Category Archives: Communication

Difficult conversations

Communication, Generic, Patients

From “Everything happens for a reason – and other lies I’ve loved” by Kate Bowler:

Appendix 1 – absolutely never say this [my comments added]

  • Well, at least… [minimizing]
  • In my long life, I’ve learned… [good for you, have a medal]
  • It’s going to get better, I promise. [fantasy]
  • God needed an angel [only if you watch Ghost, and you think God is sadistic]
  • Everything happens for a reason. [let’s see if you appreciate my theories when you are drowning]
  • I’ve done some research [have you heard about… Forget what the professionals say, there’s bound to be a secret cure out there]
  • When my aunt had cancer [living it, thanks, would rather not have to relive someone else’s – particularly if this my opportunity to NOT think about it]
  • So how are the treatments going? [not nice to have to summarise it and regurgitate it constantly, please check first if I want to talk about it today, sometimes I do, sometimes I don’t]

Appendix 2 – give this a go

  • I’d love to bring you a meal this week [bring me anything, I don’t really know what I need, what are you good at?]
  • You are a beautiful person [nice to know you are doing a good job – without this being some sort of lesson.  And don’t make it sound like a eulogy]
  • I’m so grateful to hear about how you’re doing, and just know that I’m on your team [nice to not have to give you an update, great that you’re informed and concerned, let’s talk about something else]
  • Can I give you a hug?
  • Oh, my friend, that sounds so hard [sometimes it feels like no one wants to hear about how awful it is – simmer down, let them talk]
  • (silence) [the truth is no one knows what to say – pain, tragedy are awkward.  So show up and shut up)

Sometimes our role is just to sit in the rubble with families (Judith Murray).

See Spiritual Care.

Don’t call me brave

Communication, Generic

Often said to children when they are sad or frightened. But doesn’t help, only makes it seem wrong to have feelings.

Sometimes you need to take a break. And hovering in the doorway doesn’t count.

It can feel like there’s nowhere safe in hospital, that no one understands you. Does being brave mean keeping quiet for the happiness of others?

Instead of calling someone brave, maybe try pointing out that grown ups can feel scared too. Have you explained what the test is for, and why it is needed? Have you apologised for making them upset?

Three strike policy can help an anxious child feel respected and in control.

[Sophie Lyons, BMJ 2018;360:k1299]

Writing a statement

Clinical governance, Communication, Generic

  • Include full name, qualifications, job title and how long you have been doing it.
  • Don’t assume reader knows anything about the case
  • Use first person
  • Who did what, why, when
  • Concentrate on your observations and your understanding (no need for long quotes of what was said to you, which is what a clinical report would require)
  • Say what you found, but also what you looked for and didn’t find
  • If you’re not exactly sure what you did, and nothing documented, acceptable to say “My normal practice would be…”
  • When you have referred to or discussed with someone else, give their name and who they are, describe what they did on the basis of the notes and your understanding, but don’t comment on the adequacy or otherwise of their performance.
[https://www.themdu.com/guidance-and-advice/guides/writing-a-report-for-the-coroner]

Safety Nets

Communication, Ethics, Generic

Top tips for safety-netting

  • Be specific in the advice given – ‘If xxxx happens, please ring the surgery or out of hours provider immediately.’
  • Provide a likely timescale for when you believe symptoms should have resolved – ‘Your cough should clear up soon if it’s due to the chest infection. If it’s still there in two weeks, please book an emergency appointment to see me.’
  • It can be helpful to book an appointment for follow up yourself. Telling a patient you’d like to book them in to review their progress in a couple of weeks is safer than just saying, ‘book an appointment if it’s not better.’
  • Consider giving written information and patient leaflets to reinforce verbal advice.
  • Document the specific advice, given rather than simply saying ‘advice given’.
  • Check that patients are aware of how to access advice if you’re not available, such as by giving the number of the Out Of Hours provider.
  • Bear in mind the need to re-assess if symptoms are not settling, or if there is no response to the treatment you have given. Be prepared to reconsider an earlier diagnosis.

[Sarah Jarvis, MDU]

Spiritual care

Communication, Generic

See also Difficult conversations.

Taking a spiritual history

  • do you consider yourself religious or spiritually minded?
  • where do you get inner strength from?

[Larry Culliford podcast]

[RCPsych leaflet]

All staff play a role in spiritual care.  Definition – “Allow people to explore their innermost feelings and ask the most difficult questions about suffering, illness and death”. Aim to help those in need find peace of mind.

Many levels – speaking with dignity and respect, training in bereavement, specialist spiritual care provided by department of spiritual care and wellbeing.  Spiritual care volunteers also available.

[NHSL spiritual care guidelines]

[Scottish government guidance CEL 2008.]

Staff care also important eg reflective practice, mindfulness, Schwartz rounds etc.

Family centred ward rounds

Communication, Generic, Patients

A study highlighted that the attending physicians talk outside the room as much as or more than they do inside the room.

“It is frustrating to hear the team speaking about you in the hallway before they come in and wondering what they are saying. Then, after they leave the room, they continue to have discussions in the hallway, where we can hear pieces and parts but not all of the discussion.

“We would prefer that all discussion happen in the room with the nurses and the family present.”

The nurses are the ones who have spent the most time with the family, and they have a lot of information to offer. However, the study highlighted that the nurse does not have much of an opportunity to speak during the rounds.

Sometimes, the entire rounds process is effectively over by the time the medical team comes into the room, and rounds are more of a procedural event than a discussion.

Other comments from one family:

  • It would be nice if all physicians involved in the care could participate in the family-centered rounds experience, even if some need to be on the phone. Many times, the rounding process happens but then we are left with a statement that they will wait until the other doctors come by to make a decision. This not only prolongs the decisions but also splinters the care that the concept of family-centered rounds is trying to improve.
  • We appreciate when the medical teams sit down in the room with us. It makes us feel as if we are having a discussion where everyone is invited to participate instead of a group of people standing over us. This style of communication seems to engage the patient and family in honest, open conversation, and it seems to cause the team to slow down enough to listen to our story.
  • It would be nice to have some idea of when they are coming to the room because it seems that no matter what we do, the team comes in when one of us has run to the cafeteria to get breakfast or to take a phone call in the lobby.

[Sarah Pickel, Mark W. Shen, Collin Hovinga.  Hospital Pediatrics  Jul 2016,  6  (7)  387-393;  DOI: 10.1542/hpeds.2015-0136]

Patient centred care

Communication, Generic

As seen in previous studies of medical students, junior doctor patient-centred attitudes declined during their first year of residency.

There is a clear gender gap.  Female residents were generally more inclined to a patient-centred attitude. The difference by gender was more evident for the caring component than the sharing component.

Male residents became less patient-centred in terms of caring attitude after 1 year, while female residents showed little decline.

A previous meta-analysis indicated that female physicians are more likely to address psychosocial issues, use emotional talk and positive talk, and more actively incorporate patient input.  All of this could be considered patient centred.

Role models tend to be same gender, which perhaps explains why male doctors tend to learn patriarchal styles.

Interestingly, physicians’ confidence in communicating with patients increases more in those who showed a smaller decline in patient-centred attitude.

[BMC Med Educ. 2018; 18: 20.         doi:  10.1186/s12909-018-1129-y]

See also Family centred ward rounds.