Year 2, Module 14: Doctor, how will I cope without her?
Scenario
Dr Annabel Ferguson was beginning to settle into her new GP practice. It took a while to learn the ropes but, after a few
weeks, she felt that she’d got the hang of how they did things and was starting to recognise patients who were returning
to see her. Like Jonathan Chu, a 30 year old man she’d seen 2 weeks ago, who had presented with intermittent nausea,
heartburn and alternating diarrhoea and constipation. At the time, she’d suspected IBS and prescribed Mebeverine but he
was back today, complaining that his symptoms haven’t gone away.
Jonathan looks drawn and exhausted, and Dr Ferguson begins to suspect that there is more to this than the physical
symptoms he describes. “Is there anything else wrong?” she enquires gently. Her sympathy seems to open a floodgate and
Johnathon blurts out that he is having problems sleeping, feels exhausted and is crying all the time. He is also worried as
he is getting tight sensations in his throat and this is particularly noticeable at night when he lies awake at night worrying
about the future and how he will manage.
Dr Ferguson mentally re-calibrates her probable diagnosis and wonders whether Jonathan might be suffering from
depression and anxiety. She hasn’t time in a short GP appointment to carry out a full psychiatric history and mental state
exam in order to establish the diagnosis. However, she asks him whether he’s had anything stressful happening in his life
recently, or whether he has any particular worries which are keeping him awake, whilst recognising that some people
develop depression and anxiety for no obvious reason.
Jonathan struggles to control his emotions and begins to cry, disclosing that he feels so alone since his wife, Jenny, died 12
weeks ago. She had become breathless whilst swimming on their family holiday and within two months she was dead. The
oncologist had explained to them that she had lung metastases from a malignant melanoma. She was half way through her
first course of chemotherapy when she caught pneumonia and died suddenly; leaving him alone with his 2 sons, aged 11
and 8 years. Jonathan explains that they had a very happy marriage, and he feels overwhelmed by her death and doesn’t
think he will ever be able to cope without her.
Since her death, family and friends have been very supportive but over the past month this has started to wane. Jonathan
describes feeling frightened by the responsibility of caring for his children without his wife. To make matters worse his 11
year old son keeps asking why his mother had to die and is showing signs of aggression towards his sibling and other
children at school. Johnathon is struggling to know how to support his children and is worried that he is letting them
down. It’s just his luck that Jenny had to get the melanoma and not him. She would have known how to cope with this
situation much better than he did – she was always the resilient one.
Jonathan has never experienced the death of someone whom he loved and relied upon so much (his father died when he
was quite little and although he was sad when his granddad died, it seemed more in the natural scheme of things). He’s
never really thought about what grief is, and he feels that he should be strong for his children and able to cope. This is
compounded by his view that when his father died his mother “just got on with it and bought up 5 children on her own”.
“Everyone reacts to bereavement in their own way,” Dr Ferguson explains, “but what you have described sounds like more
than grief.” Dr Ferguson suggests that he might benefit more from psychological therapy or from an antidepressant but
Jonathan is very reluctant to accept professional support and is concerned that people will think he isn’t capable of caring
for his children and will label him as mentally ill. “Depression and anxiety are real illnesses, just the same as high blood
pressure or tonsillitis,” Dr Ferguson reassured him. “And there are effective treatments. It’s not quite as simple as saying
that they are due to a chemical imbalance, but drugs that modify certain substances in the brain do have an effect on
mood. Both antidepressants and psychological treatments have an effect on the brain pathways which are involved in
thinking, speaking and regulating your emotions.”
Despite initial misgivings, Jonathan starts cognitive behavioural therapy. In one of the sessions, he discusses with the
therapist his fears and anger surrounding his wife’s death. In light of the Francis report, he couldn’t help wondering if poor
care contributed to Jenny’s death. All the horror stories in the press had undermined any trust he had in healthcare
practitioners. He describes the rage he felt when she was denied a new form of chemotherapy. The oncologist had tried
to explain that although it might have prolonged her life, it wasn’t deemed cost-effective because her quality of life would
have been so poor. He felt cheated because they’d been told that her melanoma had a 5-year survival rate of 15-20% but
then she died of pneumonia.
Indicative learning objectives
Medical Sciences
• Revise the anatomy of the brain pathways involved in thinking, speaking, and emotional regulation
• Describe the hormonal control of mood and the role of the hypothalamopituitary axis in the regulation of response to
stress
• Outline the neurotransmitters involved in mood, their actions, and their role in pharmacological treatment of depression
and anxiety
• Describe the physical manifestations of anxiety and explain their physiological basis
• Recognise key features of depression and anxiety as a differential to low mood and anxiety symptoms related to stressful
life events
• Explore the domains of psychiatric history and mental state exam in aiding correct diagnosis of mental distress as distinct
from depression
• Understand that the aetiology of both common mental health problems and major psychiatric disorders involves
biological (including genetic), psychological and social factors
• Describe principles of management and investigation of depression and anxiety in primary care
• Explain the pharmacology of antidepressant, anxiolytic and hypnotic drugs
Population Health
• Investigate underlying and contributory cause of death and articulate the difference.
Trigger question: In the scenario, Jenny suffered from malignant melanoma and then contracted pneumonia. What do you
think the cause of death would have been recorded as?
• Describe the information required on a UK death certificate. Explore the potential and limitations of using these data for
epidemiological research.
• Review the methods available for measuring quality of life in special/research studies (e.g. quality-adjusted life-years,
disability-adjusted life-years, Activities of Daily Living Scale, Short-Form (SF) 36)
• Be familiar with survival analysis, including life-table, survival curve, Kaplan-Meier curve
Health, Culture and Society
• Discuss the prejudice and discrimination associated with mental health problems. Explore the consequences that arise
from such discrimination.
• Identify the determinants of mental well-being
Tutor note: This should include individual, familial and social factors.
• Identify the coping strategies most likely to aid the development of resilience, within an individual, towards adverse life
events.
• Review the cognitive-behavioural model of depression, consider the implications for the individual, the family, and the
doctor-patient relationship in terms of providing person-centred care
• Consider cultural and societal responses to death, dying and the process of grieving; explore and critically appraise
'stage' models of grief
Professional Practice, Values and Ethics
• Discuss the impact of the Francis report on Mid-Staffordshire on the confidence that patients have in the medical and
nursing professions.
• Consider the actions that the NHS have taken in light of the report, and explore what future changes may be necessary.
Trigger question: The Francis report is mentioned in the scenario – how has the NHS reacted to the bad press surrounding
Mid Staffs and, indeed, Morecambe Bay?
Further information for tutors on this module
In addition to PBL objectives above, CALC objectives also include:
• Outline the structures and their function of the limbic system
(Year 3, Managing Long Term Conditions)
‘Real patient’ PBL
Directions to the student:
In this module you are required to take a full chronic disease history from a patient with diabetes. Your placement GP has
been tasked with identifying an appropriate patient for you.
Having taken a full chronic disease history from your patient, and using any other information gained from review of the
patient notes and discussion with members of the primary health care team, you are required to prepare a summary. Your
summary should ensure that the most important and relevant information can be presented to the group in 5 minutes.
This is vital as there will be 3 case presentations as the basis for your PBL discussions.
You may find summarising the information under the following bullet-points is helpful:
• how the patient initially presented;
• how their disease has progressed and been diagnosed or treated;
• any complications they might have had;
• the impact of their illness on their life.
Remember we will be able to expand on these areas in your discussions during the PBL session. Please bring along copies
of a printed version of the summary of your case for each member of the group to aid objective setting. Please ensure that
your summary contains no information by which the patient can be identified.
As PH and PPVE issues may not be as obviously illustrated by an individual case, please consider the general questions
below in preparation for the objective setting session:
Population Health
• What public health issues are raised by this problem?
• How does this problem affect the population and what data sources are available to describe it?
• What are the health needs of the population in relation to this problem?
• How can the impact of this problem be mitigated?
• How should health (and other services) be organised and delivered to address this problem?
• What are the main research and evidence-based practice issues raised by the problem?
• What are the main public health policy implications of this problem?
Professional Practice, Values and Ethics
• What ethical or moral issues might doctors practising in this field need to consider? e.g, are there any issues with
capacity, consent, or autonomy?
• What legal acts, statutes or precedents dictate practice in this field?
• What professional guidance is relevant to these issues?
• How might practitioners’ attitudes affect the delivery of health care in this field?
• What bearing does the history of this field have on current practices?
• Are there particular professional challenges in communicating with patients?
Be prepared for the objective setting session to be more difficult – it is intended to be challenging. However, your tutors
will guide you to ensure you obtain all the intended objectives.
Learning objectives
Medical Sciences
• Review the symptoms, investigations, diagnosis, management, and prognosis of diabetes mellitus, including routine
‘screening’, drug regimens, starting insulin therapy, and complications
• Explore the differential diagnosis for ‘tired all the time’, especially the investigations and management of common
causes such as diabetes mellitus, anaemia, thyroid dysfunction, depression, and alcohol abuse
Trigger question: What other clinical problems might present with ‘tired all the time’?
• List common causes of peripheral neuropathy, and outline how a GP would approach a suspected peripheral
neuropathy, including what tests, and referring to the neurologist for definitive investigation
• How does peripheral vascular disease present in primary care? What should be examined? When should specialist
evaluation be sought?
Population Health
• Discuss primary, secondary, and tertiary disease prevention in relation to accidents in the home, and note how social and
economic factors might influence the success of health promotion in the workplace
Trigger questions: What might the day-to-day consequences of peripheral neuropathy be? How might it disrupt home and
work life and even simple activities like making a cup of tea?
• Discuss accidents at home and work (lifestyle and occupational determinants of health); how these provide routine
health data; and the potential and the limitations (e.g. bias; healthy worker effect) of occupational cohort studies
• Outline the role of meta-analysis (and the Cochrane Collaboration) in providing evidence for health care decisionmaking, with reference to treatments for a chronic condition
Trigger question: How might bodies of evidence be critically evaluated?
• Revisit routine data sources about communicable disease (e.g. statutory notification)
Health, Culture and Society
• Outline psychological approaches to coping with a disabling condition
• Outline the basic needs for full inclusion of disabled people in mainstream life
Trigger questions: What aspects of a patient's life does a diagnosis of diabetes affect? If a patient had complications of
diabetes causing a disability, how might they feel about their life prior to diagnosis? Excluded or included in mainstream
life now? Why? What are their needs now?
• Discuss a patient’s responsibility for their own health – smoking, obesity
Professional Practice, Values and Ethics
• Describe the principles and the need for chronic disease management
Trigger questions: Who was involved in the care of your patient's diabetes? How is the care of a patient's chronic disease
different to care of acute disease?
• How does ‘NICE guidance’ (and other sources of evidence) affect professional practice (e.g. treatment of diabetes
mellitus, ‘UKPDS’)?
Trigger question: What evidence and research is available which informs diabetes care?
• Describe the circumstances in which patients need to notify the DVLA regarding their fitness to drive. What
responsibilities does a doctor have regarding patients whose fitness may be impaired?
Trigger question: What areas of a patient's life does a diagnosis of diabetes affect, or restrict?
• Describe the role of doctors working in Occupational Health – who is their main concern, the patient or their employer?
Trigger question: How might diabetes affect a patient's work life? What support is available through their employment?