kumec handbook 2013 2014 · basic medical sciences teaching in anatomy, physiology, biochemistry,...

King’s Undergraduate Medical Education in the Community (KUMEC) Department of Primary Care and Public Health Sciences King’s College London, School of Medicine

KUMEC Handbook 2013 – 2014

King’s Undergraduate Medical Education in the Community │ KUMEC 1

Preface

Welcome to KCLSM. Your clinical attachments have been planned to ensure that the themes for each term link with your learning in the other areas of the course. This includes areas such as biomedical science teaching, medical ethics and law, sociology, psychology, communication in health care, clinical epidemiology and medical statistics. During this first year you will have opportunities to meet patients in hospital, general practice and in their own homes. You will learn about why people seek medical help, the medical consultation, the process of medical treatment and the impact of illness and disability on the lives of patients and their families. You will also learn about the work of the health care team and will have the opportunity to learn about eliciting a medical history and also to explore the needs of diverse groups and individuals in the community and how they do or do not access healthcare. Communication skills will be an important thread during the programme and this year in clinical practice you will focus on talking with patients and their carers. For your hospital-based clinical attachments you will be linked, in pairs, to an FY1 or FY2 Doctor on one of the four sites – Guy’s, St Thomas’, King’s (Denmark Hill) or Lewisham. For your general practice-based clinical attachments, organised by the Kings Undergraduate Medical Education in the Community Team (KUMEC), you will be linked, in pairs, to a general practice in southeast London. Your practice will make arrangements for the teaching of various aspects of the programme and will also provide a tutor (who may be a GP or another clinical member of the team). You will be given contact details and travel instructions separate to this booklet. Throughout the course, your learning will be supported by both seminars and tutorials on the Guy’s campus. Through this part of your course we aim to provide early clinical contact to ensure that you are better equipped for your future professional lives as doctors. We hope that you will find the programme useful. We are sure that you will enjoy this early contact both with health care professionals and with patients.

Dr Anne Stephenson Head of Undergraduate Education October 2013


Contents

Preface .................................................................................................................................................... 1

Contents .................................................................................................................................................. 2

GPEP KUMEC Programme Summary ....................................................................................................... 3

Contact Details ........................................................................................................................................ 4

Course Information for Medical Students .............................................................................................. 5

Course Information for GP TUTORS ........................................................................................................ 7

Course Information for Seminar Leaders ................................................................................................ 8

KUMEC Student Transport Policy 2013-14 ............................................................................................. 9

Aims and Objectives of the Clinical Attachments ................................................................................. 10

Logbook Information ............................................................................................................................ 11

GPEP KUMEC timetable ........................................................................................................................ 12

General Practice Clinical Attachment 1 ................................................................................................ 13

Hospital Visit 1 ...................................................................................................................................... 15

Hospital Visit 2 ...................................................................................................................................... 17

Seminar Session 1 ................................................................................................................................. 19

Eliciting a Medical History Introduction and Module Overview ........................................................... 21

Eliciting a Medical History Symposium ................................................................................................. 22

Eliciting a Medical History Seminar/Simulation .................................................................................... 23


Chronic Illness and the Healthcare Team Introduction and Module Overview .................................. 26



Access to Healthcare Module Introduction and Programme Overview .............................................. 30

Access to Healthcare Symposium ......................................................................................................... 31


Presentation Assessment Session ......................................................................................................... 34

Becoming a patient and patient-centred approaches in the consultation ........................................... 36

History Taking Revision Session ............................................................................................................ 37

KUMEC Sign-Ups 2013-14 ..................................................................................................................... 38

Appendix A: Indemnity (Amended June 2011) ..................................................................................... 39

Appendix B: History Taking Framework ................................................................................................ 40

Appendix C: Patient-Centred Communication Skills Guide .................................................................. 46

Appendix D: Guidelines for Responsible Learning ................................................................................ 48

Appendix E: Communication in Healthcare .......................................................................................... 54

Appendix F: Constructive Feedback ...................................................................................................... 57


GPEP KUMEC Programme Summary

Themes for the year

Exploring medicine in the community

Why patients visit the doctor

What happens in the consultation and the doctor-patient relationship

Chronic illness and the wider community healthcare team

Learning to reflect and feed back

Patient-centred communication skills

Professionalism, consent and confidentiality

Eliciting a medical history

Access to Healthcare

Overview of timetable

The clinical timetable for GPEP covers: two symposia, five general practice sessions, two hospital sessions, one seminar and two role play sessions. There is an assessed presentation session on 12th February 2014 and an Objective Structured Clinical Examination (OSCE) in May. Questions on the course will be included in the year end exam papers.

Key dates for GP tutors

Wednesday 11th September 2013 Wednesday 9th October 2013 Wednesday 6th November 2013 Wednesday 20th November 2013 Wednesday 15th January 2014 All visits are 2pm – 4pm.

Key dates for seminar leaders

Date Day Start Finish Title

18/09/2013 Wed 09:30 13:00 Eliciting a Medical History - Symposium

20/09/2013 Fri 14:00 16:00 Introduction to Clinical Reflection Seminar

04/10/2013 Fri 14:00 17:00 History Taking Simulation Seminar

12/02/2014 Wed 14:00 16:00 KUMEC Assessed Presentations

17/04/2014 Thu 10:00 13:00 History Taking Revision Session

Key documents

Timetables, agreements, contacts, policies and resources are available here: http://www.kcl.ac.uk/KUMEC

http://www.kcl.ac.uk/medicine/research/divisions/hscr/study/undergradops/KUMEC/Teachers/Index.aspx


Contact Details

The following are available to help with students’ or teachers’ queries as appropriate:

General Practice placements

Anna Quinn, Project Coordinator, 020 7848 8698 [email protected]

Kay Leedham-Green, Years 1 and 2 Lead, 020 7848 8693 [email protected] For all organisational queries and student concerns during General Practice placements

Hospital placements

Suzanne Vaughan, 020 7188 3739 [email protected]

David Treacher, Undergraduate Sub-Dean for St Thomas' Hospital [email protected]

THE LOCATION OF THE KING’S UNDERGRADUATE MEDICAL EDUCTION IN THE COMMUNITY (KUMEC) DEPARTMENT: 4th Floor Capital House, 42 Weston St, SE1 3QD

KUMEC Department

mailto:[email protected]





Course Information for Medical Students

Teaching model

To enable experiential learning the majority of each visit to the allocated General Practice (approximately 90 minutes) will be spent in contact with patients and health professionals and the remainder (30 minutes) used for facilitated reflection. Students are encouraged to keep a reflective learning log of their experiences.

Online KUMEC handbook

An online version of the KUMEC handbook may be found on the Virtual Campus https://virtualcampus.kcl.ac.uk/vc/medicine/coursebooks/coursebooks.aspx?course=gpep

Student transport and placement policy

We do not expect any student to incur a transport cost greater than £8.90 per community day organised through this Department. We will reimburse costs that are above this amount. Students can find details of this in this handbook, on the departmental website and Virtual Campus (see above links).

Student evaluation and feedback

We aim for consistency and high standards across the community-teaching network and can only know what is going on if students tell us and talk through issues with us. We are here to support you. We use the information to provide feedback to teachers.

Importance of the KUMEC handbook

Students must:

Bring it with them to all community teaching events

Get the attendance record signed at all community teaching events

Submit the sign up page at the last community teaching event

Curriculum information

For the first year of their undergraduate training, all GPEP students will experience relevant curriculum teaching as follows:

Basic Medical Sciences teaching in Anatomy, Physiology, Biochemistry, Pathology and Pharmacology and Therapeutics.

Basic Human Sciences teaching in Psychology, Ethics and Law, Sociology, Clinical Epidemiology and Medical Statistics, Communication Skills and sessions in the hospital, community and in General Practice.

A variety of teaching methods are implemented, including lectures, symposia, tutorials, problem-solving workshops, seminars, practical session and clinical attachments in hospital, general practice and community settings

Prior to the first session in general practice

Students are placed in a general practice with a partner (some practices will have more than one pair of students). The practice details, including name, address, telephone number and the contact/liaison person for the practice, are provided by email at least 10 days prior to the visit. Students are required to make

https://virtualcampus.kcl.ac.uk/vc/medicine/coursebooks/coursebooks.aspx?course=gpep


contact with the liaison person at their allocated practice before the date of the first session to check on practice details, dress code, who to ask for on arrival and timing. It is essential for students to contact the practice to confirm start times. Afternoon Seminars and GP teaching usually begin at 2.00pm and last for 2 hours. If you have to travel far, and your morning teaching does not stop until 1pm, you will have to negotiate a mutually acceptable start time with your GP tutor/seminar leader. It is very important that students leave a telephone number with the practice so that they can be contacted if plans need to be changed. Students must inform the GP Tutor (GPT)/Seminar Leader (SL) if for any reason they cannot attend a session or if they think that they are going to be late. GPTs and practices put time into arranging learning experiences and for some of the sessions specific patients will have been invited. Attendance and punctuality are an important part of professional development and will also

require a sign-up at the end of this term (please refer to Logbook for further information).

Prior to the first hospital session

Students (in pairs) are allocated to one of the four main clinical sites: Guy’s, St Thomas’s, King’s (Denmark Hill) or Lewisham. Each pair will be linked to one of the F1 or F2 Doctors at the site. One student is required to contact this doctor who will provide the name and ward of the patient. Students are provided with back up names in case there are problems. The travel instructions and the contact details are provided near the time. Hospital visits are organised by Suzanne Vaughan, who will contact students directly with instructions in this regard. Students may need to work around the nursing or medical care, meals, investigations or visitors of the patient. They will need to contact the F1/F2 Doctor again if the first patient they are allocated is not available, not suitable or unwilling to be interviewed.

OSCE Examinations

At the end of Year 1, students will sit an OSCE. This will consist of 20 stations during which students will be marked on all aspects of their learning throughout the year. They will be expected to demonstrate practical skills as well as their ability to interact and communicate with patients. KUMEC invites students to sessions in which they will be able to practice the history taking stations and gain an understanding of how the examination will work.

The Assessed Presentation

Students will, with their general practice student partner, give a 10-minute presentation on becoming a patient and patient-centred approaches in the consultation for their assessment. Students should use their experiences of their hospital and joint experiences of their general practice attachments and their theoretical understanding from lectures and reading to illustrate understanding of this topic and this will provide 2% towards the end-of-year mark.

Missed placement sessions

Please note that any missed GP Placement will incur a fee of £70 to cover the cost of rearranging the session with the GP. If you cannot attend a session for any reason you must contact your Year administrator who can advise you on how to proceed. In the case of illness you will be asked to provide a note from your doctor to waive the £70 fee. Please give as much notice as possible and allow flexibility for your rearranged placement date.


Course Information for GP Tutors

GPEP students will come to the practice in pairs on the following dates: Wednesday 11th September 2013 Wednesday 9th October 2013 Wednesday 6th November 2013 Wednesday 20th November 2013 Wednesday 15th January 2014 All visits are 2pm – 4pm. Tutors have helped to make the Logbooks a success. The Logbooks remain the responsibility of the students and tutors will be asked to sign-up the following over the year:

Professional standards sign ups:

5 GP visits: (1) introduction to general practice (2) Eliciting a focused medical history within a patient centred framework (3) Chronic illness and the healthcare team – interviewing a patient in general practice (4) Chronic illness and the healthcare team – interviewing a patient at home (5) Access to healthcare – meeting the needs of the practice population

Membership of a medical protection organisation (at first GP visit) – student must show proof of membership

Confidentiality code (at first GP visit) – student must also sign

Fitness to practise

GP Observation : conducting a patient interview Detailed guidelines for completing the sign-ups are in the Logbook (copies will be provided for tutors). Each Logbook entry also requires the practice stamp. KCL monitor students’ professionalism at all times. If, for any reason, a student fails to attend, or if you have any concerns regarding their professionalism (time-keeping, organisation skills, general attitude etc) please don’t hesitate to contact the Year Lead.

Patient briefing

GP’s must ensure that all invited patients are fully informed about the content of the sessions. This should include the stage of the students, the structure and purpose of the interviews and the patient’s own role both as an interviewee and in giving feedback.

IT and computer availability

Under supervision, pertinent to the stage of training, students should be permitted to access the practice’s computer systems in order to ensure that they gain experience sharing case notes, moving towards case management and taking clinical responsibility. This should include the availability of the internet to check their college email & virtual campus, search online journals and access to patient records for note-keeping as appropriate. This provides a good opportunity for tutors to review the confidentiality agreement with students.

Please feel free to contact the relevant Year Lead for further clarification if required.

Clarification of GP tutor/seminar leader roles

Please see section on page 8.


Course Information for Seminar Leaders

Emphasis is to be placed on the overlap between clinical teaching and campus based learning, and preparation for the presentation assessment. Seminar leaders are asked to ONLY sign KUMEC sign up sheets if the student attended the discussion group, role play or OSCE revision sessions with the appropriate paperwork/KUMEC Handbook.

Clarification of GP tutor/seminar leader roles

Please note the following when taking tutorials or conducting seminars:

GP Tutorials (Normally with 1 or 2 pairs of students based in the practice) should concentrate on discussion about the activities arranged by the practice, information relating to patients and any other issues related directly to this.

Seminars/discussion groups (groups of approx. 12) - students use their varied experiences to learn in more depth about the topic by linking this with broader theoretical frameworks. Interactive teaching methods are pursued such as role-play, exercises and case studies.


KUMEC Student Transport Policy 2013-14

We do not expect any student to incur a transport cost greater than £8.90 per community day organised through this Department. We will reimburse costs that are above this amount.

For Years 1 & 2 and Phases 3 and 4 the Department will allocate students to different practices and seminars. For Phase 5, students will be given a considerable amount of choice about the type and location of the general practice to which they will be attached.

This is subject to the following provisos:

1. Students use public transport with a pre-planned route that is both economical and practical. The Department is pleased to assist students with planning routes. For Phase 5 the use of a car is acceptable for local journeys; travel to and from London for group teaching should normally be made by public transport; travel cost exceptions above the £249.20 amount must be approved in advance by the KUMEC Year Lead for Phase Five, Ruth Sugden.

2. Costs are calculated for transport to community placements from the Guy’s campus site.

3. The costs are based on using a Zone 1- 6 daily off-peak travel card. Where for Years 1, 2 and Phase 4 teaching placements are outside Zone 2 the session is generally planned to start at a time that enables students to travel after 9.30am. (Occasional unavoidable exceptions may apply in years 1 - 4. The Department endeavours to find as many suitable teaching practices as possible close to Guy’s and ensures that travel to the practice placements takes no more than 90 minutes.) *

4. If there are difficulties with the travel arrangements and timings of practice sessions, students are asked to discuss these with their practice. If the difficulties persist they are then asked to contact the Department of Primary Care KUMEC Administrator for their year (names and contact details are in the year booklet).

5. There are special arrangements for: Phase 5 where re-imbursement is available for transport costs which are greater than £249.20 for the eight-week attachment using either public transport or, in view of the particular circumstances of Phase 5, using a car (see also above).

6. Students will need to send their invoice for a claim, with receipts, to the Department of General Practice and Primary Care administrator of the year to which the claim responds (names and contact details are in the year booklet). College rules state that travel expenses cannot be reimbursed without documentary evidence. The request for reimbursement should be made before the end of the academic year that is being claimed for.

7. As of September 2013 and based on the present curriculum, students will need to budget for a maximum of: £35.60 for travel for Year 1; £17.80 for Year 2; £62.30 for Phase 3; £71.20 for Phase 4, and £249.20 for Phase 5 with any exceptions approved in advance.

8. Reimbursement rates are reviewed annually.

KUMEC strives to make travel financially possible for all its students. Please contact the KUMEC administrator for your Year/Phase, if you are experiencing difficulties paying for your ticket in advance so that we can help you to find solutions.

* Exceptions to Item 3 in Phases 1-4 may apply


Aims and Objectives of the Clinical Attachments

Overall aims

Building on the philosophy of the GMC document “Tomorrow’s Doctors” (2009) which is intrinsic to the KCL curriculum the overall aims of the clinical programme in Year 1 are to:

orientate students into the clinical environments of the hospital and community

provide students with direct experience of working with patients and members of health care teams

give context to students’ learning of the basic sciences (including social sciences) applied to medicine

demonstrate and reinforce the links between parallel strands of the course

encourage students to become reflective and self-directed lifelong learners

enable students to begin to develop a professional approach to all aspects of their work.

Overall objectives

Knowledge

The student will be able to describe, using clinical examples:

the impact of health and illness on individuals, families and communities

the fundamental components of the consultation and the doctor-patient relationship

patient pathways through the health care system (primary and secondary care)

the role and function of the health care team

basic principles of medical ethics and their role in professional development: confidentiality, consent, patient autonomy and justice.

Skills

The student will be able to demonstrate:

basic interviewing and history taking skills

appropriate professional conduct

skills for working in groups

the principles and practice of reflective learning

feedback and presentation skills.

Attitudes

The student will exhibit:

insight into their own values and attitudes and be aware of and respect those of others

a patient-centred approach

collaborative working with both in the multi-professional context and within pairs and learning groups.


Logbook Information

GPEP sign-ups

Early in Term 1 students receive their Logbook from the Academic Centre. In the Logbook there are a number of items that require “signing up” when successfully completed (usually by the allocated GP tutor). By the end of Year 1 students should be signed up for the following in their Logbooks:

5 GP visits: (1) introduction to general practice (2) Eliciting a focused medical history within a patient centred framework (3) Chronic illness and the healthcare team – interviewing a patient in general practice (4) Chronic illness and the healthcare team – interviewing a patient at home (5) Access to healthcare – meeting the needs of the practice population

Membership of a medical protection organisation (at first GP visit) – student must show proof of membership

Confidentiality code (at first GP visit) – student must also sign

Fitness to practise

GP Observation : conducting a patient interview There are also 2 hospital sign ups.

To enter the OSCE and take the end of year paper students must have successfully completed and submitted all above sign ups.

KUMEC has taken the following measures to ensure that students’ Logbook sign-ups are genuine:

Practices will be asked to place the practice stamp in student Logbooks at the end of the year.

For the hospital attachments, nurses on the wards who confirm your satisfactory attendance and behaviour will record their title. A sample of wards will be monitored.

A random check of Logbooks will be carried out with practices to monitor that sign-ups are genuine.

Falsifying log book sign ups is fraud and will be treated as a serious offence.

Attendance at small group activities

Attendance at discussion groups, role play and OSCE revision sessions with the appropriate KUMEC handbook will be confirmed by the Seminar Leader’s signature on the specified page your KUMEC Teaching Handbook. Evidence of attendance may be taken into account for moderation purposes at end of year assessments. Evidence of full attendance with appropriate handbook/paperwork contributes to criteria for a small number of end of year discretionary awards for model commitment to teaching of the Department of Primary Care and Public Health.


GPEP KUMEC timetable

Exploring Medicine in the Community

6th Sept 2013

Introductory Talk- General Practice Placements

Percy Roberts, Gordon Museum

11:00 – 12:00

Lecture

12th Sept 2013

Introductory Talk- Hospital Placements Hodgkin Classroom 8

11:00 – 12:00

Lecture

11th Sept 2013

Introduction to General Practice, Why do people go to the doctor and what happens in the consultation?

Allocated General Practice

14:00 – 16:00

GP Clinical Attachment 1

Date TBC Interviewing a patient in Hospital – Admission*

Allocated Hospital

14:00 – 16:00

Hospital Clinical Attachment 1

18th Sept 2013

Eliciting a Medical History - Symposium

Harris Lecture Theatre

09:30 – 13:00

Symposium

20th Sept 2013

Introduction to Clinical Reflection Guy’s Campus 14:00 – 16:00

Seminar Session 1

Date TBC Interviewing a patient in Hospital – Discharge*

Allocated Hospital

14:00 – 16:00

Hospital Clinical Attachment 2

4th Oct 2013

Simulation (Eliciting a Medical History) Guy’s Campus 14:00 – 17:00

Seminar/ Simulation

9th Oct 2013

Eliciting a Focused Medical History (Within a patient centred framework)


14:00 – 16:00


6th Nov 2013

Chronic Illness and the Healthcare Team (Interviewing a patient in General Practice)


14:00 – 16:00


20th Nov 2013

Chronic Illness and the Healthcare Team (Interviewing a patient at home)


14:00 – 16:00


9th Jan 2014

Access to Healthcare Symposium Greenwood Lecture Theatre

10:00 – 13:00

Symposium

15th Jan 2014

Access to healthcare (Meeting the needs of the practice population)


14:00 – 16:00


12th Feb 2014

Assessment Guy’s Campus 14:00 – 16:00

Assessment Session

17th April 2014

Revision Session (Eliciting a Medical History)

Guy’s Campus 10:00 – 13:00

History Taking revision session

*If you have any queries about hospital visits, please contact Suzanne Vaughan: 020 7188 3739, [email protected] or David Treacher, Undergraduate Sub-Dean for St Thomas’ Hospital ([email protected])


General Practice Clinical Attachment 1

Details

Date: 11th September 2013 Time: 14:00 to 16:00 Venue: Allocated General Practice

Aims

To orientate students to the clinical environment and to familiarise them with the purpose of the consultation and the process of the clinical interview.

Objectives

By the end of this session the student should be able to:

describe the allocated practice (practice population, facilities, services provided etc)

discuss some of the reasons that cause the patients to visit the GP

describe the doctor-patient interactions observed

outline an understanding of confidentiality/consent/truth telling

define the core communication skills used in GP consultations and interviews, particularly in relation to the opening stages of an encounter

with reference to Sociology and Psychology teaching and reading, explain the models of the doctor-patient relationships witnessed.

Outline of the afternoon in General Practice

The practice visit lasts for two hours (precise timings to be determined by the GPT’s working hours). Prior to the first visit, students are advised to complete the recommended reading and review their learning from Inter-Professional Education (IPE), Communication Skills, Medical Ethics and Law, Sociology and Psychology lectures.

1. Introductions

Upon arrival, students are shown around and introduced to the practice team. Students receive a copy of the practice profile and practice leaflet, and are given a description of the practice population and facilities.

Students must take note of the local area on their way to and from the practice, as this will help them to further understand the practice population.

2. Follow two patients through a consultation

The GPT arranges for students to follow two patients (who have already indicated their consent) through a consultation, in pairs. Students should be briefed on the content of the session, before they meet the patients and sit in on the consultations. The GPT debriefs the students before they leave.

The two patient sessions per pair of students entail:

a short pre-consultation interview with a patient regarding the purpose of the patients GP visit (typically in the waiting room)

accompanying a patient into the consultation to observe what happens

post consultation discussion with patient

discussion with student partner and write up of experiences

debriefing with doctor regarding what happened following conclusion of the consultations, a maximum of four students per briefing per GPT


3. Reflection

Students spend half an hour with their partner discussing and writing up their experiences and findings and consider:

how issues of consent, confidentiality and truth telling were addressed (overtly or tacitly)

what brought the patients to the GP

with reference to the ‘Patient Centred Interview Skills Guide’ (see APPENDIX C) how were the skills of listening, empathy, rapport and question styles (open, closed, leading and probing questions for example) employed in the doctor-patient consultation, particularly in the opening stages?

what effect did the setting of the tone of the interview have on the doctor-patient consultation (consider both verbal and non-verbal communication)?

the models of doctor-patient relationship observed throughout the consultation (eg. levels of guidance, co-operation and mutuality)

what might have been done differently? Students are required to use their reflections for their assessed presentation in February and they should therefore spend some time reading the presentation instructions.

4. Tutorial

Students will then have a tutorial where they can debrief and discuss reflections with their GP tutor (half an hour approximately).Students must treat these encounters confidentially. Students will return to the allocated general practice with their partner for three sessions next term.

Sign up

Students can get the membership of a medical defence organisation signed up during one of your GP sessions but it must be done by the end of this year in order to progress to the end-of-year examinations. It is the student’s responsibility to ensure that this is done.

Recommended reading

Stephenson A. 2004. Editor A textbook of general practice. 2nd edition. London: Arnold. Chapter 1, p 1-8

Stephenson A. 2004. Editor A textbook of general practice. 2nd edition. London: Arnold. Chapter 3, p 17-30

Stewart M. Towards a global definition of patient centred care. BMJ 2001; 322:444-445 (Available through Ejournals on KCL website – use Athens password when connecting externally)


Hospital Visit 1

Interviewing a Patient in Hospital - Admission

Details

Date: Date & time will be confirmed by Dr Alyx Taylor via email Venue: Allocated Hospital

Aims

The aim is for each pair of students to gain insight into the procedures for admission to hospital and the medical and social consequences of being an inpatient.

Objectives

By the end of the session you should be able to:

Describe the process leading to admission of your patient

Discuss the impact of illness on patients and their families

Discuss the impact of admission to hospital on patients and their families

Outline of the Session in Hospital

We want you to explore the process of admission for your patient, following the pathway to hospital admission in terms of decisions, times, people involved etc and then explore the effects of being a hospital inpatient. As part of this process you will need to find out about the medical problems that affect your patient. You should expect to spend about an hour exploring these issues, following the process through in detail. This may be possible in one stretch or you may need to split this time into two or more periods.

Areas that you may want to explore with your patient are listed below. The responses may be brief and superficial but we want you to explore them in greater depth, eliciting the patient’s ideas, concerns and expectations. You are then asked to relate this to your experience in primary care to develop your knowledge and opinion about the interface between primary (general practice) and secondary (hospital) care and the effect on patients of admission to hospital or care at home.

1. Introductions

Each tutorial group will be allocated one or more wards for their visit. If there are two wards divide the group between them and work in pairs. The first thing to do when you arrive on the ward is to introduce yourself to one of the nursing staff and say which year you are in and why you are there. The wards have agreed to have students for this session and to suggest suitable patients. However, the nurses work in shifts and the nurse you speak to may not be aware of the arrangements. You can reassure them that the sessions have been agreed with the head nurse for the Trust and with the sister for the ward. Ask them to point you towards a patient who would be able to speak to you.

2. Patient interview

Your information should come from the patient and, with the patient’s agreement, any relatives who may be present. You do not need to obtain information from the nurses, doctors or patient’s notes.

Remember that the information you receive is confidential between the patient and their carers, including yourselves. The patient should not be identifiable from the records you keep or the material you present.

Consider how you might ask the patient about the areas below using a variety of question styles (e.g. open, closed, probing, and clarifying).


Suggested areas for exploration:

The admission

What was the date and time of admission?

What was the process leading up to arrival in the ward?

What led to the admission?

How did the admission come about and who was involved in these decisions?

What has been the patient’s experience of the admission and experience since?

The effects

What’s it like to be in hospital? (You may wish to enquire about specific areas within this) and how does the patient feel about it?

What impact has it had on home life (e.g. arrangements for children, relatives, pets etc.)?

If relevant – what impact has it had on the patient’s employment?

Does the patient have any particular worries or concerns about the above?

What are the worst things about being in hospital?

What are the best things about being in hospital?

3. Reflection and logbook sign-up

After you have finished talking with the patient you and your partner should spend some time discussing your findings and your impressions, and then about half an hour writing up your experiences. Later you will need to combine this with your experience in primary care to produce your presentation at the end of this term. There will be an opportunity to explore these concepts further at the seminar later this term.

PLEASE NOTE: You will need to get your logbook signed by one of the nursing staff on the ward. They have been asked to sign the books confirming that you have been on the ward, seen your patient and acted in an appropriate professional manner during the session.

Queries

If you have any queries about hospital visits, please contact Suzanne Vaughan: 020 7188 3739, [email protected] or David Treacher, Undergraduate Sub-Dean for St Thomas’ Hospital ([email protected])

Recommended reading

Don Berwick speaking at the International Forum on Quality and Safety in Healthcare 2009 http://www.youtube.com/watch?v=SSauhroFTpk

Bruster S et al. National survey of hospital patients BMJ 1994; 309: 1542-46 http://www.bmj.com/cgi/content/full/309/6968/1542?maxtoshow=&HITS=10&hits=1...

National survey acute inpatients 2001/2: http://www.dh.gov.uk/PublicationsAndStatistics/PublishedSurvey/NationalSurveyOfNHSPatients/NationalSurveyInpatients/fs/en

Delbanco TL. Quality of care through the patient’s eyes. BMJ 1996; 313:832-833 http://www.bmj.com/cgi/content/full/313/7061/832

Lothian K, Philp I. Care of older people: Maintaining the dignity and autonomy of older people in the healthcare setting. BMJ 2001; 322: 668-670. http://www.bmj.com/cgi/content/full/322/7287/668

Dempsey OP, Bekker HL. ‘Heads you win, tails I lose’: a critical incident study of GPs’ decisions about emergency admission referrals. Family Practice 2002; 19: 611–616. http://fampra.oxfordjournals.org//cgi/reprint/19/6/611

Krogstad U, Hofoss D, Hjortdahl P. Continuity of hospital care: beyond the question of personal contact. BMJ 2002; 324:36-38 http://www.bmj.com/content/324/7328/36.full

http://www.youtube.com/watch?v=SSauhroFTpk

http://www.bmj.com/cgi/content/full/309/6968/1542?maxtoshow=&HITS=10&hits=1...

http://www.dh.gov.uk/PublicationsAndStatistics/PublishedSurvey/NationalSurveyOfNHSPatients/NationalSurveyInpatients/fs/en

http://www.dh.gov.uk/PublicationsAndStatistics/PublishedSurvey/NationalSurveyOfNHSPatients/NationalSurveyInpatients/fs/en

http://www.bmj.com/cgi/content/full/313/7061/832

http://www.bmj.com/cgi/content/full/322/7287/668

http://fampra.oxfordjournals.org/cgi/reprint/19/6/611

http://www.bmj.com/content/324/7328/36.full


Hospital Visit 2

Interviewing a patient in hospital - discharge

Details

Date: Date & time will be confirmed by Dr Alyx Taylor via email Venue: Allocated Hospital

Aims

The aim is for each pair of students to gain insight into the medical and social consequences of being an inpatient and the organisation of discharge from hospital.

Objectives

By the end of the session you should be able to:

Review the medical and social consequences of being an inpatient

Discuss the effects of good/bad communication between staff and patients

Discus the elements important in planning discharge from hospital

Outline of the Hospital Session

As in visit 1 each tutorial group will be allocated to wards at one of three clinical sites: Guy’s, St Thomas’ or King’s (Denmark Hill). Before you arrive at the hospital you should have read the instructions and reflected on the experience of your general practice sessions and the first hospital visit.

1. Introductions

The first thing to do when you arrive on the ward is to introduce yourself to one of the nursing staff and say which year you are in and why you are there. The wards have agreed to have students for this session and to suggest suitable patients. However, the nurses work in shifts and the nurse you speak to may not be aware of the arrangements. You can reassure them that the sessions have been agreed with the head nurse for the Trust and with the sister for the ward. Ask them to point you towards a patient who would be able to speak to you.

2. Patient interview

Your information should come from the patient and, with the patient’s agreement, any relatives who may be present. You do not need to obtain information from the nurses, doctors or patient’s notes.

Last term you explored issues around the admission of the patient to hospital. This time we want you to explore the question of discharge from hospital for your patient. As part of this process you will need to find out about the medical problems that affect your patient. You should expect to spend an hour or so exploring these issues, following the process through in detail. This may be possible in one stretch or you may need to split this time into two or more periods.

Once again we have provided some questions to guide you but we hope that, by now, you are becoming more confident in your approach and will be able to explore things more freely with your own thoughts. The situation has changed a lot over the last few years. Patients tend to stay in hospital for relatively short periods. However, there are times when they are medically fit to leave but cannot go home safely until various other arrangements have been made for care or support at home or elsewhere.


Remember that the information you receive is confidential between the patient and their carers, including yourselves. The patient should not be identifiable from the records you keep or the material you present.

Suggested areas for exploration:

What was the date and time of admission?

What were the symptoms that precipitated admission?

Have there been previous admissions for the same problem? If so how did they differ?

What has happened since admission?

What is the patient’s experience of communication in hospital?

Who do they see as their main source of information about:

What is the problem?

What is the management?

What is the discharge plan?

What is the patient's understanding of the diagnosis?

What are the plans for future treatment?

What are the plans for discharge from hospital?

What factors are important in decisions about your patient’s discharge?

What plans are being made for future management after discharge?

Has their experience in hospital this time altered their view about any medical problems in the future?

3. Reflection and logbook sign-up

After you have finished with the patient you and your partner should spend some time discussing your findings and your impressions and about half an hour writing a reflective account of what you learnt. We will deal with issues related to hospital care and issues around discharge in some of the scenario lectures.

There is no formal assessment from this session. It is designed to help you appreciate the effect hospitals have on patients, the role of primary (general practice) and secondary (hospital) care. You will need to get your logbook signed by one of the nursing staff on the ward. They have been asked to sign the books confirming that you have been on the ward, seen your patient and acted in an appropriate professional manner during the session.

Queries

If you have any queries about hospital visits, please contact Suzanne Vaughan: 020 7188 3739, [email protected] or David Treacher, Undergraduate Sub-Dean for St Thomas’ Hospital ([email protected])

Recommended reading

Discharge from hospital pathway, process and practice, DoH 2003 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003252 Summerton H. Discharge planning: establishing an effective co-ordination team. British Journal of Nursing 1998, 7:1263-7 http://www.internurse.com/cgi-

bin/go.pl/library/article.cgi?uid=5565;article=BJN_7_20_1263_1267

Cleary PD. A hospitalisation from hell: a patient’s perspective on quality. Annals of Internal Med 2003, 138:33-9 http://annals.org/article.aspx?articleid=715889

NHS Institute for Innovation and Improvement. Quality and Service Improvement Tools: discharge planning.http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_serv

ice_improvement_tools/discharge_planning.html

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003252

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003252

http://www.internurse.com/cgi-bin/go.pl/library/article.cgi?uid=5565;article=BJN_7_20_1263_1267

http://www.internurse.com/cgi-bin/go.pl/library/article.cgi?uid=5565;article=BJN_7_20_1263_1267

http://annals.org/article.aspx?articleid=715889

http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/discharge_planning.html

http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/discharge_planning.html


Seminar Session 1

Reviewing your clinical experiences: Clinical attachments, why do people go to the general practitioner / hospital and what happens in the consultation?

Details

Date: 20th September 2013 Time: 14.00 to 16.00 Venue: Hodgkin Building, Guy’s Campus

Aims

The aim of this seminar is to introduce and establish the small seminar groups, emphasize the link between campus based learning and clinical placements, and outline the requirements for the year end assessment.

Objectives


list and work with the agreed group ground rules

define how the clinical placements and seminars link to support learning

demonstrate an ability to apply campus based learning to patient/doctor encounters regarding: - patient autonomy - help-seeking behaviour and what brings people to medical care - the initiation of a therapeutic interview - experiences of becoming a patient in community and hospital settings (paying particular

attention to admission)

outline the requirements for the Presentation Assessment

identify the key skills involved in the exploratory phase of the consultation with reference to the Patient-centred Medical Interview Communication Skills Guide

Outline of afternoon seminar

Seminars are small groups of students that meet to exchange information, hold discussions and are facilitated by a clinician, lasting for two hours. Students will: 1. Introduce themselves and establish the group ground rules 2. Reflective Exercise- Reflect upon your clinic session and discuss what went well, what could have gone better and how could you do it differently in the future. 3. From the information gained in the clinical sessions:

Explore the reasons why people seek medical help, resulting in hospital admission, including physical, psychological, social and economic factors.

Link with lectures in Psychology and Sociology on symptom perception, social aspects of illness, psychological aspects of illness and illness behaviour


Discuss communication issues, linking learning in Communications Skills with your observations and experiences in clinical practice around patient-centeredness, particularly in relation to the opening stages of the interview

Link with Sociology lecture on models of the patient-doctor relationship.

4. Understand appropriate professional etiquette with regard to home visits and travel to clinical placements and seminars. 5. Clarify requirements for the Presentation Assessment. Students should use their experiences of their hospital and joint experiences of their general practice attachments and their theoretical understanding from lectures and reading to illustrate understanding of this topic.

Sign ups

Attendance at seminars with the appropriate handbook/paperwork, should be confirmed by the seminar leader’s signature on the specified page of the KUMEC Student Handbook.

Recommended reading

Stephenson A. 2012. Editor A textbook of general practice. 3rd edition. London: Arnold. Chapter 3, p 19-32; Chapter 12, p 219-236


Eliciting a Medical History Introduction and Module Overview

Aims

This module is comprised of important skills in preparation for Phase 3. It provides the building blocks for interviewing patients to elicit their medical history, combining communication and data gathering skills. It is important that students refer to the patient centred communication skills guide (Appendix C), as this is a critical part of the teaching on the communication skills course. Students will further develop their communication skills in this context and familiarise themselves with the rules for giving and receiving constructive feedback.


Eliciting a Medical History Symposium

Details

Date: 18th September 2013 Time: 09:30 – 13:00 Venue: Hodgkin Building, Guy’s Campus Topic: Clinical Symposium and workshops: eliciting a medical history

Aims

This session offers students a comprehensive overview of the process of eliciting a medical history, and introduces the KCL History Taking Framework (Appendix B). There is a lecture, followed by small group work with simulated patients.

Objectives

By the end of this session, students should be able to:

demonstrate a basic ability to elicit a Focused Medical History using the KCL History Taking Framework (Appendix B)

identify and demonstrate effective communication skills and a patient centred approach to eliciting a medical history (Appendix C)

Content of session

The first part of the session is an interactive facilitated lecture where students observe a doctor taking a short history from a simulated patient. Students are expected to critique and make observations of the process with the facilitator. The second part of the session is a small group seminar/ workshop where the skill is further explored with a Facilitator. A selection of students have the opportunity to explore and practice taking a Focused History with simulated patients.

Recommended reading

Appendix B: History Taking Framework A Textbook of General Practice – Ed. Dr Anne Stephenson Shah N., Taking a History: Introduction and the Presenting Complaint, Student BMJ 2005 13:309-352 http://student.bmj.com/student/view-article.html?id=sbmj0509314 Shah N., Taking a History: Conclusion and Closure, Student BMJ 2005 13:353-396 http://student.bmj.com/student/view-article.html?id=sbmj0510358 Patel P., Family and medicine, Medical Education 2007 41: 530-532 http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2007.02761.x/abstract

Attendance and sign-up

Attendance at seminars with the appropriate handbook/ paperwork, should be confirmed by the seminar leader’s signature on the specified page of the KUMEC Handbook. Due to the nature of these sessions we do not allow students to change groups.

http://www.rcgp.org.uk/shop/books/medical-students/a-textbook-of-general-practice.aspx

http://student.bmj.com/student/view-article.html?id=sbmj0509314


http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2007.02761.x/abstract


Eliciting a Medical History Seminar/Simulation

Details

Date: 4th October 2013 Time: 14.00 to 17.00 Venue: Guy’s Campus Topic: Simulation workshops: full history take

Aims

This session is designed to offer students an overview of a Full/Long History take (12 minutes) based on the KCL History Taking Framework (Appendix B: History Taking Framework) focusing on all of the complaints and concerns of a patient.

Objectives

By the end of this session, students should be able to:

display a basic ability to elicit a Full Medical History using the KCL History Taking Framework

identify and demonstrate effective communication skills and a patient centred approach in eliciting a medical history.

Content of session

Following an overview of the KCL History Taking Framework with the seminar leader, simulated patients will present scenarios covered during the year. A number of students will practice the interview/history taking skills developed during the module. This will be invaluable practice for the OSCE.

Sign up

Attendance at seminars with the appropriate handbook/paperwork should be confirmed by the seminar leader’s signature on the specified page of the KUMEC Handbook.



Details

Date: 9th October 2013 Time: 14:00 – 16:00 Venue: Allocated GP Practice Topic: Eliciting a Focused Medical History within a patient centred framework

Aims

For students to elicit a Focused Medical History from patients, paying particular attention to the presenting problem, character/onset of pain, exacerbating factors, alleviating factors, associated symptoms and patient’s concerns.

Objectives

By the end of this session, each student should be able to:

List the appropriate communication skills required to elicit a Focused Medical History

Demonstrate a basic ability to elicit a Focused Medical History from a patient (with emphasis on the presenting problem)

Describe an appropriate attitude when discussing sensitive issues

Show an understanding of issues related to patient consent and confidentiality

Explain a patient centred approach/appropriate professional conduct

Display the ability to give and receive feedback.

Content of session

Tutorial on history taking

The session starts with an introductory tutorial where the GPT explores and demonstrates the History Taking Framework (Appendix B) with the students.

Student pairs practice eliciting a focused history

In pairs, the students elicit a Focused Medical history from one or two pre-selected patients (using the History Taking Framework, focusing on the learning aims). Student pairs to be observed by the GPT eliciting one history. If only one student is observed eliciting a focused history this session, the other student should be observed eliciting one in the following session. Students should obtain consent, give appropriate assurance of confidentiality, and demonstrate empathy, respect and a patient centred approach. Please note: Patients should only be seen by ONE PAIR of students at a time in a session. A second patient needs to be recruited if the tutor has more than two students.

Reflective feedback session

A reflective tutorial with the GPT on the interview.

Sign ups

GPT to complete a Patient Interview Sign-up after observing each student elicit a history over the next two sessions. See guidelines in Logbook.

Organisation of session (for GPT information)

Fully briefed and suitable patient(s) should be invited by GPT for students to interview


Separate patient/patients for each student pair to interview (patients should only be seen by ONE PAIR of students at a time in a session)

Suitable consultation rooms to be made available

GPT observes at least one student interview per pair

Students feed back to each other and GPT after the patient has left (Appendix F).

Recommended reading

Appendices A - F A Textbook of General Practice – Ed. Dr Anne Stephenson

http://www.rcgp.org.uk/shop/books/medical-students/a-textbook-of-general-practice.aspx


Chronic Illness and the Healthcare Team Introduction and Module Overview

Aims

For students to be aware of the different roles within the multi-disciplinary team, recognise the importance of good communication and understand the impact of chronic illness on the patient, family and carers.

Objectives

Student should be able to:

describe the psychosocial effects of long term illness, and the physical constraints that a chronic illness can present

outline how this may impact on the patient and family, and carers

discuss the value of good communication, confidentiality and appropriate referral within the healthcare team

Recommended reading

Stephenson A. 2004. Editor A textbook of general practice. 2nd edition. London: Arnold. Chapter 2, p 9-16 Stephenson A. 2004. Editor A textbook of general practice. 2nd edition. London: Arnold. Chapter 9, p 161-176 Stephenson A. 2004. Editor A textbook of general practice. 2nd edition. London: Arnold. Chapter 10, p 177-186



Date: 6th November 2013 Time: 14.00 to 16.00 Venue: Allocated General Practice Topic: Chronic illness and the Health Care Team – Interviewing a patient in General Practice

Aims

To provide students with an opportunity to practice their core communication skills with patients, and to provide them with insight into the difficulties that patients experience living with chronic illness.

Objectives


discuss the salient points regarding the patient’s chronic illness – providing a brief medical history and explaining how the illness affects the patient, focusing on the main physical and psychosocial aspects of the patient’s illness

demonstrate the use of core communication skills when interviewing a patient, particularly in relation to the closing stages of the encounter

demonstrate an appropriate process of obtaining consent and ensuring confidentiality

Content of session

The practice session lasts for two hours; precise timings are determined by GPT’s working hours. The GPT is required to pre-invite a patient with a chronic illness from the practice for each student pair to meet and interview. The session commences with a half hour briefing by the GPT regarding the pre-invited patient, clarifying relevant issues concerning the patient and his/her family/carers including any particular features of the patient’s chronic illness that students need to be aware of, such as hearing or vision impairment, sociological and psychological factors.

The patient sessions entail:

1. Prior to the interview commencing, student pairs establish and agree the specific areas that they each intend to explore with the patient

2. GPT introduces the student pair to the patient, establishing that consent has been obtained. The students then interview the patient, observing and supporting each other in the process

3. After the session, student pairs spend half an hour discussing and writing up their experience and findings, providing each other with constructive feedback on the interview, before debriefing/tutorial with the GPT.

Students should spend time familiarising themselves with the instructions for the assessed presentation as they will be required to use some of the information from patients they interview for this purpose. Students then have a tutorial where they can discuss their reflections with their GPT (half an hour approximately) and plan for their next general practice session where they will be interviewing a patient with a chronic illness in their home.

Sign up

Students should sign each other off for communication skills (see Logbook).

Recommended reading

Students should complete the recommended reading for this module prior to this visit.



Date: 20th November 2013 Time: 14.00 to 16.00 Venue: Allocated General Practice Topic: Chronic illness and the Health Care Team – Interviewing a patient at home

Aims

To provide students with an opportunity to practice their core communication skills with patients and explore the consequences for patients living with chronic illness.

Objectives

By the end of this session students should be able to:

describe the physical and psychosocial aspects of living with chronic illness for patient/carer

list the effects of good and bad communication on those living with chronic illness

outline the support provided by the Health Care Team to the patient and carers

list the support provided by informal carers such as family members

discuss issues of consent and confidentiality relating to home visits

define the key communication skills involved in the closing phase of the consultation (with reference to APPENDIX C – Patient centred medical interview)

Outline of the session

This afternoon’s practice session lasts for two hours, precise timings are determined by GPT’s working hours.

The session will start with a briefing by the GPT in the practice regarding the patient home visit this afternoon, focusing on the impact of the patient’s illness on the family and the involvement of community services and informal carers.

The patient session(s) will entail:

1. Prior to the interview students should agree on who will ask what and clarify areas to cover (see guidelines concerning consent, home visits and interview)

2. Travel to the patient’s home at a time pre-arranged by GPT

3. Student pairs sharing interviewing the patient, observing each other doing so

4. Students return to the allocated practice discussing and writing up experience and findings with clinical partner, giving each other constructive feedback on the interview, before debriefing with the GPT.

Students should spend time familiarising themselves with the instructions for the assessed presentation as they will be required to use some of the information from patients they interview for this purpose. Students then have a tutorial where they can discuss their reflections with their GPT (half an hour approximately) and plan for their next general practice session where they will be interviewing a patient with a chronic illness in their home.

Sign up

Students should sign each other off for communication skills (see Logbook).


Recommended reading

Stephenson A. 2004. Editor A textbook of general practice. 2nd edition. London: Arnold. Chapter 2, p 9-16 Stephenson A. 2004. Editor A textbook of general practice. 2nd edition. London: Arnold. Chapter 9, p 161-176 Stephenson A. 2004. Editor A textbook of general practice. 2nd edition. London: Arnold. Chapter 10, p 177-186

Home interview

How to start

Introductions, establishing a friendly rapport with the patient and any family members or carers who might be present

Discuss confidentiality and encourage the patient to discuss any concerns in this regard

Ensure that the patient understands the purpose of the visit and that they have given consent to the practice for the interview to take place.

Information to elicit during the interview

An informal history from the patient of their condition. (It is preferable to allow the patient to ‘tell their story’ about their health in their own words first before asking specific planned questions).

Some background on the patient’s circumstances. Do they live alone/who supports them/family background? (Do not press areas that seem sensitive unless the patient seems comfortable with this).

Explore how they have been affected (both individually and as a family) by the condition (i.e. socially, economically and psychologically).

What are the patient’s ideas, concerns and expectations about their condition and its impact on their lives?

What are the positive adaptations they have made in response to the situation?

How to close

Patient should be re-assured about confidentiality

Ask them to complete the feedback form and consent audit (Appendix **) which should be photocopied and returned to your seminar leader

Patient and their family/carer must be thanked for their help. A short thank you note or card might be appropriate as they are giving up their time for your education.

After the interview

Spend half an hour making notes of the interview for discussion with GPT and seminar leader and for use in preparation for end of year clinical presentation.


Access to Healthcare Module Introduction and Programme Overview

“Learning about, and respecting the diverse perspectives of others is the essence of patient-centeredness, and can help health professionals develop supportive, co-operative and more effective relationships and alliances with patients. This is fundamental to the doctor–patient relationship: it validates the legitimacy and worth of others’ backgrounds and provides a more effective base for better communication.”

Extract from `Valuing Diversity` Royal College of General Practitioners (1999)

In response to this changing climate the Exploring Medicine in the Community programme has been evolving over some years. This Access to Healthcare module has been developed in response to the feedback from both students and tutors who wished to look at issues around diversity in its broadest sense, thus more of a focus on the individual patient. This necessarily meant looking at issues of access, responding to patients’ needs and looking at the ‘story’ behind the eliciting of a medical history. It has been planned to complement and integrate with the input by Psychology, Ethics, Public Health and Sociology. We hope that students will be able to relate their theoretical learning in these subjects to their own lives and the experiences and lives of real people in the community through attachments to practices and small group learning.

Please note - The OSCE at the end of this year will test skills learnt throughout the first year of the course. It is therefore very important that students attend all aspects of the course.

Aims

To provide for the students with an understanding of the diversity of background, experience and expectation of patients and colleagues in the health care environment and community.

Objectives

By the end of this module, students will be able to:

discuss ideas and issues regarding belief systems, assumptions, illness behaviour and how these impact on the health care encounter

outline health care issues concerning access to resources, service provision and identifying gaps

demonstrate a patient-centred, confident style as a member of a multi-professional team that represents diverse ways of being thinking and doing

display a raised awareness of own values and attitudes and how these might impact on the health care encounter, particularly the doctor patient-relationship.


Access to Healthcare Symposium

Details

Date: 9th January 2014 Time: 13:00 to 16:00 Venue: Greenwood Lecture Theatre Topic: Clinical Symposium - Access to Healthcare Symposium

Aims

This symposium provides insight into how some groups of people experience gaps in service provision and barriers to accessing to health care.

Objectives

By the end of today’s session, students will be able to:

describe the clinicians’ responsibilities and outline the impact of current service provision on individuals and diverse communities

discuss the diverse backgrounds and experiences that can cause barriers to accessing healthcare for individuals and groups.

Content of session

A panel of invited specialist clinicians will explore the health needs of particular groups, these may include:

men and their particular issues when accessing sexual health services

the housebound

the homeless, alcohol and drug abusers

refugees and victims of torture

clinicians themselves.

Comments from last year

“Brilliant; Emotional; Enlightening; Disturbing; Excellent; Fantastic; Informative; Insightful; Interesting; Relevant; Thought-provoking; Valuable; Well-delivered; Broad; Interesting.”

Please note that this session was highly valued last year, but also contains some disturbing content.



Details

Date: Wednesday 15th January 2014 Time: 14.00 to 16.00 Venue: Allocated General Practice Topic: Access to healthcare – meeting the needs of the practice population

Aims

Students will gain insight into the services provided by their allocated GP practice, and observe how the needs of the practice population are met. To gain insight into whether the needs of marginalized groups and groups with special needs are actually met

Objectives

By the end of this session, students will be able to:

Identify significant features of the practice population

Demonstrate an understanding of the difficulties and opportunities of providing patient centred care to diverse communities

Discuss how/whether the needs of marginalized patients are actually being anticipated and achieved

Content of the session

(GP to provide a hard copy of the practice profile)

1. Tutorial and practice interviews on issues surrounding access to healthcare

The GP teacher provides and explains the local area profile to students, including economic, social and cultural factors. He will then be interviewed by the student pair regarding the issues as a clinician, before directing students to interview the practice manager or senior member of the practice team familiar with the practice population. This second interview is to gain insight from the funding (income generation) perspective (QOF, QIPPs, national and local targets, Clinical Commissioning Groups). The following questions may provide some ideas for the students when interviewing the GP and Practice manager. This is not a finite or comprehensive list:

How big is the list?

How many men/women?

What are the predominant age groups?

What social/economic/cultural/ethnic backgrounds do the patients come from?

How long have you been working in the practice?

What is your role within the practice?

Have you identified any issues regarding (problems with) access to healthcare in the practice population?

In what ways do you feel the practice itself is able to meet the needs of the groups identified at the practice, and what specific issues do they present?

Do targets (national and local) influence clinical decisions?

Does this provide conflict for you in your role in this practice?

Are you aware of any specific current issues that people may present with/difficulties they may have accessing healthcare?


Are there ways in which you feel the practice could improve its service to meet the health needs of the practice population – specifically the housebound (patients with MS, diabetes, COPD), sex workers, the homeless, alcohol or drug abusers, refugees, sex workers, vulnerable adults and children.

Students should reflect on the following:

The different roles of all practice team members and how their agendas may differ and cause conflict for the clinician

The policies and procedures used by the practice to facilitate access to their services

The barriers to accessing healthcare at this practice

Enquire about the local community/area, services available etc on the way to and from the GP practice

Students should reflect on social stigma (Goffman) and discrimination, and the ethics and practicalities of equity in healthcare.

2. Student pairs practice eliciting a focused history from a patient

Students then have an additional opportunity to take a focused history from a patient. GPT should consent one or more patients from their list and observe one student from (each/the) pair elicit a focused medical history, providing feedback. Please note the patients should not be seen by more than two students at once. If the GPT observed one student from a pair elicit a history during the last session, they should observe the other student elicit a history in this session.

3. Reflective feedback session

A reflective tutorial with the GPT on the interview.

Suggested reading

http://www.healthknowledge.org.uk/public-health-textbook/medical-sociology-policy-economics/4a-concepts-health-illness/section3




Presentation Assessment Session

Details

Date: Wednesday 12th February 2014 Time: 14.00 to 16.00 Venue: Guy’s Campus Topic: Becoming a Patient and Patient-centred Approaches in the consultation

Aims

For student pairs to present their learning from clinical attachments and seminars.

The presentations

As part of the in-course assessment students will, with their general practice student partner, give a 10-minute presentation on becoming a patient and patient-centred approaches in the consultation. Students should use their experiences of their hospital and joint experiences of their general practice attachments and their theoretical understanding from lectures and reading to illustrate understanding of this topic. Students will be assessed as a pair or group of three based on the criteria below and this will provide 2% towards the end-of-year mark.

Presentation guidelines

During this presentation students should aim to reflect upon what they have learned during your clinical attachments in general practice and hospital in relation to:

The process of becoming a patient /admission/discharge

The experience of being a patient in different settings (community and hospital) and the influence of appropriate communication and planning on the patient’s ability to cope

The types of approaches taken during the doctor-patient consultations and your student-patient interviews

The interactions that you observed and experienced

An important part of the presentation will be to point out how experiences link with lectures and reading. Students will also be marked on presentation skills.

Students may use a maximum of four PowerPoint slides per pair (two each). Following each clinical placement, students were required to spend at least half an hour with their partner, discussing and writing up notes of experiences and findings. These notes should serve to inform the choice of appropriate cases for the presentation.

Students have attended two community seminars: Introduction to Clinical reflection and Chronic illness and the health care team. The students should consider and revise these two subject areas.

Seminars explored the process of becoming a patient, the reasons why people seek medical help and are admitted to hospital - including physical, psychological, social and individual factors. Students should link their observations with lectures in psychology and sociology on symptom perception, social aspects of illness, psychological aspects of illness and illness behaviour. Students should think creatively.

Suggested areas for reflection include:

Difficulties meeting dietary requirements at home or in hospital (eg. Medical issues such as diabetes and requirements regarding beliefs).

Does the patient live alone?


Does the patient have dependants?

Problems the patient may face once he has returned home or is back at work.

Experiences of interviewing, and communication skills, perhaps describing insight into how their personal approach might improve or develop.

Consider the ‘model’ patient-doctor relationship.

The principles of confidentiality and consent.

Did the GP ask for consent from the patient to allow the student to observe? What happened? Did the student feel uncomfortable? What impact did the student’s assurance regarding confidentiality being maintained within the team have on the interview?

Consider two styles of consultation observed which demonstrated a Patient centred approach, and a Doctor centred approach for contrast.

The psychological effects of long term illness, the physical limits that a chronic illness can present and the impact on the patient, their family and their careers.

Students must demonstrate that they have reflected on what they have observed and experienced and link it back to their lectures/teaching/reading.

Draw on references from KUMEC handbook and notes from other areas.

How to reflect

There are many models, but a simple one is: 1. When ... happened (concrete experience – what did you see, do or hear), 2. I felt .... (try to describe an actual feeling rather than a judgement), 3. Because ... (try to analyse based on your learning from lectures, tutors and recommended

reading etc.) 4. Therefore ... (how it will change your future practice).


Becoming a patient and patient-centred approaches in the consultation

ASSESSMENT GRID FOR STUDENT PRESENTATIONS

Criteria Mark Guideline for allocating this grade

USE OF CLINICAL EXPERIENCES (Marked as a Pair)

5 Well-informed choice of clinical experiences, presented informatively and concisely. Provides evidence that clearly illustrates the relevance of their choices

4 Good choice of clinical experiences, concisely and informatively presented. Interesting and relevant.

3 Satisfactory choice of clinical experiences - sufficient to demonstrate some learning, and of adequate relevance to the presentation.

2 Adequate choice of clinical experiences, but evidence to demonstrate learning would benefit from further development

1 Inadequate choice of clinical experiences with insufficient evidence to support learning

UNDERSTANDING OF BECOMING A PATIENT AND THE PATIENT-CENTRED APPROACH. (Marked as a Pair)

5 Clear and coherent understanding of becoming a patient and the patient-centred approach, with focused linking of experience (attachments) and theory (lectures and reading).

4 Reasonable understanding of becoming a patient and the patient-centred approach with good linking of experience and theory.

3 The basics of becoming a patient and the patient-centred approach are understood. Some linking of experience and theory.

2 Weak understanding of the process of becoming a patient and the patient-centred approach. Linking of experience and theory could be further developed

1 Unable to demonstrate understanding of the patient centred approach. No linking of experiences to theory.

PERSONAL INSIGHT AND REVIEW OF LEARNING. (Marked as a pair).

5 Creative thoughts on insight gained from clinical attachments and how personal approach might be changed or developed.

4 Good thoughts on insight gained from clinical attachments and how personal approach might be changed or developed.

3 Some insight. Thoughts on personal change adequate.

2 Little insight or thoughts on change.

1 No insight or thoughts on personal change.

PRESENTATION SKILLS (Marked Individually)

5 Strong presentation skills. Well structured, clearly delivered in a coherent and well linked order.

4 Good presentation skills. Clearly delivered with good linking of ideas demonstrated.

3 Adequate presentation skills. Some clarity in delivery and structure.

2 Inadequate presentation skills, unclear with very little linking of ideas. Poor use of time allotted

1 Unprepared and incoherent presentation


History Taking Revision Session

Details

Date: 17th April 2014 Time: 10:00 to 13:00 Venue: Guys Campus Topic: Simulated History Taking workshops

Aims

Students review topics covered throughout the year, which will help them to prepare for the OSCE.

Objectives

By the end of this session, students will be able to:

describe the differences between a Focused and a Long History Take

demonstrate professional conduct while taking a clinical history using the KCL Framework

demonstrate appropriate communication skills through a patient centred approach

Content of session

With simulated patients, students will take part in a workshop where they observe and practice history taking, both Focused History (5 ½ minutes) and Full History (11 ½ minutes) using the scenarios they have covered throughout Phase 2.

PLEASE NOTE: Attendance at seminars with the appropriate handbook/paperwork, should be confirmed by the seminar leader’s signature on the specified page of the KUMEC Teaching Handbook.


KUMEC Sign-Ups 2013-14

COMMUNITY TEACHING SESSIONS ATTENDANCE RECORD

Attendance at each community teaching session must be confirmed by the signature of a seminar leader. Student name…………………………………………………………………

Session Date Seminar leader signature

Print name and date

Eliciting a Medical History Symposium

18th September 2013

Seminar – Reviewing your Clinical Experiences

20th September 2013

Role Play Session 4th October 2013

History Taking revision session

17th April 2014


Appendix A: Indemnity (Amended June 2011)

THE ANNUAL TEACHING AGREEMENT 2012-13

THE POSITION BETWEEN THE PARTIES IN RELATION TO THE MEDICAL STUDENTS This document sets out the position between King’s College London, acting through the King’s College London School of Medicine (the “Medical School”) and

Practice name: __________________________________________________

in relation to the medical students, in respect of the Annual Teaching Agreement (the “Agreement”). For the avoidance of doubt, this document forms an integral part of the Agreement:

The medical students have the right to attend at the Practice for the purposes of being taught by Practice staff in accordance with the Agreement. This does not entitle the medical students to exclusive possession of any part of the premises of the Practice at any time. For the avoidance of doubt, their status is purely that of licensees on the premises.

For the avoidance of doubt, there is no contract of employment between the medical students and the Practice. Accordingly, the Practice does not have duties and liabilities towards the medical students, which it would have if it were their employer. However, whilst on Practice premises, the Medical School will procure that the medical students will abide by all and any Practice policies which are notified to the medical students as applicable to them.

Whilst on Practice premises, medical students will remain accountable to the Medical School but will follow the reasonable instructions of the Practice and the instructions given on the Practice’s behalf by those individuals responsible for supervising the medical students during their teaching at the Practice.

The Medical School has a duty to the Practice, its employees, agents and patients when placing a medical student with the Practice in accordance with the Agreement. If the Medical School is aware that a medical student’s professional competence and/or behaviour might be affected by personal or health problems whilst on an attachment to the Practice, then the Medical School will advise the Practice Manager/ Liaison Person accordingly, provided always that this will not necessarily be sufficient to discharge the Medical School’s duty of care in this regard.

If Practice staff consider a medical student’s behaviour to be offensive or unacceptable to the Practice environment, they have the right to require the student to leave the Practice premises without notice, pending a recommendation to the Medical School via the Head of the Medical School, that the medical student be suspended.

The Medical School shall procure that the medical students shall become members of a defence society.

During the medical students’ attendance at the Practice premises, they will be covered, when they are undergoing directly supervised training in accordance with the Agreement, under the NHS indemnity arrangements in respect of those patients of the Practice to whom the medical students are involved in providing care and treatment.

King's College London will take out Public Liability Insurance in case it is found guilty of negligence in a Court of Law.

Where any claim is made, whether or not legal proceedings are issued, arising out of or in connection with the attendance of the medical students at the Practice’s premises in accordance with this Agreement, the Medical School will co-operate fully with any investigation by the Practice in connection with any such claim and will give all such assistance as may reasonably be required by the Practice regarding the conduct of any legal proceedings and shall procure that the medical students shall do likewise.

The Practice does not accept any responsibility for the personal property of medical students while they are on Practice premises or for any vehicles of medical students parked on Practice premises.

The Medical School shall procure that the medical students will co-operate with the Practice in discharging its duties under the Health and Safety at Work Act 1974 and other health and safety legislation and that the medical students will take reasonable care for the health and safety of themselves and others whilst on Practice premises.

The right of each medical student to attend at the Practice’s premises will automatically terminate on the termination of their placement with the Practice or on the termination (howsoever caused) of their course or their participation in the course, at the Medical School and on the death of the medical student.

The provisions noted at paragraphs 7, 8, 9 and 10 above, shall survive the termination, howsoever caused, of the Agreement.

The original of the agreement will have been signed annually by the practice before teaching begins.


Appendix B: History Taking Framework

Aims

To develop interviewing and data gathering skills in preparation for Year 3.

To include:

A clear structured approach, which emphasises the importance of communication skills when interviewing patients.

A KCL History Taking format which can be learnt across the school and used in Year 3, 4 and 5.

General procedure

Eliciting a history from a patient is an essential part of being an effective doctor. It:

Establishes the doctor-patient relationship

Identifies how the illness has progressed to date

Establishes how the illness has affected the patient and their family

Explores the patient’s ideas and concerns about the illness and their expectations of the doctor

Identifies the patient’s physical, psychological and social environment

Often leads to diagnosis Ineffective communication is the most common reason for complaints against doctors. The majority of malpractice allegations arise from communication errors. You are expected to use patient-centred communication skills during all patient encounters, including taking a medical history (see Appendix C). Interviewing the patient in private, introducing yourself, helps building a relationship with the patient and explaining the purpose for the interview with approximate time needed. Taking a history is not just going down a checklist of symptoms. Books have been written about how to consult with patients and there is no set “right way”. Eliciting a patient’s history does not need to be done in a set order. You may have observed doctors who adapt their questioning so that it naturally follows the conversation they are having with the patient. At the end of the interview the doctor can mentally check that all aspects of the history have been covered before structuring the history into the traditional medical model. It is not just information-gathering from the patient, it is a two way communication in which you need to be aware of what and how you are communicating and its impact on the patient. It does include active listening to the patient, awareness of non-verbal communication, with respect and support of their feelings. It is important to use your communication skills effectively, in order to data gather and reach a diagnosis, so that you may decide with the patient the appropriate management. Use the communication skills you have learnt and practised, and your own experience when talking with people.

Summary of History

Introduction and consent Presenting complaint History of presenting complaint (HPC) Systemic Enquiry


Past medical history (PMH) Drug History Drug allergies Family history (FH) Social history (SH) Review Summary

Introduction

Remember to introduce yourself, wear your name badge and state the purpose of the interview and approximate time needed. What the patient will be discussing with you may be very personal to them, so remember that the content of the interview is confidential. Students should explain to patients that any personal information disclosed may be referred to members of the multidisciplinary team responsible for the patient’s ongoing care. Try to be aware of basic details such as name and age before you meet the patient. Confirm with them their name, and any other appropriate identifiers. This may give you valuable information, which can help with diagnosis and management. Remember to ask retired patients their previous occupations. We recommend that you do not use a patient’s first name unless invited to by the patient.

Presenting complaint (PC)

This is your opening question. Remember, it is important to start with an open question. Try a variety of questions and see which you prefer. Your choice may depend on the circumstances of the interview. Some options include:

What has the problem been?

What made you go to the doctor?

Can you tell me the background to how you came to be in hospital?

History of presenting complaint (HPC)

This is the main part of the history and you will need to spend time discussing this with the patient. There are two parts to the HPC:- 1. A description and exploration of the patient’s problem 2. How the problem affects the patient personally You should look both these areas in detail.

1. A description and exploration of the patient’s problem

You can start with: “Can you tell me more about your problem?” Allow the patient to tell you in his or her own words; this can take a couple of minutes of uninterrupted talk from the patient. A commonly quoted research study suggests that their doctor interrupts patients, asked to describe their presenting problem, after an average time of 18 seconds (Beckman and Frankel, 1984).


Allowing the patient to talk without interruption enhances patient satisfaction and efficacy of the interview. They are likely to need verbal and non-verbal encouragement from you to maintain the flow. You can gain a great deal of information during this time:

Observe the patient - do they appear anxious, depressed?

What are their ideas about their illness? It is difficult to address the patient’s concerns if this issue is not explored.

Listen to their story, the diagnosis may become apparent.

Gauge what the patient knows about their illness, so you can respond to them effectively. Next, think about trying to direct your line of questioning to test diagnostic hypotheses at this stage. For example, with a patient who has chest pain, it is important to assess if the pain comes on with exercise if you suspect they have angina. Asking about symptoms can follow a similar line of questioning:

When did the problem start?

Is it a new or old problem?

What did it feel like?

How often does it occur?

What starts it off?

How long does it last?

What makes it worse?

What makes it better?

Does anything else happen to you at the same time, before or after?

What medicines have you tried? (prescribed or over the counter)

What effect have they had? Questions about pain should cover the following points: Site Where is the pain? Radiation Does the pain go anywhere else? Character What’s the pain like? (Think about colicky, constant, dull, sharp, gripping, etc.) Severity How severe is the pain?

Does it wake you at night? Does it stop you doing what you are doing at the time?

Timing How long does it last? How often does it occur? Association Does it come with any other symptoms? Are there any precipitating or relieving factors? You will learn more about how to direct your line of questioning on your clinical firms throughout the course.

2. How the problem affects the patient personally

This should not be forgotten! This also connects with the assessment of mental state, particularly inquiring about symptoms of depression. You can ask:

How has this illness affected you generally?

How does this make you feel overall?


It is important to find out about the patient’s own interpretation of their illness. This allows clinicians to get to the real reason why patients have come to see them - for example; the patient may be worried they have cancer. Of equal importance, patients will not be satisfied if their concerns have not be listened to and addressed. The patient may already know what the problem or diagnosis is, or their thoughts or concerns may have come out earlier when you asked the patient to describe what has happened to them. If it hasn’t, then you can ask:

What do you think is the matter?

Are you worried it may be something in particular? Remember to acknowledge how the patient feels. We know it is common sense, but it’s amazing how often this is forgotten.

Systemic enquiry (SE)

This is also known as Review of Systems (ROS), functional enquiry, or systemic review. As illnesses affect different parts of the body, and many illnesses are multi-system, it is important to ask about connected symptoms, as well as symptoms that may point to other long-term conditions. A full systemic enquiry is typically done when a patient is admitted to hospital, at the ‘admission clerking’. In addition, when a patient may go to the operating theatre it is important to assess their operative risk, so a detailed systemic enquiry is also done. You can start with an open question such as:

Have you noticed anything else wrong? More specific questions may need to be asked, remember to ask them without using medical jargon. For example, when asking about rectal bleeding, you can ask:

Have you ever noticed any blood when you open your bowels? You need to cover the following areas:

Constitutional symptoms: Fever, reduced appetite, fatigue, malaise.

Respiratory System (RS): Dyspnoea, wheeze, cough, sputum, haemoptysis, chest pain.

Cardiovascular system (CVS): Chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, ankle swelling, palpitations, and intermittent claudication.

Gastrointestinal System (GIS): Abdominal pain, nausea, vomiting, haematemesis, bowel habit, blood P/R, melaena, weight gain/loss.

Genitourinary System (GUS): frequency, nocturia, polydypsia, loin pain, haematuria. As appropriate: Menarche, menopause, cycle, intermenstrual bleeding, post coital bleeding.

Central Nervous System (CNS): Headaches, visual disturbances, memory impairment, sleep, hearing, tinnitus, light headedness, blackouts, fits, unsteady gait, weakness, and parasthesiae.

Musculoskeletal (M/S): Myalgia, arthralgia, back pain, joint swelling.

Psychiatric (Ψ): Mood, confusion. The Mental State Examination will be taught more formally in your psychiatric attachment. Remember, depression is common and may often co-exist with physical ill health.

At this stage, do not worry if many of these terms are unfamiliar to you. You will learn more about them in the course of your studies. At each stage you will need to think about how you convert the medical terminology into questions both you and the patient will understand.


Past Medical History (PMH)

Always ask the patient if they have or have had any serious illnesses. The precise details will depend on the clinical condition and the circumstances. Include:

Operations

Hospital admissions

Ask specifically about Hypertension, Ischaemic Heart Disease, Strokes or TIAs, Diabetes, Asthma, Jaundice, TB, Rheumatic Fever

Family History (FH)

This gives a clue to any predisposition to any illnesses and may highlight specific concerns the patient may have about a certain disease. You could ask: -

Are your parents alive or have they died?

Are there any diseases running through the family? Ask the patient what their parent(s) died from and at what age. If they have died, be sensitive to how the patient may feel about this. It is always important to acknowledge a death. You can say:

I am very sorry to hear that, it sounds very upsetting Then ask similar questions about brothers and sisters and children.

Social History (SH)

This is a very important part of the patient’s history. It provides information about:

The patient as a person

How the illness affects the patient and their family

What are the home circumstances, and the patient’s functional baseline prior to current illness

health behaviours to HPC-for example, smoking and IHD. Questions you can ask include:

How are things at home?

Who is at home?

Are there any problems at home? Remember to ask about:

Accommodation

Job

Hobbies

Social life

Diet

Alcohol

Smoking

Recreational drug use Asking about alcohol and drug use can sometimes be difficult. It is easier to be very open and straight- forward. You can just ask:

Do you drink alcohol?

If yes, how much a day?

Do you use any recreational drugs?


If you suspect a patient has an alcohol or drug problem then more detailed questioning can occur. However, this is beyond this overview. It is also important to assess a patient’s “Activities of Daily Living”. This is an assessment of how much support a patient requires to live on a day to day basis. It includes asking about: -

Help with dressing

Help with washing / toileting

Help with eating

Help with walking

Help with shopping

Outside agencies involved in care e.g. Home help.

Drug History

List all patients’ drugs and doses. Remember over the counter and alternative medicines. Some patients can be quite vague about their tablets- try and persevere. Try and assess compliance:

What problems do you have with your medicines?

Do any of your medicines give you side effects?

Drug allergy

Identify any drug allergies the patient may have, and details of what happens, for example, rash or anaphylaxis.

Review

It is always useful to summarise the history and main points back to the patient. It ensures that the patient and you agree and often stimulates the patient to remember other important facts.

Summary

At the end of presenting a history you will often be asked to give a summary to a clinical colleague. Prepare 2-3 sentences to summarise the patient’s problems. In phase 3 you will be expected to include if you can, a diagnosis, and in phases 4 to 5, your management plan. For example: "This is a 64 year old smoker, with a 3 month history of central chest pain related to exercise. He has a 10 year history of hypertension. The diagnosis may be angina."

Recommended reading

Beckham, H.B. and Frankel, R.M. The effect of physician behaviour on the collection of data. Ann. Intern Med.1984; 101:692-696 Shah, N., Taking a history: Introduction and the presenting complaint Student BMJ 2005;13:309–352 http://student.bmj.com/student/view-article.html?id=sbmj0509314 Shah, N. Taking a history: Conclusion and closure Student BMJ 2005;13:353–396 http://student.bmj.com/student/view-article.html?id=sbmj0510358




Appendix C: Patient-Centred Communication Skills Guide

Opening: establishing rapport

Greeting and introductions Verbal and non-verbal messages: facial expression, tone of voice, shake hands if appropriate. Establish rapport. Introduce self and check patient’s name. If patient has been waiting long apologise for the wait. Attention to comfort and privacy Environment, seating and positioning. Allows patient time to sit down or change position (if in bed) if necessary. Consider visiting or accompanying carers/friends Checks with the patient for their understanding and purpose of the interview Invites the patient to speak. Starts with open questions. Demonstrates attentive listening. Awareness of patient cues that might indicate emotional state Verbal cues: tone, pitch and pace of speech. Non-verbal cues: facial expression, body position and tone, hand movements. Acknowledge observed anxiety or distress and maintain rapport. Encourage the patient to continue.

Exploration and planning: managing time and content conveying empathy verbally and non verbally

Appropriate question style Generally moves from open to closed as interview progresses. Avoids interrogative style of interviewing. Listens attentively to patient's responses to each question, acknowledges patient's responses. Appropriate use of silence to allow patient to process thoughts and feelings. Allows time to answer. Surveys problems and concerns Asks, 'Is there anything else' e.g: 'what other problems would you like to mention?' or 'Tell me about anything else which might be worrying you?'. Uses appropriate eye contact, body posture, nodding and encouraging gestures. Reflects back verbally and matches patient's language. Negotiates priorities for problems Determines jointly with the patient which problems to focus on. Explores and responds to patient's ideas, concerns and expectations (I.C.E.) Facilitates potential empathic opportunities to enable patient to express concerns/emotions. Acknowledges express concerns/feelings using empathic responses.

Eg: uses statements like ‘take your time’ 'It is understandable that you feel this way about…' 'That must have been difficult for you'. ‘It is helpful for me to know that’. Remains respectful and non-judgmental. Avoid statements like ‘don’t worry about that’. Uses language the patient understands Matches language and avoids use of unexplained medical jargon.


Checks for meaning and understanding, clarifies unclear statements (from both Doctor & Patient perspectives) Uses phrases like, 'Can you tell me what you mean by…/ understand about…/ expect to happen…'. And 'Let me just try to understand this a little better/ can I just check with you…?'. Is there anything I have said that isn’t clear / you would like me to go over?’ Focuses and re-directs the patient appropriately Uses phrases like 'You mentioned X earlier on, can you tell me a little more about that?' Moves on to using more closed questions. Summarises content, feelings Employ's reflection, e.g.: 'You seem particularly worried by this' or 'You look upset'. Uses statements like: 'Can I just go over what we have discussed so far' or 'let me just go over what we have talked about so that I can be sure I fully understand how this affects you'. (Refer to explaining skills guide if detailed explanations need to be offered). If bad news is to be raised then refer to breaking bad news guide). Negotiates plan of action Outlines preferred options for further investigations / treatment or reasons for not intervening. Elicits patient’s preferences. Agrees mutually acceptable plan. Check for any outstanding concerns. Provide concrete information as to what will happen next.

Closing

Confirms course of action with patient Checks for understanding. Is there anything else the patient would like to ask or know? Asks if patient is OK before preparing final stage of interview. If in clinic or GP surgery check on how they are getting home if appropriate. Negotiates a final summary with patient Offers a summary statement. Confirms what will happen next. Closes interview Check patient’s emotional state before leaving. Shakes hands if appropriate. Says goodbye.

Recommended reading

The King’s Fund http://www.kingsfund.org.uk/topics/patientcentred_care/ Patient-centred care – tomorrow’s doctors Christine Hogg 23 March 2004 http://www.gmc-

uk.org/patient_centred_care.pdf_25397151.pdf

http://www.kingsfund.org.uk/topics/patientcentred_care/

http://www.gmc-uk.org/patient_centred_care.pdf_25397151.pdf

http://www.gmc-uk.org/patient_centred_care.pdf_25397151.pdf


Appendix D: Guidelines for Responsible Learning

An ethical approach to professionalism, personal safety, decision-making and learning for students in early years of clinical experience.

Introduction

As a medical student you are in a very privileged position in being given access to peoples’ lives, their medical and personal histories as part of your education. You should behave in a manner becoming your position as a doctor-to-be, and treat patients and your colleagues with the utmost courtesy, respect, and in confidence. These guidelines complement your formal ethics lectures and as such facilitate your understanding of the importance of ethics, not just when you become a doctor, but during your undergraduate years. This should help you develop an appreciation of ethical principles from a practical perspective as well as theoretical. Your seminars will draw on your learning and experiences so that you will be able to approach your assessments with confidence. These guidelines offer some thoughts on important aspects of your conduct and thinking that will help you now and in the future.

Professionalism & Personal Safety

Arrangements

Be clear and consistent in arrangements you make with patients, your Tutors, and your colleagues. You may sometimes need to re-confirm meeting times. Check your e-mail, and keep people informed.

Appearance

Always dress appropriately for meeting and / or being seen by patients. Because circumstances vary, take advice or a lead from your Tutor.

Attendance

Tutors and patients will have made special arrangements for you, organising their time and surgery rotas for teaching. It can be extremely irritating if you fail to turn up, and we do not want our Tutors discouraged from teaching, for your sake and for that of your successors. Tutors and Seminar leaders are asked to log in your attendance (see forms in this booklet). Any unauthorised absence will be noted and followed up. Students are expected to comply with the attendance regulations of the medical school. If you know you will be unavoidably absent or late, inform whoever is leading the session.

Punctuality

Always be punctual: lateness is a discourtesy to patients, tutors and your colleagues, and it disrupts the process of any group work, which is unacceptable.

Safety

Do everything you reasonably can to ensure your own safety and that of others at all time. Take care after dark, be sure to get good directions, and preferably go accompanied. If you are going on a


home or other visit unaccompanied, make sure someone knows where you are. If you feel uncomfortable about going somewhere, inform your Tutor. Many surgeries have personal alarm systems, with which you should familiarise yourself. Always pay attention to your personal belongings.

Indemnity

Ensure you have read the section on indemnity in the Handbook. You should be aware that the Medical School requires that all students seek membership of a medical defence society from year 1 of the course.

Boundaries

The patient tells you of their life; sometimes they will ask more of you than you feel comfortable to give, so setting boundaries is part of professional growth. Your own judgement will give you a good clue, but remember always to be courteous. It is possible and good to learn how to say “No” politely, and without giving offence. If a patient or their relative asks you for a diagnosis, prognosis or suggested treatment, you must in a polite way inform or remind them that you are not able to, as you are a medical student. This seems obvious to you but it does happen. Also patients may sometimes question their doctor's advice, asking you for your views. Again the obvious course of action is not to pass an opinion, however you may have to work on this! Some important considerations are:

Don’t give medical advice; you can however suggest the patient speaks to their GP, or that you can pass on a message

You are strongly advised not to become involved with the patient or family outside the attachment arrangements

You may be asked for your views and beliefs: like the patient, you are entitled to these, but do not impose them on the patient or your colleagues. If you need to express them, discuss them amicably

If (rarely) someone is threatening or abusive, or if you feel that your safety is in doubt, terminate the interview, and contact your Tutor or the School immediately.

Smoking and other Policies

Most Practice and Trust premises will operate a no-smoking policy – you must comply with such policies.

Property

Treat equipment and property with respect, ensuring that you obtain permission to use any items and always replace them appropriately.

Permission

Do not visit or arrange to visit patients without the express permission of your Tutor.

Demeanour

Never forget to greet the patient, introduce yourself properly, confirm their consent, thank them for their willingness to help, and reaffirm the confidentiality of the sessions. The patients will have some idea of the purpose and nature of the interviews or sessions, but you should be ready and willing to answer any questions they might have, and particularly to prepare them for the use of tape recording.


Informed Consent

The patient’s consent for any involvement in teaching is always carefully sought, and it is made clear they have the opportunity to decline without prejudice to their care. You should advise the patient to discuss the proposal with their partner, close family or household members to ensure that there are no objections. The principle of informed consent means that the exact nature and extent of the patient’s involvement should be made clear to them at the outset. The process is aided by a letter and a booklet given in advance by their GP. This makes it clear that their involvement is appreciated and the information collected is confidential. When patients agree to a recording being made, they are asked to sign a consent form. If at any time a patient decides to withdraw, remember it remains their right, so treat this courteously, and do not take offence; this is a patient-centred approach to health-care.

Confidentiality

A confidential conversation allows truth, fear and uncertainty to be expressed; breaching confidentiality destroys trust. Never discuss what you have heard, even anonymously with anyone outside the team of healthcare professionals responsible for the care of the patient. Students should explain to patients that any personal information shared during the medical interview will be referred to members of the multidisciplinary team responsible for the patients ongoing care. Particular care should be taken with any record, and the identity of patients in any such records held by students should be obscured. Tapes should be listened to only for educational purposes, and then wiped.

Decision-making

As well as arming yourself with knowledge about conditions and therapies, and gaining communication and clinical skills, you will learn how to make decisions soundly. This process involves more than logic; balancing probabilities and uncertainties are basic to medicine. Decisions can be made with reference to systems of ethical principles, which allow the decision to be robust. This type of thinking helps in every-day practice because it indicates what decisions to aim for, and how to achieve them. Clearly at this stage in your career, you will not be responsible for making clinical decisions, but you will see them being made, and should begin to understand how you will make them in due course. It is important to say that ethical thinking does not start when there are contentious issues under discussion like abortion or terminal care; if this kind of thinking is used all the time, even when apparently more banal decisions are being made, then the practice and familiarity this brings will pay dividends when the decisions do centre around issues traditionally seen as being "difficult". For this reason, we will encourage you to look at any or all of your thinking from this standpoint, to give you good practice at making ethically sound decisions. If you feel strong emotional discomfort in a particular situation, it is often a very good cue to make you review your own thinking. For instance, if a decision makes you angry or feel pity, maybe it needs reviewing.

Ethical principles

At this stage it might be useful to think about some ethical principles, which are clearly present in most medical decision-making; they are respect for autonomy, beneficence, non-maleficence, and justice. These concepts, which can be roughly interpreted as promoting patient choice, doing good, not doing harm, and being fair, sometimes conflict in clinical situations (as other situations), and the skilled clinician will chart a way through the dilemmas by balancing these principles, as well as balancing other factors in the decision.


Additionally, the apparent problem of a tension between two or more of the ethical principles often highlights what needs to be changed to solve the problem. For instance, if a patient does not want a form of treatment, is this because they don't fully understand it, and therefore shouldn't the clinician attempt to improve the patient's understanding (beneficence v autonomy)? If a certain treatment is disadvantageous because of side effects, can we find one (maybe by consulting our books or colleagues) that is less harmful, but almost as effective (beneficence v nonmaleficence)? These examples are deliberately based on ordinary problems, because it is by dealing with ordinary problems that we practice the skills that will be precious in extra-ordinary situations. In addition to those principles outlined above, certain other concepts are important. These include confidentiality, non-judgementalism, and informed consent. Managing confidentiality is a skill that you will learn, but it is important to be clear that ill-guarded words, even anonymous, can cause as much damage as outright gossip. Non-judgementalism implies not making value-judgements about patients or colleagues, not writing less than objective notes, and not being prejudicial about people. Informed consent means that the person giving consent has a rounded view of the issue, and is capable of making a decision for him or herself. These concepts apply not only to your relationship to patients, but also to your peers, particularly in group learning, where people are encouraged to explore sometimes difficult and contentious issues; such discussions are undermined if those that take part do not behave properly. Feeling uncomfortable about complex and not so complex ethical issues will be an inevitable life experience. Most health professionals and others have to develop coping strategies. As an undergraduate you may feel confused about 'boundaries' and 'confidentiality', yet have need to talk in a safe environment about what is troubling you. We encourage you to acknowledge to yourself that a situation is concerning you and to share your concerns with tutors, seminar leaders or a member of the practice team. By doing this you not only help yourself, but also you develop ways of coping that are constructive, not destructive.

Learning responsibilities

We encourage you to learn using a number of techniques. Of these, perhaps it is relevant to comment here on Reflective Learning, Tutorials and Seminars.

Reflective learning

This is a process of talking through and thinking about what you have seen or heard, or how you handled a situation, and making sense of these experiences. Kolb’s Learning Cycle may be a helpful way to understand how it works.


Kolb’s Learning Cycle

You do not need to apply it rigidly; for example you may start at any point in the cycle. The most important thing is that you are open minded and prepared to think how you can develop and change, which is the way to become a good doctor. We believe it is a useful and lively way to learn.

Tutorials & seminars

The major difference between a tutorial and a seminar is that in a tutorial, there is a clear source of information and experience (the Tutor), whereas in a seminar, everyone is an equal source. Thus, in your seminars, you are all responsible jointly for each other's learning. In a tutorial, there will usually be fewer students, which may allow you to discuss things you feel uncertain or sensitive about. The seminar leader has a main role in facilitating the group discussion, and may additionally be a resource for you.

Departmental back-up

If you encounter problems you cannot resolve yourself or with the aid of your tutor, or you would like our help, of course we will help. You should contact one of the people named in your course booklet, or just get in touch with one of the members of the Department.

Suggested ground rules for group work

These rules can be adopted by a group to form a basis on which the group functions.

Concrete experience (e.g. visit to a patient)

Observations and reflections (what you saw and reflecting individually

or as a group)

Formation of concepts and generalisations that

will inform what you might do differently in the

future

Testing concepts in new situations – trying it out

differently


Rights and responsibilities

We respect everyone’s right to choose how much we each participate. We understand that we are each responsible for our own contribution and learning. We will not pressurise each other. We have a right to question or challenge what people say about us (in terms of labels, stereotypes, limiting generalisations etc).

Interactions

We encourage clarifying questions. We will listen to other people’s points of view. We will be constructive. We will speak from our own experience, using “I” rather than “you” or “we”.

Commitments

We agree to keep to time, and negotiate any changes as appropriate. We will let the group know if we intend to miss part of a session. We will support someone who takes a risk in the group.

Learning

We acknowledge that people change their minds.

Confidentiality

We will respect confidentiality.

Constructive feedback

We will respect feedback from anyone who mentions something said in the group that they have found hurtful or oppressive


Appendix E: Communication in Healthcare

Relationship skills

The relationship skills needed in effective medical consultations have been introduced to you. Now you need to consider these skills in more depth and be familiar with research and the evidence base, which supports the integration of relationship skills in interviews:

Rapport

Patient-centred approach

Empathy

Shared decision making

Listening

Feedback

Rapport is: A term that encompasses the concept of feeling comfortable with another person. Such phrases as “we just seemed to click – she was on the same wavelength as me - i felt at ease” describe a sense of rapport between two people. Rapport is essentially identification of similarities between individuals. The messages of similarities may be subconscious, verbal and non-verbal.

Specific skills: establishing, acceptance, maintaining.

A patient-centred approach is: A collaborative partnership between the patient and the doctor. It is a move away from traditional paternalism towards mutuality. A patient-centred approach is more likely to allow for shared decision making.

Specific skills: eliciting ideas, concerns, expectations, checking for understanding.

Empathy is: The understanding and sensitive appreciation of another person’s predicament or feelings and the communication of that understanding back to the patient in a supportive way. (silverman, kurtz & draper, 1998)

Specific skills: reflection, acknowledgement, and validation

Shared decision making is: A collaborative approach in medical consultations that includes patient’s ideas, concerns and expectations (ICE). Patient participation is sought and the desired level of participation is respected. Some patients wish for more involvement than others.

Specific skills: exploring, explaining, planning, negotiating, and agreeing.

Exercise 1: Patient-centred interviewing and mutual decision-making:

Mr Calvin Johnson, aged 24 years, has recently injured his knee playing football. He is a key member of his local football team. He has been having physiotherapy for 2 weeks and his physio told him it would be another 2 weeks before he can go back to training. He has come to see his doctor to “hurry things up”. He is anxious to get back to football. He believes an injection into the knee would relieve the pain and swelling and allow him to train normally. The doctor is not keen to do this as the knee is healing well and he feels it will not be good for his knee in the long term.

Describe how you might approach this problem in a patient-centred way.

Points to consider:

Exploring Calvin’s ideas, concerns and expectations (using ICE).

Demonstrating empathy

Collaboration in the decision to inject or not to inject the knee

Who is responsible for the decision? (Links with ethics).


Listening: The benefits of effective listening in the medical consultation have been well documented (see Silverman et al. 1998, p.25-32). McKay et al have identified 12 blocks to effective listening. Can you identify any particular traits from those listed below that you have a tendency to use?

Blocks to listening

1. Comparing: e.g. “Could I do it that well?” “When my mother died I coped much better”.

2. Mind reading:

Trying to figure out what the other person is really thinking or feeling.

3. Rehearsing: Giving attention to the preparation and delivery of your next comment. 4. Filtering: Listening to some things and not to others. 5. Judging: Not listening to what they say as they have already been judged. 6. Dreaming: Half listening while something that the other person says triggers off

associations of your own. 7. Identifying: Referring everything the person says to your own experience 8. Advising: Being the great problem solver, ready with help and suggestions. You

don’t have to hear more than a few sentences before you begin searching for the right advice.

9. Sparring: Arguing and debating. You disagree so quickly that the other person never feels heard. You take strong stands and are very clear about your beliefs, values and preferences.

10. Being right: Going to any lengths to avoid being wrong. You can’t listen to feedback or take suggestions so you continue to make the same mistakes. No acknowledged areas for development, you repeat previous patterns of behaviour.

11. Derailing: Changing the subject suddenly. You derail the train of conversation when bored or uncomfortable or laugh it off.

12. Placating: e.g.Right….right…absolutely. I know…of course you are…incredible…yes…really”. You want to be nice, pleasant, and supportive. You want people to like you. You half listen, probably enough to get the drift, but you don’t get involved. You placate rather than tuning in. You don’t examine or explore what’s being said.

(Adapted from McKay, Daws & Fanning in Messages (Communication Skills), New Harbinger Publications, 1983) Exercise 2: Can you identify any particular situations or interactions in which your listening has been compromised by any of these blocks? Identify how each of these criteria could affect the process and outcome of a doctor-patient consultation.

Feedback is: goal-orientated i.e. the purpose is to help an individual to achieve a specific goal. Feedback should always be supportive and enabling. Feedback may offer a different perspective or ways of thinking about or doing something differently to be more effective.

Feedback is not the same as criticism. Feedback is necessary in the processes of teaching and learning. Feedback is a skill and involves informing another of your observations of his or her behaviour. It is not about commenting on an individual’s persona or identity. Feedback should be concentrated on what somebody has actually done behaviourally.

Allow the other person to talk first and offer a self-critique. Focus on the positive aspects first and use descriptive terms.

There may be a difference in the intention of an individual and their behaviour. In other words, we may intend to achieve something but our behaviour does not meet the original intention. It is usual to separate behaviour from intention.


All feedback is subjective. Always make your comments in the first person. The person receiving it may disagree.

Individuals can only take a few comments at a time. Keep to a few points and don’t overload the content.

Be specific. Saying “That was good” is not enough. What specifically was good, what did the person do, how did he/she do it? What was the effect of their actions and communications?


Appendix F: Constructive Feedback

Feedback is the process of informing someone (the subject of the feedback) of your observations on his or her performance and/or behaviour. Its purpose is to help people learn to become more effective in their work. If done badly, however, it can actually hinder people’s ability to learn and damage their confidence. The following guidelines outline how to conduct a feedback session, which is constructive, and will assist learning.

Before the session

Clarify goals of session, e.g. to elicit a patient-centred history

Clarify particular areas the subject wants feedback on, e.g. interview schedule, listening skills

Clarify what use is to be made of the feedback

After the session

Feedback should be given as soon as possible after the session

It is important to allow the subject to say something about the session, i.e. how he/she felt during the interview, before giving feedback

Positive feedback should come before suggestions for improvement.

Giving feedback constructively

Begin statements with 'I feel that...

Comment on effect of behaviour rather than intention (e.g. ‘An 87 year old man may have found some of the language you used difficult to understand’, rather than ‘You made the language too difficult for an 87 year old’). We recommend you make notes while observing the interview to ensure you have specific examples to work with.

Be specific and give an example where possible (e.g. ‘The second question you asked the patient about his life style may have offended the patient’, rather than ‘Some of the questions you asked were inappropriate’)

Maintain confidence

Be aware of the balance between positive and negative feedback. Always start with the positive. Consider ‘sandwiching’ a suggestion for improvement between

Suggest or ask the subject to suggest alternatives where improvements are required, rather than making negative comments (e.g. ‘A few more questions about the medication and how s/he copes with it would have been useful to the medical history of the patient’, rather than ‘There weren’t nearly enough questions about the patient’s medication.’).

How and when you give feedback is as important as what you say

Effective feedback should be focused on the amount of information the receiver can make use of rather than the amount you feel capable of giving

Think about whose needs you are satisfying when you give feedback

Focus only on things which can be changed

Receiving feedback constructively

When you receive feedback from your GP tutor, Seminar Leader or student partner:

Listen carefully

Check you have understood

Don’t be defensive

Always assume information is for your benefit and that it is intended to improve your performance


If you have sought feedback, make it clear what kind of feedback you are seeking, e.g. conduct of interview, your interviewing schedule, your applied interviewing skills

Notice your own reactions

Thank them for their feedback After you received the feedback:

Consider what aspects of your approach you would like to improve

How might you do this?

Who would be able to help you?

How will you know when you have improved? Or perhaps simply ask yourself:

What will I do next time when I interview somebody?

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