Most candidates will be in training and will inevitably have been through many communication interview stations through this process, for example the MRCS examination. The principles are essentially the same, and the standard expected is analogous to such a test. As such the general principles that are worthy of mention are:
∗ Read the question!
∗ Reflect on the theme of the station and what the examiners are looking for. Take a deep breath and wait a few seconds. Ex prime minister Tony Blair’s interview coach once gave him this advice!
∗ Always introduce yourself through full name and job role.
∗ Do not forget their name!
∗ Start with open questions, and then focus in on closed questions once the patient or relative has answered.
∗ Always initially ask what the other person knows already.
∗ If discussing with, for example a relative, always say you have gained consent.
∗ ICE: Ideas, Concerns, and Expectations Always have these three things in the back of your mind during the station.
∗ Towards the end of the consultation always check if they have any questions.
∗ Always thank the other person at the end.
The interview can throw a variety of types of communication ‘theme’ into the mix. This is often split into two sections, with two separate scenarios. Examples of themes can include:
∗ Breaking bad news
∗ History taking
∗ Angry patient/relatives
Empathy. This is an essential theme in the communication skills station. It means the difference between saying ‘I am sorry’ and actually acknowledging the patient’s or relative’s feelings. For example, it is nearly always worth mentioning- “It sounds like this has been a very difficult time for you and you must be exhausted”. This quite rightly acknowledges it has very likely been an event that has come out of the blue, such as a fracture, or cancer, or a relative being unwell.
We enclose below a series of example questions. The best way to prepare using the questions is with a colleague or friend. Each of you in turn should read the entire question and then be the ‘actor’. The actor can read the scenario to the candidate.
You are the registrar in fracture clinic, and all other staff have left the clinic, including your consultant who is not contactable. You have no notes for the next patient, however you have the following x-ray:
Sometimes they may not even give you a question in the interview. This is on purpose to see how you react and put you under pressure, which is part of the personal specification criteria. The clue here is that you are the registrar and therefore you have to sort the patient out, and that’s it. The key is asking an open question, and finding out what the patient knows and how they have come to be in clinic.
∗ The key points to this station are:
1.Finding out how the patient has come to be in clinic
2.Brief history so that you can plan your management
3.Breaking bad news that this is likely a malignancy or ‘growth’
∗ An important point is that not knowing exactly how to manage this with an operation is not going to fail you or lower your marks- in fact the management is quite complex and beyond the knowledge of an ST3 candidate. As long as you do not, for example say something that you think may be expected of you, which could be dangerous, for example a reverse shoulder replacement, which would be inappropriate in this case. If you do not know, just say.
∗ An example answer of the management could be ‘I would treat you in a special sling called a collar and cuff that allows your hand to hang, which will make you feel more comfortable. This will be a very painful injury, and as such if you are safe to do so I will send you home on strong painkillers such as co-codamol. The further management of this can be potentially quite complicated, and we need to take a multi-disciplinary team approach, and as such I need to take all of your information down including your phone number so I can discuss your case with other doctors in the team including my consultant. We may need further imaging. I will however ensure you are called back as soon as possible so that you are up to date with the plan.
∗ This example above is exactly that- merely an example! The management obviously depends on the exact nature of the malignancy and patient.
The patient in question 1 was operated on by a non-consultant surgeon and given a humeral nail. This has subsequently failed and requires referral to a specialist bone tumour centre. The son is present and would like to speak to you on the ward. It is your consultant’s patient.
Quickly during the consultation the son asks if he can meet the surgeon responsible for the operation.
∗ They key theme in this station is dealing with an angry relative and explanation of condition
∗ Introduce yourself in full name and role, including you are the consultants registrar
∗ Say sorry! And say it early! Some feel this may be accepting or admitting blame. However obviously if you were not there, you cannot personally accept the blame. Saying sorry can diffuse a situation and acknowledge that the other party is upset.
∗ Explain that although you were not present in the case, now it has been brought to your attention, you want to ensure everything is sorted out to the best of your ability.
∗ Explain the consultant will need to be involved in the care and you will discuss this with him/her.
∗ The son may try and appoint blame to the surgeon who performed the operation. Under no circumstances can you do this. You can explain that the matter will be looked into, and you will try and organize a meeting between the family and the consultant/ the surgeon if possible. You can also mention if the relative continues to be unhappy that the Patient Advice Liaison Service is available.
You are the registrar on call and attend the ward to see a patient you operated on earlier. You are seeing the patient in between cases. The nurse in charge approaches you very upset, and explains the orthopaedic ward doctor is not doing discharge summaries, not answering the bleep and has not seen any of the patients. She also explains the doctor has been very rude. You are subsequently are then called back to theatre to perform a DHS who is on the table.
∗ Dealing with an angry member of staff/managing juniors
∗ The mneumonic SPIS applies here: Seek information, Patient safety, use your Initiative, Support the member of staff
∗ The key is patient safety! You must check with the nurse and ask if there are any immediate patient safety concerns.
∗ You could ask the nurse the make a list of jobs that need to be performed for the ward doctor for when he comes around and that perhaps he is busy in A&E
∗ You must reassure the nurse that you will ensure this is looked into and that you will speak to the doctor, but also acknowledge you need to go back to theatre immediately as you have a patient on the table
∗ Listening to the nurse and all of her concerns is important
∗ Offer your help with work if and when you will be available
You find the junior doctor from question 3 later in the mess after he does not answer his bleep several times. You sit down with him to have a conversation regarding the concerns that have been raised:
Later it becomes apparent that the doctor is exhausted as his wife has just had a baby and he did not get any sleep the last 3 nights, which is why he is not coping.
∗ Dealing with a failing trainee
∗ The SPIS mneumonic applies here also
∗ The opening question is very important and must be non-accusatory. There may be a very good reason why the doctor is not answering bleeps, for example- the battery may be dead. It may also be possible the doctor is suffering from a health problem, or a grievance/bereavement that can affect their performance at work.
∗ Offering help to the above doctor is essential, such as a swap off duty or emergency leave.
∗ Discussion regarding whether the consultant should be involved.
You are the registrar oncall and have been referred a 2 year old with a femoral diaphysis fracture with an unusual mechanism of injury. A social services referral is required and the child needs to be admitted. Please discuss with the parents.
∗ Breaking bad news/ angry relatives
∗ Full introduction in role and name
∗ Early involvement of paediatrics team who will be better trained to deal with child protection issues
∗ The key is being non accusatory, and explaining that this is standard procedure for this sort of injury and that it is the law, but the child will need admission for treatment anyway