EBM Reflection Piece

Stephen, a 67 year old gentleman, was one of the many patients I started to see by myself, before Commented [B1]: Do you need to provide any further
my supervisor stepped into the room to finalise findings, provide advice and management. When I background, or is age/gender enough?
first called him from the waiting room and introduced myself, I instantly knew he was experiencing a Commented [B2]: and
low mood and felt hesitation towards speaking to me. However, he proceeded to step into the room Commented [B3]: &
and asked about the results of his recent blood test. When I looked through, the most abnormal Commented [B4]: not needed
finding was his low iron. I asked about his general health, and I found he had long-standing, Commented [B5]: Rephrase: The most abnormal finding I
diagnosed Type 2 diabetes, hypertension, and hyperlipidaemia. I also asked about his diet, in which observed was his low iron
he admitted that he only had 2 meals a day – tea and toast for breakfast, and a frozen meal a day. I Commented [B6]: Not needed
briefly discussed the benefits of having a healthy diet, especially with his other conditions, before he Commented [B7]: Replace with: “considering”
swiftly interrupted me to tell me he had “heart all of this before”. After some gentle questioning, I
Commented [B8]: Typo: “Heart”
found out he was found to have low Vitamin B12 levels last year, and regularly comes in for Vitamin
Commented [B9]: Is this needed?
B12 injections. He also told me that “his wife used to do all the cooking”, and that since their recent
divorce, he has not been able to cook for himself.

I quickly realised this was not just a medical consult, but would be one that briefly explores his Commented [B10]: Rephrase from passive to active
mental health. I asked him more about his social history and learnt that his second had left him language: “briefly exploring”
when he was admitted into hospital for bipolar disease in 2017, and “took a lot” from him, so much Commented [B11]: Typo: learned
so that he states he does not have as much financial stability as before. He had long-standing issues Commented [B12]: Second wife?
in maintaining a healthy diet before then, and notably did not manage it well when in China for Commented [B13]: Rephrase: “further stating that he
business in 2013, and admitting bad diet in 2016, but it has notably worsened since the divorce. He lacks his previous financial stability”.
also describes he had been feeling more stress recently, because of his recent appointments with
the urologist, and has started to drink alcohol to “calm his nerves” daily. Again, when I gently
explored these feelings, I learnt he was sent to the urologist for a general check-up of his prostate.
However, he felt overwhelming stress and worry when the urologist suggested to do more Commented [B14]: Can we condense to just “stress” or
investigations, including an MRI and potentially a biopsy, to “be sure of the risk for prostate cancer”, just “anxiety”?
since Stephen’s father died of prostate cancer, and Stephen’s PSA levels had been slowly increasing
since 2017. Stephen told me he wanted to delay these further investigations, and wanted to just Commented [B15]: Break this down into two sentences
check his PSA level in few months instead, to “avoid going back to [the urologist]”.

It was then that my supervisor stepped into the room, and I summarised our discussion so far.
Because she had known him since 2006, when he first visited the clinic, she was able to be frank and
to tell him that he needs to change his diet, for the better, and to avoid alcohol while other Commented [B16]: Rephrase: “she was able to be more
conditions are being managed. He told her that he is “not motivated to eat well”. To which she frank in telling him to”
replied, “but you need to do it for yourself now”. She found that the clinic had not received any
communication from the psychiatrist recently, and Stephen admitted he hadn’t gone back there for
a few months. She wrote up a new referral for him to see his psychiatrist again, printed out scripts
for his usual medications and administered his Vitamin B12 injection. Finally, before she finished Commented [B17]: Replace: “was”
with the consult, she confirmed that his Care Plan Review is now due, and his Diabetes Cycle of Care Commented [B18]: Rephrase: “and with his Diabetes
will be due in a few months, and that it would be a good thing for him if he could change his diet Cycle of Care due in a few months, she advised it would be a
good idea to improve his diet before then”
before then. He left promising to attempt adding more fresh vegetables and fruit into his day.
Commented [B19]: Replace: “try”
His previous health issues, recent divorce and negligence of healthy diet and exercise, has resulted in Commented [B20]: Replace: neglect
a difficult position where his mental health is now being affected, and causing his mental health to
Commented [B21]: Remove this
negatively affect his capacity for self-care. As a male patient, he is at more risk of a substance use
Commented [B22]: Add a reference for this
disorder – hence the advice to stay away from drugs and alcohol is very much warranted.
Commented [B23]: Replace: “avoid”
Demographically, older men tend to be more apprehensive to seek help and be involved with Commented [B24]: Rephrase: “involve themselves”
treatment for mental health issues, due to the stigma surrounding mental health issues.1,2 It can also Commented [B25]: SUCH AS?
be seen in this case that Stephen benefited from relationships in which his female counterpart took
care of the cooking; causing a lack of understanding and skill in preparing healthy meals for himself
now that he is alone. He also lacks a supportive social network, and his only form of social contact is
seeing his general practitioner, and a local social group monthly. Both his lack of social support and Commented [B26]: Maybe discuss earlier in the essay
previous identity as a husband has made his current situation all the more challenging. how you discovered his social life info during the consult –
this comes out of the blue
My supervisor was rather direct towards the patient, which I attribute to her multiple consults with
him during the years and communicating in a way that would work for him. I imagine that if this was
a female patient, and since females tend to have higher risk of suicide my supervisor would be much
more empathetic, explore emotions and suicidal risk more, and potentially attempt motivational
interviewing. It was almost a fine balance for my supervisor between providing advice, but not over- Commented [B27]: Perhaps provide a reference for this,
stepping her boundaries, and communicating according to what she knew he has already been told even if it is your own personal reflection
before, so as to not cause frustration within himself, as well as working with time constraints of the
consult itself.

A Diabetes Cycle of Care often involves measuring blood pressure, BMI and feet examination 6-
monthly; but healthy eating, physical activity and self-care education annually.3 This procedure was
implemented to ensure appropriate management of patients with Type 2 Diabetes. However for
Stephen, despite constant instruction and reminders from multiple doctors regarding his diet,
exercise and self-care, his mental health and marital status has prevented him from fully committing
to the advice to make appropriate lifestyle changes that increase his own quality of life. Commented [B28]: Tell us how gender can influence this

I’ve known previously that general practitioners must prioritise various issues a patient may present
with, and that one consult may not be enough to manage all issues at once. I knew this meant Commented [B29]: Rephrase: “I’ve known that general
general practitioners are more involved in a patient’s progression with their health through many practitioners need to place priority on certain issues, if a
patient presents multiple; a single consult may not be
months, even years. However, it was from Stephen’s case that I learnt a 2-year history of poor diet enough to manage every issue at once” – sigh this is a bit of
and loss of motivation could still persist until today, and that perhaps his lack of social supports may a tough phrase
contribute to this. I truly learnt what it meant to be patient with your patients – and to have the Commented [B30]: Learned please
energy to keep providing advice and encouragement in cases when changes cannot be achieved
quickly. Perhaps just a small change in his diet will assist in having more positive mental health, and
allow him to manage his other medical conditions appropriately. Commented [B31]: In this paragraph you need to
emphasise again how gender can influence the state he is
currently in.

1
https://sophia.stkate.edu/cgi/viewcontent.cgi?article=1542&context=msw_papers
2
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2875324/
3
https://www.racgp.org.au/your-practice/guidelines/diabetes/