Topic outline

  • Rapport

    Think:

    • Achieving a rapport with all patients is essential for good medical management

    • How should I greet a patient to establish a relationship? (even if it is only briefly in a busy casualty or clinic)

    • What difficulties may arise to impair this relationship? - eg. a language barrier, other disabilities or my own prejudices

    • Does my body language and communication convey to my patients that I am interested in their problems and value them as a person?

    Activity:

    • Maintain interest in your patient

    • Ask questions to establish a relationship (it may be relevant to know what they do for a living and how their eye condition impacts on their life)

    • Be aware of communication skills scenarios and attend any courses run by your Trust or elsewhere

    • Be aware patients may not understand medical jargon - avoid using it

    • Ask a colleague to observe you talking to a patient and provide feedback about your rapport

    • Do I need to attend 'conversation classes' to improve my English?

    • Ensure that you get some multisource feedback

    • Undertake a patient satisfaction survey

    • Listen

      Think:

      • How do you filter relevant information from irrelevant?
      • What should I tell the patient about how information on their case will be used?
      • How can I phrase questions appropriately?
      • How can I ask questions without my patients feeling interrogated?
      • Have I fully addressed the patients concerns?
      • How do you listen to a patient? (it is difficult especially in a busy clinic or casualty)
      • How do you draw the consultation to a close
      • Should I add to the verbal communication by a follow-up letter, email or phone-call to the patient?
      • Do I use too much jargon? Beware that words you take for granted and use in your workplace every day may not be understood by your patients
      • Remember your patient may not know what to expect

      Activity:

      • Remember to listen actively and to try and sort the wood out from the trees
      • Do not let your mind wander - you might miss something relevant
      • Try not to repeat anything, unless you really don't understand - it looks and sounds as though you are not listening
      • Make sure you especially listen to any questions the patient, relative or carer may have and specifically answer them
      • Do not allow the patient to wander - keep control of the consultation
      • Give your patient clear signals of what you are doing -'to start with' 'now your treatment plan' 'I am going to check your eyes'
      • Ensure that you sum up the problem, check the patient's understanding and allow time for any questions
      • Carefully avoid anything which could be construed as jargon
      • Clearly indicate that the consultation is coming to an end and close with a summary to include any further action
      • Ask a colleague to sit in with you during a consultation and give you feedback
      • Ensure that you get some multisource feedback from colleagues
      • Undertake a patient satisfaction survey

      Reflect:

      • How could the consultation have gone better?
      • What questions may have been left unasked/unanswered?
      • What might the patient have misunderstood?

      Resources:

      • Be aware of communication skills scenarios and attend any courses run by your Medical Board or elsewhere
      • Neighbour R. The Inner Consultation: How to develop an effective and intuitive consulting style. Radcliffe Publishing Ltd, 2nd edition 2004

      • Deliver information

        Think:

        • Information needs to be delivered to the patient, their relatives and carers appropriately and sensitively. How do I do this without confusing the patient or appearing to be insensitive?

        • How do I handle challenging questions?

        • Does the patient fully understand the benefits/risks of my recommendation?

        • Should I add to the verbal communication by a follow-up letter, a patient information leaflet, email or phone-call to the patient?

        • What should I tell the patient about how information on their case will be used?

        • How should I approach enquiries from the media?

        Activity:

        • Put yourself in the patient's position. If you had the same problem, how would you wish the information to be given?

        • Don't talk down to the patient but be aware that you have more knowledge than the patient sometimes needs

        • Be aware of the impact that this information will have on the patient

        • Be prepared to justify the treatment you recommend

        • Advise the patient of any period of recovery and/or activity restrictions

        • Discuss and guide the patient on any rehabilitation needs

        • Ask a colleague to sit in with you during a consultation and give feedback

        • Ensure that you get some multisource feedback from colleagues

        Reflect:

        • How could the consultation have gone better?

        • What questions may have been left unasked/unanswered?

        • Did the patient understand all you told him/her?

        Resources:

        • Be aware of communication skills scenarios and attend any courses run by your Medical Board or elsewhere

        • Sources of information

          Think:

          • What other information is available for your patients, their relatives and carers?

          • What is the best format for information (leaflet, video, website, audio?)

          • How can patient support groups help my patients?

          Activity:

          • Find what patient information leaflets are available in your department. Have them prominently displayed in the waiting area and clinic rooms

          • Find out how patient information leaflets are written and approved in your hospital (information governance)

          • Familiarise yourself with your Trust's patient occupational therapy and rehabilitation process

          • Review the internet resources available for patients with common eye conditions. Do they provide accurate information in a sensitive way? Are they commercially driven? Could you learn from them or suggest any improvements?

          • Offer to write or update a patient information resource for the department

          Resources:

          • Be aware of patient user groups especially local ones. Use the internet to become aware of the numerous groups that are there

          • Be aware of the advantages and the disadvantages of recommending such groups to your patients

          • Be aware of what community social services are available to assist your patient in their rehabilitation

          • Consent

            Think:

            • What are my local Trust rules for consent and how may they differ from national rules (eg GMC rules)?

            • What information do I need to provide to patients, their relatives and carers to allow them to have an informed opinion as to their condition and its management?

            • How do I convey this to patients who may be limited in their understanding of their problem?

            • What are the implications regarding patient care and consent of the Mental Capacity Act?

            • How can written information contribute to the consent process?

            • Which procedures am I competent to take consent for?

            • In which procedures should I seek training in order to be able to take consent?

            Activity:

            • Put yourself in the position of the patient or their relative. What would you wish to know and how will it impact on your life?

            • Explain any risks that a particular procedure might produce, but be aware of any anxiety that this might engender

            • Remember to explain the benefits of the procedure as well

            Resources:

            When completing consent forms for a particular procedure make sure you are aware of any local Trust guidelines and the GMC guidelines

            For example


            • Breaking Bad News

              Think:

              • This is particularly important and may be the source of much distress to both the patient and the doctor

              • The way bad news is delivered will be remembered by the patient and may affect them for the rest of their life

              • How may a patient react when potentially bad news is communicated to them either during the consultation or possibly by letter; how can support be provided in this context?

              Activity:

              • Check whether the patient wants a friend/relative/carer in on the discussion

              • Be aware of the implications this will have to the patient, their relatives or carers

              • Do allow ample time for questions to be asked and to have the appropriate responses ready (so prepare yourself)

              • In most cases an appropriate timely follow-up should be made with yourself and/or another appropriate professional, as the patient will probably forget much of what they are told; a follow-up phone-call, letter or email may also help

              • Ask a colleague to sit in with you during a consultation

              • Seek feedback from colleagues so that it becomes a learning experience for you

              • Be aware of local support groups that may be able to help your patient

              Resources:

              • Barrier to Communication/ Language

                Think:

                • What is the effect of not being able to communicate effectively to patients because of a language barrier or because of culture, hearing impairment, age or mental state?

                Activity:

                • Try and identify this barrier before the consultation. Work out how you are going to rectify this, for example using an interpreter or inviting relatives or carers into the consultation

                • Ask a colleague to sit in with you and seek their feedback following your consultation

                Reflect:

                • How could the consultation have gone better?

                • What questions may have been left unasked/unanswered?

                • Did the patient understand all you told her/him?

                Resources:

                • Be aware of communication skills scenarios and attend any courses run by your Medical Board or elsewhere
                • Body language

                  Think:

                  • Body language is very powerful and forms much of the opinion gained by you of the patient and vice versa. How is your non-verbal communication revealed to patients, their relatives and carers and what about theirs to you?

                  Activity:

                  • Be aware that your body language can reveal much about you and your attitudes to the patient

                  • Often patients do not like to communicate as much as they want in front of a doctor that they may not know, and/or who has very little time to see them. Appreciate this and use cues that they may employ to extract as much information from them as you need

                  • Ask a colleague to sit in with you during a consultation and identify any non-verbal communication that you or the patient employs

                  • Ensure that you get some multisource feedback from colleagues

                  • Complaints

                    Think:

                    • Complaints will arise during the course of a medical career. These may be directed at you or at your organisation. How will you respond to these complaints and how might it affect your relationships with your patients and colleagues?

                    • What support may I and/or other staff require in coping with a complaint, and from where can such support be provided?

                    • What can I learn from dealing with this complaint? - document this in your e-portfolio

                    Activity:

                    • You should understand and comply with local Trust guidelines and know who your Complaints Officer is within the Trust

                    • Accept that you will get complaints and do not bury your head in the sand and ignore them. Act upon them quickly and learn from them. It is easy to become defensive in these situations, but try and react constructively. Many may be trivial, but none should be dismissed

                    • If your clinical practice is questioned ensure that you respond in a way that does not compromise the treatment of the patient

                    • If you receive complaints about the clinical practice of other health professionals you should respond in a sensitive and professional manner

                    • You should be aware of national GMC guidelines and other professional bodies.

                    Resources:

                    Example:-

                    • Communication with other professionals

                      Think:

                      • Why do I need to communicate with other health care professionals and community social services?

                      • How does it benefit the patient?

                      • What special considerations are required when I communicate with the legal profession in cases of injury or of medical mishap?

                      • When should I communicate with the legal profession and what special considerations apply?

                      • Remember the requirements "Situation-Background-Assessment-Recommendation" (SBAR) in communication with fellow professionals

                      Activity:

                      • Communicate to others using all available means such as email, telephone and even writing a letter

                      • Include all relevant information including images where helpful

                      • Respond to requests for information quickly

                      • Do not keep letters hanging around

                      • Always keep your intray empty

                      • Seek opportunities to discuss the writing of medicolegal reports with a senior colleague

                      • Attend a medicolegal workshop

                      • Ensure regular opportunities to make presentations to colleagues and others, using visual and other aids as appropriate

                      • Be certain that you always have processes in place to ensure that referrals you make and receive are acted on and the patient followed up so that they do not get lost in the system

                      • Always ensure that the patient knows to whom any information will be sent

                      Resources: 


                      Assessment:

                      • You may be assessed on your letter writing/receiving skills

                      • Keep Clinical records

                        Think:

                        • It is essential to keep clear, well written patient notes

                        Activity:

                        • Ensure that every note you write in a patient record or relating to a patient is contemporaneous, accurate and legible

                        • If you use electronic records, ensure that these are secure

                        • Be aware of the security and patient confidentiality of every record

                        • Ask a colleague to scrutinise a patient record and offer constructive criticism

                        • Letter writing and dictation

                          Think:

                          • Communication with others is essential. How does it affect patient management?

                          Activity:

                          • Write letters regarding patients accurately and immediately; make sure you dictate a letter where appropriate after seeing the patient rather than wait until the end of a clinic

                          • Ensure that the dictating machine is working and that you speak legibly. Some secretaries have the talent to interpret the most illegible speech but mistakes can be made to the patient's detriment

                          • Make sure that you read the secretary's hard copy before you sign your letter to ensure that what is written is accurate and reflects what you have told the patient

                          • You might think it appropriate to send copies to other health professionals, for example the referring optometrist. Make sure you have the patient's permission before doing so

                          • You may also find it useful to send a copy to the patient themselves or a parent

                          • Ask a colleague to scrutinise a patient letter and offer constructive criticism

                          Resources: 

                          • Prepare an operating list

                            Think:

                            • How do I best prepare an operating list?

                            • How will it help the patients and myself as a trainee

                            Activity:

                            • Observe someone more senior preparing an operating list in your hospital

                            • Ensure that you know in which order patients are operated and which take priority. You may want to bear in mind the age of the patient (younger children often go first) or other medical conditions (diabetics are often put higher up a list)

                            • Some units do intraocular procedures first. Also be aware that if you are in the operating theatre, how you can manipulate a list to allow you the time to operate on suitable cases

                            • Planned and unplanned leave and on-call

                              Think:

                              • Having a break from work and study is vital for your health and the health of the patients. How does your absence impact on the running of the service?

                              Activity:

                              • Ensure your full involvement with colleagues in the planning of rotas and other clinical duties

                              • In particular ensure that your absence for leave does not impact greatly on the service. Make sure that it is planned well in advance and notification is given to all appropriate parties

                              • Be aware that there may be times due to unexpected leave taken by colleagues that you will have to assume other duties in addition to your own. Accept this gracefully as you may be the one that needs the leave next time

                              • Always plan study leave for courses and self-directed learning well in advance. Be aware of your timetable for examinations etc