Your two communication stations can cover a wide range of different situations.
There are some excellent books that cover a variety of cases that you may experience: a couple of these include Communication Scenarios for the MRCPCH or MRCPCH Clinical: Short Cases, History Taking and Communication Skills.
There are some excellent video commentaries about practical procedures at the Hands-on Guide to Practical Paediatrics website, which you may find helpful.
In addition, the “Me first” model is something that you may find useful for improving your consultation skills.
To provide a few other examples, we have tried to highlight a few possibilities for you below, and have grouped them into four broad categories.
1. Counselling parents
A child has been brought to A&E with a febrile convulsion. You have to explain to the parents what has happened, and answer some questions about febrile convulsions.
Some background information to help:
- Commonest age range = 6 months to 5 years.
- The convulsion is a generalised seizure, in a child with a history of a febrile illness, who does not have a CNS infection and is otherwise neurologically normal.
- Common: 3% of children will have one.
- Simple febrile convulsions: usually the convulsions last < 15 minutes, with no focal features, and with no recurrence over the following 24 hours.
- Complex febrile convulsions affect approx 10-30% of presentations, with one of the following features: duration > 15 minutes, focal features at onset or during seizure, recurrence within 24 hours or within same febrile illness.
- Risk of recurrence: 30-40%
The risk of epilepsy is commonly asked by parents. In most cases, febrile seizures do not lead to epilepsy, but there is an increased risk (6-8%) if there is a family history of epilepsy, if there are any neurodevelopmental problems in the child, or if there are any atypical febrile convulsions (prolonged or focal).
Speak to a mother who has been admitted with preterm labour at 23+3 weeks / 25+5 weeks etc
As well as an overall knowledge of the Epicure outcome data, the way that you approach this discussion is most important. Different gestations could be chosen by the examiners to address different factors in the counselling process. Make sure you structure you discussion in a sensible way, in order to understand the parents’ ideas, concerns and expectations:
- Introduce yourself clearly. Explain your role.
- Sit down, and use good open body language and posture.
- Explore the parents’ ideas, concerns, expectations and knowledge in the initial conversation. Explore religious views.
- Discuss the options ahead with some very simple statistics.
- Explain what will happen and who will be present at delivery.
- Explain options for comfort care if appropriate.
- Counsel parents about periods of gasping about that if the baby is not resuscitated, that the heart may take time to stop.
- Summarise the agreed plan, and give the parents an opportunity to ask any questions.
How to perform common procedures at home
Think of commonly performed procedures in paediatrics: use of an EpiPen, correct use of an asthma inhaler, performing an IM injection etc.
Consenting for lumbar puncture
Explain that you need to do a lumbar puncture for a child, and answer the parents’ concerns.
The following information may be helpful:
- Explain that precautions will be taken to prevent iatrogenic infection.
- The spinal cord cannot be injured (the needle enters below it).
- The body replaces the small amount of fluid removed within 36 hours.
- The rationale for testing CSF: this may be to rule out infection, or to find out more information about an underlying condition.
- Sedation / general anaesthetic / local anaesthetic (or a combination) may be used.
Complications of the procedure include:
- Failure of the procedure / dry tap.
- Child is too restless to proceed.
- Blood staining of the CSF affecting results.
- Headache (settles within 48 hours)
- Small amount of swelling/pain where the needle went in.
A mother has asked to speak to the doctor about breastfeeding. She wishes to understand why she should breastfeed, and what the benefits are.
Some key information that you may find helpful:
- Explain that breastfeeding is specifically designed for her baby – it’s quick, clean, free, no need for sterilisation, always at the correct temperature etc.
- Benefits include:
- Passive immunity from antibodies that are passed on. Can help protect against infections.
- Less likely to develop constipation.
- Reduced incidence of allergies/eczema/asthma.
- Helps mother to regain normal weight, and get over postnatal depression.
- Further help: breastfeeding nurse specialist / community breast feeding advisor.
2. Dealing with difficult situations
Death of a Child
This station would combine showing skills of empathy and sensitivity, along with some practical knowledge that you might have picked up from your work as a junior doctor.
- Logistical: Parents can stay with their child as much or as little as they prefer. The whole family can go to the mortuary, but if there will be no post mortem, the child does not have to go to the mortuary – they could instead go home or to a Chapel of Rest.
- Psychological/spiritual: Ask about religious beliefs – the hospital can arrange support from any denomination, regardless of faith or belief. A ceremony of blessing can be arranged, even if the family is not religious. There are also charities and helplines that you could signpost.
- Memories: many parents find it helpful to keep memories like photos, locks of hair, footprints, hospital band etc.
- Legal: registration of death within 5 days. A coroner must be consulted if sudden or unexplained death, and a post mortem would be performed regardless of family wishes (this is a legal requirement). A death certificate cannot be issued until the coroner has concluded their work.
- Transplant: if appropriate, this could be discussed with the family, and a transport co-ordinator could be called.
3. Breaking bad news
Do Not Resuscitate (DNR) Discussion
You may be asked to speak to a family about a do not resuscitate decision. Important points to consider include:
- Preparation: team decision, in conjunction with parents. This is usually a consultant-led process.
- Discussion with parents: explanation that this does not mean “withdrawal of care”. The decision is continuously reviewed, and that no changes will be made without consulting parents.
- Support: variety of hospital/charity services available – consider family, religious support, bereavement services.
- Logistical: documentation in medical and nursing notes, along with any specific wishes of the parents.
- Useful reading: recent RCPCH Guideline about this topic: “Making decisions to limit treatment in life-limiting and life-threatening conditions in children: a framework for practice” – discusses this topic in great detail – click here to read more.
4. Working with colleagues
These scenarios include the usual situations that you may be asked about in paediatric job interviews or training selection interviews. Consider situations like:
- How to deal with a colleague who keeps turning up to work late.
- Talk to a colleague who has not been replying to bleeps from the nurses all day
- Speak to a junior colleague who has come to work smelling of alcohol
- You notice that a colleague has made a prescribing error, and that the drug has already been administered to the child. Speak to the a) parents about the error; b) colleague about the error that has occurred.