GP STAGE 3 PATIENT-DOCTOR CONSULTATION

😢 😞 😢 😞 😢 *SADNESS/ANXIOUS*: offering re-assurance and solutions

"I know this harder said than done; but I think it's important not to get too upset or start blaming yourself for what's happened. I can understand you're worried but you've taken the right step by coming in today and speaking to me about it".

*RELATIVE CONCERN: REQUEST TO AMEND MEDICAL RECORDS* e.g. because of a one off bad incident in A&E with drugs/alcohol

"Mr/Mrs X, I appreciate your concerns and I thank you for telling me all this. When it comes to a medical records and a request for them to be amended; we can only cross it out if it's factually incorrect. I can understand you're worried about how this will affect future employment but remember that one cannot access medical records without your consent. Furthermore; I'm not sure what the company's policy is on when it comes to employment; it might not be so much of an impact.

INTRO/DATA GATHERING

"although I have your notes with me; I'd like to get a bit more information from yourself about what's been happening if that's ok?" "could you tell me a bit more about what's been happening..what's been going on?" If speaking with a relative: consider the following introduction dialogue adapting your question to what the patient says e.g. - Patient: "I just wanted to speak to you about my mother" - Doc: "ok sure, tell me what's on your mind" - Patient: well you see, the nurse is going to discharge my mum but I'm worried doctor - Doc: "ok, could you tell me a bit more about what's troubling you - if its a relative concerned about a patient and they're being vague "ok.. could you tell me a bit more about what you've noticed" "is there anything else you've noticed that's troubling you?" If they give you a piece of info: reflect on it: Doc: "ok, so you mention that she wasn't coping at home; could you tell me more about that?"

*SICK NOTE** REQUEST 😝😝😝 ---> employees only need a sick note if been out of work for >7 days ---> consider hidden agendas e.g. bullied at work, someone at home is sick, depressed, etc ---> consider genuine causes: chronic pain causing impairment of duties: ---> always think about DEPRESSION: can be due to the chronic pain and being off work/impairment of duties or bereavement ---> note: some patients may say a bogus diagnosis e.g. asthma; clearly, there's a hidden agenda. First focus your questions on the asthma as above.. then if it's obvious: ask "is there any other reason you feel you can't work?". If the situation is sensitive and the patient worried about what you write as a reason; just write 'stress': it will allow the employer to try and make changes to help support him/her. 1) explore reasonings for request 2) *EXPLORE CONDITION* how has it been manage so far? any ideas or thoughts of what we can do to improve it? 4) *DETAILS ABOUT WORK* how long they've been off work now: ----> if <7 days; they need to discuss that with your employer - ask more about what the work involves and the impact they're having on their condition - ways of getting back to work?: discussions with occupational health? reduced hours maybe? alternative work 3) *PSYCHOLOGICAL IMPACT* show empathy and ask about the impact this is all having on him/herself (*psychological impact*) e.g. "SAM": sleeping, appetite and mood. 4C) *I*CE - e.g. discussions with occupational health - alternative employment? ------------------------------------------------------- 5) signpost and offer solutions to all three issues 6) follow up

"doctor I need a sick note please" 1) "tell me more.. what's been the problem?" <<< e.g. back pain >>> 2) *EXPLORE CONDITION* - how long for? how is it affecting you work duties? how have you managed it so far? 3) *EXPLORE WORK* - what kind of work do you do? - how is it having an impact on work? - have you thought of ways on getting back to work? --> maybe reduced hours? 4) *EXPLORE MOOD* "I am sorry to hear this having such an impact on your life. How have you been coping in yourself? "I can imagine.. Mr X, it must be quite difficult" ---> yes it is doctor.. ask "SAM": "are you *s*leeping ok, *a*ppetite? and drinking?" *m*ood? <if patient gets angry with all the questions; consider a hidden agenda "Mr/Mrs X; I see you're not happy with all these questions I'm asking, I'm sorry, these are just the usual questions we must ask for anyone in your case. Is there anything that's particularly upsetting you?" --------------------------------------------- 5) right.. Mr X, I'd like to touch on a few things here - *PSYCHOSOCIAL IMPACT*: you mentioned earlier about how your coping; it sounds like you might be a bit depressed over all of this which is completely understandable given what you're going through; have you thought about ways of coping: speaking to loved ones? therapy. We can offer medications if you'd like them? - *CHRONIC CONDITION*: in regards to dealing with your pain; we could may try some stronger pain relief; maybe try some codeine? I warn you this medication can cause you to feel more constipated and drowsy; so I'd advise to be careful if you're doing activities like driving. As for the codeine, we can give some laxatives to take when you need them. Sound good? - *WORK*: I'm happy to issue a note, but I advise to try and get back to work when you can 6) follow up: I'd like to follow you up in 2 weeks time to see how you're doing with everything. Of course, give us a call in the meantime if you have any further questions.

*WHEN DISCUSSING RESULTS* - explain the tests that have been done and brief bits about what they were

"right Mr X; so I have your results. The good news is that your FBC is normal; so you don't have anaemia. Your liver and kidney function tests are also fine. The only thing thats slightly concerning is your raised sugar levels over the last 3 months; your HbA1c. It indicates your at a level of what we can 'pre-diabetes'. *right Mr Y; so you had CT scan performed of your head; this scan usually helps us detect things like bleeding and tumours; I'm happy to say it came back normal. You also had an MRI; the slightly longer test in the large tube machine.. it provides a more detailed analysis of any tumours; I'm happy to say this is also normal".. so all in all your tests were absolutely fine. *right, so Mr Z; you attended for a colonoscopy last week; this is the camera test inserted up the bum to detect any abnormalities in your bowel; I'm glad to tell you that it was all normal; importantly there were no tumours detected".

WHEN UNCERTAIN/UNSURE ABOUT DIAGNOSIS/DETAILS ABOUT SOMETHING

"to be honest with you, I am less experienced in this field compared to my senior colleagues but I'll try to answer any questions you might have" "I think that's quite a difficult question for me to answer especially given the sensitivity of this matter" relative: why was I not informed about this/that?! doctor: "that is a very difficult question for me to answer I'm afraid; honestly, I am not certain as to why; but I can ask my seniors and get back to you on that" "i'm afraid I don't know too much about this to give you a clear answer.. but I can look into further and get back to you on it"

ICE

*Ideas*: have you any thoughts about the cause for all of this? *Concerns*: do you have any particular concerns you'd like to discuss? *Expectations*: is there anything you'd like me to do to help you with this?

😞 😞 😞 *SADNESS*: acknowledging patient's sadness

*e.g. poor experience in the hospital*: "Sounds like you've had quite a difficult time, I'm sorry to hear that" "I'm sorry to hear this Mr/Mrs X; sounds like you had quite a stressful time <e.g. in the hospital>" "I'm sorry to hear what you've had to go through; it sounds terrible" "I'm really sorry to hear that; it sounds like you had quite a rough time" *e.g. difficult coping at home/work/dealing with relative with dementia, etc*: "Sounds like things have been quite difficult for you; I'm sorry to hear that" "I'm sorry to hear that; sounds like you're having quite a tough time right now" "Sounds like you've having to endure quite a lot right now" *I'm really sorry to hear how stressful this is for you right now" *responding to "I'm am worried about this" "yes, I can understand this must be quite distressing for you/you all"* e.g. after being told bad news/new diagnosis: for example pregnant woman with Down's syndrome/patient with newly diagnosed cancer "I'm sorry to hear that; that must have been quite shock for you to hear" "I can understand this situation's quite stressful for you at the moment" "I'm sorry to hear this; how are you coping with this news?" Patient: "i'm sorry to have to cry.. this is so embarrassing" Doctor: "don't feel embarrassed. Understandably you're upset about this and I'm glad you came to speak to me about it" when re-assuring: "ok.. I can understand why you'd be concerned/worried about this and I think you've done the right thing by coming in today to speak to me about it" .. then explain what you think could be happening. when a patient blames themselves "I don't think you should focus on blaming yourself or being too upset about this

INITIAL REACTION WHEN A PATIENT/RELATIVE TELLS YOU THEIR DEVASTATING DIAGNOSIS e.g. cancer OR AN UNEXPECTED DEATH

*empathy* initial reaction: "I'm really sorry to hear that, it must've come as quite a shock to you"

general responses to patient/relative concerns 1) "I have my own life and family and now having to look after my parents, its stressful" 2) "I don't want my mum discharged to that nursing home!!" 3) for empathy: "you see doctor, I've recently been diagnosed with womb cancer.. and need to have surgery in the next couple of weeks" 4) "I don't know whether you're aware.. but my wife has been recently diagnosed with cancer" 5) "I'm so sorry to cry... <sobs"

1) "certainly that makes sense; it's important that your parents are in a safe and well supported environment that takes care of their needs effectively. We can always arrange a social worker to discuss things; they'll be able to discuss the involvement of carers.. does that sound reasonable?" 2) "I can understand your concern; I'll have to discuss this further with the social workers and discharge liaison team. They will ensure your mother/father is discharged safely. 3) I'm really sorry to hear that.. that must've come as quite a shock to you.. 4) I'm really sorry to hear that... must be devastating for you" 5) its ok.. take your time..

*MANAGING THE IMPACT OF RECENT CANCER DIAGNOSIS/DEATH OF A LOVED ONE ON A PATIENT/RELATIVE'S LIFE* 1) *explore story*: e.g. type of cancer? has it spread? or how long since they passed away? what happened? 2) *empathy* of the news 3) *explore prior understanding/knowledge* of the situation if not done already e.g. how long ago? if cancer; has it spread? what have the hospital doctors said? 4) *impact of news on themselves* (if not explored already) ?able to sleep, eat/drink, meet friends/family, work duties? 5) have they spoken to anyone else: *support network*: family/friends/macmillan team and how are friends/relatives coping with news? ----------------------------------------------------------- 7) acknowledge difficulty hearing the news and thank patient for bringing this to your attention and re-assure 8) acknowledge the need for support at this time/offer solutions - friends/family/macmillan team - taking time off work - counselling 9) follow up

1) "could you tell me a bit more about that", "could you tell me a bit more about what's on your mind?" 2) "i'm really sorry to hear that; the news must've come as quite a shock for you all" 3) if cancer: "so what have you been told so far by the hospital doctors?" 4) are you having trouble with sleep? eating ok? 5) "have you shared your concerns with anyone else about this?"... and how are they coping with the news? "do you have any loved ones nearby that can help support you through this difficult time?" if cancer: "have you been able to speak to the macmillan team?" ------------------------------------------------------ 7) "I can understand this being incredibly difficult for you and your family and I'm glad you came here to discuss it with me. 8) It's certainly important to be surrounded by a lot of help and support during this difficult time. (A) "it's nice to hear about the support you've received from loved ones but I encourage you to speak to them more about how hard you're taking this; I'm fairly sure they'll be happy to continue supporting you " (B) "maybe it's a good thing if you took some time off work; I'm sure they'd understand giving the situation. If its difficult, I'd be happy to write a letter" (C) if its too much; there's always the option of counselling 9) "we talked quite a lot today.. I would like to follow you up next week if that's ok; just to see how you're coping".

*THE ISSUE OF CONFIDENTIALITY: RELATIVE ASKING FOR DETAILS ABOUT SOMETHING*: Scenario 11/12 1) explore reason for request (ICE) - e.g. wife wants to know if husband has been assessed for STDs --> ?thinks he's cheating - e.g. father/mother requesting records to check if daughter was prescribed the pill --> ?too young to have sex 2) explain confidentiality - e.g. but she's only 15!?: discuss guidelines rules <IMPORTANT NOT TO GIVE AWAY INFORMATION ABOUT WHETHER DAUGHTER CAME IN OR NOT ASKING FOR THE PILL> 3) explore: ICE 4) solutions - if in the case of the pill (A) encourage parent to speak to daughter about their concerns (B) family can come in to discuss it all - in the case of a cheating husband if he/she has chlamydia (A) encourage an open discussion between the two people; warn that if this doesn't happen; there's a risk of having a relationship breakdown (B) bring in husband into the practice; we can also discuss it together

1) "could you tell me a bit more about what's been happening?", "ok, tell me what you've noticed", "ok, could you tell me what's on your mind?" 2) "before we go on any further; I should probably explain that I cannot discuss your daughter's/mother's/father's medical records without their prior consent. I realise it's quite a difficult thing to hear.. but we have to respect their rights to confidentiality. - "yes I do realise that your daughter is only 15. I should probably explain our guidelines in a bit more detail; does that sound ok? Us doctors have strict rules to help deal with those under 16 who request the pill. If a girl under 16 came to ask for the pill; we are (A) *trained to assess their level of maturity*. We (B) *discuss the risks and benefits* and try to (C) *encourage them to speak their parents*. If they're considered mature enough to take the pill and continue to remain sexually active and put themselves at risk of becoming pregnant; we would prescribe the pill at their request. I hope that makes sense? 4) solutions (A) "I can understand why you'd be upset but it often helps if parents discuss their concerns with their daughter directly; in a safe environment where they don't feel threatened; that way; she'll discuss things more openly" (B) "you are more than welcome to come in as a family and we can all discuss it together if that helps?"

RELATIVE CONCERN: LOOKING AFTER PARENT AND IS MAIN/ONLY CARER: PARENT REFUSES HELP FROM ANYONE ELSE. This case explores the difficulties the carer is facing. The aim is to look out for carer's needs and discuss options about what to do next 1) explore/data gathering 2) acknowledge concern 3) social situation ?lives alone ?any other carers/other family that could help out/support 4) explore more about carer's life: why is she not coping ?busy job ?children 5) spoken to parent about carer's concerns: have you spoken to your mum about how this is affecting you? ------------------------------------------------------- 6) acknowledge/re-assure and thank them for bringing this to your attention 7) ICE: expectations 8) offer solutions: ---- (A) carer to discuss issues with mother/father ---- (B) consider respite care but if doesn't want to leave home: carers; organise social worker ---- (C) if home is not suitable: organise occupational therapist to come visit 9) what if relative feels guilty about not being able to look after her mum --> aim to re-assure/others in similar situation

1) "could you tell me a bit more about what's happening", "what's on your mind?", "ok.. what is it you've noticed" 2) "I can understand the difficulties you face"... 3) does she live by herself? is there anyone else involved with her care? do you live close? 4) "right.. I can see how this is a difficult situation for you. What is it you do? is family life/work busy? is there anything else I should know about that's having an impact on your duties as a carer? 5) "I can realise the stress this must have on you. Have you spoken to your mum about how this is affecting you?" 6) "right ok... so firstly, you've definitely made the right choice by coming in today to speak to me about this. Clearly, this is a difficult situation for you with all that's happening and I think it's important to prioritise your own health. I can understand why your mother has concerns over other carers but I think it's important to have a discussion with her about the struggles you are facing and the impact on your own health. I'm sure she'll understand 7) expectations: "have you any ideas about how to look after your mum given the situation you're in?8) With that in account; I think the best and only option here is to get in touch with a social worker who will discuss options for care in more detail.. <reflecting> I understand the situation with your father and the poor care he received; but there's no guarantee that will happen again with your mother. I feel your mum will understand the struggles you're facing right now and may accept the option of respite care. 9) I can understand why you'd feel guilty but I think it's important for any carer to look after themselves first before they can consider looking after others. We have services available not only to help you but your mother as well.

RELATIVE CONCERN: SON/DAUGHTER HAS A DRUG PROBLEM 1) explore/data gathering 2) empathy 3) spoken to person him/herself 4) spoken to the other parent 5) living status, alcohol use? any issues at school? 6) parent's ideas about what led to this situation? ------------------------------------------------ 7) acknowledge their concern and thank relative for bringing this to your attention 8) re-assure "its common for this/that" 9) solutions ---(A) ask if its ok to speak to the person directly ---(B) parent to talk with him/her about this problem ---(C) support groups, Frank drugs helping, CBT, rehab programmes available. if relative has many questions during your data gathering: "I'm sure you have many questions at the moment, I'll come on to those later; I just wanted to get a bit more information about what's happening"

1) "establish the story/data gathering*; "could you tell me a bit more about what's been happening/what you've noticed", "ok.. tell me what's on your mind", *you mentioned this/that.. could you tell me a bit more about that? 2) *empathy*: 'I'm sorry to hear this; it must be quite difficult for you", "this must have come as quite a shock to you" 3) have you *spoken to anyone else* about your concerns? 5) *empathy & parent's ideas*: this must be very difficult for you.. have you any ideas about how your son/daughter ended up in this position? 6) *empathy & thank patient*: "I can certainly understand why you'd be concerned about this and I thank you for bringing this to my attention. 7) *re-assure*: it's a common problem amongst teenagers in the community and there are variety of options available about what to do next 8) *offer solutions*: (A) "doctor to speak to person directly": I think the first thing for me to do is have a chat your son/daughter; would it be possible to find a way to bring him in? (B) "it's important he's surrounded by a loving and supporting atmosphere" (C) "we have support groups available, Frank drugs helpline, talking therapies like CBT, rehab programmes for your son/daughter to try"

*EXPLAINING ABOUT AN OPERATION* e.g. - ABDOMINAL OPERATION: bowel surgery, appendectomy, cholecystectomy, hysterectomy +/- removal of ovaries and fallopian tubes - ORTHOPAEDIC: HIP REPLACEMENT key things to know - cannot drive until you're able to do an emergency stop: usually 6 weeks after the operation - they will need approx 6-12 weeks off before going back to work but suggest to speak to employer about this: returning to work with lighter work - general complications: *risk of infection, bleed, clots and pain*; most common 1) how can I help you today? 2) explore prior understanding/what they know already? 3) ICE 4) be honest and explain your not the expert but assure you will attempt to answer their questions 5) explain what you know: on the day, during (keyhole or open) and after the procedure; discuss the impact it will have on their daily activities e.g. driving, work. 6) follow up: feel free to come in if you have any further questions about this.

1) "how can I help you today?" <i'm having an operation and I have questions> 2) "could you tell me a bit more about what's been happening?" "what have you been told already?" "why are you having the operation?" 3) "any ideas, concerns or expectations over the procedure? 4) "I'll try to answer your questions about the operation but, I can only do so on the most basic and general terms. I can assure you however that the surgeon will give you much more information about what to expect during and after the procedure. 5) reflect on patients ICE - what happens on the day/what to expect you should be seen in hospital by the consultant the day before your operation where he or she will go through everything: what it involves, the risks, benefits, complications and ask if you still want to go ahead with the operation. - the operation itself: it could be a keyhole surgery or an open one but this will depend on what the consultant has discussed with you - afterward; you'll be monitored on the ward for complications and be managed appropriately. So the common complications are the risk of infection, clots, bleeding and pain; which will be managed appropriately by the hospital team. - It should take approximately 6-12 weeks to fully recover and perhaps be able to return to work. if you don't know something; be honest "I'll be honest, I'm not too certain about that but I'll discuss with my seniors and contact you back about it". 6) follow up: feel free to come in if you have any further questions about this.

*GIVING BLOOD RESULTS: RAISED LFTs: EXCESS ALCOHOL SOCIAL DRINKER* <assuming patient is stable and results are moderately abnormal> 1) how can I help you today? 2) ask why they had the tests done 3) check understanding of what they're expecting (ICE) 4) explain the results and what it means 5) ask about alcohol intake 6) CAGE questions: helps determine if alcoholic or social drinker ----> if alcoholic: explore why ?stress/anxiety, relationship breakdown, depression, chronic pain, bereavement. Consider also their fitness to drive. Discuss solutions like alcohol anonymous and support groups if they want to stop but finding it difficult. ----> if social drinker: just acknowledge it with the patient and advise to cut down but don't talk about support groups or alcohol anonymous, etc. 7) remind patient of the average amount per week and discuss complications and offer solutions of ways to cutting down 8) discuss other risk factors: health promotion 9) follow up and offer leaflets

1) "how can I help you today?" <just come for my blood results> 2) "yes that's correct.. do you know why you had the tests done in the first place?" 3) do you know why you had these tests done in the first place and do you have any ideas or concerns about what it could show? 4) right so.. let's run through the results.. the good news is that your.. xx is normal but we just found that one of your liver function tests is a bit out of range. <what does that mean?> "we usually see this picture in those drink more than the average amount of alcohol" 5) may I ask if you drink and how much? 6) "ok, so what you're describe is certainly above the average range... we usually ask some routine questions to patients who present similarly to you.. would that be ok? - have you ever thought about *C*utting down on your drinking - have you ever been *A*nnoyed if someone criticises you for drinking - do you feel *G*uilty by the amount that you drink? - do you feel like you have to have a drink in the morning (*E*ye opener) just to get yourself going "Mr X, I can see you're quite annoyed by all these questions, please bare with me, I'm almost done 7) "so ideally, you shouldn't drink more than 14 units of alcohol per week; when it comes to units; I know it can be confusing, so we'll give you a leaflet explaining all of that". The reason why we're strict about alcohol consumption is because too much increases your risk of heart disease, stroke and of course liver problems". I suggest maybe trying at least 2 alcohol free days per week.. how does that sound? 8) it's also important to regularly exercise and eat a healthy well balanced diet. May I ask if you smoke at all? 9) would it be ok to come back in 6-8 weeks just to see how things are going?

*REQUEST FOR ALLERGY TESTING* theme: explaining the management of atopic eczema and re-assuring mother that steroids are safe to use 1) how can I help you today? 2) explore story; ICE 3) check prior knowledge/clarify their understanding about the condition itself and how to manage it 4) explain condition yourself: definition, cause, triggers 5) offer solutions and explain why allergy testing might not be helpful 6) follow up

1) "how can I help you today?" <my son's got eczema and I just wanted an allergy test so we can get to the bottom of it?" 2) "right; ok, could you tell me what's been happening so far with his eczema? what's been happening? <seen last week, the doc prescribed emollients and steroids> "how much have you been told about how to manage his condition?" 3) "yes.. ok, I can see why you want to get this sorted.. before we go onto that.. it's important we discuss a bit more about eczema itself; what do you know already about the condition itself if ok?" 4) "eczema is a very common condition found in children that causes the skin to become red, itchy and cracked. It mostly occurs on the face, scalp, hands, inside the elbows and back of the knees. The cause is unknown but we do know certain things may trigger it off like detergents, soaps, stress or even food. Usually most children grow out of it later. At the moment, we focus our management on treating the symptoms and the best things for that are emollients and steroids - emollients help keep the skin soothe and hydrated; you can use it when you like; usually it's applied daily 4x or more to the entire body. It's completely safe to use. - topical corticosteroids are used to reduce swelling, redness and itching during flare-ups; a small amount is all that's needed to be applied to the areas affected. We usually give it 2-3x/day when there's a flare-up. Hydrocortisone is a weak steroid and is perfectly safe to use in small quantities and can be used in all areas; even the face. 5) solutions - continue with the current therapy you're on at the moment; I'd be be happy to give you a leaflet explaining how to use the steroid cream and emollient - going back to your request to do allergy testing, I don't think that would be useful at this stage. It would be ideal to keep a diary to find out what is triggering your son's symptoms and then making sure your sons avoids it. - if you suspect that food could be the cause, then it might be useful to test for that; by all means please back and we'll arrange that. 6) "lets follow this up in a few weeks to see how things are getting on"

*RELATIVE CONCERN: HUSBAND HAS A DRINKING PROBLEM* DOCTOR!!! 1) obtain the story: how long has been drinking, how much? impact on his life? impact on family's life? 2) empathy 3) explore ICE: her ideas of a cause/precipitating factor 4) explore: his mood? 5) explore: spoken to him? 6) explore: spoken to anyone else? 7) explore: family impact 8) explore: his work life 9) explore: red flags: self-harm? harm to others? ------------------------------------------------------- 10) acknowledge their concern and thank relative for bringing this to your attention then explore 11) *E*xpectations 12) reflect and offer solutions ---(A) bringing husband in: for alcohol intake assessment? ---(B) once husband assessed: consider solutions like support groups and counselling 13) given the sensitivity of the issue: arrange follow up

1) "ok.. could you tell me a bit more about what's going on? "could you tell me what you've noticed?" patient: "he has a drinking problem" doctor: "ok.. could you tell me a bit more about that?" 2) show empathy: "i'm sorry to hear; this must be really stressful for you right now" 3) "do you have any ideas as to why this has happened?" 4) "how's his mood been generally?" 5) "have you spoken to him about your concerns?" 6) "have you spoken to anyone else?" 7) "are you worried about the impact this has on the rest of the family?" 8) "have you any concerns about his performance at work?" 9) "are you worried about what he might do?; in regards to harming himself or others? 10) "hmm ok (sad).. I can understand this being a difficult for you all. I'm glad that you came in and brought it to my attention. 11) "have you thought about how we should approach this?" 12) reflect and offer solutions ---(A) I understand that your husband can be quite stubborn but I think it's important he does come in so we can have a chat.. do you think there'd be any way to convince him? ---(B) I think once I've assessed him; we can start to consider alcohol support groups maybe or even counselling.. does that sound reasonable? 13) "I think we should follow up next week and see how things are... sound ok?"

😠 😠 😠 DEALING WITH A *COMPLAINT* e.g. angry daughter concerned over the nursing care on the ward

1) "right.. so firstly I'd like to *THANK YOU* for bringing this to my attention; I realise that must've been difficult to do" 2) "I'd like to *examine* your mother/father, etc e.g. bed sore and *apologise* to her (e.g. about the care that's she's received whilst on the ward)* 3) I think it's important for me to *speak to the nurse in charge* and explain the situation; they can then investigate, learn from the mistakes made and create measures to prevent them happening again 4) lastly; I'd like to make you aware of the official complaints procedure via *PALS* whom are down in reception. They'll take aboard your comments and be sure to write a formal letter of apology. <this ensures you are acknowledging the seriousness of the situation in the interest of patient safety>

😡 😡 😡 RELATIVE *ANGRY*: *DELAYED DIAGNOSIS* - wants answers: why was this not picked up sooner?

1) *empathy*: "I'm sorry to hear about your father's diagnosis; this must be a very difficult time for you all "it must have come as quite a shock to you all" 2) *explore relative's understanding* "could you tell me a bit more about what happened?" <at this point; the patient should've told you something along the lines "I can't believe you missed it> 3) *acknowledge the mistake and show empathy* "I understand why you're upset at this that his diagnosis wasn't picked up sooner. Would it be helpful if I explained what happened when he last came to the surgery? <at this point; patient will say yes 4) *offer full explanation of events*; "as you know, your father came in several months ago and was seen by one of my colleagues who'd taken a history, examined and sent him for investigations... etc. He had a CXR which allows us to pick up many causes for his symptoms but this came back normal. At the time; there was nothing to suggest he had cancer' 5)

😓 😓 😓 RELATIVE *WORRIED* OVER THEIR PARENT.. consider why? - used to be independent with ADLs; now not so much; fatigue, weakness, not as social... *?depressed*: if signs of depression, ask about their mood has been generally - *social situation*: lack of support for parent due to busy lifestyle/own family to deal with, no friends/siblings to help, parent lives alone, occupational issues (e.g. 2 floors; difficulty going upstairs) - concern over *dementia*: remember that if you're going down this root, you cannot establish this diagnosis until all other pathological causes have been ruled out

1) *establish the story*; what is the relative's concerns; and explore e.g. "you say she wasn't coping well before she came into the hospital; could you tell me more about that? "you mentioned that your mother has neglected herself; could you explain a bit more about what's been happening" 2) ask relative about *their own ideas*: ICE: "have you any ideas about what could be going on?" ----> at this point they will say ?unsure, ?depressed ?possible dementia 3) have they *spoken to anyone else* about their concerns: "have you spoken to your mum/dad about your concerns?" --> note if they have dementia confirmed, ask if there's a power of attorney 4) *explore social situation*: live alone? in own home/care home? any other relatives and do they live close-by? how far does the concerned person live in relation to their parent? <show empathy wherever possible> Patient: "i'm so busy with my own work, I'm not sure how I'll be able to look after my mum..." Doctor: "i'm sorry to hear that/it must be quite difficult for you. 5) *appreciate the relative's concerns* "right, so you've given me a lot of information and I'm glad you've brought this to my attention 6) *re-assure*: "rest assured; this is a common problem and many sons and daughters are often too busy to look after their parent when they get older. I can understand the difficulty you face. 7) *explore expectations*: "have you anything in mind about what to do next?/the various options" 8) *sum up/plan/offer solutions*: "at this point in time, it's too early to ascertain exactly what's going on with your mother/father (A) I would have to have chat with her/him about everything that's going on first. There could be multiple reasons for his/her behaviour so it's important to explore this in more detail. (B) "I know it's difficult, but as long as your mum/dad has capacity; it's important for you to discuss these matters with him/her as it will help establish a plan on what happens in the future. (C) if there are concerns on whether he/she can look after themselves at home; there's always the option of a *care home* but if your mum/dad doesn't want that, we can always organise a *social worker* to discuss his/her needs and see if a carer can come over to help in his/her own home.

<<<<<*NON COMPLIANT WITH MEDICATION*>>>>>> SECOND CASE: DEALING WITH A PATIENT WITH *MEMORY PROBLEMS* things to know: - dosette box 1) *intro*: how can I help you today? <"hi doctor; the receptionist said I needed to talk to you about my repeat prescription> 2) explore prior knowledge 3) discuss importance of each medication: aspirin, atorvastatin and omeprazole - note omeprazole could be stopped if not having any GI side effects 4) *explore why they're not taking the medication compliance with the medication*: type? frequency? feeling any side effects? 5) test memory 5) assess social situation? 6) assess support network 7) summarise: memory issues and offer solutions 8) write information and send in post

1) *intro*: how can I help you today? <"hi doctor; the receptionist said I needed to talk to you about my repeat prescription> 2) "yes that's correct. It's from our understanding that you haven't requested your repeat prescription 3) check patient's understanding and assess - do you know *what medications* you're taking? - do you remember the *last time* you took? (evenings/mornings?) do you know *how often*? - do you know *why* you're taking them? side effects? ----> at this point you should note the patient has issues over her memory.. 4) Mrs X: is it ok to ask you a few silly questions just to test your memory? *6-CIT TEST* (I) do you know the *year* is? (II) do you the current *month*? - give address to remember: e.g. 4 Pondfield Road, Colchester (III) roughly what's the *time*? (IV) count from 20 to 1 (V) say months of the year in reverse (VI) address I told you? 5) *social*: do you live alone? do you have anyone to take care of cleaning, with meals 6) assess *support network*: friends/family 7) summarise: Mrs X; I'm just a little worried about your memory; it might be the reason why you're having difficulty with your medications. I have a few solutions here: (A) dosette box: this is pill box which either yourself or a carer will organise by placing pills by order of time and day making it easier for yourself to remember when you've taken them or not (B) important to refer you to a memory clinic (C) we'll arrange a social worker to come visit you and discuss everything in more depth; they'll assess whether you'll needed a carer to help with cooking, cleaning, etc.. how does that sound? 8) what I'll do is write everything up for you and send it in the post; would that be ok?

RELATIVE CONCERN: SON/DAUGHTER CONCERNED ABOUT CARE IN NURSING HOME 1) obtain story 2) acknowledge concerns/obtain story 3) have you spoken to him/her about this? 4) complained to the place in question? 5) any siblings that can take responsibility for care? 6) ICE: any expectations? ------------------------------------------------ 6) acknowledge and thank 7) solutions ---(A) speak to person in question directly ---(B) situation complex: discuss with seniors and MDT discussion ---(C) consider advising to make an official complaint to the nursing home

1) *obtain story*: *could you tell me a bit more about what you've seen?", "what's on your mind?", "you mentioned this/that..could you tell me a bit more about that?" 2) *empathy*: "I'm sorry to hear about the care your mum/dad has been receiving in the nursing home. You are right; by what you describe, it certainly sounds inadequate" *who else have they spoken to?* 3) "have you spoken to your mum/dad about these concerns?" --> note if they have dementia, ask about a power of attorney 4) "how about the nursing home?" *other family members?* 5) "have you any siblings that could responsibility for the care" *expectations* 6) "I understand you don't want your mum/dad to be discharged back the nursing home; have you any thoughts about other options?" *acknowledge, thank and sum up* 7) "right.. ok, Mr X, thank you for bringing this to my attention firstly, what you describe about the nursing home certainly sounds inadequate. The no.1 priority is your mother's/father's care. 8) *solutions*: (A) I think it's important your concerns are shared with your mum/dad. I'd be happy to speak with her about it if that's ok (B) I will have to have a chat with my seniors and maybe organise an *MDT meeting* (probably the most important if patient lacks capacity/no power of attorney) to ensure your mum/dad gets discharged safely. If you give me your contact details, I can chat with you over the phone and discuss the outcome of the meeting. Does that sound reasonable? (C) *given the inadequate care you've witnessed; have you thought about filing an official complaint?*

*GIVING RESULTS AND BREAKING BAD NEWS* 1) "SPIKES" *S*etting: private, comfortable *P*erception: current knowledge, ICE *I*nvitation: assess level of information they want to know *K*nowledge: discuss the results 'best/worst scenario* *E*motions: empathy + re-assurance, ask about support network. Answer any questions they have if possible.. how? why? what happens now? *S*upport network *S*trategy, *S*afetynet: discuss the plan from here 2) follow upu

1) INTRO: "how can I help you today?" ----> still have this cough doctor/come for my CXR result 2) *E*XPLORE/PERCEPTION (unless anxious) "yes.. Mrs X; I have your results on me but before I dwell onto that, could I ask what's been happening so far in your own words? *"yes, Mr X, I have your results on me; would it be ok if I asked you why you had these tests done in the first place?* "right, Mrs Roberts, I have the results, but before we discuss them, is it ok to get an idea in your own perspective about what's been happening?" "in your last consultation, did you have any discussions about why you're having the CXR done and what to expect?" (if anxious): "Mrs Jones, you look really anxious; usually I ask a bit of background info from yourself but maybe it's best we discuss the results first" ----> story told about cough ICE"are you at all concerned? have you any ideas of what it could be? 3) *K*NOWLEDGE <break down gently> right.. ok. Mrs Roberts; I have your CXR with me.. and I'm afraid it's not good news... the scan has picked up on an abnormal mass on your lung; now the BEST CASE SCENARIO it might very well be nothing..probably just a harmless nodule... in the the worst case scenario.. it could be cancer. ----> no no no, what you talking about? ----> OMG... I can't believe it" 4) *E*MOTIONS <respond with empathy> <if patient shows signs of denial/unexpected> "I can see you're quite emotional right now...." "I realise this is quite difficult for you to hear and I'm sorry I couldn't give you better news" <then pause and let them express their emotions> <if patient expected> "I'm so sorry to have to tell you this.." *S*UPPORT NETWORK: "clearly this news has upset you... do you have any friends or family who can help support you through this time?" 5) <assure> "let me assure you at this stage, it's too early and there's no confirmation it's cancer until we've performed further investigations". ---> so what happens now? 6) *S*TRATEGY: we need to refer you to the respiratory team; you'll be seen within 2 weeks and you've have another scan called a CT: it's a quick 5 minute test under a dome which gives us more information about what we're dealing with. ---> what if it really is cancer?! what do I do?! "again, its far too early to say" ---> how/why? "most lung cancer is related to smoking.. may I ask if that's something you do? 7) *S*AFETYNET - you must let us know immediately if you don't receive a letter in the post within the week so we can chase up the appointment for you 8) FOLLOW UP note: some patients mention concerns about going to the hospital... probably because they had a loved one who died there "I can understand why you'd be reluctant to go to the hospital.. do you have a friends/family who you could go with to help support you?"

*DELAYED DIAGNOSIS* - ovarian cancer mistaken for IBS - testicular cancer mistaken for a cyst idea - something could've been done earlier concerns - delayed diagnosis expectations - an apology - blame needs to be placed on someone - make an official complaint

1) allow patient to vent their frustration <doctor I can't believe you missed this?> 2) I'm sorry to hear this; could you tell me a bit more about what happened? - what the doctors said? diagnosis made? is it terminal? 3) then make your little sorry and assurance speech (A) Mr X, *clearly you're upset/emotional right now*" (B) *I'm so sorry for what's happened* (C) *explore expectations*: is there anything that you'd like for me to do? <yes! someone needs to lose their job!!!> - Mr X, I don't think blaming yourself or anyone is going to help. I will discuss this with my seniors who may open an investigation into what happened and why. We would then place measures to make sure it doesn't happen again.

CASE: PREGNANT WOMAN DECIDING WHETHER TO TERMINATE THE CHILD OR NOT: *UNCERTAINTY*

1) data gathering: "could you tell me a bit more about what's on your mind" 2) data gathering: ICE: "have you any particular concerns about this pregnancy?" e.g. yes, the child was confirmed to have Down's syndrome during 12 week scan... show empathy.. "I'm really sorry to hear that"..: 3) explore impact on social life "have you spoken to anyone else about this e.g. your partner.. parents?" 4) explore prior knowledge: "may I ask how much you know about Downs syndrome" EXPLAIN DIAGNOSIS "yes you're right, Down's syndrome is a genetic disorder that causes some level of learning disability and certain physical characteristics. With the right help and support, most children with Down's syndrome live healthy, active and independent lives. 5) explore situation at home: work/finances, support 6) data gathering: ICE: if not already asked; this is the time to ask about expectations: "have you any thoughts about what you'd like to do next?" *if patient/relative hasn't told anyone else* - ask why.. do they have a fear of what that person would do? "Although I think it's important to involve your partner in this decision; the choice is ultimately yours as the one carrying the child" *if patient/relative blames themselves*: "look, I realise its difficult and I don't think you should blame yourself; that won't solve anything.. its important to that we think about what we do next and make a plan from there" *if they ask you what you directly what to do* - remain neutral: "I realise this is upsetting for you and clearly it's a difficult choice to make. Remember there are many mothers in a similar position as you. Maybe we should fix you up with support groups so you can have an idea of what bringing up a child with Down's syndrome will be like. I think it's important to weigh up the pros and cons before making a decision.. either way; there's no right or wrong answer here but whatever decision you made; I want to assure you that we will support you." - "if you decide to abort the child; it may have an impact on your psychological wellbeing; if that's the case, you're welcome to come in a talk with us or we could refer to counselling - "If you have the child; there are support groups you can join; we'd be happy to provide contact details for that. If finances are an issue; we may be entitled to benefits.

😢😢 *POST-PARTUM DEPRESSION* 1) data gathering/story 2) empathy 3) how's the baby? any concerns? 4) their own general well-being? 5) impact on work? 6) spoken to anyone else? i.e .partner 7) assess support network 8) their ideas about why they're feeling like this? 9) explain diagnosis and offer solutions

1) data gathering: "could you tell me a bit more about what's on your mind", "you seem upset.. could you tell me about what's going on? 2) empathy: "I'm really sorry to hear this, sounds like you're having to endure quite a lot" 3) any concerns about the baby? 4) how are you coping? how's your general mood been since having the baby? sleeping/eating and drinking ok? have you any particular ideas about what could be making you feel like this? 5) how's work? 6) "have you spoken to your partner about how you feel? 7) "do you have any close friends or relative to rely on for support?" 8) have you any thoughts about what could be making you to feel like this? ---------------------------------------------- 9) it sounds like you're suffering from depression; would you agree? it's common to feel like this after having a baby; I'm glad you came in to speak to me about it because there are ways to tackle the problem (A) have you thought about discussing how you feel with your family? It's important that you don't feel alone in this. If your partner knew how you feel; he may take time off to spend with you and the baby (B) I'd also advise to get as much sleep as you can, exercise and maintain a healthy diet (C) there's always the option of therapy. We can even prescribe medications to help you through this. How does that sound?

*GENERAL HEALTH PROMOTION* 1) how can I help you today 2) explore ICE 3) empathy: exploring ICE 4) go briefly though history + family history 5) clarify understanding into concern: in this case heart disease 6) discuss lifestyle factors 7) bloods for screening and BP 8) summarise and provide leaflets

1) how can I help you today <well doctor, I just need a check up?> 2) ok.. is there anything you're particularly worried about? <my brother had a heart attack> 3) i'm sorry to hear that.. is heart disease something you're afraid of? 4) I can see from your own history that you're quite healthy. Is there any family history of heart problems? 5) aside from family history, do you know what causes heart disease? 6) ok shall we run through some of the lifestyle factors that has an impact on your health? (A) may I ask; do you *SMOKE*? - if so have you thought about giving up smoking? --> if no: "are you aware of the risks involved with smoking?": not only heart disease but developing a stroke.. even developing lung cancer --> if yes: what kind of things have you tried?; --> solutions: with smoking; there are support groups available if you're struggling but want to quit, medications or patches that could also help you (B) do you drink *ALCOHOL*? - have you thought about cutting down? (C) would you say you keep to a healthy *DIET*? - advise plenty of fruit and vegetables, wholegrains and low fat yoghurt. I would avoid fatty foods, processed meats and anything fried. (C) would you say you get enough *EXERCISE*? - I also advise plenty of exercise; a brisk 30 minute walk at least every day (D) any *STRESS* in your life? - work/family: have you thought about ways to deal with stress? 7) another thing what I'd like to do is get a BP and blood test for to check for high cholesterol and diabetes --> all three of these can also increase your risk of heart disease.. would that be ok? 8) summarise: good, so we've talked quite a lot today about heart disease and the lifestyle factors involved. I'd like to get these blood tests arranged next week and follow you up soon after if that's ok? in the meantime, I'd like to give you some leaflets about heart disease which will give you more information if you had any further questions

*DELAYED DIAGNOSIS*: 2nd case: *TESTICULAR CANCER* cancer themes: - deal with angry patient - knowing the complaints procedure - knowing about testicular cancer cause unknown, risk factors: undescended testis, family history. Usually carries a good prognosis with most being treated with surgery. - dealing with the impact on social life and work 1) how can I help you today? 2) respond with empathy then explore more 3) explore: tell me more? what happened? - type of cancer? has it spread? what tests did they do? 4) <after vent>; acknowledge, apologise for the inconvenience, respond with "you're right" then assure with steps that will be taken next including official complaints procedure 5) discuss about testicular cancer if patient asks: and diagnosis has been confirmed and give leaflet ---------------------------------------------------- signpost: social impact 6) on themselves 7) support network 8) are they working at the moment? ------------------------ 8) summary/follow up/leaflets

1) how can I help you today? 2) "I'm sorry to hear about this news; it must have come as quite a shock to you" 3) *explore relative's understanding* "could you tell me a bit more about what happened?" - what did the hospital doctors tell you? and what tests did they do? - type of cancer? has it spread? <at this point; the patient should've told you something along the lines "I can't believe you missed it doctor!!> 4) acknowledge emotion, apologise, accept they're correct, assure (A) Mr X, *clearly you're upset/emotional right now and I can understand why* (B) *I'm so sorry for what's happened* (C) *I can assure you that I will discuss this case with my seniors who may open an investigation to find out what happened and why. *Measures will be placed to ensure incidents like this do not happen again*. (D) would you like to make an *official complaint*? this can be done by writing to our practice manager. They will write to you back with a detailed response. 5) do you have any questions about testicular cancer? No-one knows what causes it but it is easily managed with surgery and carried a very good prognosis ----------------------------------------------- 6) may I ask how you're feeling in yourself "SAM" - have you had any trouble *s*leeping? - any issues with your *a*ppetite - has your *m*ood been ok 7) a support network around you to help you through this? 8) are you currently in work? ----------------------------------------------- 9) once again Mr X, I'm sorry for what's happened and I can assure you that we will discuss it in our next meeting. In the meantime, you are open to make an official complaint as discussed. In the meantime, I'd like to leave you with some leaflets about testicular cancer. - ask if he's been planned to follow up with the department If you have any more concerns or questions, feel free to come back.

*CHILD PROTECTION* <look at patient's body language: closed and may have bruised on their face, arms, etc> common questions - will the children be taken away from me?: don't answer this directly; respond with: "the safety of the children is of utmost importance" 1) how can I help you today? <pick up on non-verbal cues 2) explore what's been happening <show empathy and silence when needed> 3) ICE 4) support network 5) assure: you've done the right thing by telling me this 6) safety of the children is of utmost importance 7) safety of the adult: seek senior help 8) follow up: feel free to come in if you have any further questions about this.

1) how can I help you today? 2) "Mrs X, you seem upset about something.. what's wrong? is there anything on your mind you'd like to talk about?" non-verbal cues: "Mrs X, I noticed you have a few bruises on your arms; is everything ok? <story told> show empathy and use silence: I'm really sorry to hear what's been happening.. would you mind be asking a bit more: the abuser? type of abuse? any children involved? 3) explore ICE: have you any thoughts about what needs to be done about this? any particular concerns or worries - fear of having her children taken away - fear of her partner knowing; doesn't want him to be hurt/doesn't want to be hurt herself 4) "have you spoken to anyone else: do you have any friends/family for support?" 5) "I know it must've been hard, but you've done the right thing by telling me this today.. 6) you need to know, that the safety of your children is of utmost importance; I will have to discuss with my senior colleagues and child protection lead who will contact you assess the risk in more detail. I hope you can understand "I know it's difficult to hear because of the fear but your children must take priority when it comes to risk of being hurt" "I'm afraid I can't say what will happen until I've discussed it with the appropriate services" 7) "as for yourself, it's important for me to seek help from seniors about what the next course of action is" 8) "would you be able to come back next week so I can see how you are? I need you to know that if this becomes worse, you should have no hesitation to call the police.

*REVIEW OF MEDICATION* 74 year old man with previous MI, no CCF. Has an under-active thyroid, hypertension, opthalmic herpes, post-herpetic neuralgia diverticulitis and BPH. His medications are bendroflumethazide, ramipril, simvastatin, aspirin, amitriptyline, co-codamol, thyroxine, ispaghula hulk (fybogel). remember: know the general basic medication indications and side effects 1) how can I help you today? 2) go through each one with the patient; clarifying their understanding 3) follow up if changing any BP medications

1) how can I help you today? <medication review doc> 2) "ok, would you mind telling me your understanding through each one.. then we can review together which ones to stop" 3) ok good, right; so let me point out the essential ones; aspirin, simvastatin, rampiril and thyroxine; we give in anyone who's had a heart attack in the past; they reduce the risk of a further event happening. - the simvastatin however is not the most ideal statin and atorvastatin 80mg should be given instead; explore with the patient if they had any unexplained muscle aches and pains since starting the statin ---> if yes, then advise that we'll have to do a blood test as the muscle pains could be a result of muscle breakdown from statin. ---> If the blood test is abnormal; you'll have to stop the statin and I will seek specialist advice on an alternative ---> if the blood test is normal: I consider switching to atorvastatin 80mg 4) ask about pain: consider reducing co-codamol to just paracetamol alone. Consider stopping the amitriptyline 5) bendroflumethazide helps control the BP; which is within normal range at the moment. Could consider alternative if patient says they're having side effects e.g. abdominal pains, frequency, etc ; ask patient if they tried amlodipine? ----> investigate further into urinary symptoms: ?recent ?related to BPH if you have time: primary prevention health promotion discussion: smoking, alcohol, diet, exercise

*MANAGING A PATIENT WITH MULTIPLE PROBLEMS* in this case: UTI, contraception and option for sterilisation, ovarian cancer concern and asthma (which sounds controlled). 1) how can I help you today? 2) prioritise what's most important in his/her list <note: UTI and contraception are probably the most important here> 3)

1) how can I help you today? <right so I have a list of problems> 2) ok; we may be a little short of time to cover them all; could you tell me what's the most important one that's bothering you the most?" 3)

dealing with an 😡ANGRY PATIENT 😡patient: *BREACH OF CONFIDENTIALITY* themes: - dealing with angry patient over breach of confidentiality - dealing with STD (chlamydia) - solutions to prevent marriage breakdown 1) how can I help you today? 2) respond with empathy then explore more 3) <after vent>; acknowledge, apologise for the inconvenience, respond with "you're right" then assure with steps that will be taken next ---------------------------------------------------- 4) signpost!! .. focus on the next issue: his chlamydia feelings with the result? antibiotics prescription, health promotion, information leaflet, safety-netting 5) signpost!! have you any concerns about what will happen now with your relationship? ---> would you find it helpful if you had another appointment here with your wife present: we can discuss about what's happened and try to prevent a relationship breakdown ----------------------------------------------------- 7) summary/follow up

1) how can I help you today? <your stupid receptionist told my wife I had chlamydia!> 2) respond with empathy then explore "i'm so sorry to hear what's happened (unless already known)... do you mind telling me what exactly's been going on <if the patient is still venting, give them space and time> 3) acknowledge emotion, apologise, accept they're correct, assure (A) Mr X, *clearly and rightfully you're upset/emotional* right now and *I can understand why*. Information was given out in breach without your prior consent. (B) *I'm sorry* for the inconvenience this caused you and your family (C) but I can *assure* you that I will discuss this with my seniors in our meeting and investigation will be opened up to find out what happened and why. and (D) *measures* will be placed to ensure this incident doesn't happen again 4) Mr X, is it possible to move passed this now and discuss your chlamydia result? (A) "how does the (+) result make you feel?" (B) so, we advise treatment with antibiotics; a 1 of dose is to be taken orally. (C) I advise you to avoid sexual contact for a week after taking the tablet. (D) In future; the use of condoms to prevent STDs would be beneficial. (E) If symptoms persist, please come back so we can review it Breaching confidentiality is a matter that's taken very seriously. An investigation will take place and measures should will be taken to make sure it doesn't happen again 5) have you any concerns about what will happen now with your relationship? ---> would you find it helpful if you had another appointment here with your wife present: we can discuss about what's happened and try to prevent a relationship breakdown

*CERVICAL SCREENING* 55 year old lady with borderline changes of smear test *knowledge of cervical smear results* - negative result: regular screening in three years (if aged 25-49), (or five years if aged 50-64) - inadequate: not enough cells in the sample. Or they had their period or an infection, these may have affected the result. Repeat required within 3 months - borderline/low grade dyskaryosis --> they will require HPV testing (A) if HPV+ ---> refer for colposcopy within 6 weeks (B) if HPV- ---> back to routine screening - high-grade dyskaryosis; will need referral for colposcopy within 2 weeks understand that: - there is no need to treat partner - HPV is a common virus spread through sexual contact; although it's best to use protection like condoms; it doesn't guarantee full protection - re-assure the test doesn't mean they have cancer 1) how can I help you today 2) acknowledge you have the result and check prior understanding of cervical smear and why it's done 3) explain cervical testing 4) any questions 5) prepare to discuss risk factors and symptoms of cervical cancer and offer solutions

1) how may I help you today 2) before we dwell onto the results; I just wanted to ask what you know already about cervical smears and why we do them? (ICE) 3) so let me explain, just so we can clarify the information. - cervical screening is done every few years; in your case every 5 years till you reach 64. - we do this to screen if a patient is at risk of developing cervical cancer. - anyone presenting with abnormal result would be tested automatically for a virus called HPV to see if that is the cause for the abnormality. You wouldn't need to have another smear test; the lab will automatically test for it. - HPV is a virus spread through sexual contact; although helpful to use protection, it doesn't guarantee that you will not have it. - If you are HPV+, we will refer you to have a camera test to check your cervix within 6 weeks. If the test is negative, you'll go back to the usual routine of having a smear done every 5 years. - Let me assure; the smear test does not test for cancer itself. Many people receive abnormal results on their smear and it turns out not to have cancer. 4) I hope I've clarified that all, did you have any questions? RISK FACTORS AND SYMPTOMS 5) - although cervical cancer is very rare nowadays, there are several risks to look out for; I will give you a leaflet on this later, but the most important is smoking. May I ask if you smoke? ---> <"yes doctor I smoke"> women who smoke are twice as likely to develop cervical cancer than those who don't. Furthermore, it puts you at risk of developing heart disease, stroke and lung cancer. Have you considered quitting? there are various ways to help: support groups, medication or patches (once a day: instead of taking nicotine via a cigarette, it's taken through a patch). - the early symptoms for cervical cancer include: unusual bleeding during or after sex, between periods or even after menopause; it's important to come back to us if you ever experience any of those. I will give you a leaflet on cervical cancer and what to look out for

*REQUEST FOR UNNECESSARY MEDICATION* EPIPEN CASE 1) obtain story and any reason why they want the medication (ICE) 2) clarify their own medical history 3) discussed with anyone else about concerns? 4) check prior knowledge of drug ------------------------------------------------------ 5) discuss knowledge about medication and situation when its used 6) discuss reasons for not prescribing 7) empathy + explore reasons: clarify if other concerns? 8) solutions e.g. - allergy testing: if request for epipen - cholesterol levels: if request for statin - swab/delayed course: if request for antibiotics 9) clarify if ok with your reasonings for not prescribing

1) obtain story: "could you tell me a bit more about that", "ok.. what's on your mind?", "could you tell me a bit more about what you've noticed" <show empathy if they tell you about any traumatic recent event> e.g. i'm really sorry to hear that.. how is he/she at the moment?", "i'm sure it must have come as quite a shock to you all" 2) ask about medical history e.g. for Epipen request: "do you have any known allergies?" 3) "have you discussed this with anyone else?" 4) "ok.. could you tell me what you know already about this medication?" e.g. the epinephrine injectable pen 5) "yes, you are right; this is an injection that's usually given in the muscle to prevent a severe reaction from happening from an event such as a bee sting. However; it is rare for this to happen so we only prescribe epinephrine pens in those with a history of severe allergy. I'm really sorry and can understand your request but I'm afraid we cannot prescribe it for you at this time. 6) other reasons for not prescribing - <medication> if used inappropriately; it could cause more than harm than good - furthermore; if we were to give pens to everyone and there turned out to be a shortage; those who have true allergies may suffer. 7) "I can see this is worrying for you. Is there anything else I should know that's troubled you into making this request?" 8) "how do you feel now about not having being prescribed this medication/treatment?"

*BEAUREVEMENT* 1) explore 2) respond with *empathy! empathy! empathy!* 3) "i'm glad you brought this to my attention" and explore more about events 4) *how is the patient in themselves*?/assess for depression.. - sleeping ok? appetite? mood? 5) empathy +/- *support network*? 6) *working* status? 7) ICE + *solutions* - counselling - antidepressants 8) speech: *empathy.. supporting messages..re-assurance* "it's normal to feel like this.. want you to know we support you" 9) *follow up*

1) what's on your mind? how can I help you? <my son just died> 2) EMPATHY/RESPOND "oh my I'm so sorry to hear that...must've come as quite a shock for you" <patient cries> "take your time.." <i'm sorry to have bothered you about..> 3) "no, its ok.. you did the right thing by telling me. Would you mind me asking what happened exactly? <well you see.. this and that happened> EMPATHY "this must be devastating for you right now" 4) "how are you coping? have you been able to sleep ok.. how's your appetite been? how's you mood been lately? 5) "it must be really hard for you right now... do you have any friends or family nearby to offer you support through this difficult time?" 6) are you working at the moment? 7) "in situations like these, many people often find it difficult to seek help. I think it's very important that they do. (ICE) Have you thought about ways to get through this? There are ways we can help you get through this: - work: i'd be happy to write a letter to your employer explaining that you'll need time off - "have you thought about the option of counselling?": these are councillors who will understand what you're going through and talk through it. They'll help support you through this time. - another thing we could try is medications; antidepressants which could help relieve your symptoms 8) "Mr X... - the emotions you're going through are normal... and I can completely understand how difficult a time this is for you right now. With the right help and support; over time; you should start to feel better. 9) I think it's important for you to come see me again next week; just to see how you've been coping.. would that be ok?

*DEPRESSION / ANGER* <patient requests sleeping tablet> 1) explore 2) respond with *empathy! empathy! empathy!* 3) "i'm glad you brought this to my attention" and explore more about events 4) *how is the patient in themselves*?/assess for depression.. - sleeping ok? appetite? mood? - suicidal thoughts? (if in low mood) 5) empathy +/- *support network*? 6) *working* status? 7) ICE about sleeping tablets (this way, you can explore if they've ended up going to alcohol/drugs) 8) offer *solutions* - counselling - antidepressants 9) speech: *empathy.. supporting messages..re-assurance* "it's normal to feel like this.. want you to know we support you" 10) *follow up*

1) what's on your mind? how can I help you? <my wife left me for another man> 2) EMPATHY/RESPOND "oh my I'm so sorry to hear that...must've come as quite a shock for you" <patient cries> "take your time.." <i'm sorry to have bothered you about..> 3) "no, its ok.. you did the right thing by telling me. Would you mind me asking what happened exactly? <well you see.. this and that happened> EMPATHY "this must be devastating for you right now" 4) "you've told me already that you've haven't been sleeping. How's your appetite been? how's you mood been lately? - something we routinely ask when patients are in a low mood is if they have or ever had any thoughts of self-harm or harm to others? 5) "it must be really hard for you right now... do you have any friends or family nearby to offer you support through this difficult time?" 6) are you working at the moment? 7) you mentioned that you wanted sleeping tablets: have you any ideas and expectations about these? what do you know already about them? 8) "I realise this is a difficult time for you right now, have you thought about other ways to manage what you're going through aside from sleeping medication? - "have you thought about the option of counselling?": these are councillors who will understand what you're going through and talk through it. They'll help support you through this time. - another thing we could try is medications; antidepressants which could help relieve your symptoms - sleeping tablets may help in the short term but they do carry the risk of complications.. e.g. drowsiness that could carry on the next day; that may have an issue with work and with driving. They do have the potential for addiction but that's only if used in the long term which may not be relevant. 9) "Mr X... - the emotions you're going through are normal... and I can completely understand how difficult a time this is for you right now. With the right help and support; over time; you should start to feel better. 10) I think it's important for you to come see me again next week; just to see how you've been coping. One thing I need to say is, if you do have any thoughts of wanting to hurt yourself; contact us immediately. We are here to help you get through this. Does that be ok?

common presenting lines SYMPTOMS 1) "doctor my chest is still hurting" <concerned> 2) "my knees/wrist is still painful" <concerned/frustrated> 3) "I have these nasty headaches" <concerned> 4) "I feel so tired all the time" 5) "I have a lump of my breast" <embarrassed/concerned> 6) "I have a lump on my testicle" <embarrassed/concerned> 7) "I need some viagra" <embarrassed> OTHERS 1) "I was seen in hospital a couple of weeks ago.." 2) "just come for my results" 3) "I need to terminate my pregnancy" 4) "I'd like to be discharged today" 5) "I need a sick note"

doctor responses 1) "i'm really sorry to hear that; could you tell me more about this?" 2) "I'm sorry to hear that you're (still) having these pains; could tell me more about this?" 3) OTHERS 1) "I'm sorry to hear you were in hospital..." 2) "yes, I have your results with me; but before I go into that; I was hoping you could tell me a bit more about why you had these tests done in the first place?" --> after patient has given his story, you can explain the results then explore ICE. 3) "I see, I'm sorry to hear that. Before we dwell onto that, would you mind me asking about what brought you to this decision? Explore ICE 4) "I see, is there a reason why'd you like to be discharged today?" 5) "I see, is there a reason why you'd like me to issue you a sick note?"

😡 😡 😡 *ANGER/FRUSTRATED* PATIENT/RELATIVE

e.g. inadequate care/lost results/relative requesting information on relative *"I can see you're quite emotional/frustrated Mr/Mrs X and you have every right to be given what's happened. Let me assure you that we take matters like this seriously and it will be dealt with. In the meantime, I can only offer my apologies for the inconvenience that it's caused you and your family. I think it's important we look passed this now and start looking at ways on going forward"* "I can understand you're frustration Mr/Mrs X; what you've had to go through sounds very upsetting "Clearly, I can see how upset you are about all this Mr/Mrs X" "I can understand your frustration. Clearly you're quite anxious about this. e.g. angry patient/relative concerned about the nursing care e.g. bed sores due to insufficient turning and cleaning of urine "i'm really sorry to hear this (about the care your mum is receiving). Clearly you're upset and rightfully so <acknowledges patient concern, apologises and shows empathy>

*REQUEST FOR UNNECESSARY MEDICATION* ANTIBIOTICS indications for tonsillectomy: - 7 or more in the preceding year - >5 in the preceding 2 years - >3 in the preceding 3 years 1) empathy then obtain story and any reason why they want the medication (ICE) 2) clarify if patient is ok at present 3) discussed with anyone else about concerns? 4) ask if they had any expectations from the specialist? what they would do? 5) check prior knowledge of condition/antibiotics ------------------------------------------------------ 6) discuss knowledge about condition and the use of antibiotics with the mother. Discuss reasons for not prescribing 7) empathy + explore reasons: clarify if other concerns? 8) solutions e.g. 9) clarify if ok with your reasonings for not prescribing

how can I help you today? <doctor my son needs a referral; I feel i've been fobbed off> 1) "i'm sorry to hear how upset you are.. can you tell me what's been happening? what's wrong? - recurrent episodes? did they go away without antibiotics? 2) how is your son at the moment? empathy: I can understand how anxious one can be if their child becomes unwell.. 3) have you spoken to anyone else: what were their opinions? 4) did you have expectations from the specialist? 5) how much do you know about tonsillitis/UTRI? 6) so.. tonsillitis is very common in childhood and most cases are caused by viruses rather than bacteria. Most times, children grow out of it having these infections. From what you've told me, it sounds like your child developed viral infections so antibiotics simply wouldn't work because they target bacteria. If he continues to have recurrent tonsillitis, we would be happy to assess him. If he needs antibiotics regularly; then we can consider referral but at this time, there would be no indication for surgery. I'm sorry, I hope you can understand 7) any other concerns 8)

<<<<<*NON COMPLIANT WITH MEDICATION*>>>>>> and missed routine appointments e.g. BP medications *explore and let them explain* 1) *intro*: how can I help you today? "hi doctor; the receptionist said I couldn't have my tablets until I had a chat with you 2) *discuss what you know already* from the notes and *ask the reasons* they had for the missed appointments ---> ?too busy ?difficulty getting to the surgery 3) ask if there were *any other reasons* e.g. issues with the medications themselves 4) *explore their compliance with the medication*: type? frequency? feeling any side effects? 5) *explore understanding of their condition* 6) *explain diagnosis and consequences* 7) *pick up on cues/solutions* (A) self-monitoring at home (B) adding reminders on phone/computer to take medications (C) alternative medication for *health promotion* 8) smoking, alcohol, diet, exercise *clarify and follow up* 9) any other questions, summarise 10) red flags and follow up

respond to urgency non-verbal cue: "Mr X, I can see you're in a rush; please bare with me, I just need to ask a few more questions, it shouldn't take long" 1) how can I help you today? 2) I see; so from what I understand is, you've missed several BP checks with the nurse, is that correct? <from the notes given> -----> "doctor, I've just been so busy" 3) "I can imagine.. is there any other reasons you can think of why you haven't been able to attend? -----> "well not that I can think of?" 4) explore other reasons: - have you been taking your medications ok? -----> "if patient says yes.. --> offer to check BP and discuss more: what medication, how frequently, when, etc, feeling any side effects? -----> "if patient says no --> explore ?too busy with work ?inconvenience ?side effects (feeling dizzy particularly when getting up, dry cough) 5) *explore understanding of condition*: "do you mind me asking what you know already about having high BP? 6) explain diagnosis: "so high BP means blood is flowing through your arteries too quickly; it could be genetic or through diet alone. If it's left uncontrolled, you could develop a heart attack or a stroke. 7) solutions and pick up on cues (A) you mentioned earlier that you were busy with work to get to the appointments; what I'd suggest is maybe to monitor your BP at home yourself *(self-monitoring)*; initially just for 5-7 days in the morning and night; before and after you go to work. The nurse will offer you training for this. We need to make sure your BP is below 135/85. All you would need to do is call us with the readings and we'll manage it from there. How does that sound? (B) you also mentioned that you forget to take the medications; have you thought about adding reminders of your phone, watch or even alarm in the mornings? or at night? (C) I understand that you developed a dry cough since starting the medication. What you've been prescribed can cause a dry cough and it could be the reason. Would it help if I prescribed an alternative medication? ------------------------------------------------------ 8) aside from your BP; may I ask you a few more questions about your health? diet, smoking, alcohol and exercise 9) right so we've talked quite a lot about this; did you have you any questions? 10) right so I think maybe it's best to follow you in 4-6 weeks to see how things are going