Examples of Good Learning Log Entries

Please note – you do not have to stick to the subheadings in the RCGP’s learning log section of the ePortfolio. These subheadings are there to guide you. You do not have to employ that framework if you don’t want to. However, do write something in boxes marked with an asterisk (*) as they require some data input.

EXAMPLE OF GOOD LOG ENTRY 1

In this example, the trainee uses some of the professional competencies as subheadings to help structure his write-up. In doing so, it helps focus him and therefore reduces waffle; as a result, this entry only took him 15 minutes to write. As you can see, one does not need to write much to ‘hit’ a competency – providing you stay focused on demonstrating that competency.

Date: 20/02/2016

Subject title: Continuing contraceptives

What happened?:

DATA GATHERING AND INTERPRETATION:

A lady who was taking COC attended my clinic. She was UKMEC 2 but was at borderline for UKMEC because of her weight. From her I gathered she was aware of it and had tried to reduce weight in the past with some success. But she then stopped monitoring her weight and put on a few kilograms. At present she did not have any plans to reduce the weight.

What, if anything, happened subsequently?:

MAKING A DIAGNOSIS AND MAKING A DECISION:

The UKMEC scores encouraged me to have a professional chat with her about her risk with taking oral contraceptives. Sometimes scores like these can be good for helping one with decision making about where to go next in terms of explanation and management.

MORE DATA GATHERING & CLINICAL MANAGEMENT & COMMUNICATION SKILLS

I went through all the questions for a pill check, checked her BP. She actually thought there was almostno risk of being on the oral contraceptive as so many of her friends were on it. I decided to show her the UKMEC scores and explain what these actually meant – she seemed surprised and we explored this. As a result we negotiated a management plan that I feel that she was now hooked into – that we would carry on with the pills (3 monthly rather than 12 monthly) and that she would commit to weight loss and I’d see her again in 3 months. The consultation went well and I felt she was motivated to take responsibility for her own health.

EXAMPLE OF GOOD LOG ENTRY 2

In this example, the trainee writes in a more narrative way and signals when he has written about a professional competency by signposting it in brackets. This one is longer than the previous but note that he hits 8 competencies compared to the previous one which hit 4. Not surprisingly, this one took 40 minutes to write, but as you can see, it was worth it. The trainee enjoyed writing about it and the action of writing it up made him think more deeply and widely, helping him to make generalisations from this specific situation to help in future situations (and thus with his learning).

Date: 10/02/2016

Subject title: Clinical Blinkers

What happened?:

A patient with an alcohol dependance came in with epigastric pain and vomiting to A&E. He had previously had episodes of pancreatitis. The paramedics provisionally diagnosed another pancreatitis episode. I followed the usual protocol within A&E for this type of thing. Bloods, Venous gas, Fluids etc. The venous gas showed an acidosis which was a little bit abnormal for a patient with pancreatitis. (CLINICAL MANAGEMENT).

What, if anything, happened subsequently?:

There was something about this patient that didn't add up – he looked better than what he was reporting and after some IV fluids, he said he felt much better! So I decided to wait on some bloods and I was planning to discharge him if these were all okay.

His blood glucose was raised although Amylase and other bloods were normal. The blood gases showed an acidotic picture – which was odd! I decided to ask my registrar about this as I felt that I was out of my depth (FITNESS TO PRACTISE). He suggested we did a check for ketones - and these came back as high. Subsequently, I called the medical registrar, communicated the relevant information, answered any further questions from him and got him admitted for alcoholic ketoacidosis (WORKING WITH COLLEAGUES).

What did you learn?:

DIAGNOSIS & DECISION MAKING - I learnt that I should pay attention to my feelings of clinical uneasiness. The protocol driven A&E pathway of DATA GATHERING led me down a narrow path where I nearly discharged the patient - and this is the problem with protocols – they are sometimes too reductionist and prevent you from seeing the bigger picture. One needs to take the blinkers off, step backand gather wider DATA if something seems a bit odd. As in this case, in the future if something niggles me, I'm going slow down and rethink. Rethinking things and discussing such niggly situations with colleagues helps reduce uncertainty and therefore risk to patients (MANAGING MEDICAL COMPLEXITY).

My trainer latter pointed me to Kahneman’s model of fast and slow thinking, and that the art of slowing one’s thinking down is called System 2 thinking ( ). It is sometimes hard in a busy A&E department, or in fact a busy GP clinic, to slow down a bit and take a fresh look at the clinical picture. However, the consequences of not doing so could put patients at risk. Therefore, when I feel things are not adding up quite as I expectedI will slow down no matter how busy the environment is (FITNESS TO PRACTISE).

PRACTISING ETHICALLY - I was initially keen on discharging and although he looked quite well, I wonder if I pre-judged him on his history of alcohol abuse. Would I have done the same with a patient who did not abuse alcohol? A learning point for me is not to be too quick in judging people and try to treat all people the same (equality).

Dr Ramesh Mehay (TPD Bradford GP Training Scheme, Jan 2016 v1)