Time efficient data gathering

Open questions have been shown to be a highly time efficient way of gathering an overview of the problem. Examiners like to see a well structured consultation starting with open questions. You might start by encouraging Barry to tell you his story.

A good question might be

"Can you tell me more about what happened from when it started up till now?"

This encourages Barry to tell his story whilst guiding him to the time window you are interested in.

In this case the most effective candidates persist with open-ended questions to explore Barry's concerns about potential income loss due to his time off work and any fear related to the possibility of having a prolapsed disc. This understanding will help you later to tailor the management approach, and inform you about his need for reassurance.

Don't forget to clarify what specific measures Barry has already attempted for pain relief. Assess the appropriateness of his ibuprofen use, and inquire about any other home remedies or self-management strategies he has considered or tried. The best performing candidates explore his thoughts on how he might cope at work whilst he is unable to do manual work during recovery. Barry knows his business network better than you and if helped to think through the problem will formulate a plan.

Reference: RCGP SCA examiner guidance on consultation structure

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Language

Use empathetic language to connect with the patient at their level. For example ,

"It sounds really uncomfortable," or "I can see this is frustrating for you."

Simplify medical terms when necessary. For instance, saying

"back pain caused by muscle strain" instead of "lumbar muscle strain."

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Validate the patient experience

Display empathetic understanding towards Barry's frustrations and concerns about his financial situation. Acknowledge his worry about a possible prolapsed disc and reassure him by explaining the low likelihood of serious pathology based on his clinical presentation. Doing so will help him to cope with his symptoms and implement your management suggestions.

"I understand your finances are tight, and that must be worrying"

Pair gloomy news with sunny news

"the vast majority of people recover fully within 6 weeks"

Reference: Linguistic and cultural factors in the Membership of the Royal College of General Practitioners examination.

Flow

Try to ensure your questions follow a logical order. For example, after establishing the pain’s onset, you might say,

"You mentioned the pain is worse with movement; can you describe which movements are most difficult?"

Keep the narrative going by acknowledging the patient’s responses,

"Thanks for sharing that. Let’s explore that further."

Reference: Linguistic and cultural factors in the Membership of the Royal College of General Practitioners examination.

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Think about the differential

• Mechanical or Musculoskeletal Back Pain (e.g., Lumbar strain/sprain)
• Degenerative Disc Disease (e.g., Osteoarthritis, Spondylosis)
• Facet Joint Pain
• Sacral Iliac Joint Dysfunction
• Herniated Disc without Radiculopathy
• Ankylosing Spondylitis (particularly if symptoms persist in a younger patient)
• Fracture (less common in otherwise healthy individuals without trauma)
• Referred Pain (e.g., from abdominal or pelvic organs)
• Infectious or Inflammatory Causes (e.g., Discitis or Osteomyelitis, although less likely without systemic symptoms)
• Malignancy (rare, typically with a history of cancer or concerning systemic symptoms)

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NICE guidance on imaging for simple low back pain

An x-ray is not indicated for non-specific low back pain according to NICE guidelines, which recommend against imaging unless there are red flags suggesting serious underlying pathology. Address his expectation by clarifying the reasons and pivot towards discussing more effective management strategies that don't involve imaging.

A strategy for managing expectations:

1. Explain the Evidence
   
   1. Clarify that most cases of simple low back pain do not require an X-ray, as imaging rarely changes management and can lead to unnecessary interventions.
2. Reframe the Narrative
   
   1. Shift the focus from "needing an X-ray" to "getting the best care." Emphasize that clinical assessment is more valuable than imaging in most cases.
3. Address Concerns
   
   1. Ask the patient what they hope to gain from an X-ray. If they seek reassurance, explain that a thorough clinical evaluation provides the same reassurance without radiation exposure.

Reference: www.nice.org.uk/guidance/ng59

Appropriate management options

Develop a management plan that includes advice on maintaining mobility, an appropriate analgesic regimen that could include naproxen or a combination therapy. Your plan should be tailored and take into account what Barry has tried already, his work schedule and his preferences. Discuss physiotherapy, postural advice, and psychological support. Your plan should help Barry to think through how his business might cope whilst he is unable to do manual work. Who could help do the manual work for him? What other work could he do? Does he have insurance to help him cover his costs? Think about long term care of his back, with healthy lifestyle and exercise measures. Encourage gradual resumption of work activities as tolerated. www.nice.org.uk/guidance/ng59