Reflecting and Giving Constructive Feedback: GP Training Case Study

This case study details a scenario in a GP practice where a nurse requests a prescription for a patient with a suspected UTI. The author, a GP and trainer, decides to examine the patient, discovering a more serious condition requiring immediate hospital admission. The case highlights the importance of thorough assessment and the limitations of relying solely on initial information. The GP uses this situation as a learning opportunity for the nurse and a trainee, employing Significant Event Analysis (SEA) and reflective practice to provide constructive feedback. The case study emphasizes the significance of good history-taking, examination, and differential diagnosis in medical practice. It discusses the three phases of reflection (anticipatory, in-action, and on-action) and how they were applied in this instance. The GP reflects on the consultation, feedback delivery, and the subsequent SEA meeting, which led to improved understanding and practice among the nurses. The case concludes with a discussion on the effectiveness of using acute clinical settings for teaching and feedback, followed by tutorials and case-based discussions. The GP emphasizes the value of open-mindedness, thoroughness, and continuous learning in medical training and practice.

GP New trainers course – Case History 2
Case study 2
Reflecting and giving constructive feedback - Most important attributes in teaching and training.
Introduction
One day a nurse requested me whether I could authorize a prescription for a patient he had seen with a
mild temperature and an abdominal pain whom he thought was having a UTI. Instead of authorizing the
prescription, I felt that I should examine this patient. On examination I found out that he has a very tender
abdomen with some guarding. His urine had trace of leucocytes and blood, but otherwise normal. Patient
needed immediate admission to the hospital for further assessment.
In this situation I decided to assess the patient rather than prescribing as requested by the nurse. It
prompted me to examine the patient due to lack of information provided by the nurse to be confident that
he had a UTI. This particular nurse was new to the practice and I was not quite aware of his competence
levels either.
I found it hard to disagree with this senior nurse, (even though he is new to our practice) and instead of
prescribing, straight away deciding to go and assess the patient. I felt difficult in disagreeing with his
diagnosis but after explaining the reasons he agreed. I felt it even harder as he had a trainee nurse with
him as well shadowing his consultations. Apparently his trainee has checked this patient’s urine sample
and had told him that it is abnormal rather than he himself, double checking what was the real
abnormality. It served to be a good learning lesson for the trainee as well as he had no knowledge about
urine dip stick abnormalities. I examined the patient with the nurses and explained to them why it can’t be
a UTI. I did give them the opportunity to examine the patient. Also they were present when I took a
detailed history. Once I have dealt with the patient I wanted to reflect on this situation and to think about
the best way I could use this situation to educate the nurses. I wanted to be as constructive as possible.
I gathered information.
Then I decided to discuss the situation briefly with the nurse involved. We then decided it would be a
good learning opportunity. I have learnt from my trainer’s conferences and workshops about Significant
Event Analysis (SEA). SEAs are a good source of learning if everyone take it as a learning experience.
So I wanted to make this a learning experience to the nurse and the trainee nurse as well. So we
prepared for the SEA meeting. Advised the nurse to write the incident and to look at what he would have
done differently.
I also advised to read about diagnosing a UTI and differential diagnosis of abdominal pain. Also we
discussed about best way of seeking advice if he was unsure about the diagnosis. Better to ask for an
assessment rather than asking for a prescription. If I did fail to assess the patient and had given the
prescription, I would have certainly put the patient at risk.

GP New trainers course – Case History 2
Reflection and giving feedback – we have discussed and learned about these 2 attributes in our trainers
course repeatedly and also all the way through training. Feedback should be constructive, so that the
trainee could learn and improve. This situation definitely made me to explore how I could use this
opportunity in order to give my nurses a new understanding and appreciation of learning through
experience and constructive feedback.
“Constructive criticism is good. Give positive feedback, and to give options how to improve performance.”
This was one of our group rules during our new trainers course.
1“There are three phases of reflection: anticipatory reflection, which used past experience for
planning teaching activities; reflection-in-action, which involved maintaining flexibility during
teaching; and, reflection-on-action, which involved thoughtful analysis of the experience”.
In this situation, all 3 phases of reflection demonstrated. I have opportunistically used the clinical situation
as a flexible teaching session. This should be regularly implemented with my trainees during the period of
joint clinics. Is there anything I could have done differently during the consultation with the nurses? I was
content that the way I gave them the feedback was constructive, explaining while assessing the patient.
By reflecting on action, Thoughtful analyzing of the experience, I decided to arrange a tutorial as well in
addition to the SEA meeting.
This is a good example that I could use with my trainees as well. People learn better through experience.
It is a valuable experience to examine an acutely ill patient with characteristic signs and symptoms, with
your trainee.
Following week, we had a SEA meeting and we discussed this case.
We discussed about taking a good history and the importance of a good examination.
End of the meeting he realised that he would have taken a better history, with more details. Also, he
realised that he would have examined the patient.
2Reflection may be most useful when viewed as a learning strategy. Used in this way, it may
assist learners to connect and integrate new learning to existing knowledge and skills.
I was glad that the nurse and the trainee nurse understood the situation perfectly well. I have been as
constructive as possible and at the same time non-judgmental. I praised the nurse for seeking advice
appropriately.
We discussed about taking a good history first. Then thinking about possible diagnoses. Then to examine
the patient including relevant examination of the patient. Finally, to consider additional tests like urine
samples.
We decided to have a tutorial about abdominal pain. Also to have some case based discussions.
We discussed about possible misleading information that patients might provide at times. We discussed
about how to keep your mind open and concentrate on symptoms rather than going with the diagnose
that patient might google and think that he has.
We discussed about what should be done differently next time.
With this incident I learnt how effective it could be when teaching and giving feedback on an acute clinical
setting. This could be followed up with a tutorial or an SEA meeting.
Also I learnt to be constructive and also to test the understanding of my trainee by asking appropriate
questions and maybe even in some instances to follow up with an Audit or a reflective diary.
1 Mann, K., Gordon, J. & MacLeod, A., 2009. Reflection and reflective practice in health professions education: A systematic review.
Advances in Health Sciences Education, 14(4), p.601.
2 Mann, K., Gordon, J. & MacLeod, A., 2009. Reflection and reflective practice in health professions education: A systematic review.
Advances in Health Sciences Education, 14(4), p.614.

GP New trainers course – Case History 2
References:
Mann, K., Gordon, J. & MacLeod, A., 2009. Reflection and reflective practice in health professions
education: A systematic review. Advances in Health Sciences Education, 14(4), p.595-621.
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