Category Archives: Communication

McCulloch case

Communication, Ethics, Generic, Patients

Clarifies an aspect of the Montgomery decision in a way that supports healthcare professionals getting consent. The decision can be found here.

In Montgomery, the Supreme Court said that a doctor ‘is under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments’. In the McCulloch case, the Supreme Court was asked to decide what legal test was applicable when assessing whether an alternative treatment was ‘reasonable’. Was it the Montgomery test or was it the Hunter –v- Hanley test? Put another way, was the decision about whether to discuss an alternative treatment with a patient one of clinical judgement, or was it one for the Court to assess and determine?

The decision was that a doctor (or other healthcare professional) who has decided that a treatment is not a ‘reasonable alternative treatment’ for a particular patient will not be negligent in failing to inform the patient of that alternative treatment if the doctor’s view is supported by a responsible body of medical opinion. In other words, this decision involves an exercise of clinical judgement and any challenge to that decision by a patient is therefore to be determined by the Hunter –v- Hanley test. In the circumstances of the McCulloch case, the application of that legal test resulted in the claim being rejected by the Court.

The court said this:

“Taking a hypothetical example – say that there are ten possible treatment options; the doctor, exercising his or her clinical judgment, decides that only four of them are reasonable and that decision to rule out six is supported by a responsible body of medical opinion. The doctor is not negligent by failing to inform the patient about the other six even though they are possible alternative treatments.

“The narrowing down from possible alternative treatments to reasonable alternative treatments is an exercise of clinical judgment to which the professional practice test should be applied. The duty of reasonable care would then require the doctor to inform the patient not only of the treatment option that the doctor is recommending but also of the other three reasonable alternative treatment options (plus no treatment if that is a reasonable alternative option) indicating their respective advantages and disadvantages and the material risks involved in each treatment option.”

[Michael Stewart, Central Legal Office]

Graphic stories

Communication, Generic

A creative way of learning/teaching about illness. But biases around being for kids, or frivolous, or simplistic.

But actually the ability to use images, fonts or other text effects means you can express things in ways both delicate and brutal that might require a lot of reading. Visual understanding is often more intuitive. By combining the two you are involving the different parts of the brain that handle language and image processing, and research shows understanding is enhanced.

They teach observational skills – you read but you must also interpret what is implied.

See MediKidz and GraphicMedicine.org.

Martha’s Law

Clinical governance, Communication, Emergency medicine, Ethics, General paediatrics, Generic

13yr old Martha Mills died in 2021 at King’s College Hospital, London, of sepsis after pancreatic trauma (fell off bike in Snowdonia). The family went to the local minor injuries unit, where they were reassured. She continued to have severe pain however, then vomiting – so they went to the nearest hospital. She was admitted to the ward, then ICU, before being transferred by helicopter to King’s College London (1 of 3 specialist centres for pancreatic injury in the UK).

“We are so lucky to be here”, writes the mum.

She was NG fed, a peritoneal drain inserted. She started mobilising after 2 weeks. Then she developed fever and diarrhoea – started antibiotics. “The consultants swooped in, and were ostentatiously deferred to by the junior doctors.

“They were chatty, assertive, grand.”

Martha then started oozing from drip sites and peritoneal drain site. A scan showed small pericardial effusion. She had a persistent fever – and it was the start of a bank holiday weekend.

Consultant went home after morning round. Martha’s mum raised her concern about septic shock but was told “it’s just a normal infection”. She was told not to look up things on the internet – “you’ll only worry yourself”.

When she developed low BP and tachycardia, then widespread rash, it was diagnosed as a drug reaction.

““Trust the doctors – they know what they’re doing,” said the nurses.

The consultant was contacted to discuss worsening PEWS – did not come in – no change in management was made. The consultant phoned PICU (routine) but gave limited info – advised against review “to avoid parental anxiety”. The night shift junior did not review. Martha was drinking copiously.

At 0545 she had a seizure, at which point people started arriving and things seemed to happen – she was moved to PICU, intubated and then moved to Great Ormond Street hospital for ECMO. She died 4 days before her birthday.

Issues

  • Mum is editor at Guardian newspaper
  • Nothing to do with insufficient resources, overstretched doctors/nurses, or cuts, or a health service under strain
  • Consultants dismissive and arrogant
  • Juniors “performing” competence
  • No one expressed concern, even if they had it
  • Lack of note keeping
  • Lack of consultant presence at weekend
  • All doctors mentioned at inquest were men

Mum’s advice to parents

  1. Our trust in doctors should have limits. Plenty of clinicians prone to arrogance and complacency.
  2. However indebted you feel to the NHS, don’t be afraid to challenge decisions if you have good reason to.
  3. Remember most of the doctors in hospitals are just [sic] training. Don’t be afraid to ask how long a clinician has been qualified. Junior doctors are often green and trying to stay composed to impress their superiors.
  4. Make sure, if you can, that a single consultant has overall responsibility: we all know that if you’re answerable for something, you try harder.
  5. Google like crazy.

Aftermath

September 2023 Riya Harani dies from invasive Group A streptococcus and influenza B. Seen in hospital the day before. Junior doctor diagnosed a virus and discharged her with advice to take over the counter painkillers and info re: management of sore throat. Consultant not involved. At inquest, coroner says ““I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation.”

UK Minister for health has said they will progress with the right to urgent second opinions across the health service.

Second Opinions

Right to second opinion already in Good Medical Practice: “In providing clinical care, you must respect the patient’s right to seek a second opinion”. But not traditionally associated with acute care and no detail otherwise.

Seeking a second opinion is more common in:

  • women, middle-age patients,
  • more educated patients, higher income or socioeconomic status,
  • chronic conditions,
  • living in central urban areas.

Motivation is to seek to gain more information, or reassurance. Potential major impact on patient outcomes in up to 58% of cases. 

Solution

Condition Help (Pittsburgh, 2000s), Call 4 concern (Royal Berkshire) – hospital hotline to call rapid response team to bedside. Ryan’s rule (Queensland) is state-wide number for review of medical care.

But evidence of benefit sparse. Tends to be pain management and communication breakdown rather than acute deterioration. 18% of patients generated nearly half of all calls to Condition Help (in 41.4% of cases, a change in care was made).

International Society for Rapid Response systems includes family trigger system as one measure of effectiveness. 

“The recurring problems of hierarchy, arrogance and poor culture have not been tackled despite decades of effort… It is not the job of patients and families to wait around for healthcare providers to sort out their culture.” [(Helen Haskell, BMJ 2023)]

Such systems do not address problems of overcrowded wards, lack of beds, delayed assessments, poor nurse:patient ratios etc… Perhaps don’t appreciate informal senior discussions that happen all the time. Potential for delays in appropriate treatment if process of getting second opinion interferes with management?


“I’d like to imagine a world in which Martha was transferred to intensive care in time and her life was saved.

In this parallel universe, I talk endlessly about the doctors and nurses who helped her. I go on a fundraising walk for the hospital.

Bright and determined girl as she was, Martha aces all her exams, goes to university, has a career and children.

She visits us at weekends and we recall those distant weeks when she was in hospital.”

Mrs Mills

Oratory

Communication, Generic, Teaching and training

We quickly get used to doing case presentations, and talking with colleagues and patients, but we don’t really learn the skills of speaking with conviction, which Winston Churchill called the most precious gift of all the talents bestowed upon men.

Important for career development, advocacy and leadership.

At the age of 22yr Winston Churchill said the essential components of oratory were diction, rhythm, accumulation of argument, analogy and emotion.

Presentation skills

It’s pretty obvious when a presentation is done badly – and so it is obvious what you need to do to give a good presentation.

  • Unprepared
  • Technical issues, esp poor sound
  • Overly busy slides, or slides that don’t seem to correspond with what is being discussed
  • Simply reading slides
  • Glaring bright slide backgrounds
  • Spelling mistakes or inconsistent formatting
  • Lack of a pointer
  • Not really understanding what a table/chart is actually showing
  • Rushing at the end, not leaving time for questions

The best presentations convey the importance of the topic, discuss real life issues, are funny (some of the time – otherwise risk of sounding callous). The speaker looks at (speaks to) you.

Media interviews

  • Consider the interviewer someone with their own agenda – know yours.
  • Reframe any questions you see as misleading.
  • Avoid patronising or over-explaining.
  • Patient confidentiality above all.
  • Know your message(s)
[https://doi.org/10.20935/AL2219.1]

Medical Humanities

Communication, Ethics, Generic, Patients

In education, Johanna Shapiro has done interesting work, for example including relevant poems into objective structured clinical examinations (Female, by Ingrid Hughes, about a woman facing a probable diagnosis of breast cancer; Dear Left Knee by John Davis; Back Pain, by Ingrid Hughes; Night on Call, by Dr Rita Iovino). A large proportion said they felt it increased empathy, and had a significant effect on how they might present bad news, on the ultimate treatment plan. Most felt the Night on call poem helped gain perspective. [Medical Education 2005]

In the same paper, adding some readings led students to say (in 1/3 to 2/3 of cases) that they would be more likely to take into consideration psychosocial insights, or that it increased some dimension of empathy for the patient, including helping them take the patient more seriously.

Themes written by doctors or medical students are commonly about the rewards and stresses, relationships, role models, death, the meaning of life – things not directly addressed in the curriculum.

The quality is less important that the utility to a particular audience.

[BMJ 2010]

Shared Decision Making

Communication, Generic
[NICE guidance 2021] See also participatory medicine and family centred care.

First bullet point is that this should be embedded at organisational level! Includes:

  • provide access to patient decision aids (PDAs) or information about risks and benefits
  • review how “information systems” might help record discussions and decisions, for example through patient held record
  • prompt patients (through media, posters, letters) to ask questions about options, and “making the decision that’s right for me“

Staff training:

  • evidence based model eg three-talk model (introduce choice, describe options, help explore preferences and make decision)
  • communication skills – avoiding jargon, explaining technical terms
  • communicating with families and others the patient would like involved

Note that NHS England has “accessible information standards”.

In practice:

  • Agree an agenda
  • Ensure the person understands they can take part as fully as they want in making choices about their treatment or care
  • When it comes to tests or treatments, explain what the health care aim is of each option, and discuss how that might align with patients “aims, priorities and wider goals”
  • chunk and check information
  • check understanding eg teach back
  • Give information away at time of discussion or very soon after, including contact details
  • Write letters to the patient rather than to their doctor, in line with 2018 Academy of Medical Royal Colleges’ guidance on writing outpatient clinic letters to patients (or at least a copy to patient, unless they expressly don’t want to receive any written information).

Communicating risk:

  • Make clear how information applies to them personally, and how much uncertainty applies
  • Use mixture of numbers, pictograms and “icon arrays” (repeated icons, with different colours, to see proportions), to allow people to see both positive AND negative framing
  • Be aware that different people interpret terms such as ‘risk’, ‘rare’, ‘unusual’ and ‘common’ in different ways
  • Use absolute risk rather than relative risk. For example, the risk of an event increases from 1 in 1,000 to 2 in 1,000, rather than the risk of the event doubles.
  • Use 10 in 100, rather than 10%
  • Use the same denominator
  • State both positive and negative framing

Participatory medicine

Communication, Ethics, Generic, Health Literacy, Patients

Patient led campaign for better involvement of patients in their own care.

Manifesto has 5 principles:

  • Share and listen – acknowledge patients are experts in their own lives and bodies, use plain language.
  • Respect one another
  • Share information responsibly – help patients access the information they need, and respect confidentiality
  • Promote curiosity – be clear even when it is difficult to explain, encourage patients to do their own research and get involved in patient communities
  • Be a teambuilder – treat patients as collaborators, respect their goals, values and preferences

These are shared responsibilities, the patient has their own duty to be honest, ask questions, advocate themselves.

Institute of Medicine describes a continuously learning system (in respect of healthcare in the US), the second feature of which is Patient-clinician partnerships. This is explained as “engaged, empowered patients – a health care system anchored on patient needs and perspectives, and promoting the inclusion of patients, families and other care givers as vital members of the team“.

Unclear this happens on any significant level, especially when it comes to communication outside the hospital or clinic room. Studies have found that when patient portals or messaging systems are used, patients often respond with further questions or comments, which suggests unmet need and desire to engage further. Other studies have found that only a tiny minority of messages in such systems are initiated by the health care team, which suggests a reactive rather than active contribution to the partnership.

Expert patients

Communication, Generic, Patients

Idea came from Prof Kate Lorig, rheumatologist in US. Trained lay educators had better outcomes than conventional clinic appointments. In 2001, became an NHS programme, aimed at cutting costs of chronic disease.

Technology has aided this massively – see “E-patients“. But of course variations in access to technology and tech literacy.

Survey of UK public found 42% had read online healthcare feedback esp researching treatment, drug, test. Mostly younger female, high income, high internet use.  Only 6% of public remember being asked to give feedback on health care experience – ever. 28% of doctors aware of feedback relating to an episode of care they were involved in. This shows a lack of organisational preparedness, given government policy paper for future of data and online services in healthcare. 

Patient centred networks not well understood. Can have links to health professionals, but can also be tied to industry/commercial interests, may even be driven by industry.  Online resources scored higher with e-patients for convenience, emotional support, empathy, death and dying, in depth medical information, practical help.  Specialist physicians rated highest for diagnosis, technical knowledge (just), managing condition after diagnosis.  So online resources score highest where medics poorest and vice versa.  So combination of both ideal!  Also, medics come and go.  Some patient groups have published their own research eg GIST group.

But behaviour change, specifically when talking about self-efficacy, is very individual and psychology focussed. Less exploration of social influences, other than focus on peer modelling.

Foucault, of course, was fascinated by how people can become obedient, self governing, and how this is produced by the efforts of “pastoral power”, in a similar way to the Christian church and the process of confession.

Trisha Greenhalgh would say that although collaboration between patient and doctor is important, it’s still just one aspect of a whole system that includes community, material conditions, law/policy, social deprivation, cultural norms etc.

Remote consultations

Clinical governance, Communication, Generic

Schedule time, rather than fit in between jobs.

Confidentiality: where you are, where they are! “Are you somewhere private?”

Consent before you proceed. “Are you happy for us to talk just now?” “Can you hear me clearly?”

Contemporaneous notes.  Explain why there may be typing noises during conversation.

Beware if not your usual patient, and long term medication/condition.  Consult with GP or other appropriate professionals.

Prob not appropriate where Safeguarding issues or doubt about mental capacity of adults.

“You may need to justify a decision to consult remotely” – not for your convenience!!!

If speaking with a child, use speaker so parents can hear.

Since you can’t see cues and can’t nod in agreement, good to check understanding and summarise what has been said to you.

Say when you will phone back if you need to discuss with someone else.

Easy to become over focussed on one particular issue and forget to assess more fully.

If becomes emotional, respond by showing you have noticed “It sounds as though you are worried/angry/frustrated about…”.  Apologise if becomes hostile.  Focus on what you can do rather than what you can’t do.  Avoid pre-empting what someone is going to say.

If parents not reassured, or your assessment of the seriousness of the condition differs from theirs, err on the side of caution and arrange a face to face consultation.

For long term conditions, it may be helpful for family to have a list of concerns before hand.

When ordering tests, discuss how these will be fed back – consider whether likely to need face to face follow up to discuss results and treatment options.

Wait until the other party has hung up.

See also Remote consultations – use of images.

Doctor-patient communication

Communication, Ethics, Patients

Verbal, non-verbal and paraverbal (tone, pitch, volume) [Ranjan 2015].

Consultations – patient’s opening chat is interrupted by their doctor after mean 18 secs.  Patient talk for 40% of total consultation time, estimated by doctor at 60%.

Wayne et al 2011 – less info given to poorer and minorities, more dialogue and more informative with better educated, more literate patients

Neumann 2011 – decline in medical empathy: significant through medical school,  further declines through residency.  “Hidden” curriculum? Hardening/cynicism? Rosenthal 2011 – humanism and professionalism student module, no decline in 3rd year student empathy.

Chen 2012 – empathy associated with women, non-technological specialty preference, high debt!

Roter and Hall 2006 – doctors like to retain authority but poor at managing confrontation (eg eye contact) and picking up emotional cues of distress

Psychodynamic approach – counter transference (disgust, judgemental), counter resistance (non-compliance).

Narrative as diagnosis!  William Osler – the diagnosis is in the story.

Communication and teamwork “skills” underestimates complexity, the affective component.  Only learned if valued, rather than as something to be acquired. 

“Heroic individualism” valued in medicine, cf dialogue.

Students struggle to make conversation with patients!  Fear of intrusiveness, failure to connect medical issues with psychosocial elements.

Best – learn through active reflection on work based learning (cf how artificial PBL etc are).  Think about values, how they shape communication.  Modelling of democratic values.  Appreciation of complexity of communication.

[ Alan Bleakley, Peninsula medical school – Homer as evidence of honour/shame/face directed behaviours, cf feminine, guilt directed behaviours etc]

Participatory Medicine

Outside of the consultation, doctor-patient communication becomes a mixture of formal and informal, but both tend to be one sided. Formal letters are an essentially one sided message from the doctor to the patient. Informal communication includes requests or questions from the patient to the doctor but again, often one sided as it does not usually lead to a meaningful exchange.

See Participatory medicine.

Oratory

Communication skills are essential to career development, advocacy, leadership. See Oratory.