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At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

The Situational Judgement Test at a Glance

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

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At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

The Situational Judgement Test at a Glance Frances Varian Frances Varian is a final year medical student at Warwick University and was seconded by Warwick Medical School to help develop situational judgement educational material and practice questions designed to enhance students' non-technical skills. Lara Cartwright Lara Cartwright is Senior Careers Consultant at Warwick Medical School and a member of the Association of Graduate Careers Advisory Services (AGCAS) and the Medical Careers Advisor's Network (MCAN). A John Wiley & Sons, Ltd., Publication

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

This edition first published 2013 © 2013 John Wiley & Sons, Ltd Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley's global Scientific, Technical and Medical business with Blackwell Publishing. Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www. wiley. com/wiley-blackwell. The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Varian, Frances. The situational judgement test at a glance / Frances Varian, Lara Cartwright. p. ; cm. Includes bibliographical references and index. ISBN 978-1-118-49098-3 (pbk. : alk. paper) I. Cartwright, Lara. II. Title. [DNLM: 1. Decision Making-Great Britain-Case Reports. 2. Decision Making-Great Britain-Examination Questions. 3. Professional Practice-Great Britain-Case Reports. 4. Professional Practice-Great Britain-Examination Questions. 5. Behavior-Great Britain- Case Reports. 6. Behavior-Great Britain-Examination Questions. 7. Judgment-Great Britain-Case Reports. 8. Judgment-Great Britain-Examination Questions. 9. Psychological Tests-Great Britain. 10. Test Taking Skills-Great Britain. W 18. 2] 150. 28'7-dc23 2012031981 A catalogue record for this book is available from the British Library. Wiley also publishes its books in a variety of electronic formats. Some content that appears in printmay not be available in electronic books. Cover image: Bigstock © Michael Jung Cover design by Meaden Creative Set in 10/12. 5 pt Times by Toppan Best-set Premedia Limited 1 2013

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Contents   5Contents Preface  6 Acknowledgements  7 List of contributors  8 List of abbreviations  9 1  Introduction  11 Personality  11 Professionalism  11 Pressures  and prioritisation  12 Effective  communication  and patient  focus  12 Teamwork  13 2  Professionalism  14 What  is integrity?  14 Social  networking  14 Understanding  confidentiality  15 The DVLA  15 Patients  involved  in serious  crime  16 Confidentiality  and the under  eighteens  18 Questioning  professionalism  20 3  Pressures  and  prioritising  22 Probity  22 Ward  rounds  22 Patient  discharge  23 Prescribing  25 Consent  26 Learning  and career  development  28 Informal  opportunities  28 Procedural  29 Prioritisation  29 Bleeps  31 4 Effective  communication  33 Five  principles  for good  communication  33 Written  communication  34 Record-keeping  34 Blood  forms  35 Clinical  coding  35 Death  certificates  35 Cremation  forms  36Verbal  communication  36 Working  with  interpreters  36 Working  with  disability  37 Communicating  personal  views  39 Communicating  with  relatives  39 Breaking  bad news  40 5  Patient  focus  42 Being  the best for your  patients  42 Patient  advocacy  42 Respecting  personal  beliefs    44 Tricky  decisions  involving  treatment:  consent  without  capacity  45 End of Life  care  45 Difficult  patients  46 6 Effective  teamwork  48 Understanding  teamwork  48 Understanding  your  role  49 Effective  handovers  50 Understanding  your  colleagues'  roles  51 The nursing  team  51 The consultant  52 The radiology  department  52 SBAR  53 Professional  conflicts  53 Seeking  support  54 The foundation  school  54 7 SJT  practice  material  56 How  do I approach  the SJT questions?  56 SJT example  questions  56 8 Answers  66 Beyond  this book    86 9  References  88 Index  90

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

6 Preface Preface What are Situational Judgement Tests? Exactly what they say on the tin! A way of assessing how you judge a situation encountered within the workplace. They are not designed to test your clinical knowledge and skills; they are designed to test your attitudes and ethical values. With this in mind, the ISFP (Improving Selection to Foundation Pro-gramme) developed nine domains of assessment for UKFPO (United Kingdom Foundation Programme Office) application: Commitment to Professionalism Learning and Professional Development Working Effectively as Part of a Team Patient Focus Problem Solving and Decision-Making Self-Awareness and Insight Coping with Pressure Organisation and Planning Effective Communication These are assessed in two ways: either by ranking five re-sponses from most appropriate to least appropriate, or by selecting the three most appropriate responses to the situation in question. The response is then evaluated against a prede-termined scoring key decided by the subject-matter experts. Download the SJT Monograph on the UKFPO website www. foundationprogramme. nhs. uk for more information. All sce-narios are evaluated by doctors in terms of their applicability to real life. The SJT scenarios in this book have also been scrutinised and cover similar issues to those offered in the 2010 pilot (AMRC 2010) as well as real situations submitted by foundation year interviewees. The following chapters deal with the nine areas above and detail juniors' experiences from their time on the wards: 1. Introduction: this chapter includes how best to prepare for the SJT, some handy ways of handling the scenarios, as well as some things to look out for on the wards. It also evaluates the importance of self-awareness and insight with respect to conducting yourself day to day in clinical practice. 2. Professionalism : this chapter covers the behaviours expected of a junior doctor together with codes of conduct, including issues of confidentiality. 3. Pressures and prioritisation : this chapter focuses on the common pressures of an FY1: probity, ward rounds, discharges, prescribing and consenting. It also addresses learning and pro-fessional development, managing career progression as well as what to do if your job requires considerable juggling. Finally, this chapter considers prioritisation-including bleep etiquette -in which organisation and planning are integral. 4. Communication : this chapter engages with common pit-falls connected with record-keeping and tips for successful documentation. Also covered are communication difficulties involving translators, disabilities and relatives. 5. Patient focus : this chapter deals with how to be the best doctor for your patients, detailing responsibility for patient advocacy, capacity, end of life care and problem-solving with respect to handling difficult patients. 6. Effective teamwork : this chapter outlines effective hando-vers, handling professional-and personal-conflicts and understanding others' roles so you can most effectively work as a team-player. These include the roles of nursing, radiology and laboratory staff as well as those more involved in your social support such as educational supervisors and foundation directors. 7. SJT practice material : this chapter covers a method of approaching an SJT question and contains 50 practice SJT questions. It concludes with a way of creating your own exam-ples and gives tips on how to develop your own learning on the wards. The aim here is to get you thinking of ways to approach the SJT under exam conditions, as well as to enhance your under-standing of the role expected of you as an FY1. The approach to this text replicated that of the ISFP; interviewing doctors, patients and healthcare professionals about the expected quali-ties of a junior doctor. This material was then integrated into the FY1 job analysis specifications outlined by the ISFP (Pat-terson et al 2010) to provide you with a comprehensive guide to tackling the SJTs. Finally, this material has been reviewed by students who sat the 2011 pilot. They have approved its utility as a preparation for the SJT exam. Please note that, whilst the information closely adheres to GMC guidance, you should refer back to the original documentation for advice in any potentially difficult situation. The information here is designed to assist your learn-ing process in thinking about what you should do in a situation, and not what you necessarily would do in practice. All the examples are from doctors' real-life experiences working on the wards; from which the SJT practice questions have been adapted. The names have been changed in some cases to protect identities. For accuracy, these questions and explanations have been reviewed by an independent writer for the UKFPO SJT selection paper, senior clinicians and foundation trainees. These questions cannot guarantee success in the SJT, but have been developed and designed to replicate as far as possible the types of scenarios encountered in the formal assessment paper (AMRC 2010). Frances Varian Lara Cartwright

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Acknowledgements   7Acknowledgements We would like to thank all those people who gave their time and expertise to advise us in writing this book. We would par-ticularly like to thank the medical students who reviewed the material-especially James Coe, James Webster, Ayrton Goddard, Jennifer Goddard, Graeme Mattison, James Haddock, Adrian Hayes and David Andrews-as well as all the patients who kindly gave their time-and their stories-to help create an interesting read. Special thanks are due to Katherine Mundy-author of the children's book Thomas Young and the Go To Tunnel -for her artistic talent in creating the original illustrations, and to Graeme Chambers for his work in translating them into the Figures in this book.

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

8 List of Contributors List of Contributors Maggie  Allen Consultant Rheumatologist, Associate Medical Director of Education and Foundation Programme Clinical Tutor University Hospital Coventry and Warwickshire, Coventry Nicholas  Ashley Foundation Year 1 West Midlands Michael  Baker General Practitioner and Educational Supervisor Solihull Anthony  Blacker Consultant Urologist University Hospital Coventry and Warwickshire, Coventry Lara  Cartwright Senior Careers Consultant Warwick Medical School University of Warwick, Coventry Samyami  S.  Chowdhury Foundation Year 2 West Midlands Linda  Crinigan Clinical Skills Practitioner University Hospital Coventry and Warwickshire, Coventry Daniel  Higman Consultant V ascular Surgeon and Foundation Programme Director Coventry Warwickshire Foundation School University Hospital Coventry and Warwickshire, Coventry Carl  Hammond Foundation Year 2 West Midlands Fraz  Hussain Foundation Year 2 West Midlands Colette  Marshall Consultant Vascular Surgeon University Hospital Coventry and Warwickshire, Coventry Sarah  Sharp Foundation Year 2 West Midlands Edward  Simmonds Consultant Paediatrician and Foundation Programme Year 1 Clinical Tutor University Hospital Coventry and Warwickshire, Coventry Anne-Marie  Slowther Associate Professor of Clinical Ethics Warwick Medical School University of Warwick, Coventry Jacqueline  Timeyin Specialist Trainee, Year 1, Paediatrics Manchester Desmond  Varian Psychiatric Nurse Cumbria Frances  Varian Final year Medical Student, Graduate-Entry Programme Warwick Medical School University of Warwick, Coventry Marakatham  Venkataraman Consultant Paediatrician and Foundation Programme Clinical Lead George Eliot Hospital, Nuneaton Ayman  Zaghloul Consultant Psychiatrist Caludon Centre, Walsgrave, Coventry

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

List of Abbreviations   9List of Abbreviations ABG Arterial Blood Gas BMA British Medical Association BNF British National Formulary BSL British Sign Language CAB Citizens Advice Bureau CAE Clinically Adverse Event CRP C-Reactive Protein CS Caesarean Section CT Computerised Tomography DDA Disability Discrimination Act DH Department of Health DKA Diabetic Ketoacidosis DNAR Do Not Attempt Resuscitation DVLA Driver and Vehicle Licensing Agency EHRC Equality Human Rights Commission EOL End of Life ESR Erythrocyte Sedimentation Rate FTP Fitness to Practise FY1 Foundation Year 1 FY2 Foundation Year 2 GMC General Medical Council GP General Practitioner GUM Genito-Urinary Medicine HLC Hospital Liaison Committee ICE Ideas Concerns and Expectations IMCA Independent Mental Capacity Advocate INR International Normalised Ratio ISFP Improving Selection to the Foundation Programme ITU Intensive Treatment Unit KMR Kohner Medical Record MCA Mental Capacity Act MEWS Modified Early Warning Score MHA Mental Health Act MHRA Medicine and Healthcare products Regulatory Agency MPS Medical Protection Society MST Morphine Sulphate Tablets NKDA No Known Drug Allergies OT Occupational Therapist OTC Over-The-Counter PALS Patient Advice and Liaison Service PRN Pro Re Nata QOL Quality of Life RCP Royal College of Physicians SBAR Situation Background Assessment Recommendation SHO Senior House Officer SJT Situational Judgement Tests ST1 Specialist Training Year 1 STAT Statim (immediately) STI Sexually Transmitted Infection UKFPO United Kingdom Foundation Programme Office

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.   111Introduction Mike, GP “Recognise where your personality is and try to understand what you are like and how you get job satisfaction; in the end work in that area... you'll feel like you're under far less pressure if you do that” This book lends insight into the kinds of scenario that a founda-tion doctor encounters. However, before we dive in to discuss life on the wards, let's take some time to consider your unique approach to the role of an FY1. SJT questions require you to think about what you should do, i. e. how to handle a situation most appropriately. First though, consider what you most likely would do. Gaining insight into this discrepancy will be helpful in approaching the SJT and, more importantly, in continuing your professional development. Considering what you most likely would do requires an understanding of your own characteristics and behaviour. This helps you to: Work with colleagues who might behave differently to you. Communicate effectively with team members, patients and their families. Evaluate your response to working under pressure. Work out how to best define your priorities. Interpret feedback in relation to your performance. Monitor your well-being at work. Perform your best in selection processes: from the SJT through to specialty training. Personality People behave in different ways, depending on the circumstances or the people they are with. However, it is widely accepted that some aspects of personality stay stable and, over the years, per-sonality testing has evolved to measure these domains. You do not have to take a formal personality test, but understanding a little about personality theory can help you to understand your-self in relation to the role of an FY1. There are five widely recognised domains along which personality is measured, known as “the Big Five”. These are shown in Figure 1. 1. It is helpful to see each of the “big five” as a continuum, with most people coming out somewhere in the middle rather than being able to be labelled as one thing or another. Research has shown that domains are relevant across cultural boundaries (Mc Crae et al. 2005). Openness and neuroticism can be used as examples to show how people respond differently to taking a test like the SJT. If you think you are on the high side of the neurotic scale, and the thought of the SJT stresses you out, you may find the wealth of practice material in this book invaluable in calming your nerves. If you are more of a conformist on the openness scale, you might find the checklists of good practice and procedures to your liking. Different personality types can do the same job equally well. They just bring their own unique stamp to the way they do it. However, different personality traits can result in different indi-vidual experiences and challenges in relation to the same job. Here are some examples with respect to the domains covered by the SJT. Professionalism If you are high on the extraversion scale, you might find it more difficult to rein yourself in on social networking sites and resist talking in an unguarded way. Conversely, if you are low on this scale, you might find it harder to challenge the actions of others and speak out when you see bad practice. If you are highly conscientious, you might find it easier to maintain punctuality. If you are highly neurotic, you might find it particularly hard to switch off from stressful days. Figure  1. 1  The “Big Five”Yes = High Scale Yes = Low Outgoing Gregarious Sociable Warm and supportive in relationships Prefers order and method Prone to worry Overemotional Inventive Imaginative Insightful Reticent Shy Go-it-alone Reserved Cool Detached Adopts spontaneous or casual approach Unflappable Laid-back Conformist Down-to-earth Sensible Extraversion Agreeableness Conscientiousness Neuroticism Openness to experience

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

12  Introduction Pressures  and  prioritisation Being highly conscientious and only mildly neurotic will make it easier to work under pressure and remain calm and in control. If you are highly open to new experiences, you will have an advantage when it comes to managing rapidly changing situations. Conversely, when following protocols, being low on open-ness may stand you in good stead. If you are high in agreeableness you may tend to seek help from others naturally; a key factor in some of the SJT questions. Figure  1. 2  Understanding yourself Yes = High Yes = Low Scale Do you find yourself at the centre of a group of friends or colleagues? After a busy shift, do you relax best in the company of others? Are you affected by patients' stories of hardship? Are you adept at putting patients at their ease? Do you remember to replace equipment in its proper place? Do you keep to your revision timetable? Do you easily get irritated when things don't go your way? Are you prone to worry about things you cannot control? Do you find yourself making reams of notes? Do you find it easy to reflect on your learning? Agreeableness Conscientiousness Neuroticism Openness to experience Do you sometimes need encouragement to give your opinion on a ward round? After a busy shift, do you prefer chilling out on your own? Do you sometimes upset colleagues or friends without knowing why? Are you generally interested in the symptoms more than the patient? Do you often find yourself looking for a pen? Do you go round in circles when you have multiple deadlines to meet? Does it take a lot before you get stressed out? Do you find you are cool in a crisis? Do your colleagues regard you as a 'do-er' rather than a 'thinker' When presenting your findings, do you find it easy to stick to the facts?Extraversion Effective  communication  and  patient  focus Introverts may find relating to patients' concerns a more dif-ficult aspect of the FY1 role. If you are highly neurotic you must remember not to relay your anxieties to the patient; having confidence in your skills as a doctor is an important aspect of the doctor-patient relationship. Being highly agreeable lends itself to good communication with relatives; if you are at the other end of the scale, you may have to work harder to empathise with others.

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Introduction   13Teamwork If you tend to “think outside the box” when problems occur, your openness to experience may puzzle or even frustrate your more cautious colleagues. If you are high in agreeableness, you may find your priority is to promote harmony within your team. This may also mean that you find it more difficult to challenge colleagues who do not pull their weight. Being high in conscientiousness will be appreciated by your colleagues Teamwork is so fundamental to the FY1 role; it is examined in more depth in Chapter 6. How is this relevant? Bear in mind the different personality traits when you test yourself during the course of this book, especially when you compare what you would do to what you should do (i. e. the right answer). When there are discrepancies, ask yourself why they exist. Is it, for example, because you don't like asking for help? Reflect on your personality and behaviour and consider how you could improve your performance. This is an important skill which will prove fruitful to your future development as a doctor. Finally, it is important that you seek out feedback on your non-technical skills in addition to your clinical competen-cies throughout your clinical attachments. This is part and parcel of continuing professional growth. The questions in Figure 1. 2 will help to guide you towards one side of a particular trait or the other. Although Figure 1. 2 does not constitute a formal personality test, if you answer “yes” easily to one set of prompts, it will give you an indication of which end of the scale you gravitate towards. If you wish for a more formal assessment, most commercially available personality tests include some measurement of these domains. Consequently, you may find it useful to complete an online personality questionnaire such as the Myers-Briggs Type Inven-tory (Myers and Briggs Foundation n. d. ).

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

14 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 2Professionalism Mithun, Consultant Psychiatrist “Take pride in being a professional... there are only a few professions which carry such a lot of trust and responsibility. People come to you at times of their weakness, not at their strength: you have to be trustworthy. Medical knowledge is only part of treatment: people skills, the instillation of hope, your smile, bedside manners... all those skills are so important. At the end of the day doctors are tools-we have knowledge and apply solutions scientifically-it' s how we relay those to the patient that is of the greatest importance. ” Always consider whether the information you present online could challenge public confidence in the medical profession. Moreover, consider whether it could change your reputation with colleagues at work. Chris, Consultant “I don't mind Facebook, I am friends with my colleagues and aware of that fact.... I never post anything other than the mundane to protect myself as a professional. Sometimes people forget who they are friends with. I experienced a situation where two secretaries were publically bullying another online and being extremely deroga-tory. I had to discipline them for it as that kind of behaviour wouldn't be acceptable in the office and certainly not online”. In terms of professionalism, foundation doctors are ex­ pected to: Display integrity, honesty and trustworthiness. Understand the role of being a doctor, including ethical responsibilities and respect for confidentiality. Be punctual and reliable. Own up to mistakes. Challenge actions and knowledge which may put others at risk. What is integrity? Integrity is mentioned in connection with the healthcare profes ­ sion in many situations, but few people consider why. Integrity is about being honest and upholding moral principles-always. This is important to realise, because you cannot simply put on your professional face at work and let loose as soon as you exit the hospital doors. As a doctor, you must have integrity woven into every aspect of your life. You are a public figure and must therefore meet public expectations for the security of the profession. Ultimately, you have to be honest, trustworthy and respect ­ able in both your work and your personal life. This leads onto the next discussion: social networking. Social networking is a common area where doctors and medical students can get caught out. Social networking As highlighted, professionalism as a doctor should extend through every aspect of your life. Doctors are expected to behave like doctors. Say, for example, your friend decides to upload a photo of you looking drunk and dishevelled on a Friday night; this might not appear so hilarious to a patient who decides to Google you. Unprofessional behaviour online will impact on your integrity, because social media has increasingly blurred the distinction between our personal and professional lives. The Department of Health (DH 2010) devised six princi­ ples by which patient­identifiable information should be utilised: 1. Justified -what is the purpose of sharing the information? 2. Necessary -how will sharing this information benefit the patient? 3. Minimum -only share what needs to be shared. For example, if you are referring a patient with a broken wrist for physiotherapy, you don't need to tell the physio that they also are being treated for chlamydia. Be responsible and think about what you share. 4. Need-to-know basis -as above, make sure you tell them what they need to know and nothing more. 5. Be aware of your role -you are their doctor, respect the fact that patients trust you and be aware that you have a duty to uphold that confidence in the public eye. Doctors without trust are like buckets with a hole in: not very good at all! 6. Legal -if you are unsure of a boundary, always check it with a senior before you share anything. THE BMA (2011) RECOMMENDS THE FOLLOWING: Be conscious that your online image will impact on your professionalism. Posting about patients or colleagues however informal and “confidential” is inappropriate - think about how that will reflect on you as a person. Sort out your privacy settings to protect personal information. Politely refuse friend requests from current or former patients and explain to the patient the reasons why it would be inappropriate for you to accept. Your ethical and legal duty to protect patient confidentiality is the same on the internet as anywhere else.

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Professionalism   15Understanding confidentiality There is a wealth of information regarding confidentiality and generally it is very well taught at medical school. Basically, you need to understand the principles of information­sharing, and, if you know those, you should know what to do regardless of the scenario. If you are unsure, always seek advice from a senior colleague in the first instance. Any scenario where confidentiality could potentially be compromised should not be rushed. Beyond this, there are assigned figures within the NHS known as Caldicott guardians. These are typically board ­level clinicians who resolve local issues regarding information ­sharing that go beyond the level of a senior colleague. Typical situations in which Caldicott guardians become involved include (DH 2010): police requesting information a patient requesting for their records to be deleted serious confidentiality breaches It is enough simply to know about the existence of these figures. You should get in touch with your foundation pro ­ gramme clinical lead or foundation programme co­ordinator for all concerns involving the legal department. FY1s are not in a position to handle such matters, nor are they expected to do so. What should you do if confidentiality is breached? A breach of confidentiality is not something that can be 'undone' and puts a serious question mark over your professional conduct. If a patient feels confidentiality has been breached, they can action a disciplinary via the GMC which has serious consequences for your career (Ministry of Ethics 2010). However, rarely does a patient decide to prosecute for a confi ­ dentiality breach. If something does happen, the Medical Pro ­ tection Society (MPS 2010) argues you can best handle this by: 1. Establishing what happened and what went wrong. 2. Offering the patient an explanation and an apology. 3. Giving assurance that lessons have been learned. 4. Identifying how mistakes can be avoided in the future. Common situations where confidentiality is breached are (MPS 2011): In a lift or canteen. In A&E departments and on wards where parents and rela ­ tives are in close proximity. Through patient's notes: commonly left in places where they are easily accessed by the public. Through computers, faxes and printers: information becomes easily visible. In pubs and restaurants (see Figure 2. 1). Information ­sharing and confidentiality can be a bit of a mine ­ field, especially at first when everything is so new. Described below are a few scenarios to be familiar with. Remember, though, that every trust should have local policy guidelines on these matters, and, if you are ever unsure, always seek senior advice. The DVLA What should you do if you think a patient is not fit to drive? The Driver and Vehicle Licensing Agency (DVLA) are respon ­ sible for road safety and have strict guidance on health condi ­ tions and fitness to drive. Three things to note are: 1. It is the driver's legal responsibility to notify the DVLA. 2. You are responsible for telling the patient that their condi ­ tion may affect their driving (see Figure 2. 2). 3. Document in the notes what you have told them. Some common conditions that patients will need to notify to the DVLA are: Epilepsy or a seizure. Diabetes mellitus on any treatment that can cause hypoglycaemia. Acute psychosis. Severe mood disorders or neuroses: especially if they may attempt suicide at the wheel. These two examples illustrate accidental breaches of confi ­ dentiality. Key learning points from these involve taking particular care with relatives and being sensitive, but recog ­ nising that your responsibilities are to the patient first and foremost. Ashleigh, FY1 “I have a really loud carrying voice. One incident that stays with me involved a lady on the respiratory ward who was dying. Her relatives were down the corridor. I was discussing the patient with the consultant behind the curtain on the ward round and we were saying how she was going to die soon. Afterwards the family approached me-they didn't complain or anything-but repeated what was said behind the curtain: 'so you think that she is going to die soon, do you?' It was obvious they had heard us.... I apologised profusely, as I didn't mean for them to hear what we were saying. Whilst our conversa-tion wasn't insensitive, it' s not nice to hear your relatives are going to die in such frank terms. It was pretty horri-ble.... I always dial down the volume now!” Jack, ST1 “There was an 80-year-old gentleman who had a haemorrhagic stroke secondary to brain metasta-sis. He wasn' t known to have cancer. The family came to speak to the registrar who then made the mistake of telling the family about it before the patient knew. The family then said they didn' t want the patient to know. So the registrar listened to this and didn' t tell him! When the consultant found out, he was very angry and went straight to tell the patient what had happened. His theory was-quite rightly-if the patient found out and didn' t want the family to know then that ship had sailed. The patient has the right not to let the family know: not the other way round. In the end it was all OK, the patient was fine with the family knowing, but it shouldn' t have happened. ”

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

16  Professionalism Figure  2. 1  Always think about patient confidentiality... wherever you are You should have seen it! Alcohol and drug abuse: especially if you suspect they may drive whilst intoxicated. Some common conditions where you would advise a period of time off from driving, but they don't need to formally notify the DVLA are: Stroke/TIA Acute Coronary Syndromes (ACS) The criteria for those with “group 2 entitlement”, i. e. lorry drivers, differ from this. Make sure you enquire about occupa ­ tion so that the patient has the correct information. If you are unsure what to do, your options are to (GMC 2009b): 1. Seek advice from a senior colleague. 2. Consult your local policy document or the DVLA (2011) “At a glance guide to the current medical standards of fitness to drive”. Here you should get the information you require about a variety of disorders and conditions that can impair a patient's fitness to drive. 3. Seek advice from the DVLA or their medical advisor; prob ­ ably not your first port of call as this will take time. What happens if your patient disagrees with you? Advise them to seek a second medical opinion but not to drive in the meantime. What happens if they ignore you and carry on driving anyway? Educate them about the consequences of driving against medical advice to try and stop them; but be reasonable-you cannot use force. Use persuasion of friends and relatives if appropriate. What happens if that fails? THEN you are advised to notify the DVLA-but tell the patient that you are going to do this first. Patients involved in serious crime You are in A&E and you are notified that a patient is coming in with a stabbing injury, what should you do? Obviously your A to E approach and acute medical assessment come first, but you need to take account of the following:

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Professionalism   17Figure  2. 2  Tell your patient when their condition may affect their ability to drive Mr Th ompson WAIT!!! 1. The history-you need to find out if this was self­harm or an attack. The police need not be informed for the former. 2. In the case of the latter, inform a senior colleague. Advise them you think the police should be informed in the interests of the safety of both patients and staff. 3. If you are responsible for informing the police, DO NOT disclose the patient's information at this stage, it is unnecessary. All the police need to be aware of is the incident. The police arrive and wish to see the patient, but you feel the patient is not up to it. What next? Your duty of care is to the patient and you should explain this to the police. When you feel the patient is ready, you can then ask them whether they wish to speak to the police. A crime has been committed, but the patient is unconscious so you can't gain consent to reveal their details to the police. What should you do? You can disclose confidential information as required by law and in the public's best interests. This is because others may be at risk of injury and/or it may aid prosecution for the crime (GMC 2009c). With any matters concerning confidentiality you should be seeking advice from the consultant in charge. Disclosing confidential information should never be rushed. Finally, if you are required to disclose anything, you must protect yourself by recording all the reasons for information disclosure in the patient's notes. You find out that this is a domestic dispute and the victim does not want to press charges. What should you do? Whilst it is appropriate to ask patients to disclose information necessary for their protection, you should abide by a competent adult's refusal if the risk of harm is only to themselves and not to others. However, you should warn them of the risks if they do not consent to disclose. You should also give them ways to seek help themselves, e. g. by informing them about domestic violence support groups. If children were involved in this case of domestic violence, however, you would be obliged to dis ­ close the information to social services (GMC 2009d: Paras

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18  Professionalism51-56). Again, it is important to reiterate that, whilst you should be aware of what to do in difficult situations concerning confidentiality, you should always seek senior advice. Confidentiality and the under eighteens If a child is having an operation, it is best practice to have consent from both parents, but legally you only need one person with authority to give permission to treat. In an emergency, you don't need permission at all, as you can operate in the child's best interests. If there is a conflict that cannot be resolved informally, consult a senior as they may need to inform the legal department. Your trust will have a local policy on this, so it is advisable to familiarise yourself with it early on-or at least know where to access the information. Any decision made to act in a patient's best interests must be able to stand up if challenged. Can a young person be seen without a parent? Ideally a young person should have someone with them. However, you would never want to give them the impression that they could not get medical help-especially if it is some ­ thing important that they do not feel comfortable telling their parents about (see Figure 2. 3). You may also want to see them on their own if you suspect there is something odd about the family dynamics. Always offer a chaperone for any physical examination if they are on their own and record whether they accept or decline. Note: divorce or separation does not make any one parent less responsible for their child. Figure  2. 3  Recognise when teenagers may be holding back Dr says, Is ther e anything else she should know ? Erm..... no... no What about a young person under sixteen years who wants contraception, an abortion or an STI check without their parents knowing? This scenario is more likely to present working as a foundation doctor either on a GP or GUM rotation. It is recommended that you treat a young person in their best interests, provided that you cannot persuade them to talk to their parents and that they fully understand both the advice and the consequences. You may be recognising a pattern here, but always seek advice from a more experienced colleague; your job is to flag up situations like this to them so they can be handled in the most appropri ­ ate manner. This does not make your role any less important however as you do not recognise where issues can arise, then problems may occur. Your job as an FY1 includes gathering as much information as possible to pass onto your seniors. How do you recognise potentially abusive or seriously harmful sexual activity in a young person? This is an important distinction to make as often you will see teenagers under sixteen in relationships with an older partner (see Figure 2. 4). Examples of when you should consider sharing information are where (GMC 2011a: 28): The young person is too immature to understand. A big difference in age is ringing alarm bells! The partner is in a position of trust-e. g. the young per ­ son's teacher. There is a force/threat suggesting emotional, psychologi ­ cal or physical pressure. Drugs and/or alcohol are involved. The child is under 13 years (under 12 years in Scotland). Generally speaking, a young person may feel more relaxed about confiding personal information to you, as someone who has been involved early in their treatment. Respect this and try to get as much information as possible, as it may be the only opportunity. If you suspect something untoward, it is often best to get the parents involved-with the young person's permis ­ sion of course. Beyond this, you may have to notify social services. Remember to record your concerns and justify any decisions made by your senior about the disclosure. You also need to be honest with the patient about the information you are disclosing. You have concerns about a parent's ability to cope with their child, what should you do? This scenario is more likely to present itself in A&E. For any patient who comes in with a serious domestic injury, mental health issue or a history of drug or alcohol abuse, you must check whether they have any children. It may be that you need to put in a referral for social services as these children could well be at risk and have fallen completely under the radar.

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Professionalism   19Figure  2. 4  Be wary of inappropriate age differences No! My boyfrien d This must be your father? It is preferable that you gain consent from the parent when disclosing information to social services. Agree with the parent the information that you will share with social services. The information you will need is all on the proforma but will include: Patient details. Details of all the individuals in the household. What the problem is. Other agencies involved e. g. the school they go to, any health visitors. It is not always necessary to get consent to contact social services. If you feel more harm would be caused to the child by not disclosing the information-for example if the parents would harm the child in some way-then you should not get consent and inform a senior straight away. In this instance, social services may be approached by telephone prior to sending the report in writing. This assessment is made on a case­by­case basis dependent upon the sense of urgency. Again, you would flag this up to a senior as this decision should be made by a more experienced colleague. Jackie, ST1 “A&E is the place you are safeguarding children... try to get as much information for social services as possible. It' s a pain in the middle of the night on a busy shift, but it' s important. You should also tell the parents about the referral. There is a box on the form asking whether you have told the parents. I wouldn't be happy submitting the form without the box ticked on my own judgement.... If I think getting consent is going to cause more harm than good, I get senior advice. ” For your reference, the GMC (2011b: para 60) advise the following order of preference for seeking advice: 1. An experienced colleague. 2. A named practitioner for child protection-your foundation clinical lead would help you with this. 3. A Caldicott guardian. 4. The GMC or another professional body (e. g. BMA, RCP) or defence body (non­EU). Only the first two points are applicable to the FY1 as the founda ­ tion school would liaise with three and four on your behalf. If social services call and ask for the medical records of carers of the child, what should you do? You should consider any specific requests for information very carefully. Only very rarely would you disclose whole records

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20  Professionalismand this would not be your decision to make. It is most appro ­ priate to get your consultant to review any records, for which you would need the permission of the individual concerned. With any case, you should be aware that information can be disclosed if it is in the public interest. Although this is not your duty, it is important to be aware of it so that best practice is adhered to. If you see something wrong that could potentially breach confidentiality, you are expected to speak up: this is an aspect of 'integrity' that is often mentioned. A young girl is diagnosed with cancer and her parents do not want you to tell her, what should you do? Although breaking bad news is not the responsibility of an FY1, you should explore with the parents their reasons for not telling their daughter. You should explain to them that you should assess the capacity of the child and deliver information in a way they can understand. This is because children and young people usually want to know about their illnesses. Exceptions to this are when: The information would cause “serious harm”. The child specifically requests that someone else makes the decisions for them. You should not withhold information unless the patient refuses knowledge of that information. The exception to this is if the information would cause “serious harm”, which is more than making the patient upset or meaning that they might refuse treatment (GMC 2010). For example, if a child was particularly unwell, and the parents felt that giving the diagnosis would cause the child more harm and distress, you should get a senior to review the situation. However, you should also go and see the patient yourself and make your own judgement about the situation. If you agree that it would cause further harm, record this in the notes. The decision to withhold the information should be regularly reviewed and the information shared at the earliest possible opportunity. As a junior doctor, you should be aware of the patient's prefer ­ ences at all times even though it will not be your sole respon ­ sibility to make these decisions. You are expected to advocate for your patients, and get as much information as possible to inform your colleagues. Questioning professionalism Samyami, FY2 “Professionalism can quickly be lost.... I had a colleague in a bad mood who-rather than saying 'these bloods have been incorrectly labelled'- threw them at me, shouted on the ward in front of patients, rela-tives and everyone, before storming off. That' s a massive question mark over their professionalism and it' s moments like that where you completely lose credibility. ” If you realise that you have made a mistake and your integrity has been compromised, remind yourself that you are human and these things happen. There are however a few steps that you should take: Apologise to the person it affects: patient, colleague, relative. If it concerns a patient, document the apology in the notes and explain what problem was. The majority of mistakes that happen will be minor things; you can simply fill in a Clinically Adverse Event (CAE) form, learn from the mistake and move on. If the mistake is significant, inform your seniors. Complete a reflection piece within your eportfolio. Tom, FY2 “If you have made a mistake you always need to be honest with the patient. I made a mistake prescribing Warfarin. After I told my consultant, she said I needed to tell the patient. I went to tell the patient that we had accidently overco-agulated her and potentially put her at harm, but that we had corrected it and she was now within range. The patient hadn't come to any harm but I wanted to let her know .... She was fine with it. The next day her daughter came up to me, clearly very angry. She told me that she had lost all faith in doctors because of this incident. That was pretty hard to hear. I still think it was the right thing to tell the patient-not because the consult-ant told me to-but because it showed me that there was a consequence of my mistake, even though I hadn't harmed her. ” How should I learn from mistakes? Charlotte, FY2 “If you make a mistake you do need to reflect on it-and I know that' s a cliché but you really have to. You have to be honest with yourself. Everyone makes mistakes; some are worse than others, but it' s about how you deal with them. If you look into them seriously then you are unlikely to repeat them.... If you make a mistake once, you shouldn't really make the same mistake again. ” Expect to make mistakes; what's important is how you learn from them. Everyone groans at medical school at the mention of the word “reflection”. Unfortunately, however, this is a crucial aspect of professionalism that is vital for your learning and personal development. HERE ARE SOME TIPS FOR GOOD REFLECTION: If something has happened that affected you - write it down! Self-regulation is an implicit aspect of reflection; evaluate what you could have done better. Most of the time it is only you who will question your decisions. If you find a gap in your knowledge, address it; no one else will do it for you. Know the personal state you were in and the circumstances under which the mistake happened. How can you flag these up in the future? Talk to your peers about it; chances are they will have been through a similar experience. Less is sometimes more. Don't reflect because you feel you have to, reflect at times where you know you will learn from it and it will make a difference. It's not about ticking a box.

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Professionalism   21Mithun, Consultant Psychiatrist “As a doctor, you have to be proud of being a professional, and part of being a professional is being good at what you do-that is of the utmost importance. As a junior doctor, learn the importance of not taking short cuts... taking an extensive history... having an inquisitive mind. Be self-critical, want to better yourself and be the best there is. Ask yourself constantly: what can I do to improve my weaknesses?” TOP 5 TIPS ON PROFESSIONALISM: 1. Be conscious of your image as a professional within your personal life. 2. Stop and think before you share information. 3. If you are unsure at any point, consult a senior for advice. 4. If something goes wrong, find out what happened, then apologise to all those concerned. 5. Reflect on the important things that you know you can learn something from.

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22 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 3Pressures and prioritising Carl, FY2 “I really cannot stress the importance of organisation enough. You may think a lot of what you do goes unnoticed, but it is well appreciated. As soon as you have a house officer that is not organised it really becomes appar-ent... especially on surgical ward rounds... they have to run very quickly. If you are not on top of it they will notice. ” As far as coping with pressure is concerned, a foundation doctor is expected to: Work under pressure and remain calm and in control. Have effective coping mechanisms for stress. Demonstrate good judgement under pressure. Remain resilient and not give up easily. Deal with difficult situations and manage the unexpected. Know where to seek support. Deliver good time-management. The common pressures which present themselves in foundation placements include: Probity Ward rounds Discharges Prescribing Consenting patients Learning and career development Probity Like integrity, probity is a word frequently bandied around the healthcare profession with assumed understanding. To be explicit, probity is about being honest and trustworthy and acting with integrity at all times, especially when under pres-sure. The following examples are experiences where probity has been challenged: Mike, FY2 “The patient' s family did not want alcohol as the cause of death to be written on the death certifi-cate. They became quite irate as they did not feel this was relevant. After speaking to the registrar-who confirmed it must be recorded-I went to explain to the family that I could not omit the information because that would be falsifying a docu-ment that I had a professional and legal obligation to fill out truthfully. They appreciated I took the time to find out all the information before discussing the death certificate with them and accepted my explanation. ” This is an example of external pressures being put on you by people asking you to falsify information. Another point on probity is being honest and trustworthy with respect to your colleagues: Jeff, Consultant “It was around Christmas time and one of the registrars asked to swap his New Year' s Eve shift for Christmas Eve. Ordinarily this is quite a good switch. The registrar swapping had to rearrange a few family things but did it as a favour to his colleague. Two days before New Year' s Eve the registrar who swapped rings and says 'you have to do New Year' s Eve now because I have family coming that I forgot about'. This was rude and so unbelievably out of order. Ordi-narily we wouldn't hear about such matters but this was so inappropriate, we were all appalled-suffice to say he would not be getting a reference from anyone in our department! Nobody trusted this person and it wasn't long before he moved on. After all there' s nothing that should stop you from being on call, even if you had a holiday booked-we would expect you to get a later flight. ” SOME KEY THINGS TO REMEMBER ABOUT PROBITY WHEN UNDER PRESSURE: Document EVERYTHING: legally speaking if it's not written down, it didn't happen! Always read BEFORE you sign. Always be honest - that extends to being honest with your colleagues (see Figure 3. 1). Remember that being trustworthy is integral to gaining respect. Ward rounds Sarah, FY1 “There' s always pressure, particularly on surgical ward rounds. They can be really rushed, but you have to remember that the consultant and specialist regis-trars have lots of other things to do. If you mess up the ward round in the morning, it messes up their whole day and can leave them in a really bad mood.... Being organised is really the key. ” Understand that as an FY1 you effectively run the team from the bottom up; you are the eyes on the floor. A large part of your role is clerical and, as the ward junior, you need to ensure the ward round runs smoothly. You will be expected to fill in the relevant gaps of each clinical case for the consultant as their commitments may mean they are unable to see the patient every day.

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Pressures and prioritising   23 TIPS FOR A SUCCESSFUL WARD ROUND: Get to the ward at least 30 minutes before the round starts to prepare the notes. Know where your patients are. Ask the nurses whether there were any problems overnight. Have a system for writing the notes: date, time, ward, area and those present are the basic essentials. Summarise patient information before the round starts: the patient's observations now and when they came in, background, presenting complaint and results of any investigations. Know how to access bloods and images quickly. Remember to write your jobs in two places - in the notes and on your list - otherwise you might forget to do them. If you are unsure of the plan made, repeat it back to check. There is nothing more irritating for the consultant than having their management plan messed up, or you calling them later in the day to say “what did you actually mean by that?” Always clarify at the outset. Patient discharge There is huge pressure from the nurses and ward clerks to discharge patients. However, your priorities as a doctor are different from those of your colleagues who are expected to prioritise patient flow. Whilst you should support your Charlotte, FY2 “Discharges can take a long time- often because you are multi-tasking (see Figure 3. 2). Nurses will be asking you questions, physios asking you questions, OTs asking questions... your attention is con-stantly divided so what should take five minutes ends up taking thirty. ”Erm, no... hav en't seen them Have you seen Mr Philips' charts? Figure  3. 1  Be honest with your colleagues colleagues and respect their roles, you must have an appropriate plan that completes the clinical journey such that patients are neither lost in the system, nor return to hospital (hopefully!). Discharge letters may be dull but they are highly important. If they are not done properly, mistakes can lead to the patient getting lost in the system and not being followed-up, the GP not receiving the right information, the patient not getting the right medication.... The list goes on. Here's an example: Priya, FY2 “I had just joined a different hospital and I didn't know their policy on prescribing Warfarin on dis-charge was different. I prescribed it on the system, but didn't realise Warfarin had to be prescribed in the little yellow book for it to be dispensed. It wasn't until the nursing home rang me that I realised my mistake. I apologised and someone came to collect the prescription in the yellow book. From now on I always check the simple things when I move to a new hospital. ”

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24  Pressures and prioritising What if a patient wants to self-discharge? This would typically be against medical advice. In that case you should contact the patient's GP in person as the patient is at high risk of further illness. The GP can also set about trying to get in touch with the patient. If the patient is a child, the situation is different. You can always stop them, or their parents, from trying to self-discharge provided you feel it is in the child's best interests to remain in hospital. You can do this by calling security in hospital, or the police if the patient is outside the hospital (in which case social services should also be notified). Jackie, ST1 “Although parents have the right to self-discharge; they don't have that same right concerning their child. One child was referred in from their GP with an exacerbation of asthma as his sats were 90%. I gave him an inhaler and his sats had improved, but I wanted to keep an eye on him as I wasn't completely happy for him to go home. His mum wasn't concerned and his sats were back up so she took that to mean he was fine. She said she had been waiting long GENERAL TIPS FOR A SUCCESSFUL DISCHARGE SUMMARY: Fill it in as you go along, from admission. That way you have less to do at the end and you won't forget things. Be comprehensive: the more detail you give, the better the follow-up. Don't forget the GP! They will need to know WHY drugs have been started or stopped, what investigations need to be followed up and WHY to continue management. Know the procedure for each hospital as this can catch you out. Figure  3. 2  Try to avoid distractions when writing discharge summaries Has Miss Br own had her cup of tea? Where is Mr F azi for his physio?Have you cannulated Mrs Jones? FOR ACCURATE PRESCRIPTION AT DISCHARGE: Review medications on the patient's drug chart. Ensure they are correctly transcribed - dose, duration, frequency, prn (when required). Ensure you sign and write down your bleep number and ward so the pharmacy can dispense them to the right place.

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Pressures and prioritising   25enough and wanted to leave. I still wanted the registrar to review him though so I asked her to sign a self-discharge as I wasn't happy. I then pleaded that she at least wait for a new inhaler, but she left before even getting the medicine. If I was concerned about the child' s asthma status I would have got the police to bring them back, but I wasn't overly concerned. I spoke to the registrar who suggested I contact the GP to get the medicine to them-which I did. ” Prescribing Prescribing mistakes cost the NHS £500 million annually in England and Wales (DH, 2001). Nationwide, 5-7 % of acute medical admissions are due to prescribing errors, 50% of which are attributed to just four drugs: antiplatelets (16%), diuretics (16%), non-steroidal anti-inflammatories (11%) and anticoagu-lants (8%) (Howard et al. 2007). Prescribing should be consid-ered as the most hazardous area for a junior doctor. Whilst you would never attempt a high-risk practical procedure without supervision, prescribing can be equally harmful-and you carry this out unsupervised from day one (Maxwell and Walley 2003). Strikingly, 90% of the prescribing done in any one hos-pital is by junior doctors; typically for paracetamol, morphine or metoclopramide (DH 2000). Learn the common mistakes now, so you don't make them. The British Pharmacological Society (BPS 2010) lists ten principles of good prescribing: 1. Know WHY you are prescribing the drug. What is it for? How will it benefit your patient? 2. Know the patient's drug history (including OTC medica-tions) and allergies. 3. Consider individual factors, e. g. age, pregnancy, kidney failure. 4. Elicit ideas, concerns and expectations (ICE)! Yes, that all important aspect of establishing a doctor-patient partnership is crucial for compliance. 5. Choose the best medicine for the patient considering: formulation, dose, frequency, route, duration and of course ... cost. 6. Adhere to national, and local, guidance. Put into practice the textbook answer you use when your consultant asks you about antibiotic choice: “ I would use the one given in local hospital guidelines. ” 7. Be aware of the common prescribing errors so you can avoid them e. g. write units, not U. 8. Monitor the medication and know how to report adverse drug reactions. Each BNF has a yellow card in the back which can be filled out and sent to the Medicine and Healthcare Prod-ucts Regulatory Agency (MHRA). Alternatively you can access the MHRA online (MHRA 2012) and report side effects directly. 9. Document your reasons for prescribing and communicate these to patients, their carers and colleagues. 10. Only prescribe within your limitations, seek help early and get calculations double-checked. Lorraine, ITU sister “The two-person check is so important. We are all human and anyone can make a mistake.... You can listen without hearing and see without looking as well. The two-person check means you look at it, think about it and see it properly. ” Learn to be meticulous about prescribing and double-check. Names, doses and frequency should be legible. DO NOT DO ANYTHING BEYOND YOUR COMPETENCE even if you feel pressured to do so. Never guess when prescribing; if you are unsure, ask a senior. Remember not to PANIC (see Figure 3. 3) and you should avoid the common pitfalls: Prescription Allergies Notes Interactions Clear Right Drug Right Dose Right Route Right Patient PRESCRIPTIONS should always include the identity of the patient, the drug name, dose, frequency and start/finish dates. Eighty-five per cent of the errors that occur happen at the prescribing stage (Lesar et al. 1997) so check the British National Formulary (BNF) or ask someone for advice. Always ask about ALLERGIES and record any informa-tion on the chart properly. Do not write NKDA, use 'nil' or 'unknown'. Some consultants interpret NKDA as a sign that you simply haven't bothered to ask the question. Only in rare situations (i. e. an emergency) would you order a verbal prescription; hence, always write them up in the NOTES and on the drug chart beforehand to avoid mistakes. When prescribing multiple medications, be aware of INTERACTIONS and potential side effects. Furthermore, always take a full drug history. If the patient is unable to give you one, ask whether the ambulance brought anything in, or contact their GP. Finally, be CLEAR and write in CAPITALS when writing prescriptions, use the generic drug name-e. g. Ibuprofen instead of Nurofen-and write units correctly-i. e. micro-gram not mcg. Have a clear signature and remember the date, month and year. Be clear in communicating “your instructions to colleagues” rather than vice versa and, most importantly, be clear about your limitations. Always seek help early where patient safety is concerned. Sally, FY1 “I prescribed the wrong medication once. I was supposed to prescribe Metronidazole for bacterial vaginosis, but instead I prescribed Metformin!! The dosage,

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26  Pressures and prioritisingfrequency and patient details were all correct, and I entered the correct drug name in the patient records, but I just wrote the wrong drug name on the prescription. Thankfully I had written “No Alcohol”, and this alerted the pharmacist to the error so the patient received the correct medication in the end. Although this seems like one small error, its ramifications are huge. What if I had written Morphine instead of Metformin and the phar-macist had not realised? Then the patient would have been instructed to take 200mg of MST twice a day, with horrific consequences! It' s likely the mistake occurred because I was chatting to the nurse as I wrote the prescription. Now I always take great care when prescribing, and double check what I've written. ” If you make a mistake when prescribing, the Medical Protec-tion Society (MPS, 2011) recommends the following actions for righting the wrong: 1. Explain what has happened to the patient and apologise. 2. Analyse the potential effects of the mistake and correct accordingly. 3. Apologise to any colleagues involved. 4. Fill in a CAE form so that lessons can be learned. Paul, FY2 “There was a lady on the medical ward who was diagnosed with a pulmonary embolus and was being Warfarinised. She had been given loading doses and was slow to get into range. Her INR hadn't been checked for 3 days and I had been asked to dose the Warfarin. It was 4. 30 p. m. and I knew that if I took the bloods, I would have to hand it over for somebody else to dose. Her last INR was 1. 3 and she'd had 3 doses since so I figured it would be OK. I dosed her and put a request out for the phlebotomist to take some bloods so that it would be ready for the next morning to accurately dose it. The INR came back as 10. 7! We had to give her Vitamin K to reverse it. The patient didn't come to any harm and I explained to her what happened, but I am much more rigorous about prescribing Warfarin now and I don't take shortcuts. ” Consent As consent is such a huge topic, this book breaks it into more manageable chunks. Capacity and not being able to consent are considered in Chapter 4. This section covers consent from the perspective of patients with capacity and the different pressures they may create. For the most part, as a junior, the consent you gain will be implied or verbal. For example, gaining consent for venepunc-ture is easy; most of the time the patient will stick their arm out without you having to say anything. At other times, you would simply give a brief explanation of the ins and outs of the process. Tying together issues of confidentiality and implied consent, Figure  3. 3  Try not to PANIC when faced with a difficult prescription???? ???

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Pressures and prioritising   27however, complicates the matter-particularly regarding the disclosure of information to relatives. The informal nature of a phone call or a family member approaching you at the ward desk can be challenging. Take stock of the situation first, and then make your judgement call. Carl, FY2 “As a house officer you are on the ward all the time and the patients and family will see you as their doctor because of that. The family will often come to you at the desk whilst doing discharges to ask how their family member is. If you know that they have a good relationship with your patient and have been involved in their care from the outset, then you can disclose some information. You have to be sure it' s OK, though, as anyone could just walk in without even seeing the patient and ask how they are. You can' t disclose in that instance, so don' t feel pressured to do so. However, if disclosure includes important information such as diagnosis or sensitive investigations then you must always check if the patient is happy for you to disclose. ” What if I am asked to gain written consent for something I'm unsure of? Being asked to gain written consent for a procedure that you are not so comfortable with may be something you are faced with as a junior. The way you manage this is important. The GMC (2008a) recommends that the responsibility for consent lies with the person doing the procedure. If someone delegates gaining consent to you, they are still responsible. Thus, whoever delegates the responsibility to you should make sure you are familiar with and understand the procedure and the benefits and risks involved. In this case you have two options: 1. Explain you don't yet have the experience but that you would like the opportunity to learn. 2. Begin the consent process and do what you can, leaving the formal signing to a more experienced colleague. Judgement in this situation has to be made on the basis of your own knowledge, recognising where your limitations are. If you feel comfortable explaining some aspects of the proce-dure, then the second option is preferable. This assists the consent process but leaves the formalities to your more expe-rienced colleague. In this situation you need to have a good relationship with your senior and to be sure that they will meticulously go over the information with the patient before signing the form. In reality, there are only a few surgical pro-cedures for which you yourself will obtain consent and these will vary from locality to locality. What should I do if a patient doesn't want to know? Sharing information and knowing how much to share is central to good decision-making, but difficult to gauge. This can be daunting at first. The GMC (2008a) recommends tailoring all discussions to the patient without assuming the information they want. Ultimately you should:1. Find out why they don't want the information. 2. Respect their decision not to have the information, BUT 3. Give them enough to gain consent: e. g. why you are doing it, a brief description of the procedure, any serious risks involved and whether they will have any pain afterwards. 4. If they won't have even the basic information, write down that this is what has happened and explain to them what that means. For example, this may mean that their consent is not valid. What if a patient with capacity wants someone else to decide? If the patient has capacity, the bottom line is that no one else can make the decision for them. The GMC (2008a) recom-mends that you: 1. Explain that it is important that they understand the options and the implications of any treatment. 2. Find out why they don't want the information. 3. Iterate that their consent won't be valid if they do not have this information. What about consent in an emergency? The GMC (2008a) recommends that you should gain oral consent in these circumstances but the patient should still have all the information they need. Record this in their notes. If the patient is unable to consent then you can act in their best inter-ests (see Chapter 4). Ultimately you should recognise that, as a junior, you have only been qualified for a short time. Issues of consent are highly complex and the consequences of one decision over another are largely beyond what you can see. You must share this responsibility and find someone with more experience to give you advice. If something such as a breach of confidential-ity happens because you have not gained consent, it cannot be taken back. Nevertheless, the right actions can be sought afterwards. Amit, FY2 “I was looking after an elderly gentleman with hypercalcaemia who was intermittently confused. His daughter was heavily involved in his care. She asked one of the nursing staff about his CT results. And the nurse- without checking with anyone-said 'Yes, we're doing some further investigations to confirm whether the mass is cancer'. I looked up and thought what have you done?! We hadn't told the patient yet because he was intermittently confused, but between episodes he seemed to have capacity. We then had the situation where the relative had been told and the patient didn't know. The daughter then spoke to me and asked me to keep it from him because she thought he wouldn't take it very well and he had been quite down recently. To be asked by a relative not to tell the patient is completely wrong. I spoke to my consultant and we had a team meeting with the nursing staff to discuss the breach ... in the end the patient was OK with it. ”

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28  Pressures and prioritising Learning and career development Samyami, FY2 “Never forget you are there to learn- not just to complete jobs and discharge patients-that way, you'll really enjoy your foundation training. ” Training whilst doing a job means that pressures in terms of learn-ing and career development are constant. With some tips and good time-management however this can be something to enjoy. A foundation doctor is expected to: Have a desire and enthusiasm for continued learning. Take responsibility for their own development. Learn from others and from others' experiences. Be open and accepting of feedback-appraisals are a key time for this. Have a desire and willingness to teach others-medical stu-dents are usually there for you to impart your wisdom to them. There are plenty of opportunities for learning beyond your protected teaching time. These can be considered within three broad areas: Informal Procedural Teaching Figure  3. 4  Have a desire and willingness to teach medical students Umm....Errr....So, who can tell me what' s wrong with this patient?Mohammed, Consultant Surgeon “Know what you want from your career so you can target the areas of interest and make the most of experiences you know you won't have again in the future.... I made the most of medicine because I knew I wasn't going to do it again. ” Informal  opportunities Remember to learn on the job (see Figure 3. 4). Go down to theatre and practice your suturing; the surgeons will be more than happy to have you. Engage in meetings by presenting cases or clinically adverse events. Get involved with an audit, and do it early! You will have to complete them throughout your career. The trick is to pick something simple; this will lessen the time pressure and make it easier to repeat. When you start a job, let your consultant and/or educational supervisor know what you want from the rotation and-if you know-from your career. This way they can offer you extra experience or direct you towards another team who can help.

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Pressures and prioritising   29Procedural Take every opportunity to learn new skills. Get as much practical experience as you can: go and see lumbar punctures, chest drains etc. If you have a quiet job and a lull in the day, remember that you are a trainee, so try to develop your skills in that time. Don't just chill out and have a coffee as you may not get another chance. Carl, FY2 “Your Registrar or SHO will always want to teach you, as they don't want to be the only person that can do something. Most jobs come with one or two specialist procedures that you should take the opportunity to learn. Once out of that job, you may never get that opportunity to gain that skill. I did a gastro job and I did 30 ascitic drains in four months. I feel confident now that I can do them on my own. If you can get one or two good transferable skills from every job, then you John, FY2 “Ward teaching happens all the time. I pick up something new every day: new drugs and new indications, or changes to guidelines. I find that I learn things that I would never get from a book or even remember in a lecture-but the fact that I was told about it and then asked to prescribe it makes me remember it. ” Alice, FY2 “Know that these two years are probably going to be the best two training years as you get to do a bit of everything. You should go into each of your rotations with an open mind and not think 'well I'm going to do surgery so I don' t care about elderly medicine'. Every speciality you do is going to be important in terms of what you go on to do. If you pick up lots of little skills then you won' t feel daunted about doing a different specialty; in that respect you should already have developed the practical skills to do the job. ”Teaching medical students Nick, FY2 “FY1s and FY2s give some of the best teaching as they still remember what it' s like to be a medical student. Having been through finals, they know the level that you need to know. As a medical student you can overestimate what you really need to know and much of it you will never be asked in finals. Formally teaching students also forces you to brush up on knowledge that you haven't looked at over the past few months-though you would never admit this-so you learn as well!”have done well in terms of learning opportunities-any more than that is perhaps unrealistic. ” Figure  3. 5  Important/urgent grid (adapted from Covey 2004)Important Not important'Critical activities' Sick patient Answering your bleep Meeting deadlines e. g. appraisal, eportfolio 'Interruptions' Answering the ward telephone Responding to colleagues interrupting you'Important goals' Patient safety Helping out colleagues Discharge Death certificates Clinical audits Taking a break 'Distractions' Checking email Social networking Jobs you could delegate to others e. g. bloods, drawing up drugs Urgent Non-urgent Prioritisation Fraz, FY2 “If you are organised it allows you to be more efficient and prioritise more effectively. Prioritisation isn't easy at first, but it comes easier if everything else is organ-ised in a timely fashion. ” For effective organisation and planning, as a foundation doctor you should: Manage and plan workload effectively. Display efficient time-management. Deliver tasks on time. Prioritise effectively and reprioritise where appropriate. Assimilate a range of information and identify key issues. Think creatively to solve problems. Be proactive and take initiative. Attend to detail. Learning to prioritise your workload can be the hardest part of adapting to your foundation job. One particularly useful time-management tool-the Important/Urgent Grid-is described by Covey (2004) see Figure 3. 5.

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30  Pressures and prioritising Excuse me Doct or, I've been waiting hours!Look out fo r that water!!Aaagh! cough... cough... cough... Doct or, doctor Figure  3. 6  Try to prioritise your workload to avoid overload Covey (2004) describes a grid formation of tasks divided with respect to urgency and importance. This system allows you to prioritise tasks more efficiently and use your time more effectively, leading to a more successful and less stressful working day. It's easy to prioritise tasks that are both urgent and important (top left quadrant). These “critical activities” include the “quick wins” and general buzz of “getting the job done”. However, this can lead to a feeling of being constantly busy, but unproductive overall (Figure 3. 6). Covey (2004) highlights how you must focus on the impor-tant and non-urgent tasks as well as the urgent. Prioritisation will therefore be more successful if you concentrate your time in the “important goals” area of the grid (top right quadrant). A few examples of these tasks are included in Figure 3. 5 but the list is by no means definitive. While on your clinical placements, consider arranging tasks in this format to aid your prioritisation; starting early means you can hit the ground running when you qualify. Sarah, FY1 “After a ward round I sit down with all the notes and the list of jobs and put them in order of priority of urgency: urgent, important and those that can wait. Radiol-ogy requests are usually the first thing I do, then discharges, as I know nurses are under pressure to discharge patients. ” If at any stage you feel “critical” tasks are overloaded, consider the reasons why. Some will be “crisis” items which could not have been foreseen; however, some might have been prevented from becoming urgent if they had been tackled at an earlier stage. For example, if your appraisal is imminent

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Pressures and prioritising   31Bleeps At any one time on the wards you could potentially have two bleeps: Your personal bleep An on-call bleep This should NOT be SOMEONE ELSE'S bleep! On-call bleeps are notoriously difficult to prioritise-espe-cially in medicine where, in smaller localities, you may be the only doctor covering all the medical wards in the hospital. At the same time as prioritising your patients, you also have to find time to attend to your own bodily functions: peeing, eating, etc. Ideally, you should not hand over your bleep to another colleague as this is effectively handing over responsibility for your patients to them. Sarah, FY1 “On call in medicine you get bleeped con-tinuously. My colleague handed his bleep to a nurse whilst he had a very quick pee on call last Saturday and during this short time his bleep went off 13 times! The nurses bleeping you will want to get whatever they are asking for done imme-diately, and often will be quite insistent that you need to do this cannula NOW, despite the fact you are currently singlehandedly juggling a septic patient, a pulmonary embolism and an acute exacerbation of asthma-as I was 2 weeks ago. In this situation you will be stressed, hungry and tired. Trying to be firm about the priority of a cannula but simultaneously remaining polite is really, really hard. And it is a daily example for junior doctors on the importance of professionalism. ” There are a few situations in which it is acceptable to hando-ver or 'silence' your bleep, these include: During handover (see Chapter 6). When breaking bad news (see Chapter 4). During protected teaching time. An important point to note about breaking bad news is that patients can see you ignoring your bleep if it goes off HERE ARE SOME TIPS FOR PRIORITISATION: Sick patients come first - without exception. Try to predict your workload over the course of the day and plan accordingly. Scans can take a few hours to arrange, so it's best to discuss them with the radiologist early. Bloods need to be done early, otherwise you end up handing over the results to the ward cover rather than acting on them yourself. Discharges are a careful balancing act as patient flow is important, especially considering the nurses are under real pressure. Getting these done will make things easier for the nursing staff. Ask your immediate seniors for help. They have done the job recently and can tell you what the priorities are. and you haven't completed your self-reflection, ask yourself if you could not, realistically, have done this earlier to avoid the additional stress? Generally speaking, if you spend a high percentage of your working day tackling tasks in this quad-rant, stress levels will be high. At this point you should con-sider asking for help, as you will either need to find another way to manage your workload or to raise the issue that the workload is simply too much for one person to handle. “Distractions” should be considered as time-stealers which prevent you from achieving your goals. Question whether such tasks can be delegated, rescheduled or simply avoided: should you really be checking your email for the tenth time that morning? These could also be things that others want you to do for them, rather than things which contribute to your own goals. Saying no politely but firmly at an early stage is one strategy, but you must also remember that teamwork is about give and take. See Chapter 6 for considering other team members' roles. Finally, interruptions are difficult to avoid, especially when working on the wards. If you find that this is causing particular delay, consider whether you need to find a different place to do your paperwork, or to redirect some of it elsewhere. Part of being a good team-player, however, is being open to interrup-tions. In this respect, the most important thing to remember is to make sure your priorities are flexible: Fraz, FY1 “If you're working on call on a surgical rota-tion and you're the only FY1 available, you have to quickly prioritise. For example, if you have cannulas and a patient crashing; just because the cannula is number one on your list doesn't mean you do it, you have to switch around and swap your priorities. ” With respect to prioritising patients, every patient should be assessed in terms of their CLINICAL needs as this determines their investigations and treatment. On a side note, the GMC (2009a) stresses how these priorities should never be affected by your personal views of the patient; hence even if they are a repeat attender or behaving badly, you prioritise their clinical needs regardless. See Chapter 5 for additional information on patients. As a medical student, you are well schooled in recognising the sick patient; it is the more day-to-day tasks that can be initially hard to prioritise. Nick, FY1 “Prioritisation is key: for patient safety more than anything. It' s hard initially as you're unsure which jobs to do first and how fast to do them. I remember my first week as an FY1, I clerked a patient in with hemiplegia and I had bloods, an ABG... a whole list of jobs were just piling up with no idea where to start. I sought advice from the FY2 and she knew straight away which ones to put at the top of the pile. ”

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32  Pressures and prioritising-demonstrating that you are giving them your undivided atten-tion. Hence, not silencing your bleep can be a positive thing and should be judged specific to the situation. Your personal bleep should be with you at all times and answered in a timely manner. The exception to this is during protected teaching time. Here you are usually asked to hand in your bleep before enter-ing the lecture theatre to ensure your learning is uninterrupted. Ignoring a bleep without very good reason is not acceptable, as this could seriously compromise patient care. TOP 5 TIPS ON PRESSURES AND PRIORITISING: 1. Be honest, clear and up to date with all information. 2. Take responsibility for - and pride in - your job role. 3. Be systematic with your jobs list and prioritise according to urgency and importance. 4. Adapt quickly to situations. 5. Remember you are learning: so seek every opportunity to do so.

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The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.   334Effective communication Mary, patient “A good doctor is able to communicate well: be comprehensible, direct, and sensitive to my responses and my needs as the patient. Having patience is also key... for example, when presented with oedema around the ankles, saying 'it' s not exactly life-threatening is it?' isn't par-ticularly helpful!” (see Figure 4. 1)skills. But what constitutes “good” communication skills? Kurtz (1989) outlines five principles for success: 1. Interaction rather than dictation: in other words, a two-way conversation. 2. Reduce uncertainty by allowing the patient to ask questions. 3. Plan and think about the outcomes. Know beforehand what you want to achieve from the conversation or what you want to convey to others in writing. 4. Dynamic: be flexible from one patient to another and be responsive to individual needs. You will encounter a wide variety of patients for which you must adapt your approach. 5. Helical: what one person says influences another and so on and so forth, so that the conversation evolves. This can be challenging, as it requires you to adapt your thoughts to the patient's response. Whilst you may enter the conversation having a set number of points to cover, you may leave having taken a very different tangent. The BMA (2004a) also list barriers to communication which are summarised below in order to help you evaluate your own communication skills. Do you find yourself falling into any of these traps? Lack of understanding of conversational interaction: see Kurtz's principles above. Inadequate recognition of non-verbal skills, including body language and the setting. Figure  4. 1  Don't belittle patients' concerns What?!You'll be okay to swim over, won't y ou? With respect to effective communication, a foundation doctor is expected to: Communicate with patients, relatives and colleagues effectively and sensitively. Adapt their style of communication to individual needs and context. Ensure they have all the relevant information before communicating. Ensure the surroundings are appropriate when communicating. Seek clarification to gain and check understanding. Readily answer questions and keep patients, relatives and colleagues updated. Five principles for good communication The British Medical Association (BMA 2004a) recognises that a doctor must have competent written and oral communication

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34  Effective communication Regarding communication as a low priority. Often all patients need is to feel listened to, and they will feel well cared for. Not having the confidence to communicate effectively. Lack of clinical knowledge about a condition. If you find yourself in this position, be honest with the patient and say that you don't know. It is not appropriate to deliver inaccurate information. Human factors : know yourself well enough to recognise fatigue and stress. Act on this accordingly: for example, all you may need is a 10-minute break. Personality differences : understanding your personality will help you communicate better. Moreover, you also need to rec-ognise the personality of others, i. e. patients, colleagues and relatives, to better communicate with them. Sophie, FY1 “Lack of communication can be a big issue-there are different types of doctors and differ-ent bedside manners (See Figure 4. 2). Sometimes there can be paternalistic styles which are out of keeping with patient expectations and medical practice, and sometimes compas-sion is not shown. This can leave the patient quite upset. It' s not that they are bad doctors, they just haven't communi-cated in the right way for that individual patient. ”The common complaints involving communication arise from three areas (BMA 2004a): patients not being involved in changes to their care; patients given conflicting information by different people (especially doctors and nurses); and clinical notes not being clear or not referred to appropriately. Good communication with colleagues and accurate record-keeping can resolve the latter two areas. Written communication It is essential that your writing is legible so that others can read it and follow up on patient care. If you have spent any time on the wards, you will have seen how difficult it can be to read some of the patient notes. Please think about your colleagues and try to write as clear as possible. Rajen, ST4 “We do audit notes for legibility. All entries should be signed including the GMC number. We will have words with doctors who fail to meet such standards.... Have you seen the nursing notes? They are always fantastic! We should be keeping the same standards. ” Record-keeping Mithun, Consultant Psychiatrist “A key skill is good documentation. I expect everyone to write everything down-almost verbatim-not just to sit down and try to Figure  4. 2  Good communication requires interaction... often all a patient needs is to be listened to Hmmm... Inter esting??!... ??! Erm... doctor?

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Effective communication   35summarise things from perception. Verbatim is more powerful in psychiatry and carries more weight than summarising find-ings. Writing should be legible, and each entry dated with the patient' s name and date of birth on every page. If it' s not, and the continuation sheet is lost, you don't know where it' s come from. ” Good writing in the notes is part of communication. For the majority of the time, the purpose of writing is so that somebody else can read a summary of the patient's problems. If your writing is illegible, this may result in a patient's plan not being actioned. Carl, FY2 “I always fill in everything on the blood form. There' s nothing worse than having to re-bleed a patient ... especially if they're difficult. ” TIPS FOR SUCCESSFUL DOCUMENTATION: (See Chapter 3 for tips on ward rounds and discharges): Always write in BLACK ink in the margin: date, time, ward and area. Always sign your name, print it and put your bleep and/or GMC number. Use only accepted, well-known and unambiguous abbreviations e. g. BP, HR, MEWS. Be thorough: Write LEFT not L. and RIGHT not R.-this is critical in surgery, taking off the wrong limb or removing the wrong organ is a 'should never happen' event. Be contemporaneous and NEVER retrospectively change notes. Tony,  Consultant  Surgeon “A peer of mine who worked in a dysfunctional department told me this story. A patient came in over the weekend and was seen by the locum registrar. The patient was a young lady with pyelonephritis who sadly died on the Monday. This registrar then went and wrote in the notes over the weekend AFTER the event.... He never worked in that hospital again. ” What else should you document? Sam, FY2 “My first few months I forgot to document things half the time. Anything beyond routine jobs you should really document so try to get into this habit early. All discussions with relatives and other professionals... even informal discussions with OTs and physios. Put it down even if it seems obvious, especially if you are not around the next day to impart that information, as it may not be obvious to the ward cover or on-call doctor. ” There is a multitude of certificate and form-filling as an FY1. Routine elements considered here are: blood forms, clinical coding, death certificates and cremation forms. Blood  forms Sarah, FY1 “Taking bloods is a great opportunity to sit down and have a chat with the patient; you get to develop your relationship with them and that means they get better quicker. ”THE FOLLOWING TIPS APPLY TO BLOOD REQUESTS: All requests should be clinically indicated. Don't just tick boxes because you can. Think: is the information you have put on your form enough for the laboratory staff to be able to call you about an abnormal result? Blood tests mean little without the clinical context (Patel and Morrissey 2011). Fill in ALL the required information on the blood bottle and the form, otherwise it won't get processed and patient care will be compromised. Follow up the results: your test, your responsibility. Clinical  coding This is something you may have heard described at medical school. You should have a good induction on coding at your trust when you start working, but here are some basics. Throughout the UK, the system is called the Kohner Medical Record (KMR). Coding involves putting every patient admitted -their diagnosis, co-morbidities and any procedures/treatments -into the computer (or on a written form in the front of their notes). This is an important form of communication because, if you miss something vital in the diagnosis (e. g. hypertension), then it may be missed at handover and so on throughout their care. The KMR is also important for population statistics and the allocation of resources, as the more patients the hospital treats with co-morbidities, the bigger the budget they are assigned. Finally, you should consider utilising this data as a valid selection method for a clinical audit (Patel and Morrissey 2011). Death  certificates Ahmed, FY1 “I made a mistake certifying early on. It was for one of my patients who came in with a fall and died two weeks later from something unrelated. I didn't realise that, because she'd had a fall, she had to go to the coroner. The process was delayed as a result, so it' s worth getting it checked. ” Examine the patient thoroughly to confirm death. It has- very rarely-happened that a patient has woken up in the morgue! Remember to check for a pacemaker: this is important if they are being cremated. Understand there may be specific religious wishes that you need to be sensitive towards. To sign the death certificate you must have seen the patient alive at least 14 days prior to their death (ONS 2010).

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36  Effective communication Know the circumstances in which a death needs to be dis-cussed with the coroner (procurator fiscal in Scotland). Their duty is to decide whether to issue the certificate, order a post-mortem or start an inquest into the cause of death (Patel and Morrissey 2011). Be accurate about the cause of death. Ask advice from someone more senior as, if not done accurately, this can delay the whole process and the family cannot grieve in a timely manner. Cremation  forms This is a paid professional duty and should be done in a timely manner to avoid delay for the family. Two people independ-ently certify for cremation. The first person fills in part one and the second person-with 5 years' experience-fills in the second part. These forms need to match the death certificate, and it makes things smoother if you contact the person who signs part two to let them know that you have completed your section (Patel and Morrissey 2011). You should have identified the deceased; you should have seen them recently, and after death to confirm they do not have a pacemaker or radioactive device which could cause an explosion! Finally, you need to speak to the named nurse who was caring for the patient and was with them when they died as this information is required on the form. Common errors in completing this form, which result in a delay for cremation and funeral for the family are (Ministry of Justice 2012): Not completing the questions in full. Missing out questions. Filling the form in incorrectly. Illegible handwriting. Discrepancies between the two parts on date and time of death. Your local trust will have policy documents for you to view on death certificates and cremation forms which you should famil-iarise yourself with. If you want to look at the forms in the meantime, you can search for the Ministry of Justice website online or follow this link: http://www. justice. gov. uk/coroners-burial-cremation/cremation. Verbal communication Whilst oral communication skills require practice and self-reflection, there are some key points to consider regarding situ-ations where communication can be difficult: Working with interpreters. Communicating with patients with a disability. Communicating your personal views. Communicating with difficult relatives. Breaking bad news. Working  with  interpreters Carl, FY2 “It is difficult to refuse an offer from the family to translate, but if you feel uncomfortable about it, then you have to. I was working in a haematology clinic and had to disclose diagnoses such as lymphoma. With this, it was hospital policy to routinely test for HIV and Hepatitis B/C. Disclosing that information via a translator is hard enough, but if you are using a family member, then there is too great a potential for conflict. Because there is an emotional tie, there are a lot of potential for problems, and you can cause a lot of damage if you don't disclose in the right way. Also, if you are disclosing things like that in clinic, it is always better to have a chaperone. ” When you encounter a language barrier, try to arrange an inter-preter. It is rarely appropriate to use a family member-except perhaps in an emergency where they can give you a history and medications. The problems with using a friend or relative are (Phelan 1995): Their views produce inaccuracies. They try to protect patients from bad news. They don't reveal side effects as they think compliance will be better. The patient may not want to disclose 'embarrassing' informa-tion to them. Tony, Consultant Surgeon “I remember a case 5 years ago of a chap who spoke Urdu and his daughter was translating for him. It was really important that he understood that he had a staghorn calculus in his left kidney that would eventually stop it working, as I wanted to take out his right kidney with the tumour in it. He wasn't that keen on treatment and said 'No I'll leave it'. The medical student then said-once they'd gone out: 'she just said “you've got a stone on the left and stone on the right, you need surgery” and didn't tell him what the matter was. ' He therefore left with no idea of the importance of getting treatment so couldn't make an informed decision. It just shows how families can find it difficult to be objective and relay your issues straight across. ” The best options for interpretation are professional services such as the in-hospital translation service or telephone transla-tion service. You should check what services are available at each trust. SOME KEY TIPS FOR WORKING WITH INTERPRETERS: (As suggested by Phelan [1995]): Debrief the interpreter before and after the consultation. Direct questions to the patient and maintain eye contact with them and not the interpreter. Speak simply and pause to allow for translation. Respond to non-verbal cues. Check the patient's understanding. Try to use the same interpreter for future interviews where possible.

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Effective communication   37Figure  4. 3  You should seek a professional interpreter where possible to avoid miscommunication Mr P etrucci, you'r e going to be okay, but y ou will need to change y our diet and start exer cising I'm sorry Mrs P atel, ther e's nothing mor e we can do f or you They're exploring other angles, mum You'r e /f_ine! Another situation in which you may consider using an inter-preter is when patients have a communication disability. Com-munication support includes: lip readers, British Sign Language (BSL) interpreters, deafblind interpreters, note takers, etc.. If communication support is needed, notice should ideally be given up to six weeks in advance (Directgov 2011). Working  with  disability Depending on the focus of the teaching, the distinction between impairment and disability may have already been drummed into you at medical school: so one more time is probably not going to hurt! Impairment is considered the actual physical or mental 'effect'. For example, someone who is obese may be

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38  Effective communicationunable to walk for more than fifty metres without resting, resulting in mobility restrictions. This impairment would extend to a disability if the effects meant the individual was unable to work or carry out their daily functions as usual for at least 12 months (ODI 2010). Disability is therefore determined by the effect of the impairment; defined by the Disability Discrimi-nation Act (1995) as “a physical or mental impairment which has a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities”. This is why you must ask every patient how their condition (i. e. impair-ment) affects their day-to-day life. The social implications of an illness significantly affects your management of it. Without knowing about them, you cannot truly empathise with your patients. Mental impairment can pose the greatest challenge to com-munication. The EHRC (2010) outline has some useful tips for communicating with patients with a disability to help avoid non-attendance and missed appointments: 1. Avoid “diagnostic-overshadowing” and seeing patients only in terms of their impairment. For example, a patient with autism may be behaving inappropriately because they are in pain rather than as a result of their impairment. BUT ALSO 2. Recognise that impairment can lead to health inequalities that require special attention. A patient with a learning difficulty should have the same access to healthcare services as everyone else. However, they should also receive full annual physical health assessments as research suggests they have a shorter life expectancy due to the higher risk of health inequalities. More time should be allowed for these assessments (and thorough physical examination) as impaired communication can impede history-taking (EHRC, 2010). Nick, FY1 “I had difficulties with a 35-year-old patient who-since birth-had no verbal communication. He was self-mobile and could care for himself, and his carer said he had an excellent quality of life (QOL) and was quite active. He came in with a severe pneumonia and, after maximum medical therapy, was still unwell. We called for an ITU opinion and they came down. After a short assessment they said 'no we won't take him'; deciding he had a poor QOL due to severe learning difficulties. I had to arrange for an Independent Mental Capacity Advocate (IMCA) to assess the situation. They laid out all the facts in order to make a decision and were bril-liant. The patient recovered in the meantime thankfully. ” Some key learning points from this example are (EHRC 2010): Never make assumptions about a patient's experience of their disability. For example, not every deafblind patient will have a learning disability. Also, you should avoid attributing physical complaints to a psychological cause in a patient with known mental health problems. Never make assumptions about the personal life of a patient with a disability-they have the same potential for a sex life as everyone else. Find out and remember their preferred means of communica-tion, e. g. writing everything down if they are deaf. Note any access requirements for future appointments: e. g., on discharge, are they able to find their way to their follow-up appointment in two weeks? Note any mobility requirements and make sure the nurses and healthcare assistants are also aware of them. Every effort should be made to understand patients' wishes whether or not they have capacity. As an FY1, you will have first contact with patients and therefore the time to find out from them their individual needs. If communication is difficult, simply ask them how they wish to be communicated with and make sure this is relayed to all the staff so that the patient does not have to keep repeating their requirements. Some patients may have a “passport” for health-care which has all the relevant information on their condition -take note of this. Michael, GP “Not speaking slowly and shouting are two key things you should never do! It' s about under-standing how the disability affects them.... As doctors, we are too often scared to talk about a disability but most people living with a disability are more than happy to talk about what that means. ” What about those patients who are newly diagnosed with a disability? This is very important as patients get stigmatised and margin-alised when labelled with a disability. The more you can support patients on wider social issues, the greater benefit you will be. Also note that time of diagnosis is crucial for every patient and must be handled with empathy, sensitivity and practicality to avoid any potential complaints. As a doctor you will likely be asked about (EHRC 2010): Fit notes-you will probably be expected to write these for patients for discharge, and it is necessary to know how much time the patient will need for recuperation at home. Benefits and statements for home adaptations. Disabled parking badges. If you are unsure, inform the patient about the EHRC (Equal-ity Human Rights Commission). They give telephone advice and guidance on many issues ranging from reasonable adjust-ments employers are expected to make, to expectant parents and social housing providers. There are also other sites you can go to, such as Directgov, which has a wealth of information as well as applications for disability grants and blue badges (Directgov 2012). Knowing where to direct patients is equally as helpful as having all the answers yourself. In the interim, you can also ask for senior input, advice from the nursing staff or, if activities of daily living are concerned, advice from an occupational therapist.

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Effective communication   39Communicating  personal  views Communicating  with  relatives Alice, FY2 “Patients will have no idea where you are in the cycle of being a doctor. They won't be interested if it' s your first day or tenth year as a doctor, they still expect a certain standard of you. Talking to patients and their relatives is one of the biggest challenges. ” In difficult, evocative and emotional situations you have to be really careful about the language you use and the clarity with which you provide explanations. Samyami, FY2 “I understand that this is your mum and you are very concerned and you have every right to be, but from our point of view you have to appreciate that this stroke is so extensive that she doesn't have the potential for rehabilita-tion. If she does arrest, she is going to suffer more injury and we could revive her but her quality of life would be zero. ” Always try to take a chaperone with you when you know a conversation is going to be difficult and you might run into trouble. Nurses are fantastic for this and, more often than not, have great relationships with relatives. Katie, FY2 “I had a high output family a couple of weeks ago. They had just lost their dad a few days before and then their mum had a massive stroke. She was only young, 62. She was in a really bad way and the consultant made the deci-sion to DNAR. The family didn't want it, they didn't even want us to take bloods, yet they weren't willing for us to start on the end of life pathway either. They got angry and quite aggressive, so I said ' OK I think we need to stop', but they didn't listen. The senior nurse intervened and said 'Sorry but we can't have you shouting on the ward, there are other patients'. If you know you have a challenging family, you should have a chaperone. ” Speak out if you see bad practice. Colette, Consultant Surgeon “Safety is very impor-tant. You must raise concerns as soon as possi-ble... The consultant will not get annoyed about asking questions. They may get annoyed if you do not ask and something goes wrong. ” Be careful about the language you use-is it suitable for your audience? Bill, Patient “I had polymyalgia rheumatica and was on steroids for it. At the time I was seeing a young GP at the practice who I generally got on well with, but my ESR and CRP had been fluctuating. He admitted he had been 'bollocked' by the consultant rheumatologist at the hospi-tal.... 'Bollocked' was his comment! As if I would ever use such a word... ” Don't forget, no matter how well you know the patient, you are still their doctor. Tony, Consultant Surgeon “I once referred to the hospital as 'a hotel whilst recuperating' as you're without any need for intervention. That was taken as grossly offensive by the patient. This was a misjudgement of my rapport with the patient. I don't think I've got it as wrong as that since. The patient was very angry so I apologised and took a step back. I had been slightly too familiar... it had been a less formal doctor-patient con-versation, but my description of using the hospital as a hotel didn't work for him and he took it as offensive rather than descriptive. ” Know your limitations, when to seek help, and when to have confidence in your skill set. Carl, FY2 “You need to decide how far you can manage something before you escalate it up .... That' s the skill ... working out the point at which you decide you are out of your depth, but not letting it get to that point before you make that decision. There is a fine balance between not shooting it straight up to the registrar without doing anything for that patient, and leaving it too late before you ask. You need to cut a balance to stabilise the patient and do all the necessary investigations. If you speak to the registrar and they say they don't need something, you can simply cancel the request. But if you ring them and say 'the patient is septic', and they ask what you have done and you haven't done even the initial investigations, they won't be very happy with you. That' s your bread and butter really-doing the initial work-up. When you reach the point where you don't know where to go ... then you should escalate it up. ”HERE ARE SOME TIPS FOR HANDLING DIFFICULT SITUATIONS: Explain the facts and be empathetic the whole way through. Try to explore the bigger picture. Check their understanding. If relatives start getting too angry or confrontational simply excuse yourself and give them a minute to calm down. This can be a natural grief reaction. How should I manage angry relatives? Recognise that relatives may be angry because they are worried, frustrated, scared, anxious .... The list goes on. Y ou should handle these situations by being Safe, Slow, Low and Sympathetico! Safe: bring a chaperone and make sure you know where the exit is. Slow : take everything slowly, let them vent before you speak, and slow down your speech as well as your body language to try and calm the situation. Low : keep the tone and pitch of your voice low.

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40  Effective communication Sympathetico : state empathy obviously “ I can see that you are very angry ”, offer an apology but don't impart blame “ I'm very sorry that this has happened ”. Whatever you do DO NOT TELL THEM TO CALM DOWN, it will blow up in your face. These situations are precisely the ones you should reflect on as it is highly likely you will have experienced such emotions yourself. Speak to a colleague about the events that unfolded. Most people find an angry person intimidating and may leave feeling a little 'shaken up'. Look after yourself so you can look after your patients; drifting around the ward an emotional wreck is no good to anyone (see Figure 4. 4). What if relatives want information about a patient you don't know? This situation is tricky and could well happen if you are working in a small hospital where you are the only doctor on call. Often the nurses will bleep you because the family want to discuss their relative's care with a doctor. In this situation you might not know the patient and not be involved in their care. You then have to consider whether you are comfortable discussing the case in this manner with the relatives. If you do not feel it is appropriate-especially if bad news is involved-you must explain your reasons to the nurse as to why you cannot have that particular conversation. Also get the nurse to suggest to the family that they book an appointment with the patient's consultant the following day. It is better not to communicate at all than to communicate when you know little about the situa-tion and may handle it badly. In this respect communication is all about the TPP : the appropriate Time, People and Place. Breaking  bad  news Breaking bad news is something that you should get practice doing with actors at medical school. You should be familiar with the process as you may be required to deliver bad news sooner than you think. That is not to say that you jump at the opportunity if presented. You must think carefully whether you have enough information about the patient before you decide to do it. Most importantly, take an experienced nurse with you. There are various mnemonics you can use for breaking bad news, SPIKES is particularly popular (Baille et al 2000). Setting up the interview: right place, bleep on silent to reduce interruptions etc. Perception: assess what the patient knows e. g. “what were our reasons for doing the colonoscopy?” Invitation: find out how much they want to know e. g. “how would you like the results?” Knowledge: this is where you fire a warning shot “unfortu-nately I have some bad news... ” avoid using jargon and don't be blunt-patients will not appreciate you blurting out “I'm afraid you're going to die. ” Also, avoid using the phrase “there Figure  4. 4  Seek out support if you 've had a difficult conversation

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Effective communication   41is nothing more we can do for you”, as there is always some-thing you can do: the whole palliative care pathway is designed to facilitate this. Emotions and empathy: this is the hardest part as it is often difficult to predict a patient's emotional reaction to bad news. There could be silence, crying, anger, denial.... Give them time to experience their emotions. Afterwards, address that emotion with empathy “I can see that... ”. Strategy and summary: Having a clear plan reduces anxiety but make sure that the patient is ready to hear that plan. Close by checking understanding of what has been said. This makes it sound simple, but, in reality, there are many personal barriers to breaking bad news. Rosen and Tesser (1970) described this charmingly as the MUM effect. The MUM (keeping Mum about Undesirable Messages) effect describes why it is so difficult to break bad news: the person delivering the bad news may feel anxious, burdened with the responsibility for delivering it, and fearful of a negative reac-tion. Unsurprisingly, this makes delivering bad news much harder, to the point where you become reluctant to deliver it. This effect intensifies when you perceive the patient to be dis-tressed (Baille et al 2000). Whilst you should understand that breaking bad news is not something typically done by an FY1, you may be the most appropriate person to break it if you have the best rapport with the patient. Each situation must be judged on its own merits, balancing the need for the patient to have the information in a timely manner against finding the best person to deliver it. Ultimately, the person delivering the bad news should always be certain of the information. Under no circumstances should you be delivering bad news on a 'suspected' or 'highly likely' premise. You MUST have all the accurate information and, if there are any doubts, wait for senior input. Conversely, you must NEVER deliver false hope; be honest and say you are unsure rather than reassuring the patient. Carl, FY2 “Although you may not be expected to do this, in reality, a lot of breaking bad news gets done on medical wards. You may be asked a direct question by a patient and you have to make a decision whether you are going to tell them that information or go and get help. If you feel comfortable and think it' s the right thing for them to know, you can tell them. If it' s not, then you need to find someone who will tell them in a timely manner. If they have asked for that information, they have a right to know but you have to balance this with the right person; there is nothing worse than a botched job of breaking bad news. Being quite personable and having a good rapport with patients will help. Make sure you get feedback afterwards though... ask a nurse to accompany you both as a witness and for support. ”Always consider whether you are the best person to break bad news. If it is not done properly, it can be disastrous and the patient and/or relatives will never forget. Here are a couple examples of breaking bad news badly, demonstrating how wrongly you can misinterpret the patient's views: Daniel, Patient “I was on the ward for kidney stones. I'd had a horrendous experience myself, so wasn't best pleased with the staff. The patient across from me had been very sick and, unfortunately, passed away during the night. They just drew the curtains around him and left the body in the bed! As if that wasn't bad enough, I heard the daughter come in the following morning and she walked straight past the reception into the ward. She was about to open the curtains when a nurse stopped her and said 'you can't go in there ... he' s dead!' I was shocked; I couldn't believe what had happened. That poor woman, she broke down in tears. I don't know whether they realised it was a relative of the patient but it was just horrific. ” Lorraine, ITU sister “I use this as an example in train-ing; it' s one of the most horrendous things I've ever heard. The patient had sustained a massive head injury and had partial lobectomies. I went in with the consultant to speak to the wife and two sons, daughter, and in-laws. The consultant said 'your husband' s operation was very successful. However, he will never be able to do anything for himself, never know who you are, never have a memory, or a personality... but his life will be normal longevity.... Can I make a suggestion'. The wife said 'Yes, please', and he said 'go home and make your family a lovely meal' and then he left! That was it. And I had to pick up the pieces.... ” And a brilliant one to finish: Lorraine, ITU sister “There was one doctor particu-larly good at explaining it, he said: 'we have machines on ITU that can prolong life indefinitely.... But we are not prolonging your wife' s life anymore; we are simply prolonging her inevitable death. ' That worked very well. ” TOP 5 COMMUNICATION TIPS: 1. Be sensitive towards patients, regardless of your mood. 2. Be meticulous about documentation, it is your legal lifeline. 3. Don't ignore disability, address it. 4. Dealing with relatives is an important part of patient care. Remember to be Safe, Slow, Low and Sympathetico!, and you'll handle difficult situations with ease. 5. Remember successful communication is all about TPP : the appropriate Time, with the appropriate People, in the appropriate Place.

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42 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 5Patient focus Sarah, FY1 “Part of patients getting better is them knowing and feeling they are are being well cared for and looked after. ” Patient focus is all about making the care of your patient your first concern (GMC 2010). Foundation doctors are expected to: Gain trust from patients. Be empathetic, polite and courteous towards patients. Respect patient's wishes and work jointly towards their care. Build a relationship with both patients and their relatives. Consider patient safety at all times. This means you will inevitably be required to deal with a wide range of problems concerning your patients. In this respect, foundation doctors are expected to: Demonstrate an ability to assimilate a range of informa-tion and identify key issues. Engage with wider issues and think creatively to solve problems and reach appropriate decisions. Be proactive, demonstrate initiative and attend to detail. Being the best for your patients TOP TIPS ON BEING THE BEST FOR YOUR PATIENTS: Talk to your  patients,  not about  them Julia,  ST2 “When on a ward round, try not to talk about patients in front of them-address them. If you hear your consultant saying for example 'this patient is two days post lap-choli . . . ' try to steer them away from doing it. Ask the patient how they are doing and always go back and talk to them after-wards if you feel they've been left in the dark. ” Look  after  yourself  so you can best  care  for your  patients (see Figure 5. 1) Bill, Patient “Look after your own health-sometimes I am looking at the doctor and they're so ill I'm thinking 'Should they really be here? . . . They look worse than I do'. It does make you question whether they can do their job properly. ” Realise  that  patients  are your  customers .  .  .  they  are  always  right! Be mindful that patients are people with lives outside the hospital. Your job is to get them out of that bed and back to the real world as soon as you can. Charlotte,  Consultant  Surgeon “Really good doctors don't care about the boundaries of care and see patients as human beings rather than 'that's not my speciality so I'm not doing it'. I was seeing a patient transferred from dermatology with really bad leg ulcers who required urgent investigations. The junior said 'eugh... why do we have to look after that patient from dermatology?' That attitude of 'someone else's patient not mine' is simply not tolerated. I was really not impressed. ” Be empathetic. This means understanding where the patient is coming from and that means working out what they are thinking. Without empathy you may fall into a trap: adopting a defensive position, or simply missing the mark altogether. Tony,  Consultant  Surgeon “Sometimes it can take an hour of conversation to develop a rapport with a patient so they trust you enough to let you treat them. I remember one chap seeming very angry with us, but in fact I had read it all wrong-he was just very anxious and fighting his feelings. I handled it fine but I would read that differently again. ” ALWAYS  examine  your  patient. A clinical error such as this is inexcusable. Shan,  Consultant  Surgeon “I know plenty of law suits because the clinician has failed to examine. A colleague of mine came to see me about a breast lump... she said, 'of all the surgeons in this hospital, you're the first one to treat me like a patient and actually examine me. ' I thought this was remarkable, and wholly unacceptable. ” Know  your  responsibility  for social  care  as much  as  medical  care. This is because social factors have a huge effect on the patient's physical and mental health and will determine whether they return to hospital or not. Although the nursing staff will largely liaise with OTs, physios and social services, you need to appreciate social discharge from the point of view of: Which patients require social input. How their social requirements are assessed. The support they will receive at home. Being able to report back to the patient information about their social placement. Don't  forget  about  families  and  relatives  and  be  conscious  that  you are always  being  critiqued. Most complaints come from how you present yourself to others rather than the patient. Be meticulous  about  your  clinical  style and never underestimate the need to be conscientious and diligent. This may require occasionally going the extra mile to facilitate the best patient care. Patient advocacy Sunita, FY1 “If the patient thinks that your consultant is doing a bad job then you have to relay that informa-tion.... You have to just stand back from the fact it' s your senior and be the patient' s advocate. ” Advocacy is again something that is often discussed, but, in reality, it is difficult to perceive its relationship with everyday

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Patient focus   43Erm..... So, what seems to be the problem?... cough... cough... splu/t_ter... Figure  5. 1  As a doctor you have a responsibility to look after your own health practice. Basically, it means fighting someone else's corner using your own unique knowledge base and skill set. Whilst there are external services for this such as the Patient Advice and Liaison Service (PALS 2009)-you must also remember that you are an advocate for your patient when it comes to their care. As the junior member on your team, you will have the largest proportion of contact with your patients, aside from the nurses. This means you have to understand where the patient is coming from and stand back from any difficult behaviour or negative opinions about your colleagues. Samyami, FY2 “I was working on a surgical ward with a patient in hospital for appendicitis. He also had long-standing hyperkalaemia and when he came in his potassium was 7. 0. I was working nights when he became symptomatic; I treated him and he was fine by the morning, but his potassium remained high. My team didn't think this was a priority, and, given his surgical problem was fixed, felt he should be allowed to go home. I spoke up as I didn't feel he was fit for discharge. The nurse specialist was adamant nothing was wrong, so the consultant heard us both out. The consultant agreed that I could investigate because I wasn't happy with it. My team didn't like it as it delayed his discharge for two days whilst I went on a detective hunt to find out what was wrong. In the end it turned out he was taking steroids and needed sodium replacement. I don't regret it, and I would do the same again if my patient needed it. ” This case highlights the fact that the appropriate action for medical professionals-regardless of position-is to raise concerns about patient safety. The GMC (2012) recently adapted such guidance to ensure that a culture of openness is more fruitfully embraced. As a doctor, you are expected to speak up if you think care is being compromised by anything: staff, procedures or policies. You should not hesitate to report a concern and the GMC (2012) explain why: Your duty to put patients first overrides everything else. You are protected by law against being victimised or dis-missed for exposing malpractice. Reasonable belief is enough justification, not hard proof. You are not in the position to put it right yourself. However, you must do this by following the appropriate pro-cedure and going through the proper channels. The correct reporting procedures are detailed below. However, it is advis-able to consult your local trust policy when you start your job. For adverse events or near misses: Fill in a CAE or critical incident form to prevent future recurrence. Usually these are not escalated beyond your team. Jackie, ST1 “The nurses won't think twice about doing a CAE form; they are clued up on good practice. They did one for me when I was working on a post-natal ward at the weekend. There were loads of baby checks to be done, and I kept getting called to deliveries. I couldn't get through all the checks by the time I left at 9 p. m. and the poor night SHO was discharging until 2 a. m. ! You can't avoid going to an emergency C-section though. This was a staffing issue... if you don't fill in a form, nothing will change. ”

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44  Patient focus For serious incidents or repeated adverse events that are not being adequately addressed: Raise the issue with your consultant. Then raise it with your educational supervisor or foundation director. Keep a record of your concerns and the steps taken to deal with the situation. Make sure the patient receives both an explanation and an apology. If you have no joy internally, or feel the matter has been dealt with unsatisfactorily, then you can: Raise the issue with the GMC. Make your concern public-providing that you do not breach confidentiality. It is highly likely that you will have to report bad practice at some point in your career. The irony is that you are more likely to notice it as a foundation doctor as, new to the system-there is less propensity for adopting the “this is how we do it here” mentality. Charlotte, FY2 “I had an experience of being constantly undermined by a senior nurse. All my colleagues felt the same way ... it wasn't an isolated thing. It went so far that she was making me prescribe a drug that I wasn't familiar with-I was unsure of the dose and she wouldn't allow me to check it. That was the last straw. I realised then that it wasn't safe for me or the patient. When you have serious concerns like that it needs to be raised to the supervisor and if not them, your foundation director or FY1 mentor. I raised my concerns with my supervisor rather than the nurse in this instance. They were very supportive but this person was a stable member of the team and very little could be done. Consequently I raised it externally on a deanery visit and they dealt with it, so whistle-blowing is not a bad thing -you need to protect yourself and your patients. ” If you are ever unsure of what to do GMC guidance (2012) suggests: Asking a senior or impartial colleague for advice. Contacting your medical defence body or professional asso-ciation such as the BMA. Contacting the GMC for confidential advice. Contacting 'Public Concern at Work': a charity which pro-vides free, confidential legal advice. When does crossing the line become a 'Fitness to Practise' (FTP) issue? By definition FTP involves “ serious or persistent failures ” and therefore gross misconduct. This includes situations such as those involving (GMC 2006): Risk of harm that cannot be dealt with locally. Deliberate or reckless misconduct. A health problem where the doctor refuses to follow medical advice and poses a continued risk to patients. A doctor abusing patients' trust or violating their autonomy. This may be something that you flag up, but will never be a matter that you yourself should deal with. You should report such concerns to your educational supervisor, foundation clini-cal lead or foundation programme director. They will escalate the matter to the deanery board for 'Doctors in Difficulty' and then to the GMC if necessary (see Chapter 6). Tim, Foundation Programme Director “The only inci-dent I've heard of-on the grapevine-of an FY1 being struck off was a heroin addict who was being abusive towards patients. Drink driving for example would be a 'Doctors in Difficulty' issue. Most of these can be resolved with support- and maybe an extra year' s training if necessary. Many go on to be fantastic doctors, even if they do have a rough start. ” Respecting personal beliefs Under no circumstances should you impose your personal beliefs on patients unless they are directly relevant to their care. However, this can be tricky as you may not realise you have an issue with something until it suddenly hits you square in the face. For that reason you need to stay alert to how your own personal beliefs could interfere with care. If this happens, you must explain this to the patient as well as their right to seek treatment elsewhere (GMC 2008b). Two situations to be aware of involving strong personal beliefs include the refusal of blood products by a Jehovah's Witness and the circumcision of male children for non-medical purposes. Jehovah's Witnesses are discussed below. HERE ARE A FEW TIPS FOR SITUATIONS INVOLVING PATIENTS WHO ARE JEHOVAH'S WITNESSES: If you have a patient who is a Jehovah's Witness, don't assume they will automatically refuse blood products. Enquire about their views and answer questions with honesty and respect. Seek senior advice and consult the local hospital guidelines about the options available. Some patients may not be aware of the different blood products and which are deemed acceptable or not. If you need further advice, then, with the patient's consent, you can contact the local Hospital Liaison Committee (HLC). They should have a helpline set up by the Watchtower Society (Jehovah's Witness society), which is available via the 24-hour Hospital Information Service. “Bloodless medical procedures” are available in some hospitals. Again, you can get these details from the HLC (GMC 2008b). Jackie,  ST1 “We had a patient in his late teens admitted under surgery with a splenic rupture. He initially went to one hospital and was then transferred to ours because we had cell salvage facilities. He didn't have any problems in theatre but there was a fairly high risk he would need transfusion. You always try to accommodate patient's wishes as best as possible. ”

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Patient focus   45Tricky decisions involving treatment: consent without capacity All patients with capacity are assumed able to consent to treat-ment. Patients also have the right to refuse medical care (if over 18 years), even if it means they may die. This premise is compli-cated whenever a patient lacks the ability to consent. Broadly speaking, you will encounter three different types of situations where you may be required to treat a patient without their consent: Psychiatric : e. g. a patient with acute onset psychosis could be treated under the Mental Health Act (MHA). Organic: e. g. a patient with delirium tremens could be treated under the Mental Capacity Act (MCA) 2005. Emergencies: e. g. a patient with diabetic ketoacidosis (DKA) could be treated under the doctrine of necessity. The MHA, MCA and doctrine of necessity are generally very well covered in medical school. Moreover, the MHA should be fairly self-explanatory for a given psychiatric case and not something that you would be involved in as a junior. What is most relevant to FY1 practice is how to approach organic con-cerns of impaired capacity. If a patient lacks the capacity to decide you should firstly (GMC 2010): Know what decisions about care are to be made. Check through all the notes for any legal documentation concerning care, e. g. advanced directives. Next you should enquire about a legal proxy e. g. lasting power of attorney or court-appointed-deputy (England and Wales). This is because, if there is no legal proxy, your consult-ant-as the patient's doctor-would be responsible for the decisions made about treatment for that patient. This means deciding on the “overall benefit” of treatment. In this situation you must involve those close to the patient as well as other members of the healthcare team to help inform your decision. Do not despair if there are no close family or friends available. In this instance, you can contact an IMCA-as Nick did for the patient who couldn't communicate (see Chapter 4, p. 38). An IMCA can be consulted in most difficult decision-making processes; including where there may be a conflict of interest. They act as an independent person outside of the healthcare system to represent the patient's views. Their service may also be required where relatives or friends are available but one of the following circumstances applies (Lee 2007): The friends and relatives are unwilling to be consulted about the patient's best interests. They are too frail to be consulted. They are too far away to logistically be consulted. They refuse. You suspect abuse in the relationship. Places you can look to contact this service include the Depart-ment of Health (DH) website, PALS or the Citizens Advice Bureau (CAB). This however does not apply when an urgent decision needs to be made, as in an emergency. In a life or death situation you treat under the doctrine of necessity. Here, if the consultant “reasonably believes” a treatment is necessary to save the patient's life and the patient lacks capacity, then the treatment can be given without a formal assessment. This is because in an emergency-for example, when a patient is having a cardiac arrest-it is not really appro-priate to be filling in paperwork. You would, of course, do your best to keep the patient informed and consulted where possible (DCA 2005). Most importantly, wherever your job is, your trust will have local policy documents on capacity and consent. Familiarise yourself with them when you start; or at least know how and where to access them. What about confidentiality and information-sharing? You will often find that those close to the patient will want information about the patient's diagnosis and the likely pro-gression of the course of the illness. If the patient has capacity, you must get their permission before sharing this information. If they lack capacity, it is reasonable to assume that (unless otherwise indicated) they would want those closest to them informed about such information (GMC 2010). Remember that if the patient expressly wishes their relatives not to be involved -you must respect this-even after death. Matthew, GP “We had an interesting case recently of a patient who didn't want her information divulged to her mum even after death. This patient had many complex alcohol and mental health issues and she didn't want any of that divulged. The mum is trying to go through the ombudsman and everything to get it. You do find that comes up quite commonly but ultimately you have to respect the patient' s wishes. ” Can those close to the patient make the overall decision? Only if they are legally appointed to do so and this is formalised as such. A patient can nominate someone to be kept informed and consulted about treatment, but this does not mean they have legal guardianship to make the final decision. You should be explicit about this when discussing such issues and make it clear that their role is advisory rather than definitive. If a patient wishes to nominate someone to make decisions on their behalf for a given situation (i. e. if they lose capacity), they need to formalise it legally (GMC 2010). End of Life care Matthew, GP “One challenging factor starting as a junior stems from the realisation that people do actually die in your care, and it' s not something you realise until it actu-ally happens. The first few times it really affects you... and you might not think it will... until it actually does. ” The End of Life (EOL) pathway includes any patient likely to die within the next twelve months. As a junior you will, in part, be expected to put patients on the EOL pathway. Prepare for situations which may require you to complete the appropriate paperwork. Moreover, if you are having difficulties dealing

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46  Patient focuswith something or feel uncomfortable, seek support from your colleagues rather than burying your head in the sand. Sophie, FY1 “Putting a patient onto the EOL pathway is something I've had to do... and was very uncomfort-able doing. My registrar made the decision, and I completed the paperwork. I asked the ward sister to check what I had written and she agreed with what I had done, but I definitely felt underprepared for this. ” Although not expected to make EOL decisions as a founda-tion doctor, you should understand the reasons for starting the EOL pathway as well as the process. Be aware that the risks and benefits of each treatment are not always clear cut. What you aim to avoid is causing the patient further undue stress or prolongation of the dying process, and this should be commu-nicated to close friends and family where appropriate (GMC 2010). to DNAR, can be difficult for relatives to come to terms with. Recognise this and be sympathetic. Imagine if your family member was in that position, how would you feel? Samyami, FY2 “Clinically making a decision not to resuscitate can be hard for relatives and they can get very angry: in their eyes you're giving up on treatment, you don't care and you're leaving them to die. I have seen it so many times on the ward. You can put your best effort into explaining it, but they usually stop listening to you. At the end of the day, you have to remember that the lead clinician has responsibility for deciding overall benefit even if the family disagree. Con-versely, it can happen when the patient is started on the EOL pathway too late. Those well-read on dignity and dying will question it and would have liked it earlier; 'you made my mum suffer for two weeks instead of one'-relatives can be angry at that as well. ” Difficult patients It is impossible to gel with all your patients. Here are some tips in dealing with patients with difficult behaviours: Be prepared to experience a multitude of emotions. Michael, GP “As a junior you are flooded with many emotions you will not have experienced before. You end up having to deal with a lot of people who are very emotional, angry and upset. Most of the time this is a natural response to the situation they are in... handling this is very tricky as a junior. Ensure that you have had some good communication skills training and recognise that empathy and understanding are very important. You will always have the odd occasion where relatives may pin you down to talk to you about difficult issues such as end of life care. Work out how to deal with certain types of emotion. ” Recognise difficult behaviour may be a defence mechanism. Terry, Consultant Surgeon “Patients may be belligerent and rude and walking away from the ward rather than to theatre ... that becomes particularly challenging to manage ... sometimes it' s just because they have a hospital phobia, so you really have to understand where they are coming from. ” Never raise your voice or get into an argument with a patient. If the situation is too heavy, politely excuse yourself. Carl, FY2 “On call I went to see a patient with chronic back problems. He had been in multiple times under the neurosurgeons. Despite being on many different analgesics, he was still in acute pain and asking for IV Morphine. The pain team reviewed his case and said he didn't need it. It was 8 p. m. before I went to see him. The nursing staff told me that in-between his IV Morphine he was going outside for a fag. He was very difficult and very aggressive straight away: The GMC (2010) outlines the EOL decision-making process as follows: 1. The doctor and patient make an assessment of the patient's condition, which will include medical history, views, experience and knowledge. 2. The specialist registrar/consultant combines their experience and knowledge with the patient's opinion about their condition (where possible) to identify the relevant options. The options should then be explained to the patient with the benefits, burdens and risks of each one. The doctor may recommend one, but they must not pressure the patient into accepting their advice. 3. The patient makes the decision-regardless of the doctor's opinion. 4. The same process applies when a legal proxy is appointed to make the decision, whilst trying to include the patient as far as is possible. What about a DNAR (Do Not Attempt Resuscitation) decision? Interestingly, a patient does not have to be informed about this. If a patient is at foreseeable risk of cardiac or respiratory arrest, and the consultant decides that resuscitation would not be successful, then they should consider carefully whether to tell the patient. This decision is never assumed and it is likely that, as a clinician with the closest relationship with the patient, it will be your respon-sibility to explore whether they would wish to know about the DNAR. If they decline, seek permission to share this information with others such as a family member. If they lack capacity, the decision should be shared appropriately but ultimately, signing the DNAR is the lead clinician's call (GMC 2010). You must remember to always record any discussions and reasoning in the patient's records as this will be your responsi-bility. Furthermore, the EOL pathway, particularly the decision

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Patient focus   47demanding IV Morphine. I told him that the pain team had reviewed his case and that I could only give him Oromorph. At which point he got up and started remonstrating... threaten-ing to go to the papers. I repeated that I couldn't offer him anything more overnight, and the pain team would see him in the morning. The patient then started screaming at me again, so I politely left and went to document everything. Half an hour later the nursing staff said he wanted to apologise. Being firm and walking away when I realised I wasn't going to get any-where worked; when a patient is angry, you need to be diplo-matic and reasoned. Before you go to see the patient, think about your options and don't give in just because they are shouting. If it is getting out of hand you should try to end the conversation reasonably. ” Support your colleagues when they have difficult patients. Respect that if they come to you with a difficult patient, it's for a good reason. Matthew, GP “Nurses do a very good job and protect a lot of staff. When you are asked to sort out an angry patient, it' s a big deal. Likewise, if you get a call at night for a patient who is agitated and wandering, the nurses will have tried everything in their locker of imagination as to how they can deal with it. They won't call you for nothing and that' s hard to appreciate at first-they deal with an awful lot of stuff you just never see. ” TOP 5 TIPS ON PATIENT FOCUS: 1. Lead by example. 2. Always make sure the patient is your first priority. 3. Don't be afraid to highlight bad practice. 4. Check who the patient wants to be involved in their treatment. 5. Be mindful of your own safety and leave if the situation gets too heated.

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48 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 6Effective teamwork Nicola, FY1 “Make it known you are keen to be a team member.... Don't just turn up, do your job and go home. If you want to have a career, that' s inadvisable. ” A foundation doctor who is a good team-player is expected to: Have the capability and willingness to work effectively with others. Be helpful to others, collaborative, and respectful of others' views. Offer support and advice. Share tasks appropriately. Understand their own and others' roles within the team. Consult with others where appropriate. Understanding teamwork Carl, FY2 “Teamwork is all about being adaptable. As a medical student you come from a background where you structure your own work and all responsibility is up to you. Suddenly, you are in a team where you cannot simply work on your own; you have to communicate well with everyone. Even if their way of working is completely alien to yours, you have to find a way around it. That' s not always the easiest thing to do. ” Besides considering your personality type (see Chapter 1), an additional way of understanding yourself is by looking at the part you play in a team. Teamwork is vital to your job as an FY1, and one of the specific aspects covered by the SJT. A great deal of research has been done on the effective functioning of teams and the different roles that team members take in order to aid successful teamwork. The best-known model of team descriptors is Belbin's Team Roles (Belbin 2010a [first pub-lished 1993]). If you find it hard to identify the roles you prefer to adopt, try a formal questionnaire online to help you (see www. belbin. com). Belbin's Team Roles measure behaviour, not personality. People gravitate towards the roles which suit their natural style, but where team members seek to take on similar functions, some may adapt to take on other roles. No one role is better than another; they all play a component part in the overall team performance. A really effective team will display a balance in the Team Roles being performed; too much of one behaviour or the absence of another can throw a team into disarray. Understanding the different Team Roles will help you to think more clearly about your individual contribution to a team and how other people's contributions are different, but equally valid. You may be able to use this insight to spot the problems when teamwork breaks down: a consistent theme in the SJT. You can then share the problem with the team or, if necessary, adapt your behaviour to improve the situation. Belbin's Team Roles Annie, Consultant “Every member of a team in a hospital has to have their role defined... if they're not defined, you start having conflict. ” Belbin (2010b [first published 1981]) describes nine Team Roles. Each Team Role has strengths and correspond-ing “allowable” weaknesses. These are described below, coupled with some advice for a person who takes on this particular role: 1. Plant: Whilst a natural problem-solver, creative and imaginative, the plant tends to ignore incidentals: remember to fill in a Clinically Adverse Event (CAE) form, even for near misses! 2. Resource Investigator (RI): Enthusiastic and out-going, the RI creates networks outside the team but quickly loses momentum once the first flush of enthusi-asm for a project/idea is over: remember to stay focused- even if your new rotation has lost its charm after a few weeks. 3. Monitor Evaluator: Evaluates what others present, judges and weighs up the options. Unfortunately though, this can make the monitor evaluator overly critical of others: remember to give constructive rather than critical feedback when teaching medical students. 4. Coordinator: Spots other people's talents and del-egates accordingly, but this can result in coordinators avoiding their own share of the work: remember that teamwork is a two-way process-if you give bloods to the nurses, you can help them out with a catheter or two later on. 5. Implementer: Keeps it practical and turns ideas into tasks that need to be done. However, the Imple-menter can be inflexible and slow to respond: prioritise and reprioritise jobs according to their urgency; if you feel you struggle with flexibility, ask for help. 6. Completer Finisher (CF): Whilst painstakingly meticulous, seeing things through to the end, the CF worries unnecessarily and doesn't like to hand over to others: if you find yourself waking at midnight wondering if you handed over that investigation, it' s okay to ring the ward and check... just don't make a habit of it.

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Effective teamwork   49 7. Teamworker: Cooperative and diplomatic, the Team-worker brings people together harmoniously, but can be swayed too much by others' opinions: advice from the nursing staff is invaluable, but remember, at the end of the day, the buck stops with your decision. 8. Shaper: Enjoys the pressure of delivering to a deadline. The Shaper is dynamic and driven but can put others' backs up by being over-zealous: when diving in with your A to E approach, don't forget your manners! 9. Specialist: Contributes valuable expertise and knowl-edge from a narrow field, but can be unable to see things from a wider perspective: your nurse specialist can help you out with everything from pain management to stoma care but overall, your consultant sees things more holistically. Michael, GP “A key thing to understand is what your role is in the whole team. Sometimes you are dumped on as a junior so it' s recognising: 'do I have to do the bloods, do I have to do the venflons?' It' s about knowing what you're responsible for, but realising that you are part of a team. On the other hand, it may be that you are the only person there that can do that job at that particular time so sometimes you might have to do tasks that you don't con-sider part of your remit. ” Team Role Descriptors and icons reproduced by kind permission of BELBIN, UK-www. belbin. com Understanding your role Sunita, FY2 “If you're prepared to work a little bit harder it makes things easier and you'll be a better team member. ” Having considered the theoretical dimensions of a team, here are some practical tips: Never shy away from asking for help. At the end of the day, there is a person at the end of the phone-not a monster! Teamwork is about give and take. Don't take the attitude “that's not my job”. If you help a team member out, they will be there to help you when you need it. Good teamwork will lessen your workload and lighten your day. Learn to delegate. Sometimes you are dumped on, so know what tasks you can allocate to others during these times. Divide jobs evenly amongst the juniors so everyone does their fair share. Every hospital works in a slightly different way, find this out from the outset. Understand that your role is CLINICAL not theoretical: bloods, cannulas, TTOs and recognising ill patients are your bread and butter. Samyami, FY2 “What' s important to understand is that 80% of the work you do in med school is theoretical. On the wards it' s about practical skills, being sensible, organised and writing things down properly. That transition between bal-ancing theoretical and practical knowledge is key. If you're not confident in your clinical practical skills then carrying out the first steps of management-no matter how good your theoreti-cal knowledge is-becomes very difficult to execute. ” Sometimes, you may find yourself going above and beyond the standard duty of care. This is because you are human as well as being a doctor. Your sense of humanity is what makes you a great doctor. Nevertheless, be careful of going beyond the boundaries too often, as you may find you sacrifice your own well-being in the process. Learn to balance your needs with those of your colleagues and your patients. Faraz, FY1 “Some patients you have stronger relation-ships with. I had a patient on surgery that I had been looking after for a couple of months. Despite optimum treat-ment we knew he was going to die, and I was on call. He didn't have any family close by and he wanted someone to talk to and hold his hand. I had to juggle priorities of being the only FY1 on call and being with this man in his last minutes. I decided to stay with him and answer any bleeps as they came rather than talk to the nursing staff or have a break as I would usually do if it' s quiet. I spent most of that night with him just so he wasn't alone in his last minutes... even though you get used to death, it' s never easy. ” At the end of the day, if you feel you are doing too much, you probably are. Recognise your limitations and speak up. It could be that your rotation is not well enough staffed, and others before have had similar problems: Eve, FY2 “Workload can be very variable. A team may not be well staffed or may have a workload beyond their resources, so you end up staying well beyond 5 p. m. whilst your friends are going home on time in their job. I stayed 1-2 hours beyond 5 p. m. every day for the first 2 months on my first rota-tion. Part of this was learning the job and getting quicker, but the other part was not knowing what was an unreasonable workload. You need to take stock and think whether it is reason-able to expect you to work that number of hours beyond what you are being paid for and what is reasonable in terms of your health and general well-being. If you feel you are struggling, you need to raise it with your educational supervisor. There is no shame in saying you are struggling, as chances are the pre-vious house officers were, and the next one will be. There are some jobs where workload is way beyond staffing and, unless you raise it, it will never change. You can also ask for your hours to be monitored if you think it' s particularly unfair. Some people have done that and their FY1 jobs have changed... one of the ones I did now has 2 juniors rather than 1. ”

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50  Effective teamwork Effective handovers Fraz, FY1 “If you request bloods, X-rays, scans and then go home and forget to check them or hand them over, you will find yourself waking up at 2 a. m. But you have to ring the on-call and get them to check: regardless of the time. Always be aware that if you request them, they are your responsibility. ” Handovers are vital for maintaining patient care whilst you are off duty. You cannot simply leave at the end of your shift without making sure that care is safeguarded (GMC 2009a). The aim is to reach a shared understanding amongst staff about the priorities for each patient (BMA 2004b). What are the pitfalls which cause teamwork to break down? Not being reliable; avoiding doing outpatient clinic letters for 3-4 weeks. Being bleeped and not answering. Being abrupt with colleagues-especially with secretaries. Being defensive. Blaming others for mistakes. Not completing paperwork appropriately. Not writing legibly. Not being accurate and making things up! Christine, Consultant “As an FY1 you have to be approachable and nice and be able to speak to other disciplines. If we get a secretary-or a nurse-coming to tell us that an FY1 doctor was rude, we don't want the headache of managing that conflict. Being pleasant is a very important quality. ”THE ROYAL COLLEGE OF SURGEONS (RCS 2007) AND THE BRITISH MEDICAL ASSOCIATION (BMA 2004B) OFFER THE FOLLOWING TIPS FOR A SAFE HANDOVER: 1.   Set the scene. Set sufficient time aside within working hours, in a quiet area: ideally the same time every day. Keep it a “bleep free” zone. The most senior clinician should set out a brief plan. Have access to lab results, X-rays, clinical information, the intranet/internet and telephones. Structure the team discussion so only one person speaks at a time. Encourage a culture where information is challenged: there are no 'stupid' questions. 2.   Minimum  requirements. Patient's FULL name and date of birth. Date patient was admitted to hospital. Where the patient is (ward and bed). Current diagnosis. Results of any significant investigations. Outstanding tasks, e. g. chasing investigations, bloods etc. 3.   Additional  information. Patient condition, e. g. stable, sick - MEWS (Modified Early Warning Score) if used. Urgency of review - Now? 1 hour? None? Management plan including “what to do if . . . ” contingency plan. Operational issues e. g. ITU beds available? Discharge planning. What are the common difficulties compromising a handover? Including “non-essential” information means you can't see the wood for the trees. Not including enough information means the patient gets put to the bottom of the pile. Not having a checklist of information to hand over means things get missed. Not having the information handed over in writing: you cannot possibly remember everything. Speaking over one another such that information gets lost and misinterpreted. Craig, FY2 “Every shift works better with effective handovers. We work shorter shifts now, so there are more handovers. Each time a different doctor takes on the informa-tion, so, unless it' s clear what jobs you want doing, it becomes like Chinese whispers. By the third handover someone has the patient' s details and something about abdo pain but they don't have a clue what they are supposed to be doing. The worst part is that, if you don't have the information, and you are busy, that' s going to be a low priority as you can always say 'well, What are the consequences of these pitfalls? Jeff, Consultant “Not being accurate is annoying and we see that a lot. If you are not accurate with the doses of medication when taking a history and don't cross-check the dose and the letter goes to the GP, the GP comes back and says 'I'm sorry the dose you sent me is incorrect. ' That creates extra work for me. First, I have to get the records out-which might mean trawling through the 400 to 500 patients on my workload. I then have to fish out the records to look at the last consultation and look at what was written. If the handwriting isn't clear, it makes it even more difficult. Then I have to call the patient and ask what medi-cations they are on, go to the pharmacy and look at the prescription, fax a letter to the GP-all that because the junior wasn't accurate.... See how much work is created if things aren't checked properly. ”

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Effective teamwork   51we didn't know'. If you have ten patients you know aren't very well, you are not going to concentrate your time on the one you don't know anything about!” A colleague phones to say they are running late. They cannot give you a definite time they will be there and you have made dinner plans. How should you proceed? Patient safety is paramount, and therefore you should take steps to see that the handover is achieved in a suitable manner so that you can get away: you are not expected to stay hours beyond the end of your shift. The handover should be to a colleague working on the ward-most likely a registrar. This is not a responsibility you can delegate to a nurse, and it would be unfair to do so. Moreover, communication must be in verbal as well as written form, as you cannot rely on your colleague coming onto shift to prioritise patients simply on the basis of the notes. It is time consuming to fumble through notes attempt-ing to find previous management plans. This could delay review and potentially compromise patient safety. Be proactive and make sure your senior has all the information (ISFP 2012). Understanding your colleagues' roles Although there are a multitude of team members, the nursing team, your consultant, and the radiology department are the ones discussed here. You might like to consider others' roles whilst on your clinical placements. Take five minutes out of your day to have a chat with the ward clerks, the porters, the laboratory staff -anyone whose roles and responsibilities you are not certain of -and consider their relationship to the running of the hospital. The  nursing  team Undoubtedly you will have heard that you should cherish the nursing team: they are your best friends. Here are some reasons why nurses are invaluable: They can show you where everything is. Nick, FY1 “My first shifts at this hospital were night shifts and it was quite daunting as it was a new job, new hospital and I didn' t know any of the patients at all. I didn' t even know how to request bloods, and when you're on nights there are no seniors-well there are, but you only call them if it' s serious, not to ask how to request bloods! The nursing staff definitely saved me on my first three nights: showed me everything. They're your best friends when you start I would say, they really are. ” They can give you advice on management. Sarah, FY1 “Listen to the nursing staff-they do know what they are talking about. If circumstances arise where the opinion is not mutual, I explain why, so we come up with a shared understanding. Realistically, I accept advice from nurses every day. When you first start you feel like you are constantly demanding things off them-almost to the point of feeling like a nag-but as you develop your relationship you realise there' s so much give and take. ” They are closest to the patients and their relatives, and can raise their concerns to you. Des, Psychiatric Nurse “Nurses are at the bedside with the patient and the relatives see that. You build up a strong relationship surprisingly quickly. Nurses are also there for the emotional support of the family as well as the patient. We have an intimate relationship with patients; we can spot unusual things, as well as raise things that they haven't told you. That information is crucial for medics to have if they want communication to be successful. ” Above all, however, you must remember to communicate what you need in order for your relationship to blossom- nurses may be fantastic, but they are not mind readers: Tim, FY1 “It' s really important to tell the nurses what you want done. If you just write in the notes and then leave, no one will know. I was wondering for the first week why my plans weren't getting through quickly-it was only because I was being an idiot and didn't realise that I was supposed to tell the nurses. It' s really stupid and obvious now, but I learned this pretty quickly!” Besides helping the juniors, nurses have a vital relationship with patients. You should remember two things in this respect: 1. Nurses will stop at nothing to advocate the best for their patients. So if you don't respond to their request and they feel their patient is compromised, they will have no problems ringing your consultant at home, in the middle of the night (see Figure 6. 1). Des, Psychiatric Nurse “One of the patients on the ward was complaining of a cold leg. We called the consultant who bluntly told us to put a sock on her leg and he would be back in the morning to check on it. We weren't happy with this so eventually we rang a different doctor for another opinion. An hour later she was seen-her leg had gone completely white -and she was rushed to the main hospital for a DVT. If we hadn't been so vigilant and been willing to get a second opinion, she would have lost her leg. ” 2. Nurses are the guardians of safety. Lorraine, ITU Sister “As a nurse you find you are watching what everyone else is doing to safeguard the patient. It doesn't matter what level the person is, there is always potential for dangerous practice, so that is added pres-sure. I remember one incident of a patient who was seriously ill with a severe head injury. He needed some drug therapy to stop him fitting, so the nurses drew the drugs up. The doctor then came in, picked up the syringe and injected it into an arte-rial line by mistake! This caused massive problems. The patient survived-despite a necrotic arm-and it went to court. That was someone not knowing the difference between an arterial line and a peripheral cannula. It made you realise you have to

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52  Effective teamwork Figure  6. 1  Listen to the nurses: they also have the patients' best interests at heart have eyes in the back of your head. When there are a lot of people in a critical environment like that, there is added pres-sure on us to safeguard the patient and watch what everyone else is doing-particularly as they may not be familiar with the equipment. ” Nurses also have the added pressures of: Long days, long shifts and few breaks with stretched resources. Dealing with anxious relatives wanting lots of information, combating angry relatives, handling wandering patients. Delivering the prescribed drugs at the right time. Getting patients discharged. Jennifer, Nurse “Nursing is about bringing together everyone to make it safe. We try to achieve what the medics want us to achieve, in a safe manner, whilst watching and keeping everyone else safe as well. We should spot if you are about to make a mistake as we have more experience. ” The  consultant Having been on the wards, have you ever really considered the responsibilities that your consultant has? Here are a few pres-sures to appreciate: Busy workload: ward rounds, clinics, theatre, paperwork, etc. Politics of the job: staffing, resources, funding, budgets, salary and pension changes, etc. Duty to communicate with colleagues-especially with GPs. Responding to phone calls and emails. Ultimate responsibility for ALL their patients. Training and personal development for themselves and their staff. Mithun, Consultant Psychiatrist “Responsibility ends with me; if something a junior does is wrong, it goes to the consultant. My job doesn't end with the day. Juniors and SHOs can finish, but, if my job doesn't get done right, there is no-one to take it off my back. Juniors also need to understand that, at the end of the day, my priorities are to the patient. You must give us time and plan ahead; I don't want the junior coming to me wanting training expecting me to drop everything. I have a long-term relationship with my patients and I must be sensitive to their needs above all else. Juniors leave but my patients stay with me, it is important to remember this. ” The  radiology  department Negotiating a scan for your patients is something that you will have to do week in and week out. What you have to realise is that radiographers and radiologists also have a list of things that need to be done. Coupled with this, the radiologists have the added pressure of reporting all those scans so that the appropri-ate management can be made. Hence, if you go in hammer and tongs, you might not be very successful.

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Effective teamwork   53It is also worth noting that the radiologist may not neces-sarily communicate your conversation to the radiographer. It is therefore vital that you write down your reasons for the request (i. e. the patient history and examination findings) and the reasons for the scan (i. e. the differential you are consider-ing). This will help the radiographer to better tailor the scan to that patient. Fraz, FY1 “Get good at requesting scans and getting them authorised. Radiology love asking questions; you need to be asking for an appropriate scan for an appropriate history. There is no point talking about a patient with right iliac fossa pain and asking for a CT brain. They will raise those issues, so be precise about the clinical indication and radiology will be more than amenable. There are limited resources and limited slots, if you advocate for your patient, they know you are not just requesting willy-nilly-it' s all about having the right approach with people. ” SBAR These tips for negotiating can be applied when discussing patients with any colleague from a different speciality-and this is a daily occurrence. In this respect, the SBAR (Situation, Background, Assessment, Recommendation) approach is rec-ommended (Crocker et al. 2010). Situation -your name, grade, calling about (patient and their location), “ the reason for call is ... ” Background -include when the patient was admitted and relevant history and background, e. g. medications, blood results, tests or surgical procedures. Assessment -what you found on examination, e. g. MEWS 4, what has changed and your interpretation. Recommendation -what you think the patient may need, or what you need advice on. An action plan should then be agreed. The aim of SBAR is to make communication more succinct. It is particularly useful in high-risk situations (see Box 6. 1). This is something you can practise on the wards with a fellow student. Akin to summarising findings, SBAR is something you will require on a daily basis. HERE ARE SOME TIPS FOR NEGOTIATING A SCAN: Explain the context - why you are there and why you are interrupting - before launching into your request. E. g. “I was asked by Dr X to come down here because we have . . . ” Ask nicely, “Would it be possible to . . . ?” Say please and thank you. Niceties go a long way, but you'd be surprised how many people forget. If they still say no, your senior will not be surprised, it won't be the first time, nor the last. Box 6. 1 SBAR Example : Dr Coe is an FY1 working on a surgical ward. He calls his registrar about a patient who has devel-oped an irregular heart rhythm. S: Hi my name is Dr Coe, I am an FY1 calling about Mr Brown on Ward 33, bed 2. I'm concerned about a fast, irregular heart rhythm he has developed. B: Mr Brown is a 54-year-old gentleman admitted 4 days ago for a total hip replacement. His surgery was successful and there were no post-op complications. He is on 100 mg of Atenolol for hypertension. A: His heart rate is irregular, his blood pressure is 140/80, he had some shortness of breath and desaturated to 88% on air, but I have stabilised him on 2 L of oxygen. He denies any chest pain or calf pain. The ECG shows atrial fibrillation with a rate of 126 bpm. I am worried he might have a pulmonary embolus. R: I have ordered a chest Xray and sent off routine bloods to rule out infection and included clotting. Do you think he needs a CTP A? I need your advice on how to proceed. Professional conflicts Clare, Consultant “Conflicts happen all the time: either due to conflicts of interest or difficulties because of personalities. As long as you remain professional and don't personalise any issues, addressing problems objectively, you should be able to resolve them. If you are unable to resolve a problem, then raise it to the appropriate senior. Work is a com-pletely professional place. You don't have to be friends with everyone at work, but you can be friendly at work. ” If you have a concern about a colleague but are unsure how to raise it you can consider the following options (GMC 2008c): 1. Ask a senior or impartial colleague, e. g. your educational supervisor or consultant, for advice. 2. Contact your medical defence body or professional associa-tion such as the BMA. 3. Contact the GMC for confidential advice. 4. Contact Public Concern at Work: a charity which provides free, confidential legal advice. Craig, FY2 “We were working as a team of four-one colleague was worried about practical stuff and the other was very confident and they really clashed. She felt he didn't pick up his fair load of work, and he felt she wasn't any good. They ended up having a slanging match in front of the patients and the SHO-who rightly told them off. Over the next 2-3 days, the four of us had to work out how we were going to work together. In the end they never really got on but we came up with a way of dividing up the jobs evenly so we all knew what we had to do. We would lend a hand if we finished early,

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

54  Effective teamworkbut they never helped one another out. It' s not an ideal situa-tion, but we found a practical way for them to work side by side. We did our best to resolve the problem amongst ourselves, and I don't think it went any higher than our immediate seniors, so I don't think the consultants or registrars knew about it. If you can try and sort it out at a lower level, then do. If that doesn't work, then raise it at a higher level with your educa-tional supervisor or consultant-but you have to be really sure that there is a need for it because stuff like that does tend to stick. They will remember it and pass judgement. At the end of the day, we are all adults and should be able to sort things amongst ourselves most of the time. ” Seeking support Matthew, Educational Supervisor “If you feel you are struggling, every deanery should have a 'doctors in dif-ficulty' programme. The unit is well financed for those who need it. If you realise you are struggling it is better to get help earlier rather than later. You don't want to make a mistake and get referred in via another mechanism. ” It is fundamental that you seek help from your seniors on the wards. Likewise, there are external team members who are always there to help you out. The foundation school There is a whole network of professionals within every founda-tion school to facilitate your training and your personal and professional development. Although the number of professionals varies with each school, Figure 6. 2 gives you a rough idea of the school's structure. This will aid your understanding of the differ-ent roles for the SJT-without overcomplicating matters. If you have any issue as a foundation doctor, it is always best to go through your educational supervisor or clinical tutor. Liaising between managers is best done internally. The Foundation Programme Director is the head of the foun-dation school and ensures that: National (UKFPO) and deanery (e. g. Northern) policy are applied to the foundation school. The training programme covers the curriculum. The foundation school curriculum is delivered to trainees. Educational supervisors are up to the proper standards. The quality of all aspects of the foundation programme from the configuration of rotations to the spread of specialties avail-able for training is assured. With respect to your direct needs, your educational supervisor is typically first port of call with: Career advice. Issues of stress and workload. Figure  6. 2  The generic structure of a foundation school Foundation school Foundation Programme Director Foundation School Manager (operational role) Postgraduate Manager (administrative issues; assist clinical tutors) Local Trust Clinical Tutors (F1/2 personal issues; assigned at a particular hospital) Educational Supervisor (changes each rotation, discuss your eportfolio and general go-to person)

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Effective teamwork   55 TOP 5 TIPS ON TEAMWORK: 1. Understand your role as part of a team. 2. Facilitate teamwork with good communication between the team players. 3. Help out your colleagues - it's about give and take. 4. Try to sort out conflicts amongst yourselves before you escalate. 5. Your educational supervisor is your first port of call for support. Interpersonal problems, e. g. pregnancy, family difficulties, financial difficulties. Lack of training. Completing eportfolios. Conflicts within your team, e. g. difficult registrar, a lazy FY1. Most issues can be dealt with by your educational supervisor. If not then your educational supervisor the supervisor may decide to escalate further to the clinical tutors and then to the foundation programme director. Although this is the typical procedure, you can always approach your clinical tutors or foundation programme director directly if you wish. They do have a wider realm of responsibility though, so it is probably best to seek advice from your educational supervisor as they will be able to help you in the most time-efficient manner. Dan, Foundation Programme Director “Most major issues get filtered up to me. For example we had one GP practice where the trainees were having a particularly hard time-to the point that they were being bullied by one practi-tioner. This was sorted locally by the clinical tutors and we no longer send doctors there, but I was still aware of it. There aren't many circumstances in which you would need to contact me directly. If I do receive things, I usually forward them to the relevant clinical tutor as they are on site to deal with the issue. Often I am away visiting other foundation schools or in meet-ings etc. If you can't get hold of your educational supervisor in the first instance-or they are the problem-your clinical tutors are who you should be contacting. ”

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

56 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 7SJT practice material How do I approach the SJT questions? Having read this book you should have valuable insight into the types of scenarios you will be asked about, what is expected of you as a FY1, and the knowledge with which to evaluate any question. Although it is important to establish a method that best works for you, the following structure is one of the ways you may wish to approach the SJT: 1. Is this a “ranking” or a “selecting” question? It is important that you answer correctly! 2. Which options are the least appropriate? This will minimise your options and aid your decision. 3. What is expected of me at this level? For example, you are not expected to break bad news as a FY1. 4. Of the options remaining-decide which option is first by thinking: “ if I can only do one thing... which would be the most important action to take?” 5. Then cover this answer up and think: “ If I can no longer do that one, what is now the most important action to take that will resolve this situation? ” and so on. “Should” and “most appropriate” imply ranking in order of importance rather than how you “would” go about tackling the situation in practice. For instance, on the wards it may be that you would speak to a nurse first for advice about a difficult patient as they are often the nearest to hand. In the scenarios, however, you should approach a more senior member of the team first such as a registrar or consultant, as they are more likely to be appropri-ately equipped to deal with a particular situation. Here is an example : You are on call in A&E. You have been very busy and failed to fully complete the patient's hospital ID number on the blood bank request form. The lab rings to ask you to rectify the error. The patient requires a “cross-match” because they are due for surgery. What should you do? Rank these responses in order from most appropriate to least appropriate: A. Apologise and ask the laboratory staff to kindly fill in the patient ID for you. B. Go to the lab to complete the details yourself. C. Ask a competent nurse to rebleed the patient as you are busy. D. Rebleed the patient yourself and rewrite the blood form for cross-match. E. Send a medical student with the patient details to practice their venepuncture and to report back to you with the bloods. This question tests your knowledge of transfusion protocol. On the basis of the reasoning set out earlier in this chapter: 1. This is a ranking question. 2. It is not appropriate for someone else to fill in the patient's details as this could potentially cause serious harm if the wrong patient were identified. This would be irresponsible and put the patient at risk. 'A' is therefore last. 3. B is also definitely not appropriate as although you could perhaps identify the sample with your handwriting, this is not something you should do as this could again put the patient at risk. 4. D is the most appropriate option and would immediately resolve the problem. This option will ensure patient safety and leave fewer margins for error. You will know yourself which patient is the right patient and can correctly fill in the form at the bedside. 5. E is the next most appropriate option. This is a perfect opportunity to teach medical students about the mistakes that can happen and the consequences of error in blood transfusion. Ideally, however, you should take the student to the patient rather than sending them with the details. You know the patient -this will ensure that they are correctly identified. 6. This leaves 'C' in the middle. Medicine is about teamwork and it is important to know when it is appropriate to delegate tasks. However, the nurses will also be busy and bloods are primarily an FY1's responsibility, hence this is less appropriate than D and E. 7. The answer is therefore DECBA. SJT example questions 1. An 8-year-old boy comes into A&E with a badly broken leg. He needs surgery. You speak to his parents about the surgery. They explain that they are Jehovah's Witnesses and they don't want their son to have a blood transfusion. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Inform your consultant about the situation B. Consult local hospital guidelines on bloodless procedures C. Ignore the parents' wishes and treat the child in his best interests D. Tell the parents that it is unlikely that their son will need a transfusion and they should agree to surgery E. Tell the parents you will see what you can do 2. You are working in a haematology clinic. You have been seeing Mrs Alcock regularly over the past 3 months. She says she would like to express her gratitude and hands you a £50 cheque. What should you do?

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf