The KFP, it's just another working week

The KFP, it's just another working week

It's Monday morning...  

You're feeling bright and refreshed after the weekend, and looking forward to some interesting challenges. Your first patient is Louisa Hill, aged 43 years.  "I'm tired Doc".  Great start. After thorough history and examination, you find nothing.  Sound familiar?

You need thinking time.  'We should just check your urine'.   You contemplate the 'tiredness differentials' and consider Murtagh's masquerades.  As an afterthought, knowing Louisa’s complex history and failed IVF attempts, you say, "I don't think it's going to be positive Louisa but do you mind if we do a pregnancy test, just to be complete?"   Two dark lines appear immediately and Louisa shrieks with joy!  

"Thank-you for being thorough doctor! That’s amazing!"   You give yourself an inner pat on the back.  You’re Super-Doc!

Friday afternoon...

The week drags. It's now Friday afternoon, and you've been up and down all night to your sick two-year-old.  In the morning session, an elderly gent presented with an AMI and required bundling off to hospital - now you are running behind and you realise you’ve left lunch at home.  Your  next patient is 49-year-old Angela Mears.   Same story as Louisa Hill, different day.  "I'm tired Doc.”   History and examination reveal nothing again.  Angela's preg test is negative.  There was only enough wee to cover the half of the WTU strip.  You suggest to Angela that she be kinder to herself, have a holiday eat well and exercise, and send her off with a form for a fasting FBC, UE, LFT, glucose, TSH and lipid profile.  Finally, some Friday arvo URTIs, some ‘quickie’ UTIs, and a bonus… leftover pizza l in the tea room fridge! You made it through the week.

Monday morning again...  

You’ve just spent a lovely ½ hour with Louisa and her husband - her dating scan revealed a viable 10 week pregnancy.   An urgent phone call from the Lab interrupts – “Dr, just wanted to let you know that Angela Mears has a glucose of 25 mmol/L.  What would you like to do?”   Uh oh, the inner pat-on-the-back feeling disappears.   How could this be?   Angela didn’t seem sick, just tired.   Her history and examination were unremarkable – what did you miss?

Doctors are human and we miss things because we don’t recognise and respect HALT – Hungry, Angry, Late or Tired (or need to go to the toilet) – we just keep going.  That’s why we need to practice clinical-reasoning and safety-netting so that we have a backup - and that’s what the KFP is testing.   Sometimes (e.g. in an emergency,) we have to ignore HALT, but most of the time, we have the ability to recognise and address it.   

Why do emergent rather than routine presentations have well-defined protocols and algorithms? It’s because they can catch us unawares and we don’t have time to HALT.  For those routine presentations though, it’s still important to have a safe diagnostic strategy for every patient -  a ‘safety-net’ - so that when HALT catches us off guard, there is a backup plan that will ensure the patient is safe and we don’t miss anything.

As for the KFP...

That’s what the KFP is about – demonstrating that you have a safe diagnostic strategy. Studying the best resources and doing heaps of practice questions is not the answer.  Similarly, if you are seeing the same type of patient’s all the time, your thinking scope will be narrowed.   Developing clinical reasoning and safe strategies requires techniques to challenge and justify your thinking (and this is hard to do studying alone).    Until you reflect on, improve and practice your clinical reasoning in the context of daily practice,  the KFP will be a tricky exam, and you may well miss why Angela is tired on a Friday afternoon.

Dr Rebecca Stewart author image
Dr Rebecca Stewart

Rebecca is a GP, GP Supervisor and Medical Education Consultant working in Townsville, North Queensland. She delivers exam preparation education for the RACGP, Medcast and Mededexperts.