School of Clinical Medicine

Handbook for GP Tutors and University of

Cambridge students

Year 4b

Prepared by: Dr Kinnary Martin General Practice Education Group, School of Clinical Medicine, University of Cambridge August 2017

Overview

Year 4 General Practice Placements from September 2017

The overall aims of year 4a and 4bare:

a) To enable students to acquire the core assessment, diagnostic and professional skills

required of a Doctor.

b) To provide students with an experience of patient care in a variety of clinical settings

(primary, secondary, acute care, ward care, elective/day case,

ambulatory/outpatient care etc).

c) To build on their scientific foundation learning in the MVST programme with

opportunities for student selected research activity.

Specific aims for year 4 in General Practice:

Through experiential learning in the setting of a GP surgery under the supervision of a GP

tutor students will:-

Practice and refine basic examination skills routines using volunteer patients

Practice and refine the core clinical skills of consultation and examination across a

wide range of patients presenting with a variety of problems in primary care

Focus particularly on patients presenting with new problems or acute exacerbations

of existing conditions. Students will also gain some experience of the management of

chronic diseases in primary care

Gain insight into the role of the GP, the range of conditions managed in primary care,

the options available to GPs in the management of patients and the ways in which

GPs safely manage risk and uncertainty

Begin to understand how responsibility for patient care is shared by a variety of

agencies, how patients move between different health and social care services

depending on their need, and the importance of effective communication and

teamwork between these different agencies

Understand how health professionals in primary care can utilise the results of

medical research along with national guidelines to ensure patients receive the most

effective care. Students will learn how primary care contributes to medical research

Understand some of the limits of ‘evidence based medicine’ in the management of

individual patients

Intended Learning Outcomes for Year 4b in General Practice Objectives are stated as Intended Learning Outcomes ILOs are mapped to the GMC document “Outcomes for Graduates”.

Curricular Theme At the end of their GP placement the student should be able to:

Outcome 1: The Doctor As A Scholar And Scientist

Apply scientific principles, method and knowledge

Demonstrate an awareness of investigations available in General Practice

Begin to evaluate which investigation would be most appropriate, based on scientific principles

Demonstrate an understanding of the management of common conditions in Primary Care

Demonstrate a knowledge of drug actions, side effects and interactions

Apply psychological principles, method and knowledge

Discuss how psychological factors result in a varied response of individuals, groups and societies to disease

Begin to identify strategies of managing patients who present with psychological or psychiatric illness

Apply social science principles, method and knowledge

Demonstrate an awareness of health inequalities, and the effect of poverty and affluence of health and illness

Apply the principles, method and knowledge of population health and the improvement of healthcare

Understand the difference between individual and community health

Describe how health promotion and disease prevention strategies are used in Primary Care

Apply scientific method and approaches to medical research

Demonstrate how they have used up to date research findings to inform management of at least one patient

Describe one case in which they found it difficult to apply evidence based guidelines, and reflect on why this was difficult

Outcome 2: The Doctor As A Practitioner

Carry out consultations with patients Take a patient’s medical history, using the Calgary- Cambridge model, taking into account both disease and illness

Elicit patients’ questions, their understanding of their condition and treatment options, and their views, concerns, values and preferences

Take a history from the parent/ guardian of a child, and perform an appropriate examination of the child

Take a focused history from a patient with psychiatric illness, and perform a brief mental state examination

Perform a basic examination with respect to cardiovascular, respiratory, gastroenterological, neurological, ENT, dermatological, ophthalmology and musculoskeletal systems

Diagnose and manage clinical presentations

Use findings from history and examination to make an initial assessment and construct a list of differential diagnoses

Synthesise a full assessment of the patient's problems and begin to define the likely diagnosis or diagnoses

Support patients in caring for themselves

Demonstrate understanding that General Practice involves assessment and management of acute and emergency cases, chronic disease and prevention of disease/ health promotion

Communicate effectively with patients and colleagues

Communicate clearly, sensitively and effectively with patients and carers, as well as colleagues, regardless of age, social or cultural backgrounds

Communicate appropriately with

patients with mental illness, vulnerable patients and when discussing sensitive issues, e.g. obesity or smoking

Provide immediate care in medical emergencies

Assess the severity of a clinical presentation and the need for immediate emergency care, and be able to alert an appropriate person to the urgency of the situation

Provide basic life support

Prescribe drugs safely, effectively and economically

Accurately ascertain drug history, including prescribed and over the counter medication, vitamins, supplements and complementary drugs

Be able to use the BNF or other appropriate aid to gauge dosage, side effects and interactions

Carry out practical procedures safely and effectively

Perform appropriate diagnostic and therapeutic procedures which have been approved by the Practical Skills Team

Use information effectively in a medical context

Understand and comply with confidentiality and data protection regulation

Demonstrate awareness of sources of information which could be used for patient care and health promotion

Outcome 3: The Doctor As A Professional

Behave according to ethical and legal principles

Understand the GMC’s ethical guidance and standards

Understand the importance of appropriate consent

Recognise the rights and equal value of all people, regardless of age, colour, culture, ethnic origin, gender, lifestyle, marital or parental status, religion, sexual orientation or social or economic status

Reflect, learn and teach others Reflect on their own personal and professional strengths and weaknesses, and seek advice and guidance where necessary

Acquire, assess, apply and integrate new knowledge to optimise core clinical method

Learn and work effectively within a multi-professional team

Understand and respect the roles and expertise of Primary Care health and social care professionals in the context of working and learning as a multi-professional team

Protect patients and improve care Understand the role of General Practice within the NHS, and be able to describe how it relates to other agencies and services

Recognise the role of General Practice as the first port of call for patients with health needs

Recognise their own personal health needs, consult and follow the advice of a suitably qualified professional, and protect patients from any risk posed by their own health

Structure of GP teaching in Year 4b (Core Clinical Practice)

In year 4b students will have two 2-week placements in a GP surgery (the same surgery for each placement), linked to their secondary care Emergency Care and Acute Medicine blocks. Students will have completed Year 4a (‘Basic Clinical Method’) during which they will have learnt basic history taking and examination skills across a wide range of clinical areas – including the main adult systems (CV, RS, GI, Neuro, MSK); assessment of the sick child; basic psychiatric assessment and mental state examination and basic ENT, Ophthalmology and Dermatology history and examination. Students will also have some experience with the principles of gynaecology history taking but will not have had the opportunity to do pelvic examinations (they will learn this skill in Year 5). The focus should be on experiential learning, with students using the skills that they have learnt in Year 4a to take an active role in consulting with a wide range of patients, ideally presenting with acute problems. The following is a sample timetable – we appreciate that individual practice will want to adapt this to their own circumstances. The only fixed points are the Cambridge seminar days (the first Monday and the last 3 Fridays). On these days students will not be in the practice as they will be attending seminars either in Cambridge or regional hospitals

Sample timetable

Monday Tuesday Wednesday Thursday Friday

Week 1 AB and CD AB CD AB CD AB CD AB CD

AM Seminar Day

Introduction to the practice

AHP Teaching surgery

Teaching surgery

Teaching surgery

Teaching surgery

Teaching surgery

Teaching surgery

AHP

Midday Visits with GP Visits with GP Self-directed Tutorial

PM Visit Patient

Teaching surgery

Teaching surgery

Visit Patient

Week 2 AB CD AB CD AB CD AB CD AB and CD

AM Teaching surgery

Teaching surgery

Teaching surgery

AHP AHP Teaching surgery

Teaching surgery

Teaching surgery

Seminar Day

Midday Visits with GP Self-directed

Teaching surgery

Teaching surgery

Self-directed

Visits with GP

PM Visit patient

Visit patient

Tutorial

Monday Tuesday Wednesday Thursday Friday

Week 1 AB and CD AB CD AB CD AB CD AB CD

AM Teaching surgery

Teaching surgery

Teaching surgery

AHP AHP Teaching surgery

Teaching surgery

Teaching surgery

Seminar Day

Midday Visits with GP Self -directed

Teaching surgery

Teaching surgery

Self-directed

Visits with GP

PM Visit patient

Visit patient

Tutorial

Week 2 AB CD AB CD AB CD AB CD AB and CD

AM Teaching surgery

Teaching surgery

Teaching surgery

AHP AHP Teaching surgery

Teaching surgery

Teaching surgery

Seminar Day

Midday Tutorial Visits with GP Visits with GP Self-directed

PM Visit patient

Teaching surgery

Teaching surgery

Visit patient

Summary

Each week we would expect students to have:

4 teaching surgeries (one each day)

1 tutorial

1 session with an Allied Health Professional – AHP

1 independent home visit

1 self-directed session

2 opportunities to join GP tutor on home visit(s)

1 day of seminar teaching in Cambridge On the first morning students should have a brief introduction to the practice, the practice team and the expectations of them during the placement – as well as signing the student agreement (a standard agreement is available on the intranet (MedED) if required.

Teaching surgeries

Students at this stage will normally work in pairs with a GP tutor Students should have the opportunity to be actively involved in consultations from the outset including:

Observed surgeries with a GP tutor observing and feeding back on student consultations at 20-30 minute intervals

Independent surgeries (working usually in pairs – seeing patients at 20-30 minute intervals)

Limited (max 2 over 4 weeks) surgeries observing GP tutor. Under these circumstances students should be given clear tasks:

o How does GP tutor manage areas of uncertainty in diagnosis and management?

o Which investigations does GP tutor organize – what are the reasons for and potential problems with these investigations?

Ideally these surgeries should focus on acute presentations in primary care we appreciate that this will not always be possible and some patients will inevitably have chronic conditions – but we hope that practices will be able to use practice systems such as emergency surgeries, on the day appointments, telephone triage and duty doctors to identify appropriate patients with acute problems

Tutorial

We do not want to be too prescriptive about the topics for tutorials as we would like GP tutors and students to negotiate topics of particular interest (bearing in mind the overall objectives for these placements as above). We have specified one tutorial topic that is not covered elsewhere in the course, back pain, which should take up one tutorial slot (please see resources on MedEd for sample back pain tutorial). Tutorials are likely to be mainly case based – discussing cases that students have seen, and it will be appropriate for students to be asked to prepare material to present to colleagues and GP tutors. We would particularly like students to present:

o One case in which research from primary care can help to inform management

o One case in which it is difficult to apply evidence based guidelines

Allied Health Professionals

Students should spend some time each week with another member of the healthcare team such as:

Receptionist – ideally in the first week, and if possible giving students some responsibility to answer the phone or greet patients – rather than just observing

Practice nurse – particularly useful if running a minor illness clinic

District nurse

Local pharmacist

Independent Home Visits

Students at this stage should usually visit in pairs. Students should (during the 4 weeks they are on placement):

Review at least 1patient on the admissions avoidance register

Review at least 1patient recently discharged from hospital

Student guides for these visit are included in Appendix B. Students should have an opportunity to discuss these cases with their GP tutor and if at all possible contribute their findings to a practice MDT meeting

Flexibility

We would like GP tutors to feel free to be flexible in their approach to these placements – allowing students to take advantage of any available experiences particularly in relation to acute presentations in primary care and the interface between primary and secondary care. The placements are expected to be experiential and we encourage GP tutors to allow students to take advantage of opportunities that arise in practice. For example:

Ideally one teaching surgery over the 4 weeks should be replaced by a round of a nursing home – where possible

Students should be encouraged to follow up some of the cases seen – either in surgery or by phone

Students should accompany a doctor on at least one emergency visit if possible

If the opportunity arises for a student to accompany a patient into hospital during an acute emergency admission this should be facilitated where practical

Practical procedures – students should if possible be given the opportunity to undertake practical procedures (such as venepuncture and IM injections) under supervision

Self-directed time

Students should be provided with access to the internet and should be encouraged to:

Read around the portfolio cases they have seen and record learning points on-line. During the course of their Year 4 GP placements students should aim to see patients with at least 10 of the highlighted presentations from the clinical Problems List (See Learning Resources and Appendix A)

Prepare for presentations in tutorial – particularly o One case in which research from primary care can help to inform

management o One case in which it is difficult to apply evidence based guidelines

Complete MyPractice template. This will give students the opportunity to explore their specific practice demographics. Students are required to submit their findings using the template on MedEd (links on the GP pages and on the Public Health pages) for review by the Public Health team. Students should discuss their findings with their GP tutor and other relevant members of the practice team

Be prepared to present cases at Hub Seminars and at GP/Public Health Seminar on the 4th Seminar day. At the combined GP / Public health seminar students will work in groups (based on their GP practice) to present a case that reflects the wider determinants of health, that has significant public health implications, or that stimulates reflection based on concepts encountered during public health teaching.

For more details of the work they are expected to do see Appendix B

Feedback and Assessment

Students are keen to receive ongoing feedback from GP tutors during the placement. In addition we would expect GP tutors to meet individually with each student at the end of each fortnight to:

Provide formative feedback at the end of the first 2 week block Provide feedback and complete a formal assessment on-line at the end of the

second 2 week block

Appendix A Students should aim to see patients with at least 10 of the following clinical problems during their Year 4b GP placements and record this in their Portfolio The following, taken from the Problems List, are all presentations or problems that students are likely to see during their time working in General Practice (through years 4-6). For those items highlighted in BOLD they should expect to have considered the Primary Care approach to these presentations or problems during their 3 years at Clinical School. Ideally they should learn about these items by seeing relevant patients, but if this has not been possible they should at least have discussed them with their GP tutor or read about them through self-directed study.

Abdominal pain Abdominal Distension Abnormal Antibodies Abnormal Biochemistry –

Calcium High Calcium Low

Cholesterol High

Glucose High

HDL Low

Liver Tests Abnormal

Potassium High

Potassium Low

Sodium High

Sodium Low

Triglycerides High Anaemia Abnormal Haematology

Polycythaemia

White Blood Cells Low

White Blood Cells High Allergic reaction Amenorrhoea/Oligomenorrhoea Anorectal pain Back pain Bleeding/Bruising/Purpura Breast lump/pain Breathlessness Chest pain Child Health Surveillance Child Immunisation Coma/Impaired Consciousness/Delirium Constipation Contraception/Termination of Pregnancy Cough Deafness

Death/Dying Diarrhoea Dizziness +/- Vertigo Domestic Violence (Adult and Child) Dysmenorrhoea/Premenstrual syndrome Dysuria Dysphagia Earache Enuresis (Child) Emergency contraception Erectile Dysfunction Facial Pain Failure to Thrive (Child) Falls Fatigue Fever Fractures/Dislocations/Joint injuries Haematuria Haemoptysis Headache Health Promotion/Screening Heartburn Hypertension Jaundice Joint pain – monoarticular Joint pain – polyarticular Kidney Disease Lymphadenopathy Memory Loss / Dementia Menopause Mood disorder Movement Disorders Murmur Systolic Neck pain Obesity Oedema Osteoporosis Palpitations /Arrythymia

Panic/anxiety Paraesthesia Pelvic pain Personality Disorders Pregnancy Prolapse Proteinuria Pruritus Psychosis / Thought Disorder Rectal bleeding Red eye Regional Pain Runny nose/sore throat Scrotal / Inguinal Mass Scrotal / Inguinal Pain Seizures Sexual problems Skin rash Sleep Disorder Stroke Substance abuse/dependence Suicidal Behaviour Syncope/Presyncope Trauma Unsteadiness / Ataxia Urinary frequency Urinary hesitancy/obstruction Urinary incontinence Vaginal bleeding excess/irregular/painful Vaginal discharge Visual loss (acute) Visual loss (chronic) Vomiting/Nausea Vulval Soreness /Irritation Weight loss Wheeze/Stridor

Appendix B

Tasks for students on year 4(b) Core Clinical Practice placements:

Preparation for tutorials in your GP practice:

Tutorials will mainly be case based – discussing cases that you have seen. Over the 4 weeks of your Year 4b GP placement we would particularly like you to present and discuss:

o One case in which research from primary care can help to inform

management

o One case in which it proved difficult to apply evidence based guidelines

Home visits

During your 4 weeks of Year 4b GP placement you will be expected to visit some patients at home. We would particularly like you to see:

o At least 1 patient on the admissions avoidance register - you may be given

the opportunity to present this patient at a practice MDT meeting

At least 1 patient recently discharged from hospital

Visit guide for patient on Admissions Avoidance Register

During your visit consider:

o What are the current medical problems and how are they being managed o What are the current social problems o What are the current psychological problems o Who is involved in this patient’s care o What are the likely reasons for an emergency admission o What can be done to predict deterioration and to prevent admission o How are any plans communicated to the patient/carers/family o How are any plans communicated to other agencies o How and where is this information recorded o How and where is this information reviewed and by whom o What are the patients views of the support they are getting and of any plans in place

to avoid admission

Visit guide for patient recently discharged from hospital

During your visit consider:

o How did the patient came to be admitted – could this have been avoided? o How is the patient medically now o What is their understanding of what has happened to them

o Have there been any medication changes during admission o Does the patient understand any medication changes o Does the patient know what the medication is for o What social support is this patient receiving – is this adequate o Who else is involved in this patient’s care o Is there any other agency or professional who might beneficially be involved in their

care o Does the patient need for follow up in primary and secondary care – and if so how is

this organised o Is the information in eth Discharge Summary appropriate and adequate

Self-directed learning

You should use opportunities for self-directed learning to: o Complete preparation for practice tutorials and seminar days o Read around the cases you have seen and record learning points for your

own portfolio. We would expect you over the course of your 4 weeks to read up on patients with at least 10 of the highlighted presentations from the clinical Problems List (See Learning Resources for Post Christmas General Practice (4b) on MedEd for the Problems List)

Preparation for Cambridge GP seminars

For the second and third seminar days you will need to be prepared to present a case that you have found interesting – please record the (anonymised) patient history in the format of the appended template and bring this to the seminar.

For the final seminar day each group of students in a practice will be expected to give a short (10 minute) presentation of a case that has been interesting from a ‘psychosocial’ perspective (such as a patient who attends the surgery very frequently; an interesting home visit; a patent with chronically medically unexplained symptoms, a patient with complicated family or cultural problems; a patient with problems of substance misuse etc). These presentations will form the basis of the final joint GP/Public Health Seminar. In your presentation you should consider:

o Biological issues o Psychological issue o Social issues o What can the GP do now to help this patient o What services are available in the community for this patient o What are the Public Health issues raised by this case – consider:

The wider determinants of health Possible prevention (primary / secondary / tertiary) Health protection issues Health services issues encountered Wider systems issues encountered Any ideas for research, service improvements, health promotion

activity or other public health intervention stimulated by this case

Was there anything in your population demographic (as explored in the MyPractice task) that influences any of your thinking on the above issues?

o Are there any ethical/legal issues

Template for cases to bring to on 2nd and 3rd seminar days Presenting problem list: Exploration of problem:

Sequence of events

Symptom analysis

Relevant Systems Review

Patient’s perspective

Ideas

Concerns

Expectations

Effects

Background information

PMHx

Drugs

Allergies

FHx

Social Hx

Review of systems

MyPractice Task

You will have one MyPractice task to complete over the 4 weeks. This will give you an opportunity to explore your specific practice demographics. Students should discuss the template with their GP tutor and other relevant members of the practice team and it will then need to be submitted to Public Health. For details please see Appendix C

Appendix C

Year 4 2016-17 GP / Public Health task: My Practice The aim of the My Practice piece of work is to enable you to develop an overview of the population served by your host practice. As you know from your learning so far, health outcomes for individuals are inextricably linked with the environment in which they live and work so it is important for you to have an understanding of the particular influences on this practice population. For example, knowing that the population as a whole is relatively deprived in your area may influence how much emphasis you put on signposting a young family towards sources of information and support regarding their children’s diet; understanding that there is a high smoking prevalence may prompt you to remember to ask about smoking status and undertake a brief intervention with a patient; or knowing that there is a higher than average proportion of older people in your population could help to direct your studying to ensure that you understand the principles of cardiovascular risk assessment or stroke prevention. This sort of tacit knowledge is usually generated through working for an extended period of time in a particular area. Since you do not have this luxury, we will approach this in a different way. Your task is to produce a one to two page summary of the demography and health status of your practice population, and to reflect on the impact that these facts may have on your work as a student doctor within that practice. You will be required to submit the reflection (maximum 600 words) through MedEd for joint formative assessment by the GP and Public Health teaching staff. Link to the submission page https://vle.medschl.cam.ac.uk/course/view.php?id=442&section=14

Your summary must include:

- Age structure of the population (one way of expressing this is by asking if there is an average, lower or higher proportion of the population aged 65 and over)

- An indication of the relative deprivation levels - Information about the important health risks to the population, such as smoking

prevalence, obesity prevalence and any other health risk factors that strike you as important. These can be more difficult to find, and “soft intelligence” from the practice manager or the clinical staff can be a good starting point for understanding the particular issues facing their population.

You may also choose to look into:

- The levels of (un)employment, the main types and sources of employment and the potential health effects of this (are these sedentary office workers? Physically active

manual workers? Is there a single employer providing work for the majority of the town? How might these factors affect physical and mental health?)

- The built environment; what type of housing predominates? Are there green spaces

and recreational facilities? What opportunities for sport and physical activity are there?

- Health and social care services: what other services (besides core GP) are available

either co-located in the surgery or elsewhere in the local area? Where can you direct people if they need support in the community, such as for low level mental health needs or increasing physical activity?

- Mortality and / or prevalence of a disease of particular interest to you

Your reflection should include: - if and how your understanding of the patient population has changed through

undertaking this exercise - how you might use this understanding to better identify and meet the needs of your

patients - at least one idea for improving health for your population, based on the information you

have found You will be expected to discuss the information you have found with your GP tutors and you will use it again during the seminars in the final week of your GP placement. Contact Dr Anne Swift (aks76@medschl.cam.ac.uk) with questions.

Resources for MyPractice task: a starting point This sheet is designed to provide a starting point for your My Practice task which you will undertake during your first GP attachment. The task is described in a separate sheet. Your first stop for information on your practice and its population should be the “Fingertips” tools – national GP profiles – produced and published by Public Health England. These provide information on the population, overall deprivation and clinical / admin performance indicators. Your practice GPs may or may not have come across these, so it may be worth mentioning or demonstrating the tool when you discuss your findings with your GP tutor. County Insight webpages are the place to go for more detailed statistics on population demography, health, crime figures, etc. You can find the link for Cambridgeshire Insight below – other county insight pages are similar and you can find them through Google or another search engine. The data are given by geographical units called output areas; these units are combined to form small (lower layer super output areas, LSOA) and larger (middle layer super output areas (MSOA)) to look at different sized populations and areas. More on naming conventions for statistical geography (yes, boring, but useful for understanding the tables of data) is available via the link in the table. These do not necessarily map easily onto other units of geography, such as electoral wards or – in this case – GP practices. One of the learning objectives of this piece of work is to understand the data available, its uses and limitations. However you can do a “best fit” approach by taking the practice population boundaries (and this will be a bit messy, as

patients do not have to live in a defined catchment area) and superimposing the most relevant LSOA data onto that geography. Talk to the practice manager about the practice boundaries if you are struggling. This is a good starting point for understanding more about your practice population. Once you have the relevant LSOA codes (from the lookup tables, link below), you can look up information about that population such as their relative deprivation (bearing in mind that although relatively small areas, LSOAs will still conceal pockets of deprivation - a postcode, or a street – within an apparently more affluent area. This is where local knowledge is invaluable). This idea of this information is to give you a starting point for your enquiry; the list of resources here is not by any means exhaustive. Bear in mind that you have to consider the source and reliability of any data you use (I wouldn’t recommend citing Wikipedia, for example!). If you find any other resources that you think would be useful for your colleagues, please email the link and what you used it for to Anne Swift at aks76@medschl.cam.ac.uk and it will be made available on MedEd. See next page for resources table.

Topic Resource Link

Overview of practice demographics and performance

National GP profiles, published by PHE

http://fingertips.phe.org.uk/profile/general-practice

Population statistics including demographics, health, crime, employment etc

Community statistics by local authority

http://www.cambridgeshireinsight.org.uk/health/profilesdata/ccghealthprofiles#Profiles (for other counties google “[county] insight” e.g. Norfolk insight)

Deprivation Index of Multiple Deprivation (IMD)rankings 2015, by LSOA

https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015

Technical Lookup tables to allow you to identify the LSOA codes for your area; you will need this for the IMD data

http://www.ons.gov.uk/ons/guide-method/geography/products/census/lookup/index.html

Technical Explanation of geographical statistics and area unit codes

http://neighbourhood.statistics.gov.uk/dissemination/Info.do?m=0&s=1452256483547&enc=1&page=nessgeography/new-geography-codes-and-naming-policy-from-1-january-2011.htm&nsjs=true&nsck=false&nssvg=false&nswid=1280

Year 4 GP & Public Health: My Practice Task

Practice Name:

Population Information Age Structure (max. 100 words)

Evidence Used (max. 100 words)

Deprivation (max. 100 words)

Evidence Used (max. 100 words)

Important Health Issues Identified (max. 100 words)

Evidence Used (max. 100 words)

Reflection How will this knowledge inform your work in this practice? (max. 600 words) Include:-

If and how understanding of the patients you see has changed

How you can use this understanding to better serve your patients

How the health of this population could be improved