Editors: Thomas, James; Monaghan, Tanya Title: Oxford Handbook of Clinical Examination and Practical kills, !

st Edition Co"yright #$%&&' Oxford (ni)ersity Press * Table of Contents * Cha"ter ! + Comm,nication kills Cha"ter ! Comm,nication kills P-% .ntrod,ction Comm,nication skills are notorio,sly hard to teach and describe- There are too many "ossible sit,ations that one might enco,nter to be able to dra/ r,les or g,idelines- .n addition, yo,r actions /ill de"end greatly on the "ersonalities "resent012not least of all yo,r o/n3 (sing this cha"ter O)er the follo/ing "ages, there is some general ad)ice abo,t comm,nicating in different sit,ations and to different "eo"le- 4e ha)e not "ro)ided r,les to stick to, b,t rather tried to gi)e the reader an a""reciation of the great many /ays the same sit,ation may be tackled(ltimately, skill at comm,nication comes from "ractice and a large amo,nt of common sense5 h,ge amo,nt has been /ritten abo,t comm,nication skills in medicine- Most is a mix of acce"ted "rotocols and "ersonal o"inion012this cha"ter is no differentThe r,le is: there are no r,lesComm,nication models There are many models of the doctor+"atient enco,nter /hich ha)e been arg,ed o)er at great length for years- These are for the hardened st,dents of comm,nication only- 4e mention them only so that the reader is a/are of their existencePatient+centred comm,nication .n recent years, there has been a significant change in the /ay healthcare /orkers interact /ith "atients- The biomedical model has fallen o,t of fa)o,r- .nstead, there is an a""reciation that the "atient has a ,ni6,e ex"erience of the illness in)ol)ing the social, "sychological, and beha)io,ral effects of the diseaseThe 017biomedical018 model 9octor is in charge of the cons,ltation :oc,s is on disease managementThe "atient+centred model Po/er and decision+making is shared 5ddress and treat the /hole "atientP-; <ox !-! =ey "oints in the "atient+centred model Ex"lore the disease and the "atient>s ex"erience of it: o (nderstand the "atient>s ideas and feelings abo,t the illnesso

5""reciate the im"act on the "atient>s 6,ality of life and "sychosocial /ell+being-

(nderstand the "atient>s ex"ectations of the cons,ltation-

(nderstand the /hole "erson:

o o o

:amilyocial en)ironment<eliefs-

:ind common gro,nd on managementEstablish the doctor+"atient relationshi"<e realistic:

o o

Priorities for treatment?eso,rces-

<ox !-% Confidentiality 5s a doctor, health care /orker or st,dent, yo, are "arty to "ersonal and confidential information- There are certain r,les that yo, sho,ld abide by and times /hen confidentiality m,st or sho,ld be broken @ "-;%A- The essence for day+to+day "ractice is: Be)er tell anyone abo,t a "atient ,nless it is directly related to their careThis incl,des relati)es and can be )ery diffic,lt at times, "artic,larly if a relati)e asks yo, directly abo,t something confidentialCo, can reinforce the im"ortance of confidentiality to relati)es and )isitors- .f asked by a relati)e to s"eak to them abo,t a "atient, it is a good idea to a""roach the "atient and ask their "ermission, /ithin f,ll )ie/ of the relati)eThis r,le also a""lies to friends o,tside of medicine- 5s doctors and others, /e come across many amaDing, biDarre, am,sing, or ,"lifting stories on a day+to+day basis b,t, like any other kind of information, these sho,ld not be shared /ith anyone.f yo, do intend to ,se an anecdote for some after+dinner entertainment, at the )ery least, yo, sho,ld ens,re that there is nothing in yo,r story that co,ld "ossibly lead to the identification of the "erson in)ol)edP-E Essential considerations 5ttit,des Patients are entr,sting their health and "ersonal information to yo,012they /ant someone /ho is confident, friendly, com"etent, and abo)e all, is tr,st/orthyPersonal a""earance :irst im"ressions co,nt012and st,dies ha)e consistently sho/n that yo,r a""earance @clothes, hair, make+,"A has a great im"act on the "atients> o"inion of yo, and their /illingness to interact /ith yo,- Part of that intangible 017"rofessionalism018 comes from yo,r image-

The /hite+coat is still "art of medical c,lt,re altho,gh sadly a""ears to be dying o,t in the (= at this time- :ashions in clothing change ra"idly b,t some basic r,les still a""ly Be,traliDe any extreme tastes in fashion that yo, may ha)e Men sho,ld ,s,ally /ear a shirt and tie

4omen may /ear skirts or tro,sers b,t the length of the skirts sho,ld not raise any eyebro/sThe belly sho,ld be co)ered012e)en d,ring the s,mmer3 The sho,lders, like/ise, sho,ld ,s,ally be co)eredhoes sho,ld be "olished and cleanClean s,rgical scr,bs may be /orn if a""ro"riateHair sho,ld be relati)ely conser)ati)ely styled and no hair sho,ld be o)er the face- .t is ad)ised to /ear long hair tied ,"Co,r name badge sho,ld be clearly )isible012/orn at the belt or shirt "ocket is acce"table-F tethosco"es are best carried or held in a coat+"ocket012/orn at the neck is acce"table b,t a little "retentio,s, according to some )ie/so

Try not to t,ck items in yo,r belt012,se "ockets or belt+holders for mobile+ "hones, keys, and /allets-FF

0GH Psychiatry, "aediatrics, and a handf,l of other s"ecialties re6,ire a different dress code as they deal /ith "atients re6,iring differing tech012ni6,es to bondFF One of the a,thors once sa/ a female medical st,dent carrying the Oxford Handbook of Clinical Medicine do/n the back of her tro,sers /here it /as "ractically /edged bet/een her b,ttocks012not a "retty sight3 Timing .f in a hos"ital setting, make s,re that yo,r disc,ssion is not d,ring an allocated 6,iet time012or immediately before one is to start3 Co, sho,ld also a)oid mealtimes or /hen the "atient>s long+ lost relati)e has I,st come to )isit0GH .f taking the "atient from the bedside, ask the s,"er)ising doctor @if not yo,A and the n,rsing staff012and let all concerned kno/ /here yo, ha)e gone in case the "atient is neededP-J etting t,dents, doctors, and others tend to see "atients on b,sy /ards /hich "ro)ide distractions that can break the interaction- Often this is necessary d,ring the co,rse of a b,sy day- Ho/e)er, if yo, are intending to disc,ss a matter of delicacy re6,iring concentration on both yo,r "arts, consider the follo/ing conditions: The room sho,ld be 6,iet, "ri)ate, and free from dist,rbances There sho,ld be eno,gh seating for e)eryone-

Chairs sho,ld be comfortable eno,gh for an extended con)ersation5rrange the seats close to yo,rs /ith no inter)ening tables or other f,rnit,re-

<ox !-; <ecoming a good comm,nicator Kearning Kike all as"ects of medicine, learning is a lifelong "rocess- One "art of this, "artic,larly tr,e of comm,nication skills and at the beginning of yo,r career, is /atching othersThe st,dent sho,ld take e)ery o""ort,nity to obser)e doctor+"atient interactions0GH Co, sho,ld ask to be "resent d,ring diffic,lt con)ersations.nstead of glaDing o)er d,ring cons,ltations in clinic or on the /ard ro,nd, yo, sho,ld /atch the interaction and consider if the beha)io,rs yo, see are /orth em,lating or a)oiding- Consider ho/ yo, might adI,st yo,r f,t,re beha)io,r017Cherry+"ick018 the things yo, like and ,se them as yo,r o/n012b,ilding ," yo,r o/n re"ertoire of comm,nication techni6,es"ontaneity )ers,s learnt beha)io,rs .f yo, /atch a good comm,nicator @in any fieldA yo, /ill see them making friendly con)ersation, s"ontaneo,s Iokes, and ,sing /ords and "hrases that ",t "eo"le at ease- .t seems nat,ral, relaxed, and s"ontaneo,s4atching that same "erson interact /ith someone else can shatter the ill,sion as yo, see them ,sing the )ery same 017s"ontaneo,s018 Iokes and other gambits from their re"ertoireThis is one of the keys to good comm,nication012an ability to I,dge the sit,ation and ",ll the a""ro"riate "hrase, /ord, or action from yo,r internal catalog,e- .f done /ell, it leads to a smooth interaction /ith no hesitations or mis,nderstandings- The additional ad)antage is that yo,r mental "rocesses are free to consider the next mo)e, m,ll o)er /hat has been said or consider the findings, /hilst externally yo, are "artially on 017a,to+"ilot0189,ring "hysical examination, this is "artic,larly rele)ant- Co, sho,ld be able to coax the /anted actions from the "atient and ",t them at ease /hilst considering the findings and yo,r next ste".t m,st be stressed, that this is not the same as lacking concentration0126,ite the o""osite, in factP-L Essential r,les 5)oid medical Iargon The "roblem is that medics are so immersed in Iargon that it becomes "art of their daily s"eechThe "atient may not ,nderstand the /ords or may ha)e a different idea as to the meaningTechnical /ords s,ch as 017myocardial infarction018 are in ob)io,s need of a)oidance or ex"lanation- Consider terms s,ch as 017exacerbate018, 017chronic018, 017n,mb018, and 017s",t,m018012these may seem ob)io,s in meaning to yo, b,t not to the "atientCo, may also think that some terms s,ch as 017angina018 and 017migraine018 are so /ell kno/n that they don>t need adI,stment012b,t these are )ery often misinter"reted- ome exam"les are in the box o""osite?emember the name :orgetting someone>s name is /hat /e all fear b,t is relati)ely easy to disg,ise by sim"le a)oidance- Ho/e)er, the ,se of a name /ill make yo, seem to be taking a greater interest- .t is

"artic,larly im"ortant that yo, remember the "atient>s name /hen talking to family- Metting the name /rong is embarrassing and serio,sly ,ndermines their confidence in yo,5side from act,ally remembering the name, it is a good idea to ha)e it /ritten do/n and /ithin sight012either on a "iece of "a"er in yo,r hand or on the desk, or at the head of the "atient>s bedTo be seen )isibly glancing at the name is forgi)able b,t does ,ndermine yo, to a certain extentP-' 5 fe/ exam"les of /ords that may be misinter"reted by the "atientTable 1.1 Some examples of differing interpretations. Word Your meaning The patient's understanding 5c,te ?a"id onset Nery bad, se)ere Chronic Kong d,ration Nery bad, se)ere ick Ba,seated, )omiting (n/ell 5ngina Chest "ain associated /ith ischaemic heart Heart attack, shortness of breath, disease "al"itations Migraine "ecific headache disorder 5ny se)ere headache B,mb 4itho,t sensation 4eak P-O Metting started The start of an enco,nter is im"ortant, b,t is fra,ght /ith "otential diffic,lties- Kike e)erything else in this cha"ter, there are no hard+and+fast r,les b,t some iss,es that yo, sho,ld take into consideration 5re yo, ,sing a lang,age the "atient can ,nderstandP Can they hear yo,P Mreeting <e/are of 017good afternoon018 and 017good morning018- These can be ina""ro"riate if yo, are abo,t to break some bad ne/s or if there is another reason for distress- Consider instead a sim"le 017hello018haking hands 5 diffic,lt iss,e /hich, again, needs to be I,dged at the timePhysical contact al/ays seems friendly and /arms a "erson to yo,012b,t a hand+shake may be seen as o)erly formal by some- Perha"s consider ,sing some other form of to,ch012s,ch as a slight g,iding hand on their arm as they enter the room or a brief to,ch to the forearm- @ ee also "-%O-A .ntrod,ctions This is a minefield3 Co, may /ish to alter yo,r greeting de"ending on circ,mstances012choose terms that s,it yo,Title012them Older "atients may "refer to be called Mr or Mrs; yo,nger "atients /o,ld find it odd- 9iffic,lty arises /ith females /hen yo, don>t kno/ their marital stat,s- ome yo,nger or married "atients may find the term 017Ms018 offensi)e-

(sing the "atient>s first name may be considered too informal by some012/hilst a change to ,sing the family name mid+/ay thro,gh the enco,nter /ill seem )ery abrasi)e and ,nfriendlyThere are no r,les here and common sense is re6,ired to I,dge the sit,ation at the time- 4hen ,ns,re, the best o"tion is al/ays to ask017.s it Mrs or Miss <,tter/orthP018 017May . call yo, MaryP018 Title012yo, The title 017doctor018 has al/ays been a stat,s symbol and a badge of a,thority012/ithin the healthcare "rofessions, at least- Co,ng doctors may be rel,ctant to "art /ith the title so soon after ac6,iring it b,t, in these days /hen cons,ltations are becoming t/o+/ay con)ersations bet/een e6,als, sho,ld yo, really introd,ce yo,rself as 0179r018P Many "atients /ill sim"ly call yo, 017doctor018 and the matter doesn>t arise- The a,thors "refer ,sing first names in most circ,mstances b,t some elderly "atients "refer012and ex"ect012a certain le)el of formality so the sit,ation has to be I,dged at the timeP-Q tanding 5ltho,gh this might be considered old+fashioned by some yo,nger "eo"le, standing is a ,ni)ersal mark of res"ect- Co, sho,ld al/ays stand /hen a "atient enters a room and take yo,r seat at the same time as them- Co, sho,ld also stand as they lea)e b,t, if yo, ha)e established a good ra""ort d,ring the cons,ltation, this isn>t absol,tely necessaryP-!& Meneral "rinci"les 9emeano,r Mi)e the "atient yo,r f,ll attention- 5""ear enco,raging /ith a /arm, friendly manner- (se a""ro"riate facial ex"ressions012don>t look bored3 9efine yo,r role 5long /ith the standard introd,ctions, yo, sho,ld al/ays make it clear /ho yo, are and /hat yo,r role is- Co, might also /ish to say /ho yo,r seniors are, if a""ro"riatetyle of 6,estioning O"en 6,estions )ers,s closed 6,estions O"en 6,estions are those /here any ans/er is "ossible0174hat>s the "roblemP018 017Ho/ does it feelP018 These allo/ the "atient to gi)e yo, the tr,e ans/er in their o/n /ords- <e caref,l not to lead them /ith closed 6,estionsCom"are 017Ho/ m,ch does it h,rtP018 to 0179oes it h,rt a lotP018- The former allo/s the "atient to tell yo, ho/ the "ain feels on a /ide s"ectr,m of se)erity, the latter lea)es the "atient only t/o o"tions012and /ill not gi)e a tr,e reflection of the se)erityM,lti"le choice 6,estions Often, "atients ha)e diffic,lty /ith an o"en 6,estion if they are not 6,ite s,re /hat yo, mean- 5 6,estion abo,t the character of "ain, for exam"le, is rather hard to form and "atients /ill often not kno/ 6,ite /hat yo, mean @0174hat sort of "ain is it018, 0174hat does it feel like, exactlyP 018A-

.n these circ,mstances, yo, may /ish to gi)e them a fe/ exam"les012b,t lea)e the list o"en+ ended for them to add their o/n /ords- Co, m,st be )ery caref,l not to gi)e the ans/er that yo, are ex"ecting from them- :or exam"le, in a "atient /ho yo, s,s"ect has angina @017cr,shing018 "ainA, yo, co,ld ask: 0174hat sort of a "ain is it 01R b,rning, stabbing, aching, for exam"le01RP018 Clarifying 6,estions (se clarifying 6,estions to get the f,ll details: 0174hen yo, say diDDy, /hat exactly do yo, meanP018 P-!! ?eflecti)e comments (se reflecti)e comments to enco,rage the "atient to go on and reass,re them that yo, are follo/ing the story: 017Ces, . see that-018 taying on to"ic Co, sho,ld be forcef,l b,t friendly /hen kee"ing the "atient on the to"ic yo, /ant or mo)ing the "atient onto a ne/ to"ic- 9on>t be afraid to interr,"t them012some "atients /ill talk for ho,rs if yo, let them3 017<efore /e mo)e on to that, . /o,ld I,st like to get all the details of this diDDiness-018 0174e>ll come to that in a moment-018 9iffic,lt 6,estions 5"ologiDe for "otentially offensi)e or embarrassing 6,estions: 017.>m sorry to ha)e to ask yo, this b,t01R018 Eye+contact 0GH Make eye+contact and look at the "atient /hen they are s"eakingMake a note of eye+contact next time yo, are in con)ersation /ith a friend or colleag,e.n normal con)ersations, the s"eaker ,s,ally looks a/ay /hilst the listener looks directly at the s"eaker- The roles then changes /hen the other "erson starts talking 01R and so on.n the medical sit,ation, /hilst the "atient is s"eaking, yo, may be tem"ted to make notes, read the referral letter, look at a test res,lt, or similar012yo, sho,ld resist and stick to the 017normal018 r,les of eye+contact5dI,sting yo,r manner Co, /o,ld clearly not talk to another doctor as yo, /o,ld someone /ith no medical kno/ledgeThis is a diffic,lt area, yo, sho,ld try to adI,st yo, manner and s"eech according to the "atient>s ed,cational le)elThis is can be extremely diffic,lt012yo, sho,ld not make ass,m"tions on intellect or ,nderstanding solely on ed,cational history5 safe a""roach is to start in a relati)ely ne,tral /ay and then adI,st yo,r manner and s"eech based on /hat yo, see and hear in the first min,te or t/o of the interaction012b,t be alert to /hether this is effecti)e and make changes accordinglyP-!% .nterr,"tions 5"ologiDe to the "atient if yo, are interr,"ted-

9on>t take offence or get annoyed 5s /ell as being directly aggressi)e or offensi)e, "eo"le may be tho,ghtless in their s"eech or manner and ca,se offence /hen they don>t mean to- 5s a "rofessional, yo, sho,ld rise abo)e thisP-!; P-!E Comm,nicating /ith deaf "atients Peo"le /ho are hard of hearing may co"e /ith the "roblem by ,sing a hearing+aid, li"+reading, or ,sing sign lang,age- 4hiche)er techni6,e is ,sed @if anyA, some sim"le r,les sho,ld al/ays a""ly: "eak clearly b,t not too slo/ly 9on>t re"eat a sentence if it is mis,nderstood012say the same thing in a different /ay

4rite things do/n if necessary(se "lain English and a)oid /affling<e "atient and take the time to comm,nicate "ro"erlyCheck ,nderstanding fre6,entlyConsider finding an am"lifier012many elderly medicine /ards /ill ha)e one a)ailable-

Ki"+readers Patients /ho are able to li"+read do so by looking at the normal mo)ements of yo,r li"s and face d,ring s"eech- Exaggerating mo)ements or s"eaking lo,dly /ill distort these and make it harder for them to ,nderstand- .n addition to the "oints abo)e, /hen talking to li"+readers: Maintain eye+contact 9on>t sho,t

"eak clearly b,t not too slo/ly9o not exaggerate yo,r oral or facial mo)ements-

<ritish ign Kang,age @< KA .t sho,ld be a""reciated that < K is not a signed )ersion of English012it is a distinct lang,age /ith its o/n grammar and syntax :or < K ,sers, English is a %nd or ;rd lang,age so ,sing a "en and "a"er may not be effecti)e or safe for disc,ssing com"lex to"ics or gaining consent

eek an official < K inter"reter, if "ossible, and follo/ the r,les on /orking /ith inter"reters on "-!O-

P-!J

P-!L Cross+c,lt,ral comm,nication C,lt,ral backgro,nd and tradition may ha)e a large infl,ence on disease management- <eliefs abo,t the origin of disease and "reI,dices or stigma s,rro,nding the diagnosis can make dealing /ith the "roblem challenging<e a/are of all "ossible im"lications of a "erson>s c,lt,ral backgro,nd- :or exam"le, a M,slim may not take anything by mo,th in the daylight ho,rs d,ring ?amadan- This may ha)e serio,s im"lications for tablettaking, "artic,larly for chronic diseases s,ch as diabetes5bo)e all, be a/are of "reI,dice012yo,rs and theirsP-!' P-!O .nter"reters Official comm,nicators are bo,nd by a code of ethics, im"artiality, and confidentiality012friends and relati)es are not.t is often im"ossible to be s,re that a relati)e is "assing on all that is said in the correct /ayometimes, the "atient>s children are ,sed to inter"ret012this is clearly not ad)isable for a n,mber of reasons- This not only "laces too m,ch res"onsibility on the child b,t they may not be able to ex"lain diffic,lt conce"ts- .n addition, con)ersations abo,t sex, death, or other diffic,lt to"ics may be ,ns,itable for the child to be "arty to(sing an official inter"reter <efore yo, start <rief the inter"reter on the sit,ation, clarify yo,r role and the /ork of the de"artment, if necessary 5llo/ the inter"reter to introd,ce themsel)es to the "atient and ex"lain their role

5rrange seating so that the "atient can see the inter"reter and doctor e6,ally5llo/ eno,gh time @at least t/ice as long as normalA-

9,ring the exchange "eak to the "atient, not the inter"reter- This may be hard at first, b,t yo, sho,ld s"eak to and look at the "atient at all times <e "atient, some conce"ts are hard to ex"lain

5)oid com"lex terms and grammar5)oid Iargon5)oid slang and collo6,ialisms /hich may be hard to inter"ret correctly-

Check ,nderstanding fre6,ently-

:inishing off Check ,nderstanding 5llo/ time for 6,estions

0GH .f the con)ersation has been distressing, offer the inter"reter s,""ort and let their manager kno/-

4ritten information .f inter"reting /ritten information, read it o,t lo,d- The inter"reter may not necessarily be able to translate /ritten lang,age as easily Many de"artments and charities "ro)ide some /ritten information in a )ariety of lang,ages012some also "ro)ide ta"es- Co, sho,ld be a/are of /hat yo,r de"artment has to offerP-!Q P-%& .m"arting information There are some g,idelines that sho,ld a""ly /hen yo, are im"arting any information012good or bad012to a "atient .dentify the to"ic for disc,ssion .dentify the "eo"le "resent and ask if there is anyone else they /o,ld like to be there

Establish "re)io,s ex"erienceSkno/ledge=ee" the sentences and ex"lanations short and sim"le?e"eat im"ortant information5llo/ time for feedback, 6,estions and check ,nderstanding<e honest3

The im"ortance of silence .n con)ersations that yo, may ha)e /ith friends or colleag,es, yo,r aim is to a)oid silence ,sing filler noises s,ch as 017,m018 and 017ah018 /hilst "a,sing.n medical sit,ations, silences sho,ld be embraced and ,sed to extract more information from the "atient- (se silence to listenPractice is needed as the inex"erienced may find this ,ncomfortable- .t is often ,sef,l, ho/e)er, to remain silent once the "atient has ans/ered yo,r 6,estion- Co, /ill ,s,ally find that they start s"eaking again012and often im"art ,sef,l and enlightening facts /hich yo, /o,ld not other/ise ha)e gleaned5ngry "atients

(se body lang,age to take charge of the sit,ation /itho,t a""earing aggressi)e @ "-%OAThro,gho,t the exchange, yo, sho,ld remain "olite, a)oiding confrontation and resist becoming angry yo,rself Kook to yo,r o/n safety first Calm the sit,ation then establish the facts of the case- 5nger is often secondary to some other emotion s,ch as loss, fear or g,ilt

5ckno/ledge their emotionso o

017. can see this has made yo, angry-018 017.t>s ,nderstandable that yo, sho,ld feel like this-018

teer the con)ersation a/ay from the area of ,nha""iness to/ards the "ositi)e and "lans to mo)e the sit,ation for/ard9on>t incriminate colleag,es012the "atients may remember yo,r thro/+a/ay comments /hich co,ld come back to ha,nt yo,- 5)oid remarks like 017he sho,ldn>t ha)e done that018Em"hasiDe any gro,nds, for o"timism, or "lans for resol)ing the sit,ation and ",tting things right-

P-%! P-%% Tele"hone comm,nication The essential r,le of confidentiality is that yo, m,st not im"art "ersonal information to anyone /itho,t the ex"ress "ermission of the "atient concerned012exce"t in a fe/

s"ecific circ,mstances @ "-;%ACo, m,st not gi)e o,t any confidential information o)er the tele"hone as yo, cannot be s,re of the identity of the caller- 5ll comm,nication sho,ld be done face+to+face- This may ca,se diffic,lty if a relati)e calls to ask abo,t the "atient, b,t yo, sho,ld remain strict.f tele"hone comm,nication is essential b,t yo, are in do,bt as to the caller>s identity, yo, may /ish to take their n,mber and call them back-

Talking abo,t sex This is a ca,se of considerable embarrassment for the "atient and for the inex"erienced "rofessional- ex,al 6,estions are ,s,ally ina""ro"riate to be o)erheard by friends or relati)es012so ask them to lea)e- Co,r aim is to ",t the "atient at ease and make their res"onses more forthcoming-

The key is to ask direct, clear 6,estions and sho/ no embarrassment yo,rselfCo, sho,ld maintain eye contactCo, sho,ld also sho/ no s,r"rise /hatsoe)er012e)en if the sex,al "ractices described differ from yo,r o/n or those that yo, /o,ld consider acce"tableTry to become a, fait /ith sex,al slang and sex,al "ractices /hich yo, might not be familiar /ith "re)io,slyo

5 fail,re to ,nderstand slang may lead to an immediate barrier in the cons,ltation-

.n general, yo, sho,ld not ,se slang terms first- Co, may /ish to consider mirroring the "atient>s s"eech as yo, contin,e the con)ersationee "-E&O for details of the sex,al history-

P-%; P-%E <reaking bad ne/s <reaking bad ne/s is feared by st,dents and, indeed, no+one likes doing it- Ho/e)er, kno/ing that yo, ha)e broken diffic,lt ne/s in a sensiti)e /ay and that yo, ha)e hel"ed the "atient thro,gh a terrible ex"erience can be one of the most ,"lifting as"ects of /orking in healthcare<efore yo, start Confirm all the information for yo,rself and ens,re that yo, ha)e all the information to hand, if necessary "eak to the n,rsing staff to get backgro,nd information on /hat the "atient kno/s, their fears, and details of the relationshi" /ith any family or friends /ho may be "resentChoose the right "lace Pick a 6,iet, "ri)ate room /here yo, /on>t be dist,rbed Ens,re there is no inter)ening desk or other "iece of f,rnit,re

5rrange the chairs so that e)eryone can be seen e6,allyHand yo,r blee"Smobile "hone to a colleag,e-

Ens,re the right "eo"le are "resent .n)ite a member of the n,rsing staff to Ioin yo,012"artic,larly if they ha)e already established a relationshi" /ith the "atiento ?emember, it is ,s,ally the n,rsing staff that /ill be dealing /ith the "atient and relati)es /hen yo, ha)e left so they need to kno/ exactly /hat /as said

4o,ld the "atient like anyone "resentP

?emember the general "rinci"les ee "-L and "-O- 5)oid Iargon and s"eak slo/ly and clearlyEstablish "re)io,s kno/ledge .t is essential to ,nderstand /hat the "atient already kno/s- The sit,ation is )ery different in the case of a "atient /ho kno/s that yo, ha)e been looking for cancer to one /ho thinks their co,gh is d,e to a cold0174hat do yo, kno/ so farP018 0174hat ha)e the other doctors told yo,P018 Ho/ m,ch do they /ant to kno/P This is key- <efore yo, consider breaking bad ne/s, yo, ha)e to disco)er if the "atient act,ally /ants to hear it- 5sk an o"en 6,estion s,ch as: 017Ha)e yo, tho,ght abo,t /hat might be the ca,se of these "roblemsP018 0179o yo, kno/ /hy /e>)e been doing these testsP018 P-%J Co, can also ask directly if they /ant to hear /hat yo, might ha)e to say: 0175re yo, the sort of "erson /ho likes to kno/ all the a)ailable factsP018 4arning shots .f they do /ant to kno/, yo, sho,ld break the ne/s in a ste"+/ise fashion, deli)ering m,lti"le 017/arning+shots018- This gi)es the "atient a chance to sto" yo, if they>)e heard eno,gh, or to ask for more information- =ee" yo,r sentences, short, clear, and sim"le- 5 con)ersation may go like this: Co,: .>m afraid the test res,lts sho/ that things are more serio,s than first tho,ghtThem: 4hat do yo, mean more serio,sP Co,: ome of the cells look abnormalThem: 9o yo, mean that . ha)e cancerP Co,: Ces5t any "oint, the "atient may sto" yo,, signalling that they don>t /ant to hear more abo,t it.nex"erienced "ractitioners sometimes feel that they 017o,ght018 to tell the "atient the f,ll story b,t they m,st ,nderstand that many "eo"le /o,ld m,ch rather not hear the /ords said alo,d012this is their co"ing strategy and m,st be res"ectedCo,: .>m afraid the test res,lts sho/ that things are more serio,s than first tho,ghtThem: J,st tell me /hat /e can do nextCo,: O=5llo/ time for information to sink in Co, sho,ld allo/ time for each "iece of information to sink in, ens,re that the "atient ,nderstands all that has been said and re"eat any im"ortant information?emember also that "atients /ill not be able to remember the exact details of /hat yo, ha)e said012yo, may need to resched,le at a later time to talk abo,t treatment o"tions or "rognosisHonesty, abo)e all else 5bo)e all, yo, sho,ld be honest at all times- Be)er g,ess or lieThe "atient may break yo,r "re+"re"ared flo/ of information re6,iring yo, to think on yo,r feetometimes yo, sim"ly can>t abide by the r,les abo)e- .f asked a direct 6,estion, yo, m,st be honest and straightfor/ardP-%L

:or exam"le: Co,: .>m afraid the test res,lts sho/01R Them: J,st tell me, ha)e . got cancerP Co,: Ces, .>m afraid yo, ha)e9on>t r,sh to the "ositi)e 4hen told of bad ne/s, the "atient needs a fe/ moments to let the information sink in- 5fter the 017yes018 in the abo)e exam"les, yo, sho,ld "referably /ait in silence for the "atient to s"eak nextThe "atient may break do/n in tears012in /hich case they sho,ld be offered tiss,es and the s,""ort of relati)es, if nearby.f emotionally distressed, the "atient /ill not be rece"ti)e to /hat yo, say next012yo, may /ant to gi)e them some time alone /ith a relati)e or n,rse before yo, contin,e to talk abo,t "rognosis or treatment o"tions5bo)e all, yo, sho,ld not gi)e false ho"e- The moment after the bad ne/s has been broken is ,ncomfortable and yo, m,st fight the instincti)e mo)e to the "ositi)e /ith 017there are things /e can do018, 017on the "l,s side01R018, 017the good ne/s is01R018 or similarEnding ,mmariDe the information gi)en, check their ,nderstanding, re"eat any information as necessary, allo/ time for 6,estions, and make arrangements for a follo/+," a""ointment or a f,rther o""ort,nity to ask 6,estions againOb)io,sly, yo, sho,ldn>t make "romises that yo, can>t kee"- 9on>t offer to come back that afternoon if yo,>re going to be in clinic3 0179o yo, ,nderstand e)erything that /e>)e disc,ssedP018 017.s there anything that yo, /o,ld like to ask meP018 017.>ll be along to see yo, tomorro/ morning- .>ll be ha""y to come back in the meantime if yo, think of anything that yo,>d like to ask or if yo, need to talk- J,st ask one of the n,rsing staff to gi)e me a blee"-018 T,estions abo,t time 017Ho/ long ha)e . gotP018 is one of the most common 6,estions to be asked012and the hardest to ans/er 5s al/ays, don>t g,ess and don>t lie .t>s often im"ossible to estimate- Mi)ing a fig,re /ill almost al/ays lead to yo, being /rong- .f yo, don>t kno/, it is "erfectly acce"table to say so

Ex"lain that it is im"ossible to I,dge and ask if there is any date in "artic,lar that they don>t /ant to miss012"erha"s they /ant to ex"erience Christmas or a relati)e>s birthday9on>t ass,me that they are asking o,t of fear, some "eo"le are s,r"risingly "ractical and /ant to ",t their affairs in order before their death-

P-%' <ox !-E :ear+/ords

There are certain /ords /hich immediately generate fear, s,ch as 017cancer018 and 017le,kaemia018- Co, sho,ld only ,se these if yo, are s,re that the "atient /ants to kno/ the f,ll story<e/are, ho/e)er, of a)oiding these /ords and ca,sing conf,sion by not gi)ing the /hole storyCo, sho,ld also be a/are of certain /ords that "eo"le /ill instincti)ely ass,me mean something more serio,s- :or exam"le, to most "eo"le a 017shado/018 on the l,ng means cancer- 9on>t then ,se the /ord /hen yo, are talking abo,t consolidation d,e to "ne,monia3 P-%O <ody lang,age: an introd,ction <ody lang,age is rarely gi)en the "lace it deser)es in the teaching of comm,nication skillsThere are o)er L&& m,scles in the h,man body; Q& in the face of /hich ;& act ",rely to ex"ress emotion- Changes in yo,r "osition or ex"ression012some ob)io,s, others s,btle012can hea)ily infl,ence the message that yo, are comm,nicating4e>)e all met someone and tho,ght 017. didn>t like him018 or 017she seemed tr,st/orthy018Often these im"ressions of "eo"le are not b,ilt on /hat is said b,t the manner in /hich "eo"le handle themsel)es- Co, s,bconscio,sly "ick ," c,es from the other "erson>s body- <eing good at ,sing body lang,age means ha)ing a/areness of ho/ the other "erson may be )ie/ing yo, and getting yo,r s,bconscio,s actions and ex"ressions ,nder conscio,s control.f done /ell, yo, can infl,ence the other "erson>s o"inion of yo,, make them more rece"ti)e to yo,r message, or add "artic,lar em"hasis to certain /ords and "hrasesTo,ching One of the most "o/erf,l forms of non+)erbal comm,nication and needs to be managed /ith care Mreeting: to,ch is "art of greeting rit,als in most c,lt,res- .t demonstrates that yo, are not holding a /ea"on and establishes intimacy haking hands: there are many )ariations- The length of the shake and the strength of the gri" im"art a h,ge amo,nt of information- :or added intimacy and /armth, a do,ble+ handed gri" can be ,sed- :or extra intimacy, one may to,ch the other>s forearm or elbo/-F

9ominance: to,ch is a "o/erf,l dis"lay of dominance- To,ching someone on the back or sho,lder demonstrates that yo, are in charge012this can be co,ntered by mirroring the action backym"athy: the lightest of to,ches can be )ery comforting and is a""ro"riate in the medical sit,ation /here other to,ch may be misread as dominance or intimacy @yo, sho,ldn>t h,g a "atient that yo,>)e only I,st met3A- 9is"lay sym"athy by a brief to,ch to the arm or hand-

O"en body lang,age 5 cl,ster of mo)ements concerned /ith seeming o"en- The most significant "art of this is the act of o"ening012signalling a change in the /ay yo, are feeling- O"enness demonstrates that yo, ha)e nothing to hide and are rece"ti)e to the other "erson- O"enness enco,rages o"ennessThis can be ,sed to calm an angry sit,ation or /hen asking abo,t "ersonal information0GH The key is to not ha)e yo,r arms or legs crossed in any /ay-

5rms o"en: either at yo,r side or held /ide- E)en better, hold yo,r hands o"en and face yo,r "alms to the other "ersonKegs o"en: this does not mean legs /ide b,t rather not crossed- Co, may hold them "arallel- The feet often "oint to something of s,bconscio,s interest to yo,012"oint them at the "atient3

P-%Q Em"hasis Co, can am"lify yo,r s"oken /ords /ith yo,r body012,s,ally /itho,t noticing it- 5ctions incl,de nodding yo,r head, "ointing, or other hand gest,res- 5 gest,re may e)en in)ol)e yo,r entire body4atch ne/sreaders012often only their heads are in )ie/ so they em"hasiDe /ith nods and t,rns of their heads m,ch more than one /o,ld d,ring normal con)ersation ynchrony: this is key- Time "oints of the finger, ta"s of the hand on the desk, or other actions /ith the /ords yo, /ish to em"hasiDe Precision: signal that the /ords c,rrently being s"oken are /orth "aying attention to /ith delicate, "recise mo)ements- Co, co,ld make an 017O018 /ith yo,r th,mb and index finger or hold yo,r hands s,ch that each finger is to,ching its o""osite co,nter"art012like a s"layed "rayer "osition-F Eye le)el This is a )ery "o/erf,l tool- .n general, the "erson /ith their eye le)el higher is in control of the sit,ationCo, can ,se this to yo,r ad)antage- 4hen asking someone "ersonal 6,estions or /hen yo, /ant them to o"en ,", "osition yo,rself s,ch that yo,r eyes are belo/ theirs012meaning they ha)e to look do/n at yo, slightly- This makes them feel more in control and comfortableKike/ise, anger often comes from a feeling of lack of control012",t the angry "erson in charge by lo/ering yo,r eye le)el012e)en if that means s6,atting next to them or sitting /hen they are standingCon)ersely, yo, may raise yo,r eye le)el to take charge of a diffic,lt sit,ation, looking do/n on someone is intimidating- tand o)er a seated "erson to demonstrate that yo, are in charge4atch and learn There is m,ch that co,ld be said abo,t body lang,age- Co, sho,ld /atch others and yo,rsel)es and consider /hat messages are being "ortrayed by non+)erbal comm,nicationtay a/are of yo,r o/n mo)ements and consider ",r"osef,lly changing /hat /o,ld normally be s,bconscio,s actions to add to, or alter, the meaning of yo,r s"eechP-;& 4ritten comm,nication The medical notes ser)e a n,mber of ,ses- The most im"ortant are: They are record of the "atient>s illness, treatments, and medical enco,nters for ,se by other medical "ractitioners in the f,t,re-

They are the only record of yo,r action012and the means by /hich yo, may be I,dged in case of f,t,re dis",tesThey are a record of e)ents for the ",r"oses of clinical a,dit-

Ho/ to /rite in the notes Co,r entries in the notes sho,ld be tidy and legible 5ll entries sho,ld incl,de: o 9ateo o o o

Time.dentity of the inscriberignat,reContact n,mber @blee"Smobile "honeA-

(se black ink only @bl,e often doesn>t "hotoco"y easily and can fadeAo

Pre)io,s fashion /as for s,rgeons to ,se red ink for the o"eration notes and "harmacists to /rite in green012this "ractice is no/ fading-

4hat to /rite in the notes E)erything that occ,rs sho,ld be recorded- .f it isn>t /ritten do/n, it didn>t ha""en3 ?emember es"ecially to record disc,ssions /ith relati)es and the details of /hat the "atient has been told of diagnoses

There are no s"ecific r,les as to ho/ things sho,ld be /ritten012there are a n,mber of con)entions /hich /e introd,ce yo, to thro,gh the book- .n general, entries sho,ld be easily ,nderstood by another-

<ox !-J 017 tandard018 examination dra/ings The essential r,le is that the record yo, make sho,ld be easily ,nderstood by another- .f it is hard to describe /here the c,t on the "atient>s foot is, dra/ it3 There are a n,mber of diagrams /hich, altho,gh not 017official018, ha)e become /idely ,sed and are acce"ted as 017standard018Chest This is ,s,ally re"resented as a styliDed )ersion of the l,ngs seen from the front- Co, can then add symbols indicating yo,r clinical findingP-;! Heart so,nds These are often re"resented as a )ersion of a "honogram012see 5bdomen "-!OJ for exam"les-

(s,ally dra/n as a hexagon, altho,gh the anatomical stickler may add the xi"histern,m and the genitaliaPeri"heral ",lsesStendon reflexes These are often indicated on stick+men- <e s,re to make clear /hich are the left and right sides of the "ersonOther body "arts Co, sho,ld feel free to make dra/ings to ill,strate yo,r findingsP-;% Ka/, ethics, and comm,nication Bo disc,ssion of comm,nication skills /o,ld be com"lete /itho,t mention of confidentiality, ca"acity, and consent- .t is also /orth kno/ing the fo,r bioethical "rinci"les abo,t /hich m,ch has been /ritten else/here:o,r bioethical "rinci"les 5,tonomy: a res"ect for the indi)id,al and their ability to make decisions regarding their o/n health <eneficence: acting to the benefit of "atients

Bon+malificence: acting to "re)ent harm to the "atientJ,stice: 017fairness018 to the "atient and the /ider comm,nity /hen considering the conse6,ences of an action-

Confidentiality Confidentiality is closely linked to the ethical "rinci"les described abo)e- Maintaining a secret record of "ersonal information sho/s res"ect for the indi)id,al>s a,tonomy and their right to control their o/n information- There is also an element of beneficence /here releasing the "rotected information may ca,se harm<reaking confidentiality The r,les s,rro,nding the maintenance of confidentiality ha)e been mentioned @see "-;AThere are a n,mber of circ,mstances /here confidentiality can, or m,st, be broken- The exact ad)ice )aries slightly bet/een different bodies- ee the links o""osite- .n general, confidentiality may be broken in the follo/ing sit,ations: 4ith the consent of the indi)id,al concerned .f disclos,re is in the "atient>s interest b,t consent cannot be gained

.f re6,ired by la/4hen there is a stat,tory d,ty s,ch as re"orting of births, deaths, and abortions and in cases of certain comm,nicable diseases-

.f it is o)er/helmingly in the ",blic interest.f it is necessary for national sec,rity or /here "re)ention or detection of a crime may be "reI,diced or delayed.n certain sit,ations related to medical research-

Consent and ca"acity There are ; main com"onents to )alid consent- To be com"etent @or ha)e ca"acityA to gi)e consent, the "atient: M,st ,nderstand the information that has been gi)en M,st belie)e that information

M,st be able to retain and /eigh+," the information to make a decision-

.n addition, for consent to be )alid, the "atient m,st be free from any kind of d,ress0GH .t sho,ld be noted that an assessment of ca"acity is )alid for the s"ecific decision in hand- .t is not an all+or+nothing "henomenon012yo, cannot either ha)e 017ca"acity018 or not- The assessment regarding com"etence m,st be made for each ne/ decision facedP-;; Co,ng "eo"le and ca"acity 5ll "ersons aged !O and o)er are considered to be a com"etent ad,lt ,nless there is e)idence to the contrary Peo"le aged bet/een !L and !O are treated as ad,lts @:amily Ka/ ?eform 5ct !QLQAHo/e)er, the ref,sal of a treatment can be o)erridden by someone /ith "arental res"onsibility or the co,rts

Children of !L and yo,nger are considered com"etent to gi)e consent if they meet the three conditions mentioned "re)io,sly- Their decisions can, ho/e)er, be o)erridden by the co,rts or "eo"le /ith "arental res"onsibility-

Millick com"etence .n !QOJ, the /ell+kno/n Millick case /as considered by the Ho,se of Kords and from this t/o "rinci"les @often kno/n as the :raser M,idelinesA /ere established: 5 "arent>s right to consent to treatment on behalf of the child finishes /hen the child has s,fficient ,nderstanding to gi)e consent themsel)es @/hen they become 017Millick com"etent018A The decision as to /hether the child is Millick com"etent rests /ith the treating doctor:,rther reading There are many other com"lex to"ics in this area and the la/ )aries bet/een co,ntries and e)en bet/een regions /ithin the (=- There are )ery many so,rces of information on this to"ic- 4e s,ggest the follo/ing as a good start: The <ritish Medical 5ssociation: ///-bma-org-,k The Meneral Medical Co,ncil: ///-gmc+,k-org

The Medical 9efence (nion: ///-the+md,-com The Medical Protection ociety: ///-medical"rotection-org The (= 9e"artment of Constit,tional 5ffairs: ///-dca-org-,k The (= 9e"artment of Health: ///-dh-go)-,k