An alternative way of recording patient experiences is through PUNS and DENS (Patient’s Unmet Needs and Doctors Educational Needs). PUNs and DENs were originally developed by Richard Eve a GP. The process is to self analyse situations where a patient may not have received the optimal advice or treatment and, from that, identify the doctor’s own educational need.

This technique fulfils the GMCs requirement for needs based development

This example is simply a different way of recording the example on the previous web page:-

Identify PUN

I saw an 18 month child on a home visit OOH with abdominal pain and diarrhoea Extreme pressure from father (? Alcohol) for admission – admission arranged. Child did not require admission but social circumstances poor, father very aggressive and I had no real choice.

PUN was actually the need to diffuse the situation and deal rationally with the aggressive father.


Patient admitted to hospital unnecessarily and aggressive father not placated

Describe the PUN

Situation beyond my control and possibly not dealt with effectively

Record the DEN

To examine my techniques in dealing with aggressive patients

Fulfil the DEN

The OOH provider was running a half day session on “aggression in the consultation and how to deal with it” so I attended. This was very valuable and in a way cathartic in that I was able to listen to others and their experiences – one GP had even had a knife pulled on them!

The main thing I gained was a sense of not being alone in having this type of experience and indeed that others had extricated themselves from even trickier situations.

In the workshop sessions my admission of the child was seen as a good option and put myself and the child in a position of safety – the importance of letting the paeds SHO know of the background was reinforced as was communication with the patients own GP. I did however pick up that the way in which I initially dealt with the patient probably reflected his anger back on him and possibly inflamed the situation. The father had met me at the door and said “my son needs to be in hospital and you need to admit him” I replied with something like “give me a chance to see him first” which probably set the tone. I learned that accepting and being seen to accept the patients concern may have diffused the situation and that using body language to “tone down” the aggression may be important. In the situation I had responded to the aggression with aggression.

I will try to use these techniques in future and will record them as they arise.