Communication skills. 

 

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How to pass the MRCOG 1st. time

List of contents.

  1. introduction.
  2. the role-players.
  3. make sure the role-player understands you.
  4. make out a plan & keep an eye on the time.
  5. introduce yourself.
  6. devise & practise a standard form of words.
  7. find out why she is here.
  8. summarise the whole role-play.
  9. body language.
  10. don't use big or obscure words.
  11. avoid medical jargon.
  12. show your humanity and decency.
  13. don't pretend to know stuff you don't.
  14. find out her level of knowledge.
  15. is there any particular reason for the consultation.
  16. could there be a "hidden agenda"?
  17. is her main concern unstated? E.g. the fear that she has cancer.
  18. techniques to enable the patient to divulge difficult facts and secrets.
  19. explaining chromosomes and genes.
  20. make it easy for the patient to ask questions.
  21. pre-pregnancy counselling.
  22. opportunistic pre-pregnancy counselling.
  23. bereavement counselling.
  24. counselling after miscarriage / TOP for abnormality etc.
  25. always be "nosey".
  26. complaint procedures.
  27. feedback.

 

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Introduction:  

I don’t fantasise that I am an expert in communication.

The following reflects my attempts to improve my abilities and to help MRCOG and DRCOG candidates prepare for their exams.

I hope you find it useful.

Your comments and suggestions would be welcome.

There are training courses in communication.

They often video you talking to a role-player.

This lets you identify and correct bad habits to which you might be oblivious:

    picking your nose,

    frowning inappropriately,

    repeatedly saying "Hmmm",

    interrupting,

    not picking up clues,

    and so on.

It makes sense to go on one if possible.

Many hospitals have courses in "breaking bad news".

This is something everyone finds difficult.

A training course is likely to help.

Much of this section is relevant to counselling after the loss of a baby.

I have put additional information on a separate bereavement counselling page.

Don't delude yourself that this makes you a counsellor.

This requires specific training and is likely soon to be recognised as a specialty in its own right.

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The Role-players.

The role-players are mainly young trainee actresses.

A trainee actor might be used for a station like male infertility or an angry husband threatening to remove your head.

It is vital to get the role-player relaxed.

She will be treating the exercise as seriously as she would an audition for the leading role in a major West End production!

She will also be aware that the exam is extremely important for your career and will be desperate not to mess up.

So, she will be under considerable stress and you need to deal with it to get the best from her.

She will have arrived an hour or so before the examination and been given the fact sheet for her role.

She will have met with the examiner who will oversee the station.

The examiner will have tried to explain the background and the significance of the information.

The role-player has only a short time to memorise it and some of the medical jargon may be completely new to her.

As a result, she is likely to be nervous, particularly during the first few stations.

It is essential that you get her to relax and think that you are decent human being and doctor.

You don’t want her on the edge of her seat struggling to understand you.

One of the common questions on the marking sheet is: “Is this a doctor you would consult again?”.

If she finds you difficult to understand or dislikes something about you, she will not be coming back!

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Making sure the role-player understands you.

S-P-E-A-K    S-L-O-W-L-Y    AND    C-L-E-A-R-L-Y!

This is absolutely vital!

If you do nothing else, at least pay heed to this and start practising.

If you are a foreigner, like me, then you almost certainly speak too quickly.

If you work in the UK you probably think that your accent and speed of delivery are fine, as patients seem to understand you.

But you are probably deluding yourself.

The problem is that patients are too polite to tell you that you are speaking too quickly and that they don’t understand a word.

In real life they will just wait out the interview and go to see another doctor.

In the exam, the role-player is unlikely to tell you there is a problem.

If you don't pick up the clues that this is a communications disaster, you will be done for.

 

In the heat of the examination, we all tend to speed up.

This can lead to jabbering that the role-player finds difficult to decipher.

This is particularly important if you are from overseas or have an accent markedly different to that of the person you are talking to.

When I came to work in England, I found that I had to speak at half the rate I would have done in Scotland.

The natives couldn’t understand my accent and I had only migrated 200 miles south!

And I hadn't thought that I spoke particularly quickly or that my accent was especially difficult.

Although I should add that we Scots have the notion that we speak the best and clearest English!

It is highly likely that you will have the same problem as I did.

Do something about it!

I had an excellent trainee recently who could not remember to slow down and spoke so quickly he was incomprehensible.

At every tutorial I would ask the other members of the group if they could understand him.

They would all say "no" or "with difficulty".

I reiterated the need for him to speak slowly and clearly until I was fed up doing so.

He would slow down for a few moments then lapse back into high-speed jabbering.

He failed the clinical exam and I am sure that this was the reason.

Don't you fail for something that is so obvious and remediable.

This is a very basic but essential message and you need to practise.

 

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Make out a plan. Keep an eye on the time.

When we practised writing short essays, we spent the first four or five minutes deciding the key things to include in the essay.

OSCE stations are no different, they need an outline plan too.

Role-play and viva stations are very stressful.

If you rush in and start the station straight away, you will almost certainly forget something important.

Take a few minutes to make out a plan.

There will be a screen round the table where the role-player and examiner are sitting.

The details of the station and any materials will be on the screen as well as on the table.

There will be a description of the tasks you have to perform at the station.

It is vital that you read this more than once to be clear about what you have been asked to do and where the marks are.

There might be other materials such as a referral letter from the General Practitioner.

You might feel more at ease standing outside and writing your plan without the role-player and examiner looking at you.

Or you might feel that it would be easier to sit at the table so you can lean on it to write.

Choose whichever makes you more comfortable.

The role-player and examiner will wait for you to start.

Whatever you do, don't just rush in and launch into your spiel - jot down the main points you need to cover.

It is essential to keep an eye on the time.

Make sure you touch on all your "headline" points during your discourse.

One technique is to run through the list of headlines at the start.

This can be a useful technique in real life too.

A patient comes to see you for pre-pregnancy counselling as her sister has had a baby with Down's syndrome.

You do the usual introduction.

Then outline the key facts in the GP referral letter.

Then ask if there is anything else that she wants to discuss to make sure nothing has been omitted from the referral letter.

Then show your humanity by asking about the baby, how it is doing, how the sister and wider family are adjusting to having a baby with special needs and problems.

But don't spend more than a few moments on this - there probably will be no marks or one at the most.

Then say something along the lines of:

"What I'd like to do today is

    make sure that you have all the information you need about Down's syndrome,

    ask some questions that will give us some idea of the risk of you having a baby with Ds,

          this will be the possibility of the sister having a balanced translocation, how old she was, the wider family history, the patient's age etc.,

    discuss with you how we might screen and check any pregnancy for DS,

          this would include pre-implantation genetic diagnosis, combined first trimester screening, CVS and amniocentesis,

    whether you would want to have TOP if the baby had DS and how this would be done,

    also discuss with you the general things we talk to all women about like smoking, alcohol and drugs, diet, taking folic acid, being screened for immunity to German measles and chickenpox etc."

It would not take long to rattle this off in the exam and if you ran out of time you would still get some marks for having mentioned it in the preamble.

In real life it is often important to explain what you are doing and why you are asking some questions.

The patient wants to know her risk of DS.

 Andou are asking a load of questions that seem irrelevant like the sister's age and whether anyone else had a baby with DS.

But if you preface the questions with the statement: "I need to get some more information before I can work out your risk of having a baby with DS.

Please bear with me while I ask you the necessary questions".

With all of this, if you have made a list of the key things you want to say, there is less risk of omitting something important.

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Introduce yourself.

Introduce yourself. “Hello. I am Dr. ………. “

One mark!

Shake her by the hand.

Don’t attempt to shake her hand if you are male and she is obviously Muslim.

Some Muslim women would find it upsetting to shake hands with a male who is not a relative.

A mark for saying your name and shaking hands?

Is this an examination or a stroll in the park?

Devise & practise a standard form of words.

I advise that you practise a set form of words to get the role-play off to a smooth start.

You are then less likely to get tongue-tied under the stress of the examination.

The format that we drill into our MRCOG candidates is as follows:

“Hello, I am Dr. …………..

May I check your name please?

What would you like me to call you?  (Usually she will say her first name.)

Then please call me ….your first name.

Older patients may prefer a formal title: Mrs ....”.

In this case you don't need to do anything - you have already introduced yourself as Dr. ....

In this case, you stick with your title, Dr. .....”.

At this point it may also be appropriate to check her date of birth.

Never ask a lady her age - but asking her DOB is acceptable!

 

“Hello” is better than “Good morning” or “Good afternoon”, as you are likely to get them mixed up.

“May I check your name please?” is better than “What’s your name?”.

“What’s your name?” sounds hard and as if you could not be bothered to find her name from the notes.

“May I check your name please?” means that you have taken the trouble to ascertain her name, but are a super-careful doctor and want to check.

You are aware that occasionally the patient is accompanied by the wrong set of notes.

“What would you like me to call you?”

This makes the patient comfortable and puts her in charge.

She can choose informality with her first name or formality with her title.

If she wants to be called by her first name, then it makes sense for you to be called by your first name.

Every facet of you and her as individuals is a potential barrier to communication.

Sex, age, ethnicity, accent, the colour of your hair, whether you have a moustache, the character on television you remind them of, etc.

Add perceptions of each other – she thinks you are super-intelligent, highly educated, rich, spoiled etc.

At the same time, you make assumptions about her (e.g. based on her occupation, clothes, body-piercing etc).

It is surprising that we ever manage to talk to each other!

In practice, our shared humanity breaks down all the barriers.

It is just a question of getting used to each other.

One of the barriers to communication is the doctor having high status and the patient less.

White coats, stethoscopes worn prominently round the neck … are all symbols of the doctor’s superior status.

Into this category is the doctor being called “Doctor” while the patient’s first name is used.

It smacks of a condescending conversation between an adult and a child.

If you are going to call her by her first name, she should use your first name.

Don't say “then you may call me ….first name”.

”May” puts the doctor on high again – the patient needs permission to use the doctor’s first name.

But the doctor does not need permission to use the patient’s first name!

It will feel odd at first, but most of those who try it find that it helps establish rapport.

Some doctors worry that the “familiarity” of using first names will diminish respect for the doctor.

I believe the opposite.

Respect comes from how you behave and not from any posturing to establish high status.

Do you treat her like a valued human being?

The best maxim being the old one: treat her as you would wish to have your mother/ sister/ wife or yourself treated.

Are you taking her concerns seriously?

If she asks a question or makes a comment do you deal with it or ignore it and brush it aside?

Are you making medical sense?

As noted above, the quickest and surest way to lose respect is to pretend to know something when you don’t.

Lying kills respect.

 

Many doctors routinely say: "I am one of the doctors in clinic today".

Or, "I am one of the registrars in the clinic today".

Both phrases are daft and should not be used.

The patient knows she is in the clinic, so why tell her?

As you have introduced yourself as Dr.  ....... saying "I am one of the doctors..." is redundant.

"Registrar" is a technical term and should not be used without prior explanation.

For most people a "registrar" is the person at the town hall who keeps a register of births, marriages and deaths.

What such a person would be doing in the gynae clinic would be a real mystery.

I doubt that the patient cares what your rank is, so long as you are competent.

 

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Find out why she is here.

Usually there will be a referral letter from the GP.

Start with that, but remember that there may be issues that are not in the letter.

"I have a referral letter from your GP.

It says that you are planning your first pregnancy and are concerned because your nephew has Down's syndrome."

Just say exactly what is in the letter - there is a tendency to develop the themes, which should be avoided.

Check that this is an accurate representation of her problems.

"Is this a good summary of what you went to the GP about?"

But don't you let things rest there.

"Is there anything else causing you concern?

Is there anything else that you would like to discuss today?"

This will usually pick up any hidden agenda.

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Summarise the whole role-play: agree an agenda for the consultation.

This is a useful technique.

In real life it makes you focus on what should be in the consultation.

And gets the woman's participation when she agrees the agenda.

It lets you explain why you need to ask questions or do other things before answering her burning questions.

In the exam, it gets a load of boxes ticked and marks scored at the outset and for very little effort.

A good agenda could well tick all the boxes needed to get to the pass mark.

If you get into time-management difficulties, it might even get you marks for stuff you don't get to discuss in detail.

Let's look at the above scenario of pre-pregnancy counselling and a nephew with Down's.

Start by saying that you have a letter from the GP and asking if there are other issues as in the above section.

Then show your humanity.

Then go on to agree the agenda.

"I know that the main things you want to know are the risk of you having a baby with Down's syndrome.

And what we can do about it.

But to start with we need to make sure that you have all the information you need about Down's syndrome.

And I need to answer any questions you may have about it.

Then we can talk about the risk of you having a baby with Down's syndrome.

Before I can work out your risk, I need to ask you some questions, like your age and whether your sister had any tests.

Then I'll be able tell you about the risk for you.

This is usually the risk for any woman of your age

But sometimes Down's syndrome runs in families and gives you a higher risk.

This is usually due to what is called a "balanced translocation", which I'll explain.

I may need to  arrange tests to make sure that you don't have a balanced translocation.

I'll tell you about pre-implantation genetic diagnosis.

This is a way to prevent having a baby with Down's syndrome if you have a high risk of having a baby with Down's syndrome.

I'll tell you about the screening tests we will offer you when you become pregnant.

These give a more accurate risk of that baby having Down's syndrome.

I'll tell you about the tests to tell if a baby has Down's syndrome.

These are called amniocentesis and CVS.

I'll discuss the new test called cell-free fetal DNA that you may have heard about in the papers or on the television.

And we'll need to discuss the difficult matter of termination of pregnancy if the baby is affected.

I'll answer any questions you might have as we go along."

Make sure that you give her the opportunity to add to your agenda:

"is there anything else that you would like us to talk about"?

So long as you have practised this technique and written a plan at the start, it will only take a minute or two to gallop through this.

And just consider the number of boxes you have ticked: probably enough to have passed the station.

If you could continue to acquire marks at this rate you would have 100/20 by the end of the station!

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Body language.

Make sure that you do the correct body language things - e.g. look at her!

If appropriate, a smile does not go amiss.

But intense, lunatic staring and a fixed grin will disconcert her.

Don't encroach on her space.

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Don’t use big or obscure words.

You are not here to evince your erudition.

The patient may not understand your use of the arcane, polysyllabic word.

Recondite phraseology is the antithesis of good communication.

This is a demonstration.

The average patient would not understand this section.

And I am not too sure that I do either!

   

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Avoid medical jargon.

This is very difficult.

We use medical terms, acronyms etc. all the time.

Like: "I am one of the registrars in the clinic today".

They are part of the normal usage in which we are immersed.

The rules of the game are that you can use a medical term once you have explained it.

To stop using jargon, you have to develop the ability to listen to yourself.

You can then pick up on the jargon and avoid it or correct it if it slips out.

Practise by explaining something to a non-medical friend or relative. 

Get them to stop you and give you a slap every time you use a medical term without explanation.

You'll soon improve!

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Show your humanity and decency.

We deal with the most intimate and distressing parts of our patients’ lives.

Their disclosure puts the patient at huge risk of feeling ashamed and humiliated.

We need to treat the disclosure with the greatest respect and assure her of confidentiality.

She already feels terrible about it.

Don’t have the consultation with you make her feel even worse!

What is your worst secret and how would you feel about telling me all about it?

It helps if the patient appreciates that you, too, are human and not a superior being.

 

A patient comes for pre-pregnancy counselling because her sister has a baby with Down’s syndrome and she is worried about her risk.

Don’t rush in to explaining chromosomes, age-related risk, screening, amniocentesis, chorionic villus biopsy, balanced translocations and all that.

First ask: “How is the baby doing?”.

“Most families find it a terrible shock when a baby is born with a problem.”

“How is your sister coping?”.

“How are the other members of the family coping?”

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Don’t pretend to know stuff you don’t.

Stick to what you know.

If you don’t know, don’t waffle.

The patient will see that you are dishonest and any respect and trust will vanish.

This is vital in the examination and even more so in real life.

Patients do not expect you to know everything.

They will respect you for saying that you don’t know but do know how to find out.

Not only will you find out, but you tell them how you will get the information to them.

Tell them you will write or make a follow-up appointment to discuss it.

In real life make sure that what you propose is OK.

She may have a husband who opens all her mail, a mother who answers her phone etc. and you may destroy confidentiality.

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Find out her level of knowledge.

If you are discussing a particular topic, you need to find out what she knows about it and give a brief description in non-technical language.

You must use language that does not exacerbate communication problems.

One communication barrier is the patient’s perception of the doctor as highly intelligent and educated.

She will be keen not to appear stupid or ill-educated.

Use “gentle” phrases, such as “can you tell me what you have heard about …?”

Rather than “what do you know about …?”.

With “what do you know about....?”, it sounds as though the patient is having an examination and will get a score.

If she knows nothing, she will score 0 and feel stupid!

With the “gentle” question, she can say that she has heard nothing about the subject, but not feel ignorant.

It isn’t her fault that nobody told her.

The "gentle" question displaces any blame for ignorance from her to some third party: the education system, the media etc.

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Is there a particular reason for the consultation?

In situations like pre-pregnancy counselling, screening for ovarian cancer etc., make sure you ask why she has come.

Is there a specific reason for the counselling request?

She might have a friend or relative with a baby affected by some condition.

She might have a relative with ovarian cancer.

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Could there be a “hidden agenda”?

The “hidden agenda” is usually something she is loath to disclose.

She will skirt round the issue until you have gained her confidence.

In the exam the role-player will give the information if you ask the right question.

In real life it is much harder and more complicated.

You might need to see her a few times to win her trust.

Be patient!

Make sure you see her yourself and she is not bandied about from one doctor to another.

In the exam it would typically arise in a role-play about pre-menstrual syndrome, post-natal depression or chronic pelvic pain.

Train yourself to have a Pavlovian response to any OSCE relating to these subjects.

A role-play on PMS or chronic pelvic pain will almost certainly have a hidden agenda.

With postnatal depression, it will be quite likely.

Dealing with pre-menstrual syndrome I would say to patients: “there are four main aspects to pre-menstrual syndrome.

The first is your emotional and psychological make-up.

This is partly what you inherited from your parents and partly the things that have happened to you.

Some families have a tendency to depression, some to anxiety and so on.

If you had lots of bad things happen to you as you grew up, you are more likely to have emotional and psychological problems as you get older.

What was your childhood like?

Did anything bad ever happen to you?

Were your parents happy together?

Did they separate or divorce?

What age were you when this happened?

How did you react?

What was your relationship like with your parents?

Many children are abused.

This can be physical, emotional, psychological or sexual.

Were you abused in any way?”

You will often discover stuff that has never been revealed or dealt with.

Don’t take it on yourself – get her professional help.

But keep in touch to provide support.

She has had sleepless nights worrying about how to tell you.

She has made a huge investment in you by trusting you with the information.

She probably feels she has taken an enormous gamble.

If you never see her again, you have diminished her and trivialised the problem.

You'll only need to see her a few times as she will establish a relationship with the counsellor / psychologist etc. to whom you send her.

One of the things that is little taught is the doctor as therapy.

Your interest, support and understanding can be beneficial in itself.

I remember a lady in her eighties coming to see me.

Towards the end of the consultation she said: "You remind me of Dr. ...  Did you know him"?

She was taking of the family doctor when she was a child!

Decades before I was born.

She went on to say how when one of the children was ill, everyone in the house would be stressed and agitated.

Once the Doctor had visited, everyone calmed down.

Yet he had little or nothing by way of effective treatments.

The benefit came just from him.

I took the comment as quite a compliment.

I would then go on: “the next thing that can contribute to pre-menstrual syndrome is the stress in your life”.

This is particularly important if there is a clear history of the PMS only being a problem since a certain time.

Usually you can find a link between the time and some specific stress.

Ask the “open” question: “are there any pressures or stresses in your life now?”

Then go on with targeted questions as appropriate.

“How are you and your husband getting on?”

“Are there any problems at work?” and so on.

Women are often overloaded with work and responsibility, but don’t realise it as it has become routine.

I would say: “most women do the work of two or three men and most men would not be able to cope with their women’s lifestyles”.

“They go out to work.

They do almost everything in the home:

    cleaning,

    cooking,

    paying the bills,

    looking after the children,

    going to events at school,

    and running around after their husbands, who may be more work than the children.

Then, after they are exhausted by all that, they are expected to be wild and enthusiastic sexual partners!

Tell me about your lifestyle".

Finally, I would add: “your hormones have some effect.

Many women find that they are not at their best in the days before menstruation.

Their lifestyles mean that they have to be like Superwoman.

They can manage this when they are at their best, but not when they are at less than their best”.

This leads into practical areas like:

    shifting some of their work out of the pre-menstrual phase,

    getting domestic help,

    using “flexi-time” at work and so on.

You can explain that no specific hormone deficiency or imbalance has been identified.

You should counsel about caution in assessing the various magic remedies advertised on the Internet.

You can offer to remove the hormone effect using a GnRH analogue, perhaps with add-back oestrogen in the form of patches.

Many of these women will end up with treatment of some sort – counselling, hormones, anti-depressants etc.

Others will find that analysing and dealing with their problems and your support are all that they need.

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Is her main concern unstated? E.g. the fear that she has cancer.

It is useful to know her model of the illness.

There may be things you would never dream of.

With a symptomatic patient, e.g. with prolapse or menorrhagia, ask how it is affecting them.

Ask about what their concerns are: they may be mostly worried about having serious disease.

A role-player may have been primed to say she is terrified of cancer and that this is the major problem, not the symptoms as such.

The treatment option which is usually overlooked is the “null option”.

This is doing nothing once she and you are reassured that there is not a serious problem.

To get them to talk about concerns which they think you might find stupid or shameful, you have to “open the door”.

   

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Techniques to enable the patient to divulge difficult facts.

A patient with pre-menstrual syndrome may have alarming symptoms.

A common one is to find herself at a red traffic light and suddenly unsure about whether to stop or go.

She may fear that she is going mad.

One technique is to explain about the PMS and then say: 

“Women with PMS often have frightening symptoms.

For example, a woman might find herself at a red traffic light.

She may find herself unsure about whether to stop or go.

This can make her fear that she is going mad.

Have you had any symptoms like this?”

Or the woman with post-natal depression could be told:

“Many women with postnatal depression have frightening thoughts about harming themselves or their babies.

They may be too scared or ashamed to tell anyone about it.

Has anything like this happened to you?”.

One global technique I like is to set the scene to make it easy for the patient to divulge thoughts that she would normally keep secret.

“Let’s imagine it is the middle of the night and the whole house is asleep except for you.

You are worrying about this problem.

This is the time when we often have the wildest and strangest thoughts.

What would be the worst thoughts and fears that would go through your mind?”

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Techniques for helping patients with painful secrets.

Communication may be very painful and difficult for a patient.

She may have to tell you stuff that she has kept secret for years.

Or things going on in her life that she finds shameful or humiliating – the cheating husband, or worse.

A few years ago I had a patient in the antenatal clinic with some symptoms of depression.

I saw her on a number of occasions out of normal clinic hours as I suspected that there was something going on that would be difficult to dig out.

After several chats she told me, with enormous difficulty, that her husband forced her to have sex with his dog while he looked on.

There are some very strange people in this world!

She was a simple soul.

She knew that this was hideously wrong and hated it, but was not strong enough to stand up to the perverted husband.

She wanted the practice to stop, but her main concern was that she would give birth to a monstrous chimera, half human, half dog.

It took a lot of time and confidence-building to get this information out of her.

With support and counselling she got rid of this odious husband and her fears about the chimera.

Dealing with such a patient is likely to need several consultations and these are best conducted out of normal clinic/ surgery hours.

This takes the time-pressure off you so that you can devote enough time to build her relationship with you and find out what is really going on.

A couple of hours finding out what the real problem is will mean that you can sort her out.

This will benefit her and will spare you numerous shorter consultations that will probably add up to a greater expenditure of time with less reward.

I was a GP when I first started practice.

I soon learned that there were patients who needed more time than could be found comfortably in routine clinics.

I started to see them in an afternoon clinic with half hour appointments where we could sit, have a cup of tea and chat things through without the worries about patients piling up in the waiting room.

I continued this practice when I was a consultant.

 

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Explaining chromosomes and genes.

You are likely to have a station at which you have to explain chromosomes or genes.

The way I teach my MRCOG students to do this is along the following lines.

The chromosome spiel is: “When a baby grows in the womb, it starts out as a tiny egg from the mother.

This gets fertilised by an even tinier sperm from the father.

The fertilised egg then has to grow into a complete baby in the space of 9 months.

To do this it needs a huge amount of information to tell it how to grow a heart, arms and legs, a brain and so on.

The information is carried in packets that we call chromosomes.

Chromosomes come in pairs; one from the mother, one from the father.

There are 46 chromosomes altogether”.

You can go poetic and talk about the miracle that is the developing egg, that something so small has more information than you could write in a thousand books etc., etc.

But don't go on too long - there won't be any marks!

You can then talk about how an extra chromosome or a missing or partially deleted one can alter the information.

And that this may cause the baby to develop abnormally.

Sometimes it is useful to illustrate the huge amount of information that is needed.

Typically this would be after miscarriage.

I would do the bit above and then add:

"The amount of information the egg needs is so huge that it is difficult to get your head round.

Imagine that I came to your house with ten lorries full of tiny electronic components.

And told you that I wanted you to build a computer in nine months.

How good  a computer do you think it would be when I came back?

Well, a baby is millions of times more complicated than a computer.

So nobody in their right mind should try to have a baby!

It must be too complicated by far.

The miracle is that it usually works perfectly and a healthy baby is born.

Sometimes there is not enough information.

This happens in a least one case in every five.

There is enough for a placenta to grow.

It makes the hormone that stops your periods, makes you feel sick and gives you a positive pregnancy test.

But a baby is much more complicated that a placenta.

And there is not enough information for a baby to grow.

So the pregnancy will end with a miscarriage".

For genes, you cando the chromosome bit.

I usually then go on to say that a chromosome is like a coiled spring.

“If one stretched the chromosome out, it might stretch from here to London.

If you walked along its length, every few yards you would come across a single bit of information.

We call this a gene.

Chromosomes come in pairs, one from the mother and one from the father.

Genes do the same”.

If it is dominant inheritance, you explain that the abnormal gene is dominant.

The disease / condition occurs if it is present, regardless of there being a normal gene too.

If it is recessive, you explain that the normal gene protects against the disease / condition and the individual is a carrier.

But you can simplify this my not talking about chromosomes.

When you talk about the packets of information, you can just say that we call them genes.

This saves all the talk about springs etc..

 

 

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Make it easy for the patient to ask questions.

It is important to give the patient the opportunity to ask questions.

This must be put in a way that makes it possible for her confess to complete ignorance.

She must also be able to say that she does not follow your efforts at explanation.

As above, words that make her feel stupid or ignorant will simply make her pretend that she understands everything.

At this point she is likely to switch off, believing that she won’t understand anything else you say.

The way I suggest you do this is:

“I have given you a lot of information.

Some of it is quite complicated.

This makes it difficult to explain.

If I haven’t explained it clearly, please tell me so that I can try to do it better”.

Emma, one of my MRCOG students, has adopted and adapted this approach.

She finds it useful to ask: “does that make sense?” after a complicated explanation.

This puts the onus on you to give a good explanation, not on the patient to understand.

You explain this is difficult, so it legitimises the patient saying she does not understand.

The aim of this approach is to let the patient admit failure to understand without feeling stupid.

She can also say that she did not follow your explanation without worrying about upsetting your feelings.

You could also preface an explanation such as chromosomes by saying that it is complicated and difficult to explain.

Because of this, she must stop you at any point if she has a question or feels that the explanation does not make sense.

 

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Pre-pregnancy counselling.

In all pre-pregnancy counselling situations remember to do the basics:

    rubella and chickenpox screening,

    advice about:

                            weight,

                            diet,

                            drugs,

                                            prescribed, "over the counter", herbal and "complementary" and recreational,

                            fags & booze.

Ask about current or previous illness, previous pregnancy & delivery problems and the health of the children.

Ask about family illness, particularly conditions which may be hereditary.

“Are there any illnesses that run in your family?”

“Have any babies in the family been born with a problem?”

“Have any babies in the family developed a problem after birth?”

“Have any of the women in your family had problems with pregnancy or delivery”.

“Open” questions like these should cover most situations. 

But you may feel it appropriate to supplement the “open” question.

A “targeted” question might be: “Does anyone in the family have diabetes?”

If you are asking about a less common condition, you might need to explain what it is then ask the targeted question.

"Sickle-cell disease is a kind of anaemia.

It mainly occurs in people whose families came from Africa or Asia.

Do you know of anyone in your family with this kind of anaemia?"

You need to ask the same questions about her partner’s family.

Remember to ask about psychiatric illness.

The role-player will give the information if you ask the question.

She is like a dispensing machine.

Pay your money, press the correct button and you will get your cappuccino. 

 

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Opportunistic pre-pregnancy counselling.

In many situations, both in real life and the exam, “opportunistic pre-pregnancy counselling” is appropriate.

E.g. the patient wanting a repeat prescription for the Pill.

This is particularly important if she has a condition such as diabetes or epilepsy.

Pre-pregnancy stabilisation of such conditions is important and the dosage of folic acid is higher.

These patients should be told that they should see you for advice before conceiving.

For medico-legal reasons you should document this in the notes.

When I lecture GPs on these conditions in pregnancy I advise the following:

    get someone to take responsibility for identifying all of the patients with these conditions,

    ensure that all of them are seen and instructed about pre-pregnancy counselling being essential,

    ensure that they are told not to become pregnant until they have planned it with the GP or midwife,

    get suitable information leaflets and provide them to all of the patients,

    make sure that patients with epilepsy have reliable contraception - are their drugs enzyme-inducers?

    make sure that the families & work-colleagues of patients with epilepsy are trained in airway management during and after a seizure,

    Document all of this in the notes.

Information leaflets can be obtained from organisations such as:

The National Society for Epilepsy,

Diabetes UK,

NHS National Library for Health

 

Don't forget that we are also supposed to be doing opportunistic screening for chlamydia.

This applies to all sexually-active people under the age of 25, male and female.

 

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Bereavement counselling.

Much of what is on this page is applicable to bereavement counselling.

But there is a separate section devoted to it.

 

 

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Counselling after miscarriage/ termination for abnormality etc.

Usually you have to explain that the baby didn’t develop, or didn’t develop normally.

I would do the bit about the early development of the egg and the need for huge amounts of information.

I liked to give the following analogy.

“Imagine I came to your house with ten lorries full of tiny electronic components and dumped them on your front garden.

I said I wanted you to build a computer and that I would be back in nine months.

How well do you think your computer would work?

Making a baby is millions of times more complicated.

It is probably the most complicated thing that goes on in our world.

The miracle is that mostly everything goes well and the baby is healthy.

But if some of the bits are missing or in the wrong place, the baby may not develop.

Then a miscarriage will happen.”

These women may blame themselves for the disaster.

The same happens after stillbirth or FDIU when you can’t find an explanation.

A common feeling is: “I am being punished for past wickedness”.

This may seem atavistic, but is common, maybe even universal.

Most prone are those who have had previous termination on social grounds.

Women who have termination for fetal abnormality are also a very vulnerable group.

There is research evidence that most will have substantial emotional turmoil.

You might think that they would have a sense of relief in being spared the arrival of a seriously abnormal child.

Quite the reverse.

They tend to have a double whammy of guilt.

First they blame themselves for the baby being abnormal - back to “I am being punished...”.

Then they blame themselves for choosing to "kill" the baby.

One technique for dealing with this and similar scenarios is to reverse her role from patient to counsellor.

For the patient who had termination purely on social grounds and is now haunted by it, you would say something like:

“Let us imagine that you are a counsellor.

A girl identical to the one you were at that time comes to see you.

After careful thought, she decides to terminate the pregnancy.

How would you judge her?

Would you give her a hard time?”.

The answer is always “No”.

This allows the follow-up:

“then why are you judging yourself more harshly than her

You might act differently at the age you are now.

But why do you think that at that age you should have acted differently to the girl we imagined?”.

This is a powerful and valuable technique, applicable to many situations.

Counselling after pregnancy loss, either natural or induced is complex.

A comprehensive review of all its facets is not appropriate here.

Return to bereavement counselling.

 

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Always be “nosey”.

It is important to retain your sense of curiosity.

Why did she say that?

What a bizarre thing to say!

Why is this consultation not making sense?

Is this a clue about a “hidden agenda”?

I could quote umpteen examples, but will stick with one.

Many years ago I saw a highly intelligent woman, now the chief executive of an international company.

She was in her mid-twenties with some minor problems.

Her history included sterilisation at a leading London teaching hospital when she was twenty and childless.

There was no obvious connection to her current problems, but I was intrigued.

It emerged that she had married a much older man who had had enormous influence over her.

A latter-day Svengali!

He had insisted on the sterilisation and she had gone along with it.

Why the hospital had gone along with it is another matter!

A few years later, as she matured, she got rid of him.

She was now in a new relationship.

She had not realised that sterilisation could be reversed.

I did the reversal some time later and have been delighted over the years to get cards detailing the progress of her sons.

You must also be sensitive to clues proffered by the patient.

She may mention the termination of pregnancy she had at sixteen when not obviously relevant to the matter in hand.

This may be the tip of an iceberg of unresolved grief, regret, self-blame etc.

 

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Complaints procedures.

You should have a rough idea of the different stages of handling complaints.

Click here for hospital complaint procedures.

 

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Feedback.

Try all of these communication techniques in real life.

It is particularly important to practise how you are going to introduce yourself.

This gets the role-play off to a fluent start.

I’d be delighted if you let me know how you get on with them and any bright ideas you have for their improvement.

The above suggestions are not written on tablets of stone.

They are tried and tested in the examination and worked well for me in practice.

However, we are all different and have to create our own communication techniques and styles.

It sounds trite, but my experience has been that improving communication skills is a career-long activity.

 

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