Communication Advice

Introduction

This starts the moment you walk into the room. Be bright and confident and smile. The angry patient will find it difficult to stay angry. It also instantly makes people warm to you and helps to build rapport for when you need to deliver the bad news. Ensure the seating arrangements are appropriate i.e. no obstacles between you and the patient and the seats are not too close together. Introduce yourself with your full name and job role and inform the patient of the name of the consultant who is coordinating their care. Shake hands if you feel comfortable doing so. Always ask if there is anyone they would like to bring in with them for the consultation and how they will be getting home. It shows empathy when breaking bad news and that you given a thought and attention to post-procedural care when asked to explain and/or perform procedures, for example the Dix-Hallpike and Epley maneuver. We found it useful to introduce an invisible nursing colleague at the start of the interview, especially with the head and neck malignancy scenarios. 

Gathering information

Never assume anything! Start your consultation by finiding out exactly what has happened prior to you meeting the patient. Explain that as you have not met before, you would like a recap of their presenting symptoms, any investigations they have undergone and the results, any treatment they may have had and finally their understanding of all that has happened so far. At this point you should elicit their ideas, concerns and expectations which will give you an idea of whether or not any bad news you are about to break will come a shock. 

Discussion and reflection

The communication scenarios quite commonly involve breaking bad news in one form or another. These range from mistakes or delays in patient care through to life-changing and/or terminal diagnoses. These can be tricky to deal with if you do not have a structure in place. The “SPIKES” framework (Baile et al. 2000) for delivering bad news is an extremely useful tool. With minor tweaks it can be applied to the majority of communication scenarios. The SPIKES framework is broken down below:

  • S – Setting
  • P – Perception
  • I – Invitation
  • K – Knowledge
  • E – Empathy
  • S – Strategy, safety and summary

Once you have used the framework a few times, try coming up with a few scenarios of your own and see if you can apply it them. The more practice you do, the more you will find structuring your consultations becomes second nature and then you can work on the other things that will set you apart.

You may also be asked to explain or consent a patient for a common procedure or surgery. Ensure you have read and are up to date with the latest guidelines and medicolegal dilemmas surrounding consent. You should be familiar with the landmark cases; Gillick v West Norfolk & Wisbeck Area Health Authority [1985] and Montgomery Vs Lanarkshire Health Board [2015]. The RCS England published its most recent guidelines in 2016. ​

If a mistake has been made, you have a Duty of Candour to the patient. You must own up, apologise, and inform them. Answer any questions they may have and offer them support (e.g. follow-up appointments or written literature). Ensure the appropriate medical and administrative teams are notified and involved in providing support for the patient. 

Non-verbal communication

Good body language is essential for a successful station. Everybody has things they do or say when they are nervous and you will be no different. Our top tip is to video record yourself going through a consultation with a friend or trusted colleague. At first you will be amazed how often you may say “erm” or “err” and may even pick up something new, like touching your face or hair quite often. 

Positive and Negative Factors in Communication

Positive – ​Non Verbal

  • Eye contact with patient
  • Good posture, sit facing towards patient
  • Non verbal acknowledgement e.g. nodding in agreement
  • Look interested

PositiveVerbal

  • Empathy
  • Silence
  • Active listening including summarising
  • Sign posting e.g. providing warning shot
  • Checks patient understanding
  • Use open and closed questions

Generic Tips

  • Always remain calm and professional
  • When breaking bad news do not be afraid to use silence
  • “Chunk and check” –  give small bites of information and then check the patient’s understanding.
  • Active listening – paraphrasing the patient’s words to show you understand what they are saying
  • Summarise consultation at the end

Top Tips for Top Marks!

  • As with any OSCE station start any scenario with WIPER 
    • Wash hands
    • Introduce
    • Permission
    • Expose Patient Appropriately – Not required in this station
    • Reposition Patient
  • State you have come with nurse
  • Warn about red-flag symptoms and whom to contact e.g. A&E if worsening stridor, uncontrollable epistaxis
  • Offer your name again at the end
  • Your contact details
  • Involve MDT
  • Escalate and involve defense union where appropriate
  • Information leaflet
  • Follow-up appointment at an appropriate time interval

References

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