Communication skills (3)
ST1 group 2017
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We looked at consultation models.
We looked at Calgary– Cambridge framework.
ICE and PSO.
Also Introduction to CSA and domains.
Role plays – concentrating on initiation, data
gathering (empathy and rapport).
Looked at a video – observed a CSA.
Role play – explanations
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Giving feedback.
Ask the registrar what they thought they did
well
Observers says what they thought they did
well.
Registrar says what they think they might do
differently in future
Observers suggest possible changes.
Registrar constructs an action for
improvement (essential)
Identify factors that make consultations
difficult for you.
10-15 minutes
You may like to think about this by dividing this into
doctor, patient or organisational factors....or you
might not!
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Plenary
◦ Check that you know who is who
◦ (Ask yourself why the relative has come?)
◦ Welcome both parties
◦ Get the seating right so that the patient is
the primary focus but the relative is not
excluded
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Don’t get too side tracked away from the patients
problem by the relative
Think about privacy and chaperone.
You may have to ask the 2nd party to leave the
room prior to physical examination
You may need to summarise for both patient &
relative - the emphasis of the summaries may be
different
You may want to ask just the patient or both to
come back to the review appointment depending
upon which is going to be the most productive.
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Check what the patient is happy to share
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Signpost clearly who you are talking to
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Ask permission to get the relatives views
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Be alert to cues from both parties
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A mother & 14 year old daughter attend.
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Daughter has been generally healthy; the
only consults in the last few years have
been for DT/P boosters & HPV vaccine.
Role plays for mother/ father and for the
daughter
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We all have them!!
Enormous variations in what different doctors consider
difficult/ challenging consultations.
In one study, American doctors rated 15% of primary
care patients as 'difficult'. Other studies have suggested
much lower numbers.
But if even 1% of list size is ‘difficult’ the effect on
workload and morale is disproportionate.
The top 3% of attenders generate 17% of a GP's clinical
workload.
Doctor
Some of the variation in experience of 'difficult'
or 'heart sink' patients can be explained by:
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Perception of high workload.
Poor job satisfaction.
Poorer postgraduate qualifications.
Insufficient training in counselling or
communication skills.
Patient
◦ Psychiatric disorders (particularly multisomatoform disorder, panic disorder, dysthymia,
generalised anxiety, major depressive disorder and
probable alcohol abuse or dependence).
◦ Functional impairments.
◦ High use of healthcare.
◦ Lower satisfaction with care.
◦ One study in Japan found that patients who took a
more active role in the consultation were more
likely to be classified as 'difficult' by doctors.
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Early work by Groves in the US produced a well-known
classification of 'hateful patients' (those "most physicians would
dread to treat"):
Dependent clingers are excessively dependent on the doctor,
desperate for reassurance but will return continually with a new
array of symptoms. For example, "Thank you, my back's much better
but I've got chest pain now.“
Entitled demanders are also inexhaustibly needy but, rather than
using thanks and flattery, will use intimidation, devaluation and guilt
against the doctor, frequently complaining when every request is not
met.
For example, "I must see a specialist for my ingrowing toenail right
now!" This situation is likely to become more prevalent with the
increased rationing of healthcare resources.
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Manipulative help-rejectors - continually return to
the surgery to report that treatment failed. Where
any symptom is relieved, it is rapidly replaced by
another. For example, "None of the painkillers has
helped my back; I'm allergic to those other pills;
Pain Clinic did nothing. You've got to help me!“
Self-destructive deniers - whilst suffering from a
potentially serious condition, will make no effort to
alter their self-destructive behaviours, eliciting and
then frustrating medical efforts to help them.
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Examine your own reactions:
Ask yourself "What is it about this particular person that makes
me react negatively to them?“
"Why do they get under my skin?" - think about subliminal
reminders, feelings triggered from our past or present may affect
how we react to a patient. For example, sympathy for a
hypochondrial patient may be very difficult when a loved one is
terminally ill.
Examine whether our perception of the patient is, in fact, a
belief. For example, "He is manipulating me". If it is a belief,
what is the evidence and is it reasonable? Are there alternative
beliefs that fit the evidence as well/better and that may facilitate
a new approach to the patient?
Consider your communication skills.
Consider, "Am I a heart sink doctor?!!!"
◦ Keep a reflective diary – learning logs !!!!
◦ Review the patient's notes.
◦ Consider a change of focus - think about the person behind the
illness; consider what life is like in their shoes.
◦ Share the problem within the practice or with a colleague - Peer
group discussions of difficult cases may be helpful.
◦ Consider a meeting to establish ground rules for your continuing
doctor-patient relationship. Make this non-confrontational, if
possible.
◦ Benchmark - some patients have no idea what the average
consultation or referral rate is. Agree how and when you will meet.
◦ Be explicit about what you (personally, the practice, the NHS in
general) can provide as well as your limitations.
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If a customer is angry, never get angry back. It can
only turn an unpleasant little incident into an
unpleasant big incident.
Do not try logical argument on a customer in a
temper: it only adds fuel to the fire.
Do not grovel, and do not let an angry customer
draw you into accepting his assumption that the
organisation is generally inefficient because of his
own single unhappy experience.
The way to deal with an angry customer is to
apologise for the specific inconvenience only, and
to take immediate action to put it right.
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I learned long ago,
never to wrestle
with a pig. You get
dirty, and besides,
the pig likes it.
George Bernard
Shaw
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An angry customer means that you still have an
opportunity. If the customer storms out of the
office, (or slams down the phone), never comes
back, and tells all his or her friends/colleagues that
it’s a dreadful place, that’s real damage.
But if the customer comes to you in a temper, you
have the opportunity to prevent that damage - the
real disaster has not happened yet, and if you
handle the situation correctly, it won’t happen.
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Handling an angry patient (badly)
https://www.youtube.com/watch?v=mbheTo
Xlm2Y
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The angry or difficult patient
Return to fishbowl arrangement.
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Dr – you are aware that this patient has
recently been sent a written “warning” from
the practice about his difficult behaviour with
reception & the clinical staff.
Pt has most recently consulted several times
with back pain, has been referred to physio at
last appointment & given naproxen.
The receptionists warn you that “he is not
very happy”.
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Never show your boredom or frustration. It
will offend other people as well as the chatter
box.
Never bully or hector any customer, or
interrupt rudely, or shut them up by visibly
trying to dominate them.
When dealing with a compulsive talker, use
every conversational gap and lead that you
can to guide the conversation towards a
satisfactory conclusion.
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Dr – Mrs P is a frequent attender who often
causes surgeries to overrun. She rotates
around doctors and likes to spend time with
her “favourites”.
You, thankfully, are not one of them but you
are the only doctor in today and have not
seen her in over a year.
She had a normal FBC and TFT done last week
for fatigue.
PMH – gallbladder, heart valve, bunions – you
have heard all this before !
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Do not get personally upset by the rudeness of an
offensive customer. And do not fuel his/her abuse
by making ‘value judgements’, just stick to facts.
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Do not be deliberately casual or icily superior to
show an offensive customer what you think of him.
The way to deal with the offensive customer is to
keep cool, keep your professional detachment, stay
polite, and keep offering possible solutions in
strictly factual terms.
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Learn to ignore rudeness. Remember that the
offensive customer is offensive to everyone who
deals with him/her, not just you. Your job is not to
make him/her nice; you simply have to supply
him/her with what he/she came for.
It is worth recalling the, point that you do not have
to make an angry person into a nice person. That’s
impossible. All you have to do is to get them to go
away with whatever it was they came to get.
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Next up is Mr Barton – a 52 year old diabetic
patient who has reasonable control at 53 and
on metformin only.
He has no diabetic complications
The nurse removed his strips from his
prescription (as per protocol) and he was not
happy when he found out – he was rude, as
he has been before, and is known to be a
prickly character.
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Difficult people are usually difficult for a
reason.
People who are scared and anxious are most
likely to be difficult - and may remain
difficult until their problems are resolved
Anxious people can become childlike and
have “tantrums”. Treating them like children
will encourage them to act like a child, whilst
treating them like responsible adults will
encourage them to act rationally
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https://www.youtube.com/watch?v=LGc9cJpjl
ys
Why is it so hard to break bad news?
Not understanding what bad news is
Fear of how the patient will react
A sense of failure or guilt
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S = setting up the interview
Prepare yourself: familiarise with patient’s
background, medical info and anticipate
some likely questions.
Environment: arrange for privacy, minimise
interruptions and time constraints
Establish a connection with the patient –
involve family, nurses etc
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P = assessing the patient’s perceptions
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How much do they know
Correct any errors or gaps in their knowledge
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I = obtaining the patient’s invitation
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How much do they want to know
Too little/ too much detail ??
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K = giving knowledge and information
Warning shot
Clear and simple information (but avoid
excessive bluntness)
Avoid jargon
Check understanding
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E = Addressing the patient’s emotions
Give time to express feelings
Observe and acknowledge emotions
Show empathy
Encourage questions and allow time
S = Strategy and summary
Clear plans
Follow up and support
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Breaking bad news done well (9+ mins)
https://www.youtube.com/watch?v=lJN6g0V
5Q-U
Breaking bad news badly (4+ mins)
https://www.youtube.com/watch?v=xCBQUG
vZU7k
A middle aged patient has RUQ pain and has
had an USS- the practice has booked an
urgent appt to discuss the results.
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Dr – your next patient is a 56 year old man
who has been sent for an USS because of
persistent RUQ pain.
The scan shows that the liver looks as if it is
full of metastases, & the pt has been given an
urgent appt to discuss this.
Step 1: Connect
1. Try to see the world through the patient's eyes,
and discover his agenda or priorities.
Useful phrases include
How are you getting on?
What did they tell you at the hospital?
Is there anything you want to know about your
tests/illness/operation?
2. Be alert for unspoken as well as spoken
answers. Feelings perceptible at the edge of the
discussion will probably indicate the the real
state of affairs better than the facts actually
discussed.
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Step 2: Summarise
 Reflect back to the patient the impression
that you have gained of the situation. This
shows that you have understood his/her
feelings and gives the patient a chance to
correct, refine and expand on them.
Step 3: Hand over
 If you answer the questions to the best of
your ability and admit any uncertainties, the
knowledge that forms bad news is handed
over in a way that empowers the patient to
keep control of his/her life. To withhold
information is also to withhold control and
demeans the patient
Step 4: Safety net
 Safety netting is the doctor checking where the
patient is, often acknowledging his/her pain,
grief or bewilderment - "this must come as an
awful shock to you".
 Recognising the patient’s feelings – “allow” those
feelings
 Leave door open for patient to seek further
help/support
Step 5: Housekeeping
 The doctor reviews his/her own feelings.
 Not always possible/desirable to follow classic
medical profession dictum “not to get involved”
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Thank-you
Group feedback
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PBL - neurology
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