MRCP PACES communication skills and history taking notes

Session One

MRCP-PACES

ETHICS & COMMUNICATION SKILLS

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013Copyright: KM-426122-613404

1. Ethical issues:

• Respect for Patient Autonomy

• Consent

• Confidentiality/Disclosure/Public interest

• Justice

2. Public protection:

a- Driving;

• Epilepsy

• Diabetes Mellitus

• and TIA

• and Heart disease

b- GU infections/Communicable diseases:

• HIV

• TB

• HBV

3. Breaking Bad News

4. Medico legal issues:

• Resuscitation/DNR

• Advance directives

• Brain death & persistent vegetative state

• Coroner referral

• Euthanasia

• Postmortem examination

• Organs donation

• Religious bioethics

5. Counseling:

• Multiple Sclerosis

• IHD & Cardiac rehabilitation

• Cystic Fibrosis

• Huntington’s Disease

• Rheumatoid Arthritis

• Uncontrolled DM

• Bronchial Asthma/COPD


6. Procedures:

• Heart-Lung Transplant.

• CABG

• Pacemakers

• Bronchoscopy

• Endoscopy

7. Updated NICE Guidelines:

• Beta-Interferon in MS

• Infliximab (anti-TNF) in RA & CD


Layman English:

Feel edgy (an edge): Nervous

Invalid: Terminally ill

Low: Depressed

Give way: Collapse

Head piece: Brain

Fainting: Syncope

Giddiness: Vertigo

Fits/Shakes: Epilepsy/Convulsions

Ringing in ears: Tinnitus

Back passage: Anus

Bottom: Buttocks

Phlegm: Sputum

Tubes: Lungs

Puffed/Puffy: Breathless

Heart attack: MI

The Welfare: Social services

Get the sack: Lose job

Puffed up: Swollen

Tummy/belly: Stomach/bowel

Gullet: Oesophagus

Feels sick: Nauseated

Been sick: Vomited

Wind: Flatulence

- To belch: Send wind from stomach

- To part: ,, ,, anus

Toilets: Motions/stools

Water: Urine

Keep wanting to go: Frequency

To get up at night: Nocturia

A growth: A mass, cancer (also: the big C)

Lose: Menses

Pictures/Imaging: X-Rays

Temperature: Fever

Get back/Flare: Relapses

To be looking/to turn the corner: Improves

To be laid up: Confined to bed

To find one’s legs: Start walks after illness

To have a bad turn: Becomes suddenly ill

To have a bug: To catch a virus/infection

To lose one’s nature: Becomes impotent

To go steady: To have a regular partner

(Ref: English for Overseas Doctors)


The British Health System

• Guidelines & Policies:

• The General Medical Council (GMC)

• The National Institute of Clinical Excellence (NICE)

• The Scottish Intercollegiate Guidelines Network (SIGN)

• The Royal Colleges

• Hospitals (NHS): SHO, SpR, Consultants

• The GPs

• The Social Services System

• The Home Health Care

• Preventive Section, CICD

• The Legal Advisor, the Coroner system, etc

• Occupational health services & rehabilitation

• The Nursing teams:

- Specialist nurses (diabetes, Asthma,)

- District nurses

- Teams (e.g. McMillan team)

- Nursing homes

• Voluntary agencies

• Support groups & Societies (MS)


Station 4: ETHICS and COMMUNICATION

Candidate’s Instructions:

o You will be given 5 minutes before entering the examination room to read a

scenario & to make your plan of action. On hearing the bell, enter the room

& begin the consultation.

o You will have 14 minutes to interview the patient/actor & one minute after

he/she leaves the room to organize your thoughts and to prepare yourself for

the discussion with the examiners.

o Don’t re-take history from the patient and don’t examine him/her.

In this section some scenarios will be presented & will be followed by a suggestion on how

to approach similar situations when you, hopefully face them in your actual examination.

This will be preceded by short talks emphasizing essential ethical & legal issues and some

important guidelines e.g. DVLA, INF in MS, End of life decisions etc.

A comprehensive knowledge of UK law is not required from overseas candidates; however,

they are expected to know in broad terms relevant ethical & legal principles.

Many candidates fail this section of the PACES examination not as a result of its difficulty,

but because they fail to prepare to it adequately. On the other hand, many of the successful

ones feel that with good preparation, success in this section is probably more predictable

than in any other section of this exam.

***The key sentence to success is “Practice & practice till mastering”


Station 4: ETHICS and COMMUNICATION

USEFUL HINTS

• When given the scenario outside the examination rooms STUDY it carefully &

decide at first which ethical/communication principle is being tested.

Then on the provided paper write down the points that you would like to discuss

with the patient/actor & the plan of action needed to manage the given problem.

• On entering the exam. room, start by greeting the examiners then sit facing the

patient, greet her/him & introduce self and explain role e.g. “ Hello Mrs. X. I’m

doctor Y, the medical SHO who is looking after your husband”. Then agree the

purpose of the interview “We are here today to discuss the result of his bone

imaging. Is that right? Would you like to discuss any other issue?”

• Maintain good eye-to-eye contact with the patient & put him/her at ease.

• Start the interview with open-ended questions “e.g. what do you know about your

husband’s condition?” or “I learned from your GP’s letter that you have had a

seizure last weekend, can you tell me more about that?”

• Use close-ended questions as the interview progresses.

• Provide clear & understandable explanations

• Avoid using jargons

• At the end of the interview:

- Agrees a clear course of action with the patient

- Summarizes

- Check understanding (e.g. “what message you will take

home with

you?” or “what are you going to tell the other members of the

family?”)

- Shake hands & say goodbye.


PRINCIPLES OF MEDICAL ETHICS

The 4 Principles of Medical Ethics

1. Respect for Patient Autonomy

2. Beneficence

3. Non-maleficence

4. Justice

1. Respecting the patient’s Autonomy: (wishes & self-rule)

Autonomy: means self rule i.e.(the capacity to think, decide & act freely and

independently). It is the patient’s right to be involved in any decision about his health.

This requires that the health professionals help patients in making their own decisions and

respect & follow these decisions. Respect of autonomy implies that doctors treat competent

patients in accordance with their informed choices, even if these conflict with the doctor’s

beliefs.

2. Beneficence: (doing good to & promoting of what is best for the patient.)

This entails doing what is best for the patient.

In most situations 1&2 lead to the same conclusions, however, the two principles conflict

when a competent pt. chose a course of action that is not in his/her best interests.

* If such a conflict arises (Autonomy vs. Beneficence):

1. Make sure that the patient is competent

2. Explain the possible consequences of his choice (e.g. refusal of treatment)

3. Suggest discussing others (a friend, family member, etc) & a senior colleague

4. Respect the patient's autonomy

3. Non-maleficence: (do no harm, need to avoid harm)

With regard to treatment & procedures, the potential goods & harms and their possibilities

must be weighed up to decide what, overall, is in the patient s best interest.

* *These two last principles imply that:

1. Treatment must be thought likely to be successful OR that,

2. Potential benefits overweight potential risks.

4. Justice: (fairness in provision of health care)

Refers to the duty of the doctor to the whole society.

A. Patients with similar situation should get accessibility to similar health care.

B. When determining what level of care should be available to one set of patients, we

should take into account the effect of such use of resources on other patients (i.e. we

must try to distribute limited resources fairly). Using these resources to aggressively

treat a terminally ill patient is potentially depriving others of the treatment.


• *Sometimes the patient's autonomy conflicts with the "Public Interest". In such a

case the latter must be respected; as your role for the whole society is more superior

to respecting the patient's autonomy.

CONSENTING PATIENTS

Types of Consent:

1. Expressed: Written or verbal agreement for the procedure

2. Implied: e.g. the patient’s action in response to a request for exam.

3. Statuary: When the law requites a particular consent e.g. IVF

Elements of valid consent:

VALID CONSENT =

Understanding (Competent patient + Appropriate Information)

+ Voluntary decision (i.e. without coercion)

True informed consent requires that the patient does not merely passively assents to the

doctor’s decision, but specifically authorizes the doctor to initiate the medical plan.

Information to be provided to the patient:

• Diagnosis/Prognosis

• Uncertainty about the diagnosis/need for further investigations

• Purpose, details & expected outcome of procedures

• Likely benefits & probability of success

• Possible side-effects & complications

Techniques:

- Use illustrations, written or visual aids for explanation

- Allow a relative/a friend to attend if the patient agrees

- Involve other staff e.g. a nurse

- Give a balanced view

- Allow sufficient time for reflection & decision-making

Consent in English law:

What is Competence (Capacity)?

A competent patient must fulfill the following requirements & demonstrate them repeatedly

and consistently:

• Understands a simple explanation of his/her medical condition, treatment and

expected outcome.

• Is able to reason about specific goals of treatment & choose to act on the best of

such reasoning.

• Communicates his/her choice & the reason for this choice.

• Understands the consequences of such choice.


N.B. - A patient should not be regarded as incompetent merely because he makes

a decision that is against his best interest.

- Competence is “function specific”

Consent cont’d…

(1) Competent patient:

A. A competent patient may refuse any, even life-saving treatment.

Anything done without the patient’s consent, even touching, is battery (for which

damage may be awarded). In contrast to negligence, the patient doesn’t need to

prove that he/she has suffered harm as a result of the battery for damages to be

awarded.

B. The patient should be given information about the nature of the procedure or other

medical interventions (otherwise battery), common & rare side-effects, benefits &

reasonable alternatives (otherwise negligence: failure to give appropriate

information to the patient before choosing to accept/refuse a treatment or a

diagnostic test.

(2) Incompetent patient:

Possible approaches:

A. Doctors should act in the best interests of patients.

Relatives & friends may be approached as a source of information to judge the

patient’s best interests, but can’t give or withhold consent (i.e. there is no proxy

consent for an incompetent adult patient).

NB: Tutor dative (Partnership giving)

B. Substituted judgment: What treatment option would the patient choose if he

become competent?

To answer this question, Consider:

- The patient’s previously expressed preference

- His general values & backgrounds

- The doctor’s experience with other patients

C. Advance Directives:

Should be respected after ensuring that the patient was competent & had all the

relevant information and that he had considered the clinical situation that has arisen.

D. Involve hospital’s legal adviser/apply to the Court if:

There are differences of opinions/controversy in therapy.

Examination/testing & treatment without consent:

1. For life-saving procedures when the patient is unconscious/incompetent to indicate

his/her wishes.

2. Where a patient is incapable of giving consent as a result of a mental illness, the

treatment should be based on the patient’s “best interest" principle.


Documents

MRCP PACES communication skills and history taking notes