Supervisor Modules

Teaching session worksheet

“Worry is a thin stream of fear trickling through the mind. If encouraged, it cuts a channel into which all other thoughts are drained.” -Arthur Somers Roche

As part of their Mental Health Education Program, Block Releases are held for Basic and Advanced Term Registrars that cover many aspects of this topic. This tutorial is an opportunity to consolidate and build on some of this learning in a local setting. Below is a summary of the learning objectives from the Block Releases that have particular relevance to anxiety.

Basic Term Registrars (Module 1)
Objectives:

• Increase knowledge of prevalence of anxiety in the community
  
• Increase knowledge of methods of recognising and assessing anxiety in general practice
  
• Increase understanding of how to develop a suitable mental health management plan
  
• Increase knowledge of the appropriate use of pharmacotherapy
  
• Increase critical understanding of various models of patient management (including long term management strategies)
  
• Outline and practice of psychological treatment strategies
  
• Determine methods of self care and review the importance of peer support

Advanced Term Registrars (Modules 2 and 3)
Objectives:

• Build on the core skills gained in module 1 on anxiety
  
• Introduction to assessment and general practice management of mental health issues with more complex underlying co-morbidities
  
• Develop an understanding of how co-morbidities, including drug & alcohol issues, eating disorders, somatisation, chronic pain and personality disorders interplay with mental health presentations, assessment and management in general practice
  
• Introducing use of case studies, role play and “fish bowl” scenarios as Registrar education tools in topics of complex mental health presentation

Full details of the Block Release programme including useful resources are available here.

This in-practice teaching module is designed to be covered in up to 3 sessions if necessary. Section A should be completed first as it identifies potential gaps in knowledge. After Section A has been completed, Sections B and/or C can be undertaken.

Section A

Key Question 1.
What are the baseline skills of the Registrar and the Supervisor?
Are there any perceived gaps in knowledge or skills?

It can be difficult to be sure of one’s own abilities when dealing with a broad area of medicine such as anxiety. We may develop confidence as we receive positive feedback from patients and get an idea for “what works” in our hands. Registrars may not have been working long enough to go through this process, so they may find the process of seeing patients with anxiety symptoms challenging.

Your registrar should have completed a brief self-assessment of knowledge and skills in management of anxiety disorders for discussion at this point.

• Discuss your registrar’s self-assessment
  
• Discuss your registrar’s experience of the Mental Health Block Releases as outlined above. Did they find the sessions useful? Have they had any particular problems translating what they have learnt into clinical practice?
  
• Discuss your own experiences of learning to manage anxiety symptoms. Have there been any particular patients or moments of learning that have led to a change in your practice?
  
• How would a doctor become aware of having a significant “gap” in knowledge or skills in this area?

Section B

Key Question 2.
In practice how to we assess somebody who presents with anxiety?

Anxiety is a common presenting problem in the GP setting. The anxiety might be related to a serious health problem, may be related to various stressors the patient is experiencing, or may be an anxiety disorder per se. The reality is that patients do not come to their GP saying that they have an anxiety disorder.

While the registrars have had instruction on the management of anxiety disorders, the challenge is applying this knowledge and skills base to actual practice.

The first step is to sort out which patients need no specific intervention, which ones need some simple counselling and support, and which ones are suitable for more in depth cognitive behavioural interventions.

The following questions might be useful to cover. However before you discuss these in detail with the registrar, he or she needs to do some work based on their clinical experience in the practice. Please refer to the registrar worksheet for an outline of the preparation to be done by the registrar.

• Is everyone who presents as anxious, suffering from an anxiety disorder?
  
• What other types of underlying problems may present with the symptom of anxiety? How might you try to differentiate?
  
• What are your priority tasks with an anxious patient and what might their sequence be?
  
• What “red flags” might make you very concerned about a patient? How might you then respond?
  
• What sort of interventions might you put in place for someone who is anxious secondary to major life stressors?

Key Question 3.
What associated factors might affect anxiety related consultations?
[eg drug seeking, patient cultural issues, patient personality traits, aspects of the “in practice culture”]

"Now is the age of anxiety.” -W.H. Auden (1907-1973)

The aim of this key question is to raise awareness of the need for monitoring of patient outcomes, awareness of developments that might cause you to reconsider the diagnosis or your management.

Anxiety per se can be associated with a range of factors and some of these may not be evident at the start of the process. Some may not emerge until the therapeutic process gets “stuck” and progress is not forthcoming.

The following questions might be useful to cover. However before you discuss these in detail with the registrar, he or she needs to do some work based on their clinical experience in the practice. Please refer to the registrar worksheet for an outline of the preparation to be done by the registrar.

• What indicators do you look for when you are reviewing a patient with anxiety?
  
• When would you expect a response to interventions such as simple behavioural interventions, structured problem solving, antidepressants, or to CBT?
  
• Who might you get advice from?
  
• What alternative/additional diagnoses might you want to consider?
  
• What changes to management might be appropriate?
  
• How might you manage requests for benzodiazepines?

Section C

Key Question 4.
How do you schedule follow up?

Follow up plans for patients with anxiety can differ between GPs, and there are no readily identified guidelines or structures. Exploring how supervisors have come to their own individual style may help registrars develop their own framework with more confidence.

• Discuss some of the factors which might influence the time frame of follow up for different sorts of patients
  
• Does the frequency of review have any effect on the length of the review visits, or vice versa? Can this be used to your advantage?
  
• What effect may the time of day or even the day of the week have on your ability to treat these patients appropriately?
  
• Are GP Mental Health Care Plans something you routinely use to assist with planning follow up? If not, explore why this may be. If so, can you identify any ways you may be able to use them to further advantage?
  
• Do you use a formal recall system?
  
• How do you approach the patient whose anxiety is heightened when you suggest a different frequency of review than they may have expected? What strategies might you employ to come to an appropriate agreement on his issue?

Key question 5.
How and when do you refer your patients with anxiety?

The decision to refer a patient with anxiety for further management is a complex task. Most supervisors probably feel they make this decision intuitively, which can make teaching registrars this skill a challenge. The following questions may help make the decision-making pathway more accessible.

• What factors may influence your selection of which patients you refer for further management? Consider factors relating to both the patient and yourself.
  
• Do you have any concrete “indicators” to trigger referral, for example specific time milestones, particular treatment strategies you want to be employed?
  
• What are the referral pathways that you use most regularly? How do you decide which one to use for which patient? What pathways has the Registrar been exposed to in their prior practice? Are these practical in the current setting?
  
• What do you do if you feel referral is indicated but the patient expresses reluctance, or fails to attend?
  
• Review the use of Mental Health Care Plans to facilitate referral.
  

You, the supervisor will have identified two patients that you have treated over a period of time for Generalized Anxiety Disorder, Post Traumatic Stress Disorder or Social Phobia.

Discuss these cases with your registrar with particular focussed reference to the following questions:

• What has been the frequency of follow up? Can you identify if this was directed according to a formal plan or did it just develop organically? Do you recall any factors in this particular case that affected your follow up plan?
  
• Has referral been considered or discussed with the patient? Was a referral made? If so, did the patient follow through with this referral and what was the outcome? If not, has this been identified and discussed further