Communication with Patients
Patient Safety
Applied Clinical Knowledge
Now compare your comments and decisions with those of the clinical and lay examiners.
Video 1: Clinical Examiner Comments
Information Gathering
Quickly established facts, used open questions, ascertains reasons for concern, good signposting of discussion, explains terminology – meconium.
Communication with Patients
Introduced herself with name and role, explained why she had been called. Good body language, empathic and actively listening, pauses to allow patient to breathe through contraction, respects her views, gave reassurance. Acknowledged concerns.
‘Nothing without your consent.’
Personalises discussion, checks it’s OK to carry on after contraction.
Patient Safety
Offers rather than instructs increased monitoring by CTG, explains need to inform consultant, gives clear reason for not using pool, explains latent phase and significance of lack of progress, respects patient’s concerns and autonomy, maintains patient dignity through non-verbal and verbal skills.
Applied Clinical Knowledge
Synthesises a management plan – repeat VE in four hours? Offers telemetry and explains why need CTG. Needs to be clearer about risks.
Video 1: Lay Examiner Comments
Information Gathering
Finds out patient’s wishes, gives patient time to think things through – not rushed into decision, is very calm and reassuring. Addresses concerns about bonding and wanting natural birth. ‘Try to keep things as natural as you can.’
Doesn’t alarm the patient at all. Finds out the patient wants to wait for her husband, takes time to find out his name and uses it to make conversation more personal.
Communication with Patients
Compassionate, empathic and addresses the patient’s needs. Explains ‘what we offer and why’ – monitoring to listen to heartbeat to see if baby is in distress, explains need for transfer and what will happen in extremely understandable way. Hormone injection – how this will make things progress for her.
‘Making decisions together’, ‘will be a joint decision as to what we do’ – respect for patient’s views; risks put across in a non-scary way and that things may happen as a possibility, not that they will happen if she doesn’t transfer. Comes to mutually agreed plan – shared decision making – crucial.
Before you watch video 2, you may find it helpful to read the instructions given to the simulated patient. They are given detailed instructions so that their performance is consistent throughout the exam, ensuring that each candidate has the same opportunity to pass the task in all the areas assessed. The actor is given guidance about how the competent candidate will tackle the task. This may give you an insight into how the actor tries to help candidates by prompting them and asking questions. However, it is very important to remember that the actor is allowed to react to what the candidate is saying so may become upset or angry if the candidate says or does something that is ill-advised. The actor won’t shout or swear though.
You are Mary Bold, a 39-year-old solicitor in your first pregnancy. You are 41 weeks pregnant and there have been no problems during the pregnancy. You and your partner Liam have researched labour and are very keen for minimal intervention. You are very much of the view that nature is best and that doctors often intervene and create problems in so doing.
You are happy for intermittent monitoring of the baby’s heartbeat but do not want continuous CTG monitoring. Ideally you want a water birth in the Midwifery-Led Unit and cannot see why with a straightforward pregnancy this cannot be possible.
The thought of an epidural and being connected to a drip is your worst-case scenario. You are concerned that this could affect bonding with your baby and breastfeeding. Overall the health of your baby is very important to you, so if sensible proposals are explained to you then you will be flexible in the interests of your baby.
You will not accept a proposed management plan that would entail transfer to the Consultant-Led Labour Ward for continuous CTG monitoring and augmentation with Syntocinon®, but would agree to a compromise such as transfer to the labour ward and CTG monitoring alone.
The competent candidate will:
quickly elicit a history and establish the nature of the problem
explain the situation and rationale of the proposed management plan to you
advise of the need to transfer you to the labour ward for additional care
advise of the risks if you don’t agree with the management plan and work with you to reach a compromise
emphasise the need for increased monitoring and the need to involve the consultant in your care
negotiate a management plan to keep you and your baby as safe as possible
Now watch video 2 and score the candidate. How does their performance differ from video 1? Also consider how similar the approach is by the actor to each of the candidates.
Task 1, video 2: videos are hosted at www.cambridge.org/9781316627457
Video 2: Your Clinical Examiner Comments
Information Gathering
Communication with Patients
Patient Safety
Video 2: Clinical Examiner Comments
Information Gathering
Limited information gathering, straight into plan. Did use open questions but didn’t gather information about the patient’s wishes.
Communication with Patients
Good eye contact but didn’t introduce herself by name or role. Active listening but no empathy, clearly under pressure so carries on talking during contraction to get her point across.
Interrupts patient, doesn’t respect her views: ‘listen to me for a second’. Talks about costs and benefits, not patient’s agenda.
Uses jargon to intimidate patient: meconium – ‘faeces’.
Patient Safety
Recognises risks of fetal distress, mentions brain damage but in a way that is coercing patient by trying to frighten her.
Labour ward ‘safe environment’ – implies Midwifery-Led Unit isn’t safe – undermining colleagues.
‘You won’t have a normal birth’ – recognises could need caesarean section but does not respect the patient’s right to make decisions against medical advice. Doesn’t suggest involving a consultant.
Applied Clinical Knowledge
Recognises the significance of meconium – distress, meconium aspiration syndrome.
Understands cannot determine variability by auscultation.
Plan to move to labour ward, site epidural and start Syntocinon® is appropriate, but takes no account of patient’s wishes – epidural is stated, not offered.
Video 2: Lay Examiner Comments
Information Gathering
Doesn’t check understanding of the patient at all, doesn’t summarise and doesn’t recognise that the patient wants a water birth with no intervention.
Doesn’t ask the right questions.
Communication with Patients
Ignores the patient’s comments regarding breastfeeding and bonding. Doesn’t involve the partner – ‘you have to go to labour ward now’. Terms – meconium, Syntocinon® – technical terms, doesn’t say what it is, how it might affect the baby or why it is important. Bullying the patient, very threatening.
Keeps saying things are very serious, alarming the patient. Doesn’t listen to the patient or ask what she wants. Doesn’t answer the patient’s question about implications of not agreeing to the plan: ‘Will my baby die?’
Review the notes that you made before you started to watch the videos and compare your judgement with that of the clinical and lay examiners. Did you agree with them? Was there anything else you would have done in the task to negotiate an agreed management plan with this patient? Do you have a clear understanding of why the candidates were given their scores and what they could have done to improve?
It might help you to understand the examiner’s assessments if you read through their instructions.
Familiarise yourself with the candidate’s instructions and role player’s information sheet. Agree an approach to the assessment with the lay examiner.
The competent candidate will establish the purpose of the consultation and the midwife’s concerns. A relevant obstetric history will be taken, and Ms Bold’s views on labour and delivery will be ascertained.
The competent candidate will explain to Ms Bold that the current situation may be placing her baby at increased risk and so action may be necessary in order to prevent harm. The increased risks with fresh meconium in labour will be discussed, with an examination offered and a recommendation made for continuous CTG monitoring in an obstetric labour ward unit. The lack of progress in labour will be recognised, and augmentation with Syntocinon® advised.
The competent candidate will adopt a non-threatening style, acknowledging the patient’s distress and frustration, and that this was not what she had planned for her labour experience. It will be reinforced that positive steps should be taken to reach a compromise and agree a management plan, with consultant input advised.
Reassurance will be provided that nothing will be done without the patient’s consent, while ensuring that she appreciates the potential risks and implications of non-compliance.
Lay Examiner’s Instructions
Familiarise yourself with the candidate’s instructions and the simulated patient’s instructions.
Score the candidate’s performance on the results sheet.
The competent candidate will:
quickly elicit a history and establish the nature of the problem
explain the situation and rationale of the proposed management plan to the patient
emphasise the advice for increased monitoring and obstetric involvement in her care
advise of a need for transfer to the obstetric labour ward for additional care
advise of the risks if such a management plan is not agreed and work with the patient to reach an agreement
‘negotiate’ a management plan to keep mother and baby as safe as possible
Learning Points
The clinical knowledge on which this scenario is based is core knowledge. In everyday practice this situation of slow progress in labour in a woman pregnant for the first time with meconium stained liquor is common and will be familiar to all ST5 trainees. In both cases, the candidates clearly understand the implications of the situation and both know what is expected in terms of the management plan, so they clearly both have the required level of knowledge to pass this task.
Watching the videos and reading the clinical and lay examiner’s comments should explain why candidates with a similar level of knowledge can pass or fail purely due to their approach and professional attitudes.
Read the Question
It is very easy to spend the two minutes reading time focusing on the clinical scenario and making notes about what your management plan will be. While having the clinical knowledge and being able to synthesise and justify a management plan is essential, there are clues in the question about what else is needed to pass the task. What have you been asked to do?
1. Establish the full extent of the situation, including the patient’s wishes
The words ‘full extent’ should give you a clue that there is more to this scenario than managing primary arrest in labour with meconium. This should alert you to the need to ask open questions about the patient’s concerns. The simulated patient will then share with you her desire for a natural birth with no intervention, her mistrust of doctors and her desire to wait until her husband is back before making a decision. The task clearly states that it will assess information gathering and communication with the patient, so in preparing for the task, the competent candidate will recognise the need to ask about ‘her wishes’ as well as her clinical background.
2. Manage the immediate situation and agree a plan for the labour
The use of the word ‘agree’ rather than ‘decide on’ should give you a clue that the simulated patient is likely to disagree with standard advice. The skills being tested are the ability to negotiate with a patient while ensuring you keep her and her baby safe. This involves being able to establish a rapport with the patient and deal with her reluctance to accept your advice without the situation developing into anger or an argument. In negotiations, each side has to compromise a little in order to meet in the middle. The actor has been briefed to agree to a compromise if approached correctly. The task clearly states that patient safety will be assessed. It is important to distinguish between a compromise that retains elements of patient safety and collusion with a patient’s request that puts her or her baby at risk. The skill lies in being able to point out in a non-threatening way that her first request for no intervention is no longer a safe option.
3. Advise on the next steps to be taken
The use of the word ‘advise’ should alert you to the need to make a plan without confrontation. This is not the same as simply telling the patient what must be done. This implies that you need to be able to justify and explain the reasons behind your suggestions. The task states that applied clinical knowledge is being assessed and the ability to explain the clinical evidence that supports your management plan is an essential skill.
Summary
Each task will assess between three and five core clinical skills, so knowledge alone will not be sufficient to pass the Part 3 exam. It is an important part of examination technique to look for the key words in the instructions to help plan your approach and to utilise the skills that have been defined in Chapter 2 and on the RCOG website.
Task 2: Tutorial on Electrosurgery (Structured Discussion Task)
This task relates to module 2, core surgical skills (module 5 of the core curriculum), but could equally be used to assess module 1, teaching.
Candidate’s Instructions
This task is a structured discussion assessing:
communication with colleagues
patient safety
applied clinical knowledge.
The case of Mrs Joyce Adams was discussed at the monthly Governance Meeting. Mrs Adams is a 48-year-old midwife who sustained a bowel injury after elective surgery performed by her consultant. The injury was diagnosed ten days after a laparoscopic left salpingo-oophorectomy to remove a large dermoid cyst. The left ovary was adherent to the sigmoid colon and the operating surgeon used a combination of monopolar and bipolar diathermy to free the ovary. The meeting concluded that the perforation had occurred as a result of thermal damage to the sigmoid colon.
As part of the action plan, you (as an ST5) have been asked to organise a feedback session on electrosurgery. This will involve all grades of doctors in the department as well as theatre staff. Your task is to explain the background to the session and the possible mechanisms of electrosurgical damage, and to cover the basic principles of monopolar diathermy, in particular highlighting how problems can arise. You are about to explain to the Clinical Lead for Governance how you plan to approach the session. The Clinical Lead has been asked not to interrupt you over the allocated time.
You have ten minutes in which you should:
refer to the index case
cover the basic principles of electrosurgery
highlight how problems occur and how to avoid them
make reference to the items provided by way of illustration
[NOTE – equipment provided: an electrosurgical generator, a monopolar pad with lead attached, a selection of instruments including graspers, scissors and bipolar forceps with lead attached, a selection of plastic and metal trocars.]
Spend two minutes thinking about how you would approach this task, making notes if it helps you. Then watch the two videos linked to the task. Make notes about the performance of the actor playing the role of the candidate in the core clinical skills that are being assessed in this task. For each of the clinical skills, decide whether the candidate’s skills are at the level of a pass, fail or borderline.
After you have watched and scored this task you can compare your assessment with the comments of a trained Part 3 examiner. The aim of this process is to show you what behaviours are expected and to understand how you will be marked when you attempt the Part 3 exam.
Task 2, video 1: videos are hosted at www.cambridge.org/9781316627457
Video 1: Your Clinical Examiner Comments
Communication with Colleagues
Patient Safety
Applied Clinical Knowledge
Now compare your comments and decisions with those of the clinical examiner
Video 1: Clinical Examiner Comments
Communication with Colleagues
Clearly understands reasons for the session in terms of avoidable injury, has reviewed the case, recognises the need to involve all theatre staff as well as junior doctors and consultants.
Shows understanding of the need to tackle difficult issues with colleagues – experience of the consultant, using wrong hands, Hassan entry, use of monopolar diathermy close to the bowel.
Logical and coherent approach to the tutorial, good use of props. Clear plan for the tutorial.
Patient Safety
Appreciates the difference between bipolar and monopolar – safety, spread of thermal damage. Demonstrates clear understanding of equipment provided. Risk factors are identified – exit burns from monopolar pad, metal trocars, machine settings, foot peddle in reach. Notes the need to maintain visual field.
Need to call for help, general surgeons, urogynaecologist.
Checking in – identifying any implants, team debrief.
Need to incident report when re-admitted.
Applied Clinical Knowledge
Clear understanding of the clinical implications of the topic. Understands mechanism of injury.
WHO checklist, team work, use of assistant. Avoid electrosurgery near the bowel.
Justifies equipment choice and options.
Can clearly work under pressure.
Did you agree with the clinical examiner’s assessment of the candidate? Are there any significant gaps in knowledge or patient safety? Would you have chosen a similar approach to the structure, content and audience for the tutorial?
Before you watch the next video it may help to read the examiner’s instructions.
The competent candidate will establish the purpose of the session and why it is required.
The competent candidate should be able to talk openly to the Governance Lead as to the likely cause of the injury.
The competent candidate should explain that this situation should not have occurred and is most likely linked to mobilisation of the ovary.
They should be able to explain the principal of monopolar diathermy (in which the current passes from the generator through an active electrode – scissors/grasper – then through the tissues and back to the return plate and away from the patient). They should be able to differentiate between cut and coagulation currents.
They should be able to explain that bipolar diathermy does not require the patient to complete the circuit and that current passes from one side of the electrode to the other, just affecting the tissue in between that is being treated and is therefore safer.
The competent candidate should be able to discuss the risks of diathermy to include direct and indirect burns and potential issues such as surgical smoke.
They should have an understanding that there are different power settings, and different instruments will have different current densities associated with their use.
The candidate should demonstrate an ability to teach objectively using the scenario as an example, not mentioning specific details of the patient, and will support their talk with reference to the props provided.
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