mrcp paces communication skills and history taking notes

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For MRCP PACESnotes by Prof. Zain

TRANSCRIPT

MRCP-PACES

PAGE

Session One

MRCP-PACES

ETHICS & COMMUNICATION SKILLS

1. Ethical issues:

Respect for Patient Autonomy

Consent

Confidentiality/Disclosure/Public interest

Justice

2. Public protection:

a- Driving;

Epilepsy

Diabetes Mellitus

and TIA

and Heart disease

b- GU infections/Communicable diseases:

HIV

TB

HBV

3. Breaking Bad News

4. Medico legal issues: Resuscitation/DNR

Advance directives

Brain death & persistent vegetative state

Coroner referral

Euthanasia

Postmortem examination

Organs donation

Religious bioethics

5. Counseling:

Multiple Sclerosis IHD & Cardiac rehabilitation Cystic Fibrosis

Huntingtons Disease Rheumatoid Arthritis Uncontrolled DM Bronchial Asthma/COPD6. Procedures:

Heart-Lung Transplant.

CABG

Pacemakers

Bronchoscopy

Endoscopy

7. Updated NICE Guidelines:

Beta-Interferon in MS

Infliximab (anti-TNF) in RA & CDLayman English:

Feel edgy (an edge): Nervous

Invalid:

Terminally ill

Low: Depressed

Give way:

Collapse

Head piece:

Brain

Fainting:

Syncope Giddiness:

Vertigo

Fits/Shakes:

Epilepsy/Convulsions

Ringing in ears:

Tinnitus

Back passage: Anus

Bottom:

Buttocks

Phlegm:

Sputum

Tubes:

Lungs

Puffed/Puffy:

Breathless

Heart attack:

MI

The Welfare:

Social services

Get the sack:

Lose job

Puffed up:

Swollen

Tummy/belly:

Stomach/bowel

Gullet:

Oesophagus

Feels sick:

Nauseated

Been sick:

Vomited

Wind:

Flatulence

- To belch:

Send wind from stomach

- To part:

,, ,, anus

Toilets:

Motions/stools

Water:

Urine

Keep wanting to go: Frequency

To get up at night:

Nocturia

A growth:

A mass, cancer (also: the big C)

Lose:

Menses

Pictures/Imaging:

X-Rays

Temperature:

Fever

Get back/Flare:

Relapses

To be looking/to turn the corner: Improves

To be laid up:

Confined to bed

To find ones legs:

Start walks after illness

To have a bad turn:

Becomes suddenly ill

To have a bug:

To catch a virus/infection

To lose ones nature: Becomes impotent

To go steady:

To have a regular partner

(Ref: English for Overseas Doctors)

The British Health System

Guidelines & Policies:

The General Medical Council (GMC)

The National Institute of Clinical Excellence (NICE)

The Scottish Intercollegiate Guidelines Network (SIGN)

The Royal Colleges

Hospitals (NHS): SHO, SpR, Consultants

The GPs

The Social Services System

The Home Health Care

Preventive Section, CICD

The Legal Advisor, the Coroner system, etc

Occupational health services & rehabilitation

The Nursing teams:

Specialist nurses (diabetes, Asthma,)

District nurses

Teams (e.g. McMillan team)

Nursing homes

Voluntary agencies

Support groups & Societies (MS)

Station 4: ETHICS and COMMUNICATION

Candidates Instructions:

You will be given 5 minutes before entering the examination room to read a scenario & to make your plan of action. On hearing the bell, enter the room & begin the consultation.

You will have 14 minutes to interview the patient/actor & one minute after he/she leaves the room to organize your thoughts and to prepare yourself for the discussion with the examiners.

Dont re-take history from the patient and dont examine him/her.

In this section some scenarios will be presented & will be followed by a suggestion on how to approach similar situations when you, hopefully face them in your actual examination.

This will be preceded by short talks emphasizing essential ethical & legal issues and some important guidelines e.g. DVLA, INF in MS, End of life decisions etc.

A comprehensive knowledge of UK law is not required from overseas candidates; however, they are expected to know in broad terms relevant ethical & legal principles.

Many candidates fail this section of the PACES examination not as a result of its difficulty, but because they fail to prepare to it adequately. On the other hand, many of the successful ones feel that with good preparation, success in this section is probably more predictable than in any other section of this exam.

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

Station 4: ETHICS and COMMUNICATION

USEFUL HINTS

When given the scenario outside the examination rooms STUDY it carefully & decide at first which ethical/communication principle is being tested.

Then on the provided paper write down the points that you would like to discuss with the patient/actor & the plan of action needed to manage the given problem.

On entering the exam. room, start by greeting the examiners then sit facing the patient, greet her/him & introduce self and explain role e.g. Hello Mrs. X. Im doctor Y, the medical SHO who is looking after your husband. Then agree the purpose of the interview We are here today to discuss the result of his bone imaging. Is that right? Would you like to discuss any other issue?

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

Start the interview with open-ended questions e.g. what do you know about your husbands condition? or I learned from your GPs letter that you have had a seizure last weekend, can you tell me more about that?

Use close-ended questions as the interview progresses.

Provide clear & understandable explanations

Avoid using jargons

At the end of the interview:

- Agrees a clear course of action with the patient

- Summarizes - Check understanding (e.g. what message you will take home with

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

family?)

- Shake hands & say goodbye.

PRINCIPLES OF MEDICAL ETHICS

The 4 Principles of Medical Ethics

1. Respect for Patient Autonomy2. Beneficence3. Non-maleficence4. Justice1. Respecting the patients Autonomy: (wishes & self-rule)

Autonomy: means self rule i.e.(the capacity to think, decide & act freely and independently). It is the patients right to be involved in any decision about his health.

This requires that the health professionals help patients in making their own decisions and respect & follow these decisions. Respect of autonomy implies that doctors treat competent patients in accordance with their informed choices, even if these conflict with the doctors beliefs.

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

This entails doing what is best for the patient.

In most situations 1&2 lead to the same conclusions, however, the two principles conflict when a competent pt. chose a course of action that is not in his/her best interests.

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

1. Make sure that the patient is competent

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

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

4. Respect the patient's autonomy

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

With regard to treatment & procedures, the potential goods & harms and their possibilities must be weighed up to decide what, overall, is in the patient s best interest.

* *These two last principles imply that:

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

2. Potential benefits overweight potential risks.

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

Refers to the duty of the doctor to the whole society. A. Patients with similar situation should get accessibility to similar health care.

B. When determining what level of care should be available to one set of patients, we should take into account the effect of such use of resources on other patients (i.e. we must try to distribute limited resources fairly). Using these resources to aggressively treat a terminally ill patient is potentially depriving others of the treatment.

*Sometimes the patient's autonomy conflicts with the "Public Interest". In such a case the latter must be respected; as your role for the whole society is more superior to respecting the patient's autonomy.

CONSENTING PATIENTS

Types of Consent:

1. Expressed: Written or verbal agreement for the procedure2. Implied: e.g. the patients action in response to a request for exam.3. Statuary: When the law requites a particular consent e.g. IVFElements of valid consent:

VALID CONSENT =

Understanding (Competent patient + Appropriate Information)

+ Voluntary decision (i.e. without coercion)

True informed consent requires that the patient does not merely passively assents to the doctors decision, but specifically authorizes the doctor to initiate the medical plan.

Information to be provided to the patient:

Diagnosis/Prognosis

Uncertainty about the diagnosis/need for further investigations

Purpose, details & expected outcome of procedures

Likely benefits & probability of success

Possible side-effects & complications

Techniques:

- Use illustrations, written or visual aids for explanation

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

- Involve other staff e.g. a nurse

- Give a balanced view

- Allow sufficient time for reflection & decision-making

Consent in English law:

What is Competence (Capacity)?

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

Understands a simple explanation of his/her medical condition, treatment and expected outcome.

Is able to reason about specific goals of treatment & choose to act on the best of such reasoning.

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

Understands the consequences of such choice.

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

a decision that is against his best interest.

- Competence is function specific

Consent contd

(1) Competent patient:

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

Anything done without the patients consent, even touching, is battery (for which damage may be awarded). In contrast to negligence, the patient doesnt need to prove that he/she has suffered harm as a result of the battery for damages to be awarded.

B. The patient should be given information about the nature of the procedure or other medical interventions (otherwise battery), common & rare side-effects, benefits & reasonable alternatives (otherwise negligence: failure to give appropriate information to the patient before choosing to accept/refuse a treatment or a diagnostic test.(2) Incompetent patient:

Possible approaches:

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

Relatives & friends may be approached as a source of information to judge the patients best interests, but cant give or withhold consent (i.e. there is no proxy consent for an incompetent adult patient).

NB: Tutor dative (Partnership giving)

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

To answer this question, Consider:

The patients previously expressed preference

His general values & backgrounds

The doctors experience with other patients

C. Advance Directives: Should be respected after ensuring that the patient was competent & had all the

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

D. Involve hospitals legal adviser/apply to the Court if:There are differences of opinions/controversy in therapy.

Examination/testing & treatment without consent:

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

2. Where a patient is incapable of giving consent as a result of a mental illness, the treatment should be based on the patients best interest" principle.

3. Where a minor (