Communication Station Guide

Introduction

There are two short communication stations on the MRCPCH circuit where the challenge is to get across a certain amount of information effectively in a short period of time (9 minutes). The scenarios that come up will be common ones you will encounter as a junior registrar (ST4-5) and will test your flexibility as an effective communicator. Whilst communication skills can be taught, your individual communication style is something you will have to develop through practice; therefore the examples and tips provided here are not intended to be prescriptive. Even if you think one of the illustrated examples below is a good one, it is worth practising it for yourself so you come across sincerely on the exam day!

 

Approach & planning – before you go in

  • The aim of this station is not to take a history (as there is a separate station for this) but to demonstrate your knowledge base and show how you transmit this effectively.
  • Therefore whilst you can ask the “recipient” questions, remember you need to get a certain amount of information across in the 9 minutes allocated in order to score well, no matter how good your communication skills are – this requires pre-planning and practice.
  • Marks are allocated for BOTH your communication skills and demonstration of your knowledge base.
  • You are given 4 minutes to read the vignette carefully prior to entering, so make sure you take note of:
  1. The task (i.e. what do I need to get across in 9 minutes?)
  2. Your role (invariably the paediatric registrar)
  3. Your location (A&E? NICU?)
  • Think ahead about:
  1. Your tone and facial expression – the closer to real-life you imagine it to be, the better you will score.
  2. How you want to direct and structure the conversation
  3. Key points to cover – write notes (diagrams are exceedingly useful but plan ahead especially if you lack artistic skills!)
  4. What questions may be asked
  5. Further information sources you could direct “recipient” to
  6. Possible alternatives to the way the conversation will go (e.g. what will I do if the person breaks down and cries?)
  7. How you will deal with what you do not know - DO NOT MAKE THINGS UP (practise using phrases like “let me check on this and get back to you”)
  8. Remember there is also an element of artificiality to the station; if the vignette does not indicate whether you have seen the child already yourself you can usually safely assume that you have in talking to the parents (i.e. real-life scenario)

 

Basic framework for all communication scenarios

As this is not a history-taking but generally an information-giving station, you should generally aim for the following format:

  • Introduction of self and task

“Hi my name is… and I have been asked to…”

“Hi my name is… and I understand you had some questions about…”

  • What do they already know (and from whom)

“Can I just check what you have been told about…”

  • What do they want to know

“But before I begin, is there anything in particular that concerns you/ you want to talk about?”

  • Tell them what you are going to tell them/ what you are going to discuss

“First, I am going to explain… then…”

  • Tell them/ discuss the issue (see below)
  • Check understanding

“I know I’ve given you a lot to think about, so I just wanted to check whether I have done this in a way you can understand by asking you to summarise the important bits back to me”

  • Opportunity to ask questions

“Is there anything else you would like to ask about?”

  • Closure/ safety netting

“If you think of any other questions after this, write them down and I will come back a bit later to discuss them with you”

 

Tips specific to common themes

Whilst it is impossible to cover all possible communication scenarios, there are a few common themes and phrases that can be used in groups of situations. The following sections therefore summarise these common areas and illustrate where the basic framework above needs to be adapted accordingly, provided tips useful for specific examples.

Information giving to patients/ parents

New diagnosis

This is the most basic form of information giving and usually involves a complex diagnosis, e.g. Fallot’s tetralogy, Down syndrome/ other common genetic syndromes, ambiguous genitalia. The child may be a neonate on intensive care.

  • Introduction

Tip: Remember to congratulate parents about birth of new baby, regardless of diagnosis.

Tip: For ambiguous genitalia in particular, try your best not to use “he” or “she”; instead use baby’s name if parents have chosen one or “baby”.

  • What do they already know

Tip: Check if parents have had previous experiences/ know relatives or friends with the same condition e.g.

“Do you know anyone else with a similar condition to your son/ daughter?”

  • What do they want to know

Tip: Parents usually have specific ideas, concerns and expectations about a worrying new diagnosis (e.g. is my child going to die?), so enquire about these specifically as these will help you score marks for the key points e.g.

“Is there anything that you are particularly worried about?”

  • Tell them what you are going to tell them

Tip: New diagnosis information is by nature complex and parents can be easily swamped with too much, so prepare them for this e.g.

“I am going to tell you quite a bit of complicated information, so please stop me at any point if there is anything you don’t understand”

  • Tell them

Tips:

1) Focus on key points – if baby is well, remember to reassure parents about this

2) Sometimes explaining what is normal first is needed before explaining what is abnormal (e.g. congenital heart disease)

2) Diagrams/ charts where appropriate (e.g. congenital heart disease)

3) The idea of “pairs of socks” to illustrate the abnormalities present in chromosomal abnormalities (e.g. normal = 23 pairs of socks, Down syndrome = 23 pairs of socks plus an extra sock no. 21)

4) The idea that that the genetic sex of the child and the physical sex are two separate things when discussing ambiguous genitalia, and that the most important thing to exclude is a hormonal abnormality as this is easily treated. Birth registrations can be delayed by up to 6 weeks from birth.

5) Never blame the parents, especially when there is a genetic diagnosis involved.

  • Check understanding
  • Opportunity to ask questions
  • Closure/ safety netting/ further information provision

Tip: Providing a safety net that you will return later is particularly important in this situation.

Tip: Be familiar with some useful websites you can direct parents to for more information, e.g. Climb Congenital Adrenal Hyperplasia, Down Syndrome Association, The Juvenile Diabetes Research Foundation, Epilepsy Action

 

Treatment/ management issues

Usually this involves a “step-up” from current management due to a change in the child’s condition. Parents are usually aware their child requires further management but either have concerns about necessity (e.g. acute admission), side effects (e.g. steroids in asthma) or invasiveness of the investigation/ treatment (e.g. LP in a septic neonate).

  • Introduction
  • What do they already know

Tip: Check parents are in agreement with you in terms of their child’s clinical status, e.g.

“I’ve just been to see… but wanted to find out how you feel he is doing”

  • What do they want to know

Tip: In this sort of scenario this is probably the most important question to ask, as you need to address their specific concerns and not reel out information about every possible side effect, e.g.

“I gather you also have some concerns about commencing…, can I just ask what they are?”

  • Tell them

Tip: There is less of a need to outline your plan for giving information here, as parents are usually aware of the severity of their child’s illness. It is more important to illustrate your clinical thought processes which led up to the current management decision, to get parents on the same page as you e.g.

“As you know xxx has been in and out of hospital 5 times over the last 3 months with… since he was diagnosed. Whilst we have been treating him with…, you will probably agree that he has been missing quite a lot of school and his illness is affecting the rest of his life”. 

Tip: Demonstrate that you have considered the risk-benefit of starting treatment/ performing an investigation, the possible alternatives and that you are taking the path of least harm. This will need to be led by the concerns addressed by the parent(s), e.g.

“You’ve already told me that you are concerned about… However, the risk of… is low compared to the risk of… Other alternative treatments/ investigations we could use/ do include… but these are less likely to…”

  • Check understanding/ agreement

Tip: Rather than just checking understanding, there should be an indication that parents either agree with your plan or have come to some sort of compromise, e.g.

“Does what I’ve said explain to you the reasons for what we are doing a bit better now? Is that ok with you?”

  • Opportunity to ask questions
  • Closure/ safety netting

Breaking bad news

In this particular scenario, it is important to realise that there is no good way to break bad news. Therefore, being open and honest rather than avoiding the issue is important and part of what you will be marked for. Examples are counselling about the need for escalation to intensive care  in A&E or relaying the results of an MRI of a neonate with severe hypoxic-ischaemic encephalopathy (bereavement counselling/ withdrawal of treatment counselling is unlikely as this is unrealistic in the time given).

  • Introduction – remember to be empathetic.
  • What do they already know/ tell them

Tip: Even more so than when discussing treatment/ management issues, parents will already be acutely aware of their child’s unwell status, therefore there is less need to question their understanding but confirm this early on in the conversation, e.g.

“As you know, xxx came to us very unwell… We are worried that he has… and are doing everything we can for him. However, despite trying… I am sorry to say that he needs to be moved to the nearest intensive care unit where he will get more support”

  • Check understanding
  • Opportunity to ask questions
  • Closure/ safety netting

Counselling

Most counselling scenarios are probably covered by one of the other themes above. Other scenarios known to appear in the MRCPCH Clinical examination are:

  • Counselling parents with the aim of recruiting them to a clinical trial. In this scenario a detailed information pack may be given before entering the station which does not need to be read in detail but must be handed over to the parent at some point during the discussion. Depending on the study, consent may not need to be taken straightaway; it is best practice to allow parents time to think about whether they want their child to participate or not.
  • Counselling a teenager about contraception and disclosure to parents. Remember to clarify age of partner and whether the relationship was consensual. Here it is particularly important to begin the conversation with:

“I just needed to tell you before we begin that everything we say here will be treated confidentially; that is, it stays between you and me. The only time I will need to tell someone about what we say is if I feel that you are in danger of being hurt and that telling someone else will help us to stop you from being hurt more.”

 

Discussion/ teaching

This is becoming more common, where the aim is to teach a group of medical students/ junior doctors or nurses about a particular topical issue. The framework is similar to that of providing parents with new information about a diagnosis, but using medical jargon is more permissible. Common examples include

  • Topical clinical issues – e.g. discussing problems with prematurity or any other clinical topic where the “recipient” is a student rather than a parent!
  • Ethical issues – e.g. discussing whether you can disclose that a teenager has asked for contraception to her parents, disclosure of sexual abuse
  • Management issues – e.g. clinical governance

As the “recipients” are health professionals, the basic framework can be altered slightly, e.g.

  • Introduction

Tip: Remembering who exactly you are teaching or discussing issues with is particularly important here, so read the vignette carefully.

  • What do they already know
  • What do they want to know & why

“Was there a particular reason why you wanted to discuss this?

“Could you tell me a bit more about the particular case that led to these questions?”

“Were there any specific issues you wanted to ask about?”

  • Tell them what you are going to tell them

“As this is a rather large topic, let’s focus on…”

“The way I would make my decision in this particular case is by examining the four ethical principles…”

  • Tell them
  • Check understanding

Tip: In a teaching type scenario, it is useful to check understanding intermittently through the discussion, e.g.

“Before I move on, can I just check that you understand everything I’ve said so far?”

  • Opportunity to ask questions

Tip: Asking questions before you summarise allows you to ensure you have covered everything that the “recipient” wanted to know about.

  • Closure/ summary/ further information provision

Tip: If the discussion arises based on a particular patient case, it may be worth planning further management steps to be taken.

Useful resources: Medical Ethics and the Four Ethical Principles, MPS: Gillick/ Fraser competence, Royal College of Nursing: Clinical Governance, NSPCC Information Sharing Factsheet, NSPCC Age of Consent/ Definition of a Child Factsheet

Conflict resolution

In these types of scenarios, emotions tend to run high. The basic framework needs to be altered substantially to deal with the issues at hand. Effective, active  listening (giving time for a parent to “rant”) is crucial; as is effective apologising without apportioning blame (this needs practice!), i.e.

“I am sorry you feel that way.”

Both these techniques help diffuse a lot of anger.

Angry parents/ dealing with complaints

  • Introduction

“Hi my name is… and I am one of the paediatric registrars. I understand that you have concerns/ are unhappy about what has happened to your daughter/ your daughter’s treatment today. I was wondering whether you would like to be able to talk through this with me so that I can see how we can improve the situation.”

  • What do they already know/ what are their concerns (if the concerns are obvious, it can be better to establish these before asking about specific issues to avoid inflaming the situation – see 2nd example)

“Would it be possible to find out exactly what it is that you are unhappy about?”

“I would like to apologise on behalf of our team that you have had to wait such a long time for these results, it must have been worrying not to know what they showed.”

  • Tell them (address their specific concerns)
  • Check concerns addressed
  • Opportunity to make a complaint

“Just so you know, if you are still unhappy about this, you can still lodge a written complaint with our PALS (Patient Advice & Liaison Service) department and it will be taken seriously.”

  • Closure/ summary

“I want to reassure you that I will speak to… regarding his/ her behaviour and how you felt about it.”

Medical errors

Examples include a patient being given the wrong drug/ dose or a neonate being given the wrong mother’s expressed breast milk. Parents may already be aware about what has happened and emotions will run high as result. Alternatively parents may be unaware, in which case the scenario will run much more like your standard “new diagnosis” information giving scenario where you can set the scene by being as reassuring as possible. Part of this scenario is aimed at testing your knowledge of clinical incident reporting.

  • Introduction

Tip: If a medical error has occurred, you should apologise that it has happened up front, even if it wasn’t your fault. Remember that most medical errors are an accumulation of “system errors” and it is rarely solely down to one individual.

  • What do they already know/ what are their concerns

“I know that there must be some burning concerns on your part as a result of this mistake, and I would just like to find out what worries you the most”

  • Tell them (address their specific concerns)

Tip: If the medical error has not resulted in any harm to the child, it is important to reassure parents of this early to diffuse the situation (if appropriate).

“Whilst I hear your concerns, the first thing I would like to reassure you about is that your child will be ok.”

Tip: Remember to take all concerns seriously; even if there has not been any harm done to the child, the parents will view it as serious.

“We always take all mistakes such as these seriously, and in our hospital our standard procedure is to file a clinical incident report. This report is fed centrally and examined carefully by our managers to determine what measures can be taken to prevent this mistake happening again. When such a mistake happens we also discuss this within our team as it is important we learn from it as well.”

Tip: There may be specific things that need to be done clinically in managing the medical error, e.g. taking blood from the donor for neonate given the wrong breastmilk, and this will need to be discussed.

  • Check concerns addressed
  • Opportunity to ask questions/ make a complaint
  • Closure/ summary/ safety netting

Supervision issues

This is also becoming another common scenario in the exam. Usually this involves a trainee in difficulty that you  have to counsel e.g. a trainee that is always an hour late for work. The basic framework, once again, has to be modified slightly.

  • Introduction
  • Check how trainee’s life situation is

“Before we go any further I just wanted to ask whether everything is going ok outside of work?”

  • Confront them about concerns raised

Tip: Try to be neutral about who has raised concerns about the trainee, and remember that as a supervising registrar your aim is to be helpful and not accusatory.

“There have been some concerns raised about… and I just wanted to see if there was anything we could do to help you with…”

  • Find a compromise/ means of helping trainee

“It is important that we find a way of helping you as it is impacting on your work. Are there things you can think of that can help us to help you find a solution to this?”

 

9 comments on “Communication Station Guide
  1. hasanul says:

    excellent information.if parents or role player say it is my fault or my baby is going to die then what will be the answer

    • Hoong-Wei Gan says:

      Hi

      The key thing to bear in mind is to be sympathetic and never blame the parents. It is difficult to give you the exact words to say when this response from a parent can come up in so many different situations! One classic situation I can think of is e.g. explaining a genetic diagnosis such as Down syndrome (which is rarely inherited) or even cystic fibrosis where the parents have been proven to be carriers. It is important to realise that in such situations there is still the randomness of genetic recombination (e.g. CF risk 1:4 for 2 carriers) which is completely unpredictable and which no one can be blamed for.

      In terms of predicting death, I don’t think you can ever say “yes” your baby is going to die. All you can say is that their baby is very sick and we are doing everything we can for them. For instance in newly diagnosed malignancy situations a patient may be very sick, parents may be very distraught, and yet the prognosis may be good with current therapies. My feeling is that it is very unlikely that they would expect you to counsel a parent in a situation when a baby is truly dying – this would be terribly impossible to do in 9 minutes!

      The important thing (and expectation) is to be sympathetic and reassuring as much as you can without underplaying the severity of illness in both situations.

      Hope that helps.

      Dr. Hoong-Wei Gan MSc MRCPCH

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  3. hasanul says:

    Thanks a lot for your kind reply

  4. Tahera says:

    I did not understand about the scenarios of Teaching. Are there group of trainees whom we have to teach in the exam???means in communication skill station . What type of scenarios are those. I didn’t understand it properly

    • Hoong-Wei Gan says:

      Dear Tahera

      The person who may be at your communication station may be acting as a medical student or junior trainee or nurse, and the scenario will be set out such that you will be asked to discuss a particular topic as a teaching scenario; much as you would as a registrar. For instance you may be asked to talk to a trainee about the issues you would discuss with a mother who is about to delivery prematurely; rather than discuss this with the mother herself.

      I hope that helps.

      Dr. Hoong-Wei Gan MSc MRCPCH

  5. MAGDY says:

    THANK YOU SOOO MUCH

  6. fatima says:

    how can we show empathy to patientor parents.please give some example

  7. Tahera says:

    Thanks a lot. it was helpful and Also I got teaching scenario in my exam. I cleared the clinical in first trial. Thanks to the absolutely great website.

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