An example of a complex simulation 

Background. Irene, a resident of the third year of vocational training in GP, told us the Guglielmo’s story. She was the “Doctor on Call” in a small village in northern Italy, where met a complex patient: Guglielmo . We built the canvas and we put it in the scene. Here we want to show the viedo of the simulated consultation

The Guglielmo's story

Guglielmo is a well known patient by the doctors on call because of his multiple requests at "Doctor on Call Service", both in person and by phone.

 

Guglielmo is a single, alcoholic, overweight, depressed patient, with a generalized anxiety disorder, mild mental disorder, hypertension, COPD, osteoarthritis of the dorsal and lumbar spine.

 He lives in a protected facility with 3 other people with similar problems.

A local nurse sees him every morning and gives him his medications.

He’s supposed to deal with all the basic needs (dressing, cleaning and eating) by himself.

 

This evening, at 11.30PM, he calls the Doctor on Call, saying he feels back pain since the same afternoon and he requests a home visit (this is his usual request).

 

The doctor checks his profile in the database and sees that:

 1. he went to the Emergency Room (ER) two days earlier 

2. he called the doctor on call the previous evening for the same reason.

 

In the ER he was examined and he had a chest X-ray that didn’t show any particular problem.

The phisical examination gave also negative feed-backs.

He was prescribed an aerosol with Beclomethasone and Salbutamol 1 vial + 5 drops, twice a day (to do at home) for five days.

The ER doctors suggested to repeat the chest X-ray if the FM-GP considers it necessary.

 

The Doctor on call last night suggested he takes 1g of paracetamolo.

 Usually the patient goes once a week to the ER and calls or goes to the Doctor on Call on Saturday, or even more than once a day on Sunday and some nights in the week.

 

In the database the doctor can check his therapy:

 Ramipril HCT 5+25 mg 1cp al di;

Escitalopram 10mg gtt 10 gtt al di; 

Foster  ( = BECLOMETASONE + FORMOTEROLO) 100/6mcg twice a day

Paracetamolo + Codeina in case of pain

 

The doctor decides to go to the patient's home.

“GUGLIEMO” LESSONS LEARNED:

  1. It is important to listen to the patient's needs.

  2. Problematic patients must be treated, considering that not all we say is understood in the way we mean it.

  3. Nothing should be given for granted. Every patient should be evaulated as if it was the first time we examine him/her.

  4. It is important to explain to the patient what is happening using his/her own understandable language

  5. We need to think and consequently act according to “perceptions”

  6. It is necessary to adapt to the patient’s level of understanding

  7. Nothing should be taken for granted.

  8. We have to make decisions utilizing our scientific knowledge together with our own conscience and to truly communicate with patients

  9. It is important to maintain a human relationship with the patient, even when you focus on the clinical aspects.

  10. Sometimes our is a very difficult job

  11. It is important not to be biased by prejudice, we need to think and act objectivitly

  12. There are many different opinions.

  13. We should trust our own ideas and instincts and the take decisions when needed.

  14. It is important to keep your attention up, even when you deal with frequent needy patients.

15. Using our own medical vocabulary doesn't necessary means that the patient understands our message. And the opposite is also true.

The video of consultation
(in Italian with English subtitles - lenght 20 minutes)

After the consultation

We work with the class with our methodology.

Brief information about our methodology:

- Our brief reflection (in this site, (link)

- Poster presented in Wonca confernce 2009 (link)

At the end of simulation

Every lesson is closed with a short anonymous feedback ("oggi ho imparato che"): everyone writes a short sentence, (two minutes) witch summarized the learning producet by the simulation.

The teacher reads immediatly the sentences in front of the classroom, without observations, to share te collective learning.