are any lifestyle changes the patient could make that would improve
their wellbeing? Do you think the patient is motivated to make any changes to their
lifestyle? If not, is there anything that they might have needed to make changes e.g. more
information or support?
• For these patients, can you, with your GP’s help, identify any apps or resources that might
help your patients better manage their problems?
• How does your GP look for information that is accurate and evidence based?
3Expert patient interviews
After the initial check in, we are asking you to arrange an expert patient to meet with up to 4 of the
students on MS Teams. Ideally, this will be a patient with a current or past kidney or urological
condition or a patient with a chronic health problem/addiction that has required significant lifestyle
change ‘activation’. The difference from last term is that you will not be present throughout or
leading on the patient interview.
We have written a FAQ document available here that you can text/email/show to your patient
before the consultation. Basically, this advises them that medical students are trained in and bound
by the same confidentiality guidelines as doctors, that the meetings cannot be overheard, any notes
are anonymised, and the meetings are not recorded. It advises that it is just the students talking to
them to help them learn, they will not be able to answer any of their medical questions and that
they contact the GP who arranged it if they have any concerns.
As before you will need to send the link to the patient once the meeting has started and tell them
what time to join. Ideally this will be on a computer, pasting the link into their browser, so they can
join as a guest. Alternatively, some GPs prefer to bring a patient into the surgery, setting them up in
Teams on a computer there.
Please be there briefly at the beginning of the meeting to introduce the patient to the students and
check that everyone is happy to proceed, all questions answered etc. The students also have an FAQ
for speaking with patients online without the GP teacher being present, you can read this here. The
students should be told how to get hold of you if they need to. You will then need to leave the
students to talk to the patient, who can leave once the interview is over. The meeting should last 20-
30 minutes, but it is fine if it is longer. Students should take it in turns to lead the interview and be
prepared to feedback to each other on consultation skills. Ask the students to observe the
communication skills used to help the patient tell their story (see questions below) and be prepared
to feed this back.
• What showed you were listening?
• How did you encourage the patient to talk? Were there any silences?
• Were there any difficult points in the interview and how did you deal with these?
• Note down examples of open and closed questions
• Reflect on how you or the person you observed facilitated rapport with the patient.
When they have finished the students should end write up the case and get ready to present back to
the group with any learning points or questions they have. They can stay in the Teams meeting or
use the buzz groups and when they are done, they can start the additional activities below. *
Observing consultations on accuRx
See here for how to use accuRx with your students and a patient.
When the four students are set up with their patient, you leave the meeting, to start the video
consultations via accuRx with the remaining pair who also need to leave the main Teams meeting.
Ideally you do three consultations, but it can be more. You can book patients in yourself in advance,
take patients from the duty list, or open the slots for reception to book patients in for a “teaching
slot video consultation” depending on your preference. If you think it will be interesting and relevant
for the students these can be follow-ups. Please see templates for inviting patients here.
4• Patients will need to give verbal consent in advance for the students to be present. You can
send the FAQ if you like and document that students were present in the notes.
• These consultations can be about anything.
• Please try to involve the students in the consultation where possible. Remember the
previous focus on formulating: you could pause and ask the students:
o What other information might you need?
o What other information might you want to ask and why?
o How might you phrase the questions you want to ask?
• When it comes to explaining, you could pause and think with the students and patient
o What the patient wants and needs to know?
o Chunking and checking – and teach back
o How can you ensure a shared understanding with the patient?
o Would any visual aids and leaflets or signposting to online info help?
• In relation to activating
o Is lifestyle relevant in this consultation?
o Any opportunity to activate patient self-care? Is the patient motivated?
o How can a GP help with this? What resources might help?
• There is more info below taken from the student resources and an observation guide based
on consulting remotely using the COGConnect model in the appendix and here.
Specifics for student to observe.
• How did the consulter introduce him/herself and start the conversation?
• Were there any silences?
• Did a good rapport develop? What seemed to help or hinder this?
• Examples of closed and open questions and then reflect on the effect this has on the
encounter
• Were there any difficult parts of the consultation or emotions observed, how were these
managed?
• How did the patient make you feel?
• If appropriate, what body language did you observe?
• Use of verbal/non-verbal communication
• Conversation or consultation structure/flow. Did you observe any signposting or
summarising?
• Any cues/hidden agenda/elephant in the room?
• Patient satisfaction
*Activities for students after the Expert patient interviews
Virtual primary care
The students can view one or two face-to-face consultations based on urinary symptoms on Virtual
Primary Care. This resource was developed by the Medical School’s Council using the consultation
recorder for the Channel 4 series GPs Behind Closed Doors. You will not need to prepare anything for
this, but it will give the students another authentic (albeit virtual!) patient encounter which they can
present and discuss. You can read more about this here. https://www.medschools.ac.uk/our-
work/education/virtual-primary-care
5You do not need to view the consultations in advance, but if you would like access to the resource
for this, please contact Alison Capey at phc-teaching@bristol.ac.uk.
Info given to students for this session (full details in appendix)
Two complete recorded consultations are available for you to access – on the GP1 GI playlist. Please
watch one, or both and, as well as the suggested things to observe for in consultations, consider the
specifics suggested. You may be asked to present the case in the debrief and there should be time to
discuss any relevant issues with the teacher and group.
You do not need to know about or understand all the clinical context of these consultations though
this may expand your learning. Most important is to focus and reflect specifically on the consulting
skills, by considering the questions below.
Case 1. 009A (12.5 min)
This is a consultation with an urgent care practitioner – a young female patient with urinary
frequency. It involves asking some sensitive questions about sexual history.
Case 2. 120A (16 min)
This consultation is a middle-aged woman presenting with mixed urinary incontinence. It shows the
significant impact that these symptoms can have. There are also some contributory issues with the
possibility for some activating within this consultation.
Other options
If you wish you can instead arrange a further expert patient (as above) or a further meeting with
one of the patients met in the Autumn term for some longitudinal follow-up. This may be
straightforward as this patient should already be familiar with the process/MS Teams etc. The
students can find out how the patient has been since they first met them and more specifically
about their family history, social history, and lifestyle. They can ask about how the Covid pandemic
has affected the patient.
Debrief and discussion notes
The student should also be starting to present back a coherent narrative about a patient they have
seen to you and the group. This is likely to be more of ‘the story so far’ rather than a structured case
presentation but please support them in developing this. Please discuss the consultation skills and
encourage them to reflect on what worked well, especially with regard to gathering and formulating.
Further activities if needed (e.g. cancellations or technology issues)
Role play
Student 1 has 5 mins to read up on (patient.co.uk) and prepare a case for a consult. Student 2 plays
the GP, practising preparing, opening the consultation, and taking a history. Others can observe and
feedback. The students will need some basic info and lots of guidance but should be able to give it a
go, it is great practice, and it will help make the discussion about themes more real.
The first scenario is just about assessing hydration and enables further practice of asking about GI
symptoms and sensitive questions. The second allows the students to practice asking these sensitive
questions about urination and will help develop their knowledge on a common presentation in
general practice.
6• 20-year-old, student with frequent watery stools with some blood in. Some gripey tummy
pains. Trying to drink water but everything is going ‘right through him’. The GP has sent off a
sample, but they think it may be a bacterium called campylobacter as your housemate had it
and you both ate the same takeaway chicken. You are passing urine but a bit less than usual.
https://patient.info/digestive-health/diarrhoea/campylobacter
• Or a 36-year-old woman, previously well other than migraines for which he/she takes
painkillers when needed. 5-day history of passing urine more frequently, and in the last 2
days it has started stinging and the urine is cloudy and smelly. No fever or vomit. Mild low
tummy pain. Last period 2 weeks ago. No vaginal discharge. Married, low risk STI.
https://patient.info/womens-health/lower-urinary-tract-symptoms-in-women-luts/cystitis-in-
women
Speaking clinically
An alternative is for the students to access Speaking clinically, a video archive of patients talking
about their symptoms and health experiences medical conditions. It is operated by the Medical
Schools Council and all students can access it. See appendix 4 for specific links and further info. You
do not need to view this, but you can log in at https://speakingclinically.co.uk/accounts/login if you
wish. Use email as phc-teaching@bristol.ac.uk. Password: primcareGP1GP2
Activity to practice introductions
As per previous guides, further info available on the website here.
Show and tell with common consulting room equipment. E.g. thermometer, auroscope, sats
probe, sphyg. Hold one up and ask students to tell you what it is, how to use, what is normal etc.
APPENDICES
Appendix 1
Exploring sensitive topics
Appendix 2
Remote examination of the urinary system and patients doing home urine tests
Appendix 3
COGConnect reminder
Gathering info and explaining – importance for activating
Activating
• Motivating patients to make lifestyle changes
• Why is lifestyle important
• Supporting patients to live well with lifestyle changes. Understand the patient perspective
and ideas, concerns and expectations.
• Wellbeing wheel
• Motivating patients to make lifestyle changes
Appendix 4 – additional learning activities – info given to students
Virtual primary care
Speaking clinically
Appendix 5
Creative assignment – for info only
7Appendix 1
Clinical Communication: Exploring sensitive topics
(as per previous session)
Doctors have the privilege and responsibility of gathering information about all aspects of a patient's
health and life, and as medical students you are often conferred that privilege. To start with it can be
nerve-racking asking patients about areas of life that are often 'taboo' like their bowel and urinary
symptoms.
Making sure you have got off to a good start (prepared well), developed a good rapport with your
patient and explained to them why you are asking (opened well) can facilitate gathering this sort of
information.
The gastrointestinal and urinary system covers several topics that students and patients may
perceive to be sensitive areas:
· Weight
· Bowel habit
· Urinary symptoms
· Alcohol intake
· Chance of pregnancy (and sexual history) you will cover this later in the course.
Medical student anxiety may stem from not being used to asking about these topics, not knowing
how to word questions, or not knowing how patients will react. Patient anxiety may stem from
embarrassment, worries about being judged, worries about confidentiality or being uncertain of the
relevance of the questions they are being asked.
Techniques that decrease anxiety include:
· Explain why you are asking—you may need to address confidentiality
· Ask permission
· Talk in factual terms (not judgmental terms)
· Ask about specifics not generalisations
Preparing the patient and “I need to ask you about your lifestyle to better understand your
setting the context situation”
“I need to ask you about your bowel habit to better understand
how your gut is working”
Asking permission “Is it okay if I ask you some questions about your lifestyle to get an
understanding of your overall health?"
Ask factual, specific “How often do you open your bowels?” (rather than 'do you open
questions. your bowels frequently?’ (which contains a judgement))
“Has your weight changed recently?”
Avoid generalisations and Instead:
judgmental questions e.g. “Talk me through what you eat in a typical day?”
“Do you eat a healthy diet?”
Normalise “Sometimes people notice blood in the stool or after they’ve
opened their bowels, is that something you’ve ever noticed?”
Discussing stool consistency with patients can be helped by using
the Bristol stool chart − see here:
https://www.bladderandbowel.org/wp-
content/uploads/2017/05/BBC002_Bristol-Stool-Chart-Jan-2016.pdf
8Assume the behaviour is “How often do you have a drink containing alcohol?"
already happening
(normalizing) but be careful
as these are leading
questions…
Closed questions and a When asking sensitive questions closed questions can help relieve
“menu” of responses anxiety about how to answer as can giving a menu of responses.
“Do you open your bowels; every day, several times a day, or do
you go for a day or more without opening your bowels?”
Appendix 2
Remote examination of the urinary (and gastrointestinal) systems
Ask the students to think about what they already know about how a standard abdominal
examination should be conducted. They may have watched this* on the Hippocrates site and will
have opportunities for practical learning later in the course. The purpose of this discussion is to get
the students thinking about the different sorts of consultations that are being carried out at present
and the decisions being made about whether patients need to be seen face to face.
* http://www.bristol.ac.uk/medical-school/hippocrates/medsurg/gastrointestinal/
What can we examine over the phone?
• Patient can self-report weight and height and BMI can be calculated
• Can ask patient if looking/others noticed pallor/jaundice etc.
• Thinking outside the box for proxy measures e.g. reduced frequency of urination or darker
urine as markers of possible dehydration
• Self-measured temperature, pulse and blood pressure.
• As a screening tool, a family member or carer can be instructed on abdominal palpation
solely to elicit any signs of tenderness. What are the advantages and disadvantages of this?
On a video consultation you may be able to assess colour, general health, and body habitus, if in
pain. Can ask to see mouth (?dry) or demonstrate skin turgor to assess hydration status.
The GP surgery may be able to supply urinalysis equipment and some patients will have strips to test
their urine for specific things e.g. ketostix for diabetics.
Clinical Skills: Urinalysis
Dipping a urine sample with a multistix test detects several substances in the urine including glucose,
proteins, red cells, ketones and by products of bacteria such as nitrites. It is used to help investigate
for urinary tract infection, and test for and monitor diabetes, kidney disease, high blood pressure,
liver disease and other conditions such as metabolic disorders. It is also used for monitoring in
pregnancy.
An explanation to patients about what a urine dipstick test is can be found here:
https://patient.info/treatment-medication/urine-dipstick-test and how to collect a mid-stream
specimen of urine here: https://patient.info/mens-health/urine-infection-in-men/midstream-
specimen-of-urine-msu
9Appendix 3
Clinical Communication: taken from students’ resources
PREPARING OPENING
Am I prepared? Are we off to a good start?
Preparing oneself Establishing the agenda
Preparing the space Establishing relationships
Checking the medical record Initial observations
GATHERING FORMULATING
Have we covered all the relevant areas? What is going and what is next?
Sources of understanding Bias checking
History Considering the options
Clinical examination Red flag signs and symptoms
EXPLAINING ACTIVATING
Have we reached a shared understanding? Is the patient better placed to engage in self-care?
Chunking Identifying problems and opportunities
Checking Rolling with resistance
Visual Aids Building self-efficacy
PLANNING CLOSING
Have we created a good plan forward? Have I brought things to a satisfactory end?
Encourages contribution Summary
Proposing options Patient questions
Attends to ICE (IE) Follow Up
DOING INTEGRATING
Have I provided a safe and effective intervention? Have I integrated the consultation effectively?
Formal and informal consent Clinical record
Due regard for safety Informational needs
Skilfully conducted procedure Affective progressing
10Gathering clinical (hi)stories
A comprehensive history is essential to help activating patients with self-care and lifestyle change.
Students are encouraged to obtain a well-rounded impression and to consider the information they
gather in the 3 domains:
• Nature of the medical problem
• Patient perspective on the problem
• Relevant background and lifeworld
Activating
Describe how clinicians can work collaboratively with patients, to activate patients' own resources,
and motivate change from within
Motivating patients to make lifestyle changes
The skill of motivating patients to make lifestyle changes builds on the skills of explaining we
addressed in the GI case. One reason we might give explanations to patients is to motivate them to
make changes in their life. If patients understand that their nutrition, habits, or lifestyle are causing
some of their symptoms, or puts them at future risk they may be more motivated to make changes.
In your EC Lab you will have started to learn some techniques and skills for communication and
consultation around behaviour change. We want you to be aware of why doctors need to
understand a patient’s lifestyle and the role doctors have in engaging the patient to take care of
their own health.
Why is lifestyle important?
People’s lifestyle has an enormous impact on their health. Smoking, sexual risk taking, inactivity,
poor diet and alcohol are the cause of a number of diseases. There is also considerable evidence that
improving lifestyle factors improves symptom control in a number of chronic conditions. Most
evidence-based guidelines such as those produced by the National Institute for Health and Clinical
Excellence (NICE) address lifestyle factors as a key part of treatment. For example, the British
Thoracic Society recommends that patients with Chronic Obstructive Pulmonary Disease (COPD) are
referred for pulmonary rehabilitation to improve exercise capacity, health status, dyspnoea
(breathlessness) and psychological wellbeing.1 The NICE guideline on Depression in adults:
recognition and management recommends that a treatment programme should address sleep,
physical exercise, social isolation, and engagement with social activities.2
There is little people can do to influence their genetic susceptibility to illness, and social
circumstances can be difficult to change in the short term, but people can make changes to their
lifestyle and influence their health if they know how to do so, and why it’s important to them.
Doctors are in an ideal position to advise people on healthy lifestyle and encourage people to make
changes. People are often particularly willing to review their behaviour at times of transition such as
pregnancy or illness.
11Some areas where patient self-care is important
Doctors can:
• Provide objective, accurate information
• Compare a patient’s behaviour with normal or recommended e.g. see box 1 physical activity
• Give specific advice tailored to the patient, and make it personally relevant
• Help the patient make concrete plans and goals, or refer to another service e.g. pulmonary
rehabilitation
• Support and encourage over time
1
British Thoracic Society. BTS Guideline on Pulmonary Rehabilitation. Bolton CE, et al. Thorax
2013;68:ii1–ii30. doi:10.1136/thoraxjnl-2013-203808
2
NICE Depression in adults: recognition and management available from:
https://www.nice.org.uk/guidance/cg90 (accessed 28.2.18)
3
Department of Health. Start Active, Stay Active: A report on physical activity from the four home
countries’ Chief Medical Officers available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216370/dh_12821
0.pdf (accessed 28.2.18)
12Supporting patients to live well with challenges to their health
Patients are experts on themselves and their lives and make choices about their health and
wellbeing. Unless a patient is admitted to hospital for intensive care e.g. after major trauma or relies
on a carer to provide their needs, most people look after themselves for the majority of their lives
and make their own decisions. In the context of an adult’s life, a visit to the doctor is a very short
and (usually infrequent) occurrence. Most symptoms e.g. sore throats, tiredness, headaches, and
joint pains are managed in the community without people seeking professional healthcare. To help
them self-manage people may look up information about their symptoms or get advice from friends
or family. There is a vast amount of information available in magazines, online and from Apps. But
how do people know what is accurate information? When we see patients, it should be part of our
routine consultation to make sure they know where to access advice that is helpful, accurate, kept
up to date and evidence based.
Once someone has visited the doctor, they have to put into place the management plan agreed with
the doctor whether it is to monitor their symptoms, make changes to their lifestyle, do prescribed
exercises, take medication, or book a further appointment. Often patients can’t take on board all the
information they need to manage their health in one consultation with a doctor, and they may have
further questions that they didn’t think to ask in the consultation. This is where doctors can help by
providing symptom or disease specific resources. It may be a charity or support group for patients,
or it may be further information about their condition.
Wellbeing wheel for activating self-care
You may have discussed the wellbeing wheel when talking about self-care and resilience in
Foundations of Medicine. Using tools such as the wellbeing wheel can be a good starting point in
consultation with patients. It can be a good way to get patients to consider what things impact on
their health, and what impact their health has on other areas of their life. This can be a useful point
at which to begin discussions about Activating.
13How to complete your Wheel of Wellbeing
For each of the three domains (Daily Life, Physical/Mental Wellbeing, Connectedness) there are 4
areas to consider. For each area, ask yourself “how am I doing in this area right now?”. If you’re
doing well at sleep for example, then shade the whole segment in from centre to outer edge. If
you’re doing not so well in Finance for example, then you might only want to shade the central
section of this particular wedge. When you’ve done this for all 12 areas, you’ll have a wheel that
might look a bit like this (it will be different for everyone).
Once you have completed your wheel, reflect on how well-balanced things are for you right now.
What are you happy with and what are you doing to maintain that area? What are you struggling
with – is there something you could change to improve things in this area?
The Wellbeing Wheel is a way to assess your (or a patient's) lifeworld at a point in time. Used over
time, it can be a way to monitor health and wellbeing and identify areas needing support. The wheel
can help us consider what supports health and what drains it, what helps us 'roll along' and what
'trips us up'. Balance is often more useful than perfection.
The prompts below will help you consider each area as you complete your wheel.
CONNECTEDNESS
Self - How in touch do you feel with the things that give meaning and joy in your life? What are your
sources of joy and strength? How connected do you feel to yourself? Are you able to get in touch
with a sense of peace or stillness?
Family – for some people family is a source of joy and happiness. For others, family is a challenge, or
even a trauma. Whatever your circumstances, the question here is ‘how happy am I with current
circumstances?’ Do you feel as connected to your family as you wish to? Are your significant others
available to you if you want them to be? Who are the people who matter most to you?
Friends – for some, large networks of people are preferential, for others, small core groups or
individual friends are key. Who are the people who matter most to you? Are there important
relationships in your life? Are you able to share your feelings and experiences comfortably? Do your
close relationships sustain and support you?
Community – this may mean your ‘community of practice’ (i.e. other medics!) or your housemates,
or church, a community group, your halls, sports groups, clubs, voluntary organisations. Again, it can
mean different things to different people. What is the social atmosphere like where you live, work,
play? Do you have people who you get along with? Are you getting what you need from your
community?
14PHYSICAL AND MENTAL WELLBEING
Healthy eating – How is your digestion? Do you understand the principles of a healthy diet? Are you
able to apply these? Are you looking after your body and mind by eating well? How are your energy
levels? Do you know how to cook, and shop?
Sleep – How is your sleep? Do you know how much sleep you need? Are you able to get that? Does
your environment help or hinder your sleep? Do you manage to get to sleep at roughly the same
time most nights? Is there anything (physical, environmental, or emotional) which keeps you awake
at night?
Exercise – How are you physically? Are you in pain? Are you able to do as much physical exercise (to
the level you wish/are able) as you would like? Are you looking after your mind and body with
physical activity?
Emotional wellbeing – How well are you able to manage stress, and how much does it affect you?
How helpful is your pattern of thinking? Does your pattern of thinking get in your way? What are
your levels of anxiety like? How easy is it to know what you are feeling? Can you express how you
feel? Are there some feelings you won’t allow yourself or are unable to shift?
DAILY LIFE
Finance – How is your financial situation affecting your health? Are there competing demands on
your finance? Do you feel confident looking after your money?
Work – How is your work situation affecting your health? Are there competing demands on your
time? How do you balance this? Are day to day tasks manageable for you (like cleaning and
cooking)?
Environment – Do you feel safe? How do the places you live and work in affect you? Is there fresh
air and natural light? What are the noise levels like? Can you get out into nature or be outdoors
easily? What do you need around you to feel comfortable?
Fun – how are your energy levels? Are you able to enjoy things? Do you have a hobby or society you
belong to? What do you enjoy and are you able to do this? Are you able to laugh easily? What
supports this?
For more information including some of the research background behind each of these areas, have a
look at your OneNote. Dr Brown and Dr Thompson have adapted this for medical students from
generic wheels (google ‘wheel of wellbeing’). We would also specifically like to acknowledge The
Penny Brohn Centre who adapted and developed a wellbeing wheel for use in healthcare settings.
We are grateful that we have been able to adapt the questions provided by Penny Brohn to help
students understand the concept of each domain and area in the wellbeing wheel.
Your GP may use the BNSSG toolkit with patients.
1516
APPENDIX 4. Additional learning activities – full info given to students
Virtual Primary Care
Two complete recorded consultations are available for you to access – on the GP1 – Urinary playlist.
Log in at https://vpc.medicalschoolscouncil.org.uk/ Please watch one of these and, as well as the
suggested things to observe for below, consider the specifics suggested. You may be asked to
present the case in the debrief and there should be time to discuss any relevant issues. You can
watch the second if needed or on another occasion if you wish.
You do not need to know about or understand all the clinical context of these consultations though
this may expand your learning. Most important is to focus and reflect specifically on the consulting
skills, by considering the questions below.
Case 1 009A 12.5 min
This is a consultation with an urgent care practitioner – a young female patient with urinary
frequency. It involves asking some sensitive questions about sexual history.
Observe and take notes on the following:
• How did the consulter introduce him/herself and start the conversation?
• Were there any silences?
• Did a good rapport develop? What seemed to help or hinder this?
• Examples of closed and open questions and then reflect on the effect this has on the
encounter
• Were there any difficult parts of the consultation or specific patient (or doctor) emotions
observed and how were these managed?
• How did the patient make you feel?
• If appropriate, what body language did you observe?
• Use of verbal/non-verbal communication
• Conversation or consultation structure/flow. Did you observe any signposting or
summarising?
• Any cues/hidden agenda/elephant in room
• Patient satisfaction
Other things to consider:
• How does the practitioner start? Can you think of any other ways to have structured the
questions?
• Did the practitioner ask about ideas, concerns and expectations?
• The patient did bring some up some cues. Can you identify any of these? Not all of these
were addressed. What might you have said / asked?
• In terms of the closed questions asked, what other conditions is the urgent care nurse
practitioner trying to exclude?
• The nurse asks about discharge from the front passage and uses some medical terms like
‘leucocytes’. Any thoughts on this?
• How did the nurse practitioner approach asking potentially sensitive questions about her
sexual history? What might you do differently? What further information would you ask?
• Do you think there was any opportunity in these consultations for activating? Possibly about
sunbeds, fluid intake or sexual health?
17Optional further reading
A useful overview of evidence based management of lower urinary tract
infections https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/
Patient information on STI screening https://www.nhs.uk/live-well/sexual-health/visiting-an-sti-
clinic/
Article on Interpretation of urine dipstick results https://patient.info/doctor/urine-dipstick-analysis
Practical video on how to dipstick urine https://geekymedics.com/urinalysis-osce-guide/
Case 2 16 min 120A
This consultation is a middle-aged woman presenting with mixed urinary incontinence. It shows the
significant impact that these symptoms can have. There are also some contributory issues with the
possibility for some activating within this consultation.
Watch and observe and take notes on the features in italics above. In addition consider the
following:
• What specific urinary symptoms did this patient present with?
• At one point this GP asks a few specific questions to assess for any ‘red flag symptoms’. Can
you recall what these symptoms were? And can you think of any other questions you might
like to ask this patient to rule out a more sinister cause for her symptoms?
• Weight is a factor that can commonly make stress incontinence worse. Can you think of any
reasons why the GP did not bring this up in this consultation?
• At approximately 01.22 this patient discusses her drinking habits; what other questions
might you consider asking to explore her drinking habits further?
• This patient has a history of alcohol excess. Other lifestyle factors are discussed which can
impact on urinary symptoms. Did you see any activating?
• The GP explains the two different types of incontinence, how is this done? Did you see any
chunk and check?
Optional further reading:
Urinary incontinence; management in general practice: https://www.gmjournal.co.uk/urinary-
incontinence-in-women-management-in-general-practice
Conservative management of urinary incontinence / overactive bladder (OAB) / stress incontinence
in women. https://gpnotebook.com/simplepage.cfm?ID=x20061102234446896780
Speaking clinically
https://speakingclinically.co.uk/videos/ketoacidosis/
This young man describes his presentation with type 1 diabetes, generally well controlled except for
an admission post alcohol excess with dehydration as part of ketoacidosis.
https://speakingclinically.co.uk/videos/overactive-bladder-syndrome/
A man who is fearful of drinking in case it worsens his symptoms or irritable bladder who talks about
all the tests he has been through
https://speakingclinically.co.uk/videos/primary-bladder-neck-obstruction/
A man with urinary tract symptoms now needing self catherization, resulting in frequent infections.
18Appendix 5
Creative assignment – for GP tutor info only
You may wish to ask students about plans for their creative assignment. This is submitted to their
EC Lab tutors (campus-based teaching groups) rather than to the GP, but students may choose to
base their piece on a patient they have met either in primary care, secondary care or during their
HCA. If they complete a piece based on their GP placement, you may want to ask them to share it at
a future session. This work is usually of high quality, lovely to see especially if based on a patient you
know and facilitates interesting and useful reflection and discussions within the group. The remit for
this is broadly the same as for previous years but there are some amendments to the criteria
because of the impact of Covid. See the guidance given to students below: for info only.
One of the key things we want you to experience in Effective Consulting is the chance to engage
personally, and individually, with medical themes through creative work. An artistic approach gets us
to focus on the individuality of the situation, and to deal with the emotional responses we often
have to clinical situations. This approach can help us learn about ourselves, and about our patients
and colleagues, and can also be a form of self-care helping us to manage the personal and emotional
challenges of medicine. In the COGConnect model of clinical encounters which you will learn in EC
this year, the final stage is Integrating. Whilst this includes some very practical things, like note
writing and ensuring continuity of care, it also incorporates the ability to process our emotional
responses to consultations. Some individual clinical encounters with patients will affect us deeply,
for a variety of reasons, and it is this we want you to explore in your assignment for EC.
Additionally, there are 5 Core values which we expect all Bristol Medical students to bring to each
clinical encounter: compassion, curiosity, critical thinking, creativity and collaboration.
Creativity will most usually mean developing creative and novel solutions, but we broaden this to its
fullest meaning to include the arts in medicine. You may want to look at this article on compulsory
creativity for more information. In Foundations of Medicine you worked together as a group to
develop creative work for the FOM Conference. Here, in EC, you have a unique opportunity to
expand on this, and to explore your clinical contact with an individual creative piece which you will
share with your EC colleagues.
You can choose to do your creative piece on any one of the following:
1. A clinical encounter you have personally had this year
2. Your clinical examination skills learning
3. A virtual primary care consultation
4. An observed consultation of a GP and a patient
5. Wellbeing in doctors and medical students during the pandemic
Once you have chosen the clinical encounter you should consider and chose a way to extend your
understanding using creative methods. You can produce your creative work in any media,
including but not limited to photography, art, dance, music, poetry, creative writing, digital
storytelling, video, drama, blogging, vlogging etc. Your creative work should be accompanied by a
narrative of approximately 500 words.
Consent should be sought to use a patient's story as the basis of your creative work. This should be
documented in your narrative or explained if impractical. All information should be anonymised.
Prizes and commendations are awarded for the best work in the EC Creative Assignment (Overall
Prize money £200 to be shared by winners).
19You can also read
