1. I don’t know what it is but I don’t think it’s serious Confidence and Decisiveness in Primary Care

2. What is the problem? Think of a doctor you have known who you perceive as being decisive and confident Jot down some of the characteristics of that person What effect does that have on aspects of their work ? How does it affect patients?

3. What is the problem? Think of a doctor (trainee or not) who does NOT show decisiveness and confidence. Jot down what characteristics they have What affect does it have on their lives and work? What affect does it have on their patients?

4. Bruce Thomas – 1987 Is there any point in being positive? A group of 200 patients who presented in general practice with symptoms but no abnormal physical signs and in whom no definite diagnosis was made were randomly selected for one of four consultations: a consultation conducted in a "positive manner," with and without treatment, and a consultation conducted in a "non-positive manner," called a negative consultation, with and without treatment.

5. Methodology Positive was a firm diagnosis – you will be better in a few days. Diagnoses included sore throat and back pain and cough and tiredness. Negative was “I cannot be certain what is the matter with you” ? Is this statement always true?

6. Medication A positive prescription was given with the advice - “this will certainly make you better” A negative prescription was “I am not sure that this treatment I am going to give you will have an effect” A positive non script was “you don’t require one because you will get better” A negative one was because of uncertainty in diagnosis “And therefore I will give you no treatment”

7. Results Two weeks after consultation there was a significant difference in patient satisfaction between the positive and negative groups but not between the treated and untreated groups. Similarly, 64% of those receiving a positive consultation got better, compared with 39% of those who received a negative consultation (p = 0.001) and 53% of those treated got better compared with 50% of those not treated (p = 0.5).

8. How would you take this further? How we can know things? What research could be done?

9. Paul Little et al Outcomes of Patient centredness and positive approach Developed a questionnaire to test what patients thought of the consultation in 5 domains of patient centredness. Communication and partnership, personal relationship, health promotion, positive and clear approach to problem and interest in affect on life

10. Factor 4: positive and clear approach to problem Statements relating to doctor Very strongly agree Strongly agreeAgree Neutral/ disagree Factor loading Explained clearly what the problem was 125 (20)129 (21)220 (36)138 (23)0.59 Was definite about what the problem was 123 (20)115 (19)197 (32)173 (28)0.70 Was positive about when the problem would settle 141 (23)126 (20)233 (37)122 (20)0.61

11. Results Outcomes measured by post consultation questionnaires MISS, Howie’s enablement, MYMOP at 1m Positive effect on resolution of symptoms Positive effect on Satisfaction, Enablement and Symptom Burden

12. Doing Tests GPs are natural Bayesians What we can infer about the probability of a result depends on Prior Probability So we need to know what the likelihood is of “x” before we do a test. Highly seNsitive tests are good for ruling out things (snout) – examples Highly sPecific tests are good for ruling things in (spin) – examples

13. How do we explain Risk Paling perspective scale http://riskcomm.com/pdfdocs/PPS04HomeBa seColorWEB.pdf http://riskcomm.com/pdfdocs/PPS04HomeBa seColorWEB.pdf Paling palette http://www.riskcomm.com/images/Palette1D owns http://www.riskcomm.com/images/Palette1D owns

14. The few certainties in life Some certainties Some cases where risk is so small it should not be mentioned (fluoride) Genuinely 2 or more viable and reasonable decision paths Pythagoras Theorem – Chinese and Greeks The sun will rise in the morning

15. Pragmatism Is it safe for my child who has no known allergies to have standard doses of paracetamol for pain and fever? Is it safe for me to leave this tiny unchanging mole with no malignant features? Is it better for my baby to sleep on her back? Will my cancer get better without treatment

16. Judgement Is it safe to have this endoscopy? Are these antibiotics/antidepressants/antihypertensives safe for me? Or necessary? Will you be able to cure me of this early breast/endometrial/skin cancer? Is it safe to have a general anaesthetic?

17. Communication skills – passing over responsibility in uncertainty GPs need to know their stuff It is not a text book case of anything and a number of features of a mild condition but a serious condition cannot be ruled out just now Implicit or explicit fear of the severe condition Reasonably well albeit with some symptoms MDU subscriptions have gone up

18. Reassurance Breaking good news takes time Check the patients’ agenda So what is the problem Who is involved – own GP? Consultant? The GP’s baggage No certainties Impossible to diagnose early cases Defensive medicine Patient’s baggage

19. T ASK – D EVISING R EASSURING EXPLANATIONS In each of these options imagine the doctor presents the following “reassuring “ explanation to a patient – captured on video. Working in threes try to come up with a better way of explaining the examination findings and reassuring. Your aim is to develop an examination routine which includes the most useful elements of physical examination and how you could could use and explain the findings of the examination to better reassure the patient. Mum brings in a 10 month old with a history of 24hours mild fever, drinking fluids, not eating, lively at times, miserable, but not clingy and a few spots. The trainee says, “I have checked him over and there are no signs of meningitis”.

20. Tips and Tricks to increase confidence SCBU Using the web BP is never just OK Glucose to be proud of Lungs of a 21 yr old