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 am not an expert in communication.

You might think that this would preclude me from advising on the subject.

My lack of expertise is put aside by my megalomania!

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.

The only justification I can offer is that it is the advice I have given since OSCEs were introduced.

It works as the pass rate for those who attended the tutorials at my home was usually 100%.

It has also been the basis for the approach used by our gold medallists.

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.

Do not 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 critical for your career and will be desperate not to mess up.

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 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 her script and some of the medical jargon may be completely new to her.

This will add to her apprehension, particularly during the first few stations; how can she respond appropriately and not confuse you?

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

You do not want her on the edge of her seat struggling to understand you.

One of the common questions on the marking sheet used to be 'is this a doctor you would consult again?'.

It is not used now but indicates how the lay examiner will view things.

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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, 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 may be deluding yourself!

The problem is that patients are too polite to tell you that they do not understand a word.

In real life they will just wait out the interview.

They will ask the nurse to explain once you have gone and next time they will make sure they see another doctor.

The role-player will not tell you that there is a problem.

If you fail to 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 could not understand my accent and I had only migrated 200 miles south!

And I had not thought that I spoke particularly quickly or that my accent was especially difficult.

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

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

Do something about it!

I had a super-bright trainee 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 'ith 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 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. Create an agenda in role-play stations. Keep an eye on the time.

In the old days with essays for Part 2, you spent the first four or five minutes deciding the key things to include.

Part 3 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 read the question carefully.

What are you being asked to do?

This must be mapped to the 5 domains:

       a. Safety:

                   try to include it every time even when it is barn door obvious failure to do so often underlies disaster.

                       mainly about the patient, but remember the baby!

                   think of wider issues: family, future children, staff & wider public, even the Trust.

       b. Communication with patients and their relatives.

       c.  Communication with colleagues.

       d.  Information gathering.

       e.  Applied clinical knowledge.

Then make out a plan that covers the instructions and the 5 domains.

This is not easy to do in a couple of minutes and need practice.

Try to do it with every patient you see in clinic.

Your exam skills will improve and your interactions with patients will improve.

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 task you have to perform.

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.

You can easily get sidelined and lose your way.

If you have a list of the main points you can get back on track.

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 means creating an agenda.

If you rattle off the key points of the agenda at the start you will almost certainly satisfy the examiner and pass.

Agreeing and agenda 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 introduce yourself.

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.

And advise that she can add anything she thinks of as you go along.

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.

Then say something along the lines of:

'I think it would be useful to make a list of all the things we need to talk about today so we don't miss anything.

What do you think? - she will agree.

I'll list all the things I need to talk about so that you have all the information you need for any decisions you might need to take.

Then I'd like you add all the things you would like to talk about.

    I would like to:

    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,

        the risk is usually down to your age, but Ds can sometimes run in families and this gives a bigger risk,

        this is about something called balanced translocation, which I'll explain and how we will find out if it applies to you,

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

        this would include things called pre-implantation genetic diagnosis, combined first trimester screening, CVS and amniocentesis, which I will explain,

whether you would want to continue with the pregnancy if the baby had Ds,

what is involved in termination of pregnancy if that is what you would wish,

discuss with you the general things we talk to all women about like being as healthy as possible before and during pregnancy; we call this pre-pregnancy counselling,

this mean things like smoking, alcohol and drugs, diet, taking folic acid, being screened for immunity to German measles and chickenpox.'

It would not take long to rattle this off in the exam and if you ran out of time you would still get credit.

The examiner does not have a list of key facts to tick off.

They just have sections for each of the things you were instructed to do.

For each section you are scored as good, average or rubbish.

A good agenda will show them that you are good!

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.

But you are asking a load of questions that seem irrelevant like the sister's age, 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.

The above is a 'blurb'.

You need to practise writing blurbs to have a bank of common ones like explaining recessive inheritance, pre-pregnancy counselling etc.

It also develops the skills necessary to produce one on a new subject in the exam.

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Introduce yourself.

Introduce yourself. Hello. I am Dr. xxxx. Use your surname.

Shake her by the hand.

Do not 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.

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. xxxx. Use your surname

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 stick with your title, Dr.

At this point it may also be appropriate to check her age.

 

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 is your name?.

What is 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 know her name, but are a supercareful doctor and want to check.

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.

Please call me xxx - 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, tattoos, 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 etc. are all symbols of the superior status of the doctor.

Into this category is the doctor being called Doctor while the first name is used for the patient.

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

Do not say then you may call me xxx.

May or can puts the doctor on high again: the doctor dictates how the patient will address the doctor.

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, 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.

Patients don't expect you to know everything.

But they expect you to be a means for them to get the information they need.

If you pretend to know stuff that you don't, they will soon realise that you are lying and the will stop trusting you.

You need a blurb which will vary with the situration.

The basic blurb would be something like:

I don't know enough about this to advise you, but I know someone who does.

I'll contact them when we finish this discussion and get the key facts.

I'll then discuss them with you.

The patient will now have complete trust in you.

When you don't know something, you will tell her and consult someone who does

When you tell her something, she can be confident that you know the facts.

Don't make daft statements.

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. xxxx, saying I am one of the doctors is repetition.

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 roleplay: agree an agenda for the consultation.

Much of this is repetition of what is above, but worth it to get it into your head.

This is a useful technique.

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

And gets the participation of the patient as it is a shared agenda.

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

In the exam, it makes a great impression at the outset.

A good agenda could well mean a pass before you do anything else.

If you run out of time, it means you have touched on all the important things.

See the above scenario of prepregnancy 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.

Make sure that you give her the opportunity to add to the 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 few minutes to gallop through.

Make sure that you open things up to questions.

I am going to give you a lot of information.

Some of it is technical.

This makes it difficult to explain well.

If there is anything I do not explain really clearly, please stop me and I will try to do it better.

You will hear me talk ad nauseam about it being your responsibility to explain, bot hers to understand.

And just consider the wondrerful impression you will have made on the examiners..

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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.

Do not encroach on her space.

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Do not 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.

As the above demonstrates!.

The average patient would not understand.

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 will soon improve!

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Show your humanity and decency.

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

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.

Do not 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.

Do not 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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Do not pretend to know stuff you do not know

Stick to what you know.

If you do not know, do not 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 do not know but do know how to find out.

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Find out her level of knowledge.

If you are discussing a particular topic, ask 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 her perception of the doctor as highly intelligent and educated.

She will wish to be esteemed by the doctor and will be keen not to appear stupid or uneducated.

Use gentle phrases, such as can you tell me what you have heard about xxx?

Rather than what do you know about xxx?.

With what do you know about xxx?, 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 is not her fault that nobody told her.

The gentle question displaces any blame for her not knowing 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 prepregnancy counselling, screening for ovarian cancer etc., make sure you ask why they have 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 premenstrual syndrome, postnatal depression or chronic pelvic pain.

Train yourself to have a Pavlovian response to any station dealing with these subjects.

A roleplay on PMS or chronic pelvic pain will almost certainly have a hidden agenda.

With postnatal depression, it will be quite likely.

Dealing with premenstrual syndrome I would say to patients: there are four main aspects to premenstrual 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.

Do not 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 will 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. xxx  Did you know him?

She was taking of the family doctor when she was a child, decades before I was born.

She was a professor and highly intelligent so I found this very interesting.

It may say much about how our power is diminished when we become patients that she saw me, three decades her junior, as akin to the God-like figure of the GP from her childhood.

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 do not 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 the lifestyles women have.

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.

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 roleplayer 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 us 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.

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 very strange 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 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.

 

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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 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 have to do 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.

 

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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 will not 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 have not explained it clearly, please tell me so that I can try to do it better.

Emma, now a consultant of high repute and one of my MRCOG students many years ago, adopted and adapted this approach.

She found 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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Prepregnancy counselling.

In all prepregnancy 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 the family of her partner.

Remember to ask about psychiatric illness.

The roleplayer 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 prepregnancy 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.

Prepregnancy 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 medicolegal 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

 

Remember 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 did not develop, or did not develop fully.

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.

Women often blame themselves for the disaster.

The same happens after stillbirth or FDIU.

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 TOP 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.

Get in there!

 

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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 roleplay off to a fluent start.

I would 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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