Good Practice Student's Book

COV-19 2020

Good Practice Communication Skills in English for the Medical Practitioner

Student’s Book Marie McCullagh Ros Wright © Cambridge University Press 2007

COV-19 2020

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© Cambridge University Press 2007

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It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning and research at the highest international levels of excellence. www.cambridge.org Information on this title: www.cambridge.org/9780521755900 © Cambridge University Press 2007 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.

First published 2007 20 19 18 17 16 15 14 Printed in Italy by L.E.G.O. S.p.A. A catalogue record for this publication is available from the British Library ISBN 978-0-521-75590-0 Student’s Book ISBN 978-0-521-75591-7 Teacher’s Book Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Information regarding prices, travel timetables and other factual information given in this work is correct at the time of first printing but Cambridge University Press does not guarantee the accuracy of such information thereafter.

© Cambridge University Press 2007

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Contents Introduction

page 6

SECTION 1: INTRODUCTION TO COMMUNICATION • Recognising the different elements that make up communication • Understanding how good communication benefits the patient interview

page 8

SECTION 2: DEVELOPING LANGUAGE AND COMMUNICATION SKILLS FOR THE PATIENT ENCOUNTER Unit

Communication skills

Language focus

Texts

1 Receiving the patient page 14

• Greeting patients and putting them at ease • Introducing yourself and your role • Asking the opening question and setting the agenda for the interview

• Conveying warmth • Formulating the opening question • Language for setting the agenda • Phrases to facilitate, repeat and clarify

Reading • Patient questionnaire Listening • Presentation: the importance of seating arrangements • Patients present their perspective • Receiving and greeting a patient • Asking the opening question • Setting the agenda for the interview

2 The presenting complaint page 22

• Encouraging patients to express themselves in their own words • Taking an accurate history of the presenting complaint • Asking about the intensity and degree of pain • Using techniques such as facilitation, repetition and clarification

• Using exploratory questions • Adjectives to describe types and intensity of pain • Patient speak: the suffix –ish • Patient speak: phrasal verbs with up • Facilitating the encounter: voice management

Reading • Patient-centred approach to history-taking Listening • Using exploratory questions • Exploring the presenting complaint

DVD clips 1 and 2: The presenting complaint 3 Past medical and family history page 32

• Requesting the patient’s past medical history • Discussing the family medical history • Taking effective notes during an interview • Writing an effective patient note • Summarising and structuring the interview

• Language to request the past medical history • Patient speak: common expressions to describe state of health • Expressions for signposting and summarising • Standard medical abbreviations

Reading • Past medical history: the components • Patient note • Pedigree diagram Listening • Conference presentation: the pitfalls of taking the PMH. • Taking a past medical history • Taking a focused past medical history

DVD clip 3: Taking a medical history

© Cambridge University Press 2007

Contents

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Communication skills

Language focus

Texts

4 The social history and telephone consultations page 42

• Enquiring about the patient’s social history • Employing good telephone etiquette • Ensuring an effective telephone consultation • Summarising and checking information

• Asking about lifestyle and environmental health • Language for summarising and checking information • Patient speak: common suffixes in medical terminology • Expressions for consulting by telephone

Reading • Telephone consultations Listening • University seminar discussion on taking a social history • Asking about occupational health • Discussing lifestyle and environmental health • Carrying out an effective telephone consultation

5 Examining a patient page 52

• Indirect language for polite • Preparing and reassuring instructions, the patient during an • Patient speak: verbs and examination prepositions for giving • Explaining examination instructions procedures • Giving effective instructions • Effective intonation for instructions in a patient-friendly manner • Softener: just

6 Giving results page 60

• Explaining results in a way that patients can understand and remember • Encouraging patients to express their fears and concerns • Explaining medical terminology to a patient • Giving a prognosis

• Language for giving a diagnosis • Phrases used to organise information • do for emphasis and confirmation • Word stress for emphasis • Language for explaining medical terminology • Patient speak: colloquial questions for asking about prognosis • Language of probability

Reading • Jaundice • Acute bronchitis • Erythema nodosun Listening • Explaining test results • Organising information

7 Planning treatment and closing the interview page 69

• Explaining treatments to a patient • Discussing options • Describing benefits and side effects • Advising on lifestyle • Negotiating treatment • Closing the interview

• How to negotiate a plan of action • Language for making suggestions • Phrases to explain advantages and disadvantages • Patient speak: expressing likelihood • Language for negotiating treatment

Reading • The New Quit Guide, So You Want to Quit?

Listening • Outlining a treatment plan • Describing possible treatment plans for hypertension • Negotiating treatment with the patient • Advising on lifestyle changes

Reading • Techniques of the trade Listening • Giving instructions during a physical examination

DVD clip 4: Examining a patient

DVD clip 5: Planning treatment 8 Dealing with sensitive issues page 77

4

Contents

• Broaching sensitive issues without bias and remaining non-judgemental • Reading and responding to patient cues • Employing question techniques: CAGE • Writing concise and accurate notes • Updating the patient note

© Cambridge University Press 2007

• Language to broach sensitive issues • Identifying non-verbal patient cues • Techniques for contextualising, reassuring and asking permission • Patient speak: drug culture • Ensuring specific and concise notes

Reading • Reading cues • Letter of referral • Questionnaire: Know your drink Listening • Broaching sensitive issues.

• Discussing sexual and reproductive health • Asking about alcohol consumption

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Communication skills

Language focus

Texts

9 Breaking bad news page 87

• Delivering bad news in a sensitive way • Reassuring a patient or relative • Showing empathy

• Patient speak: expressions showing level of understanding • Softening the question • Language to deal with emotions • Patient speak: talking about current knowledge of condition • Voice management when communicating bad news

Reading • A time to listen Listening • Breaking bad news • Preparing the patient for receiving bad news • Dealing with emotions of an HIV patient • Consulting with a relative by telephone • Breaking bad news to a relative

DVD clip 6: Breaking bad news SECTION 3: INTERVIEWING DIFFERENT PATIENT CATEGORIES 10 Communicating with challenging patients page 95

• Encouraging a withdrawn patient to speak • Calming an aggressive or angry patient • Asserting your role as a doctor

• Reviewing question types • Using facilitative language • Language to respond to body language • How to validate emotions • Patient speak: expressions to describe different emotional states

Listening • Receiving an uncommunicative patient • Interviewing an irritated patient • Dealing with a manipulative patient

DVD clip 7: Communicating with challenging patients 11 Communicating with the elderly page 102

• Carrying out an effective interview with an elderly patient • Showing sensitivity and respect to an elderly patient • Communicating with depressed elderly patients

• Asking questions specific to the elderly • Patient speak: collocations to describe conditions common in the elderly • Language to show sensitivity • Techniques for communicating with patients with hearing problems • Simple choice questions

Reading • Talking to the dying patient Listening • Visualising life as an older patient • Interviewing an older patient • Interviewing patients with sensitivity and respect • Consulting patients with hearing problems • Student presentation: tool for assessing the ability to live independently • Dealing with a patient with depression • Assessing a patient with mental issues

12 Communicating with children and adolescents page 112

• Establishing and developing rapport with a child • Reassuring a child • Gaining a child’s consent to be examined • Explaining procedures to a child • Responding to a child’s verbal cues • Communicating effectively with an adolescent

• Compliments for children • Expressions to show empathy with must • Language for reassuring a child • Child-friendly instructions • Patient speak: bodily functions and body parts • Techniques for communicating with adolescents

Reading • Now I feel tall: What a patient-led NHS feels like Listening • Interviewing young children and their parents • Reassuring a young child • Examining children and giving instructions • Interviewing an adolescent patient

DVD clip 8: Communicating with children Role-play and other additional material Audio scripts Answer key

© Cambridge University Press 2007

page 121 page 137 page 152 Contents

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Introduction Who is Good Practice aimed at?

Good Practice is intended for qualified doctors and medical students with an upper-intermediate to advanced level of English who are looking to work in an English-speaking environment. Mirroring the increased emphasis on communication-skills training in medicine, this course aims to develop the language and interpersonal skills essential to the establishment and maintenance of rapport between doctors and their patients, thus enabling medical practitioners to carry out their duties in English more effectively and with greater confidence. Good Practice has been written in accordance with the Calgary-Cambridge observation guide*.

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What aspect of medical English does the course deal with?

With reference to numerous medical communication experts and through exposure to authentic clinical scenarios, Good Practice demonstrates the impact of good communication on the patient–doctor relationship. The course will train you how to sensitively handle a range of situations, from taking a patient history, through the physical examination and describing treatment options, to breaking bad news. It will also prepare you for dealing with different patient types, including children and the elderly, as well as patient situations requiring more enhanced levels of sensitivity.

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How is Good Practice structured? ●

Medical vs. language content While Good Practice does make use of medical communication models, and as a learner you will be encouraged to call on your medical expertise, it should be noted that the aim of this course is not to teach medicine and medical practices. Similarly, the trainer will act as facilitator and expert in the English language and communication skills, rather than expert in medicine (although some may be experts in both).

What are the aims of the course?

Good Practice focuses explicitly on the five components that make up communication: ●

6

Spoken communication skills: enhancing your ability to use effective communication

Introduction

© Cambridge University Press 2007

strategies to repair or avoid possible breakdown in communication with your patient; encouraging use of patient-friendly language when giving instructions or discussing treatment options; and familiarising you with language commonly used by patients: euphemisms, jargon, language used by children, etc.

Non-verbal communication skills: developing your awareness of body language to enable you to better read and interpret your patients' physical and emotional signs, as well as to better mirror your own verbal communication with appropriate non-verbal signs.

Active listening skills: ensuring a successful interview through techniques that facilitate discussion, demonstrating that you are really listening to your patient and assimilating the information given and its relevance to an eventual diagnosis.

Voice-management skills: improving use of intonation and word stress in order to build rapport with the patient, give encouragement and show sensitivity.

Cultural awareness: widening understanding of cultural issues and the impact of your own cultural background on both your patient and the interview itself.

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Good Practice is divided into three distinct sections: 1 The Introduction to communication provides you with an overview of communication, highlighting its importance during the patient encounter.

2 Units 1 to 9 take you through the kind of language and communication skills required to ensure you are able to carry out each stage of the patient encounter effectively.

3 Units 10 to 12 offer the chance to consolidate and further hone these skills, putting them into practice within specific clinical situations and with particular patient types.

Each unit ends with an extended role-play and progress check.

Audio transcripts, as well as a complete answer key can be found on pages 137–176.

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What is the approach of Good Practice?

Good Practice aims to develop the grammatical and lexical features of English, employing an approach that encourages you to discover the language and its properties for yourself. Language boxes interspersed throughout each unit highlight useful expressions, while authentic texts – medical journal articles, patient notes and doctor–patient dialogues – are used to introduce language and present the essential concepts of communication. Tasks draw on your personal and professional experiences as both doctor and patient. The extended role-play is a chance for you to consolidate and put into practice the skills covered in the unit, to observe and offer constructive criticism to your peers. A series of DVD-led lessons allow examination and analysis of non-verbal communication and voice management, as well as reinforcing those areas treated in the preceding units.

In the DVD, roles are played by doctors and are nonscripted to ensure authenticity.

How can Good Practice be used for self study? ●

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What are the special features of the Student’s Book?

Think about … sections: Allow you to reflect individually on your current knowledge of a given aspect of the patient encounter, or indeed the language used to carry it out, before tackling the target area; they also serve as a diagnostic for the trainer to evaluate your strengths and weaknesses.

Patient speak sections: Acquaint you with the language spoken by your patients – colloquialisms, drug-culture jargon, childhood expressions, etc. This important feature will aid you in deciding on the appropriate choice of language for a particular setting or audience.

Quotations from the experts: Ensure the link between theory and practice by making reference to experts in the field of medical communications skills.

Communication Skills boxes: Give you tips and hints on appropriate communication strategies.

Cultural Awareness boxes: Draw your attention to specific aspects of culture that could possibly cause misunderstanding and offer a forum for discussion.

Out & About boxes: Encourage you to further investigate the language by asking you to observe the way it is used in a particular context within your work or study environment.

Progress checks: Present you with the opportunity to reflect on the progress you have made within the unit.

© Cambridge University Press 2007

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Depending on your goals, you can either follow the course in a linear manner or you may wish to use the Contents page to pinpoint areas you find particularly difficult – breaking bad news, dealing with hearing problems, etc.

Whatever your goals or time constraints, working through the Introduction to communication (pages 8–13) will be highly beneficial.

Make use of the audio transcripts, some of which also include the non-verbal communication aspects of communication.

Refer to the answer key, which includes suggested answers to many open-ended exercises.

Use the DVD and downloadable worksheets which demonstrate the more visual aspects of communication that you might otherwise not have access to, as well as acting as a reinforcement of the language skills taught in the course book.

Do the roleplays with a colleague or friend (all patients at some time) and ask them for constructive feedback. Access to a webcam means you can record your role-plays and watch your performance later, this time taking the role of observer. Complete the relevant feedback table (downloadable from the website), depending on your particular goals.

Work through the downloadable worksheets, complete with full answer keys (see www.cambridge. org/elt/goodpractice) to build on your existing knowledge base of verbal communication and cultural awareness.

Devise a glossary of ‘Patient speak’; create a table which includes space for an example sentence and an indication of the context in which the example was spoken.

*Calgary-Cambridge observation guide The Calgary-Cambridge observation guide is a tool used for teaching medical communication, which reflects current theory and research for the doctor–patient interview. The guide lists the tasks that a doctor carries out during different stages of the consultation and the associated communication skills required. It is derived from the work of S.M. Kurtz, J.D. Silverman and J. Draper: ● Silverman, J.D., Kurtz, S.M. and Draper, J. (2005) Skills for Communicating with Patients. 2nd ed.

Radcliffe Medical Press (Oxford)

Introduction

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Introduction to communication LEARNING OUTCOMES

Lead in

At the end of this introduction, you will: ● recognise the different elements that make up communication ● understand how good communication benefits the patient interview

Communication is not only a basic part of our everyday lives, but an essential one, in the sense that we cannot not communicate.

Thompson (2003)

a

What do you think the author means by the phrase we cannot not communicate?

b

Look at these two models of communication.

1

Transmission model

2

Interactional model

In the transmission model, the communication process is complete when a message has been transmitted from the sender to the receiver. In the interactional model, the communication process is only complete when the sender receives feedback that the message has been received as intended.

This may take a number of interactions.

Think of an example of communication which follows the transmission model and one which follows the interactional model.

Discussion: Defining communication 1a b 8

Introduction to communication

Write down a definition of communication and share it with a partner.

Read the quotation at the top of the next page. How do your definitions compare with this?

© Cambridge University Press 2007

COV-19 2020 [Communication is] social interaction through messages.

Fiske (1990)

2

Fiske (1994) states that: … communication is too often taken for granted when it should be taken to pieces.

Breaking down communication allows us to examine the different components we should consider when we are communicating. While there are many ways of taking communication to pieces, this course uses five elements as a means of analysis.

verbal communication

This jigsaw represents five different components of communication. The first piece of the jigsaw has been completed. What do you think the other pieces might be?

Verbal communication 3

Write down at least three factors which make a difference to the way we communicate with somebody (e.g. the person’s age).

4a

Read this extract from a patient interview: Doctor Do you have any history of cardiac arrest in your family?

Patient No, we’ve never had no trouble with the police.

West and Frankel (1991) Clearly, the patient has misunderstood the question. Underline the expression the doctor uses that caused the misunderstanding and suggest an alternative expression.

b

In the example above, what would you suggest that the doctor says next?

Communication Skills At times, doctors may use phrases that the patient doesn’t understand. It is important for a doctor to pick up on this quickly and to rephrase things so the patient can understand. Communication strategies, such as clarifying, help to maintain communication or prevent communication breakdown.

© Cambridge University Press 2007

Introduction to communication

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Voice management 5

The way in which we use our voice can also influence the message that we send, i.e. it’s not just what you say, it’s how you say it. What aspects of voice can influence the verbal message that we send? Compare your ideas with the rest of the group.

6

0.1 You are going to hear the same phrase spoken by three different

doctors. Match how each doctor sounds (a–c) to the appropriate doctor (1–3). a bored

7

b friendly

c irritable

0.2 You are now going to hear a doctor ask a patient the same

question twice. Which one sounds more inviting?

Paralanguage [voice management] is very important, as it can add extra meaning to what is actually being said or can even contradict or undermine it.

Thompson (2003)

Non-verbal communication 8

Write down as many ways as you can think of in which we communicate non-verbally. Compare your examples with a partner.

9

Slight movement (e.g. nodding) is one way we communicate nonverbally. For each of these pictures (1–8), indicate which of the ways of communicating non-verbally (a–h) is being used.

3

1

2 4

5 7 6

8

a touch b eye contact c proximity d environment e clothing and accessories f facial expression g orientation

10

Introduction to communication

© Cambridge University Press 2007

h posture

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10

Look again at the different forms of non-verbal communication in Exercise 9. In the context of a medical interview, position them along the line below in terms of how easy/difficult you think they are for the doctor to control. easy

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difficult

Why is it important to observe and respond to non-verbal cues?

Just as the doctor is observing the patient, the patient will also be watching the doctor. Posture, eye contact, gestures, as well as words, send messages.

Bickley (2003)

Active listening 12

With a partner, discuss these questions.

1 What is the difference between listening and hearing?

2 What can prevent you from hearing what people are saying?

3 What can prevent you from listening to people?

4 How can you show you are actively listening?

13a

0.3 Listen to a dialogue between a doctor and his patient. What is

wrong with the patient?

b How accurate is the doctor in obtaining information from the patient? How effective do you think the consultation has been?

Cultural awareness 14a Write down: 1 three elements that make up culture (e.g. history) 2 three distinctive elements of your own culture.

b Compare your findings with a partner. c Read this definition of culture: Customs, world view, language, kinship system, social organisation or other taken-for-granted day-to-day practices of a people which set that group apart as a distinctive group Scollon and Scollon (2001) Think of two cultural factors that doctors, as a professional group, share.

© Cambridge University Press 2007

Introduction to communication 11

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15a Read this text and decide what kind of cultural background and bias a doctor, as an individual, might bring to his/her work (e.g. gender).

Cultural awareness means … … recognising that your beliefs, habits and attitudes are inherently biased and can be puzzling to others. It also means being tolerant of difference, being flexible and willing to embrace change. However, cultural awareness does not mean having to leave your personal beliefs behind. It means realising that language and culture are inextricably linked and, as such, cannot be separated. Lack of cultural awareness can result in unintentionally offending others.

b Can you think of a situation where your lack of cultural awareness caused a misunderstanding, in either your personal or professional life? Discuss with a partner.

16a Read this case study. As you read, circle elements that surprise you or are different from your way of thinking.

CASE STUDY A child from the Hmong community (originating in South-East Asia) living in the USA was born with a clubfoot. Doctors felt that this would not only cause social embarrassment, but also make ambulation difficult for the child, and so recommended an operation to reshape the foot. However, the family believed that by ‘fixing’ the foot, it would bring shame and punishment on both the family and the Hmong community and so refused treatment. The family went to the Supreme Court to defend their right to refuse treatment.

Adapted from Developing Cultural Self-Awareness in CASAnet Library: Cultural Competency

b Compare your findings with a partner and describe how you as a doctor might have reacted to this case.

As individuals, we each have our own cultural background and biases.

These do not simply slip away as we become clinicians. It is important to understand how culture shapes not just the patient’s beliefs and behaviours, but also our own.

Bickley (2003)

17

Look at the completed jigsaw representing the five components of communication. Based on what you have read, why do you think the ‘cultural awareness’ component appears in the middle?

voice management

verbal communication

cultural awareness

active listening

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Introduction to communication

© Cambridge University Press 2007

non-verbal communication

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Benefits of good communication Communication is not just about being ‘nice’, but produces a more effective consultation for both patients and doctors … (it) improves accuracy, efficiency and supportiveness in the consultation.

Silverman, Kurtz and Draper (2005)

18

These outcomes result from good doctor–patient communication. For each one, indicate whether it contributes to the effectiveness of the consultation in terms of accuracy (A), efficiency (E) or supportiveness (S).

1 Identify emotional distress in patients and respond accordingly 2 Get the right information from a patient within time constraints 3 Allow patients to express their concerns 4 Get the correct information to make the right diagnosis 5 Have patients who agree with and follow the advice given

Piecing it all together Verbal, non-verbal communication, listening, voice management and cultural awareness all play an important part in helping to make communication more accurate, effective and supportive.

As the course progresses, you will develop a greater awareness of how this takes place and you will also be able to develop your own skills in these areas.

19

In small groups, discuss which of the five elements of communication you consider to be: 1 your strength(s) 2 important for you to improve on during this course.

© Cambridge University Press 2007

Introduction to communication 13

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Unit 1 Receiving the patient LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● greet patients and put them at ease ● introduce yourself and your role ● ask the opening question and set the agenda for the interview

As a group, share your thoughts on this quotation from a celebrated 19th-century physician: The kindly word, the cheerful greeting, the sympathetic look – these the patient understands.

William Osler (1849–1919)

Putting yourself in the patient’s shoes 1

Prior to a consultation, some patients experience strong feelings of anxiety.

Discuss reasons for this in small groups. Why might patients be even more anxious when visiting a hospital as opposed to a doctor’s surgery1?

2a

Think back to the last time you were a patient and do this questionnaire.

Patient questionnaire 1 How do you feel when you enter a hospital as a patient?

(Circle the best answer.)

Relaxed Unconcerned Relieved Mildly concerned

Apprehensive Anxious Scared Other

2 What generally lessens any concerns you may have on entering a hospital?

(Place in order of importance, 1 = most important) Administrative staff Doctor Other

Nursing staff Surroundings

3 Have you ever left a consultation more confused/frustrated than when you arrived? YES / NO 4 If YES, why?

5 What qualities do you appreciate in a doctor?

The way you greet a patient can determine the rest of the consultation.

b

1 How might the factors in question 2 of the questionnaire increase or decrease patient anxiety? Make a list.

2 How might the age, gender or physical appearance of a new patient affect a doctor’s relationship with that patient?

Bickley (2003) 1

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Unit 1 Receiving the patient

In small groups, compare your responses and then answer these questions.

(US English) doctor’s office

© Cambridge University Press 2007

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Think about … how you would feel about establishing rapport with a patient in English.

3a

Take a couple of minutes to think about this and then rate your ability to do the following from 1 (lacking in confidence) to 5 (highly competent).

1 I can make the patient feel relaxed.

2 I can greet the patient appropriately.

3 I can set the agenda for the interview.

4 I can use an appropriate, welcoming tone of voice.

b

Discuss your thoughts with the rest of the group and talk about the language you would use to do these things.

Establishing initial contact The setting for the patient encounter is very important.

4a

1.1 You’re going to hear a communications expert talk about the importance of seating arrangements in a consulting room. Listen and choose the best seating arrangement: 1, 2 or 3.

2

1

b

3

1.1 Listen again and answer these questions.

1 Why does the expert suggest this arrangement is the best option?

2 According to the expert, how far should you sit from your patient in the UK? a 3 feet (1 metre)

b 9 feet (3 metres)

c 5 feet (1.5 metres)

3 What reason does the expert give for this?

c

Discuss these questions with a partner.

1 What do you think about the expert’s suggestion regarding the distance between doctor and patient during an encounter?

2 Why might a doctor draw his/her chair closer to a patient?

3 What should a doctor consider when interviewing a patient in bed?

© Cambridge University Press 2007

Unit 1 Receiving the patient 15

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5a

1.2 You are going to hear two patients talking to friends about a

recent encounter with their consultants1. Listen and tick the relevant column (Competent, Fairly competent or Needs improvement) to show to what extent the consultants are successful in establishing rapport with their patients.

Consultant 1 (outpatients)

Competent Fairly competent

Needs improvement

Examples

1 He was able to make the patient feel relaxed and comfortable.

2 He was able to greet the patient appropriately.

3 He was able to use an appropriate, welcoming tone of voice.

Consultant 2 (ward round) 1 He was able to make the patient feel relaxed and comfortable.

2 He was able to greet the patient appropriately.

3 He was able to use an appropriate, welcoming tone of voice.

b

1.2 Listen again and note examples (positive or negative) in the

fourth column.

c

In small groups, compare your findings and compile a list of points for the two consultants about how they could improve their technique. Share these with the group.

Greeting and putting your patient at ease 6

1.3 You are going to hear three doctors welcoming their patients.

Where does each take place: in a GP’s surgery, a hospital ward2 or a specialist’s office? How do you know?

16

1

(US English) doctors

2

(US English) hospital department

Unit 1 Receiving the patient

© Cambridge University Press 2007

The initial contact with the patient sets the foundation for the relationship. Be prepared to give your undivided attention.

Spend enough time and energy on your greeting and the patient’s response to achieve a level of comfort on the part of the patient.

Bickley (2003)

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7a

A doctor’s initial contact with a patient should include four main objectives. Look at these phrases and give each set of objectives a heading.

Objective 1

Objective 2

• Good morning, [Jenny], come in, take a seat …

• Good afternoon, Mr [Hanks], isn’t it?

• I’m a student doctor1 working with Mr [Donaldson].

• Hello, can I just check it’s [Mr Wang]? We’ve not met before …

• My name is Dr [da Silva], I’m one of the registrars2 on the ward this evening.

• [William Denby]? Hello. What would you prefer me • I’m Dr Janowicz. My colleague, Dr [Taylor], has asked me to come and see you about … to call you?

• Dr [Murad] has referred you to me for further • Hello, Ms [Kavanagh] … Am I pronouncing it investigations. My name is Dr Lozano and I’m … correctly?

• Hello, I’m Dr [May], the locum with this practice3.

Objective 3

• I’ve come to have a little chat with you about …

• I’d like to spend five minutes with you to ask some questions if that’s OK? • I wonder if we can chat for a few minutes about …

b 8

Objective 4

• If you don’t mind, I’d like to take some notes as we talk.

• Do you mind if [our student doctor] is present during our chat?

• If it’s all right with you, I’d like to have a listen to your heart.

Compare your ideas with the rest of the group.

Look back at the first sentence in Objective 3.

1 What effect might the phrase have a little chat have on the situation?

2 In which situation(s) might you avoid using this verb when greeting a patient?

9a

1.4 You are going to hear the beginning of a patient encounter. Listen

and number the objectives in Exercise 7a in the order you hear them.

b 10

What else does the doctor do to make the patient comfortable?

With a partner, practise greeting and introducing yourself to your patient.

1

(US English) medical student

2

(US English) residents

3

(US English) Dr [May], covering for Dr [Franklin]

© Cambridge University Press 2007

Communication Skills The following might be helpful: ‘I’m Dr [name]. You’ve probably noticed I’m [nationality], so I apologise if I have to ask you to repeat anything.

And please stop me if there’s anything you don’t understand.’

Unit 1 Receiving the patient 17

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Conveying warmth 11a

1.5 You are going to hear two versions of two different patient encounters. Decide if the doctors sound welcoming or unwelcoming.

Encounter 1 Version A

Version B

Encounter 2 Version A

Version B

welcoming unwelcoming

b Compare your ideas with a partner. What helps you distinguish between a welcoming and an unwelcoming voice in English / in your own language?

12a

1.6 Listen to and read these greetings. With a partner, decide what the context is for each one. How do you know?

1 Good morning, Mr Barker, isn’t it? Your consultant asked me to come and see you.

2 Anya Kaplinski? You’ve come for your six-month check-up, I see.

3 [patient knocks] Hello? Come in? Sorry for the wait, Miss Staples, we’re running a little late this morning.

4 [doctor enters waiting room] Mrs Khan?

b Repeat each phrase until you are satisfied that your voice sounds welcoming and has the right intonation. Your voice should rise on the underlined words.

c Take turns to read the greetings. Listen and decide if your partner sounds welcoming or unwelcoming.

13

Role-play these situations with a partner.

Student A: Student B:

Turn to page 122.

Turn to page 128.

Think about … how you would ask the opening question in a patient interview in English.

14a Look at this opening question. Think of two more ways of posing the opening question. Compare your questions with a partner.

What brings you here today?

b Why is the opening question so important in the patient interview?

Discuss in small groups.

c Would you use these opening questions? Why (not)?

1 So, what’s the problem?

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Unit 1 Receiving the patient

2 What’s up?

© Cambridge University Press 2007

Cultural awareness Eye contact and a smile are generally accepted forms of greeting in the English-speaking world.

What form of nonverbal greeting, if any, is considered appropriate in your country?

COV-19 2020

Asking the opening question 15a Choose the most appropriate opening question(s) (1–10) for each scenario (a–e). (There may be more than one answer in each case.)

1 Your GP has explained the situation, but I wonder if you could tell me in your own words?

Scenarios a First visit to surgery

2 What would you like to discuss today?

b Hospital round

3 Am I right in thinking you’ve come for baby [Killian’s] routine check-up?

c Follow-up visit d Check-up for newborn baby

4 How are things with the [new tablets]?

5 What brings you here today?

e Following a referral

6 Has there been any improvement since I saw you last?

7 How are you feeling today?

8 I have your notes from your doctor, but could you tell me what’s been happening?

9 So, what have you come to see me about today?

10 So, how is [little Rhana] doing?

b Discuss your choices with a partner. Why are some questions more appropriate than others for each of the scenarios?

16a

1.7 You are going to hear more of the encounter with Mr Mahoney (see

Exercise 11). Listen to the interview and answer these questions.

1 Which opening question does Dr Patel use?

2 What is Mr Mahoney’s presenting complaint?

3 Was Dr Patel’s opening question the most appropriate for this interview? Why (not)?

b As a group, rewrite Dr Patel’s opening question to ensure a more appropriate line of questioning.

Am I right in thinking

?

Note that Dr Patel could ask a follow-up question to ensure Mr Mahoney is able to express himself fully: Is there anything else you would like to discuss today / while you’re here today?

Is anything else bothering you at the moment?

Do you have any other issues you’d like to address today?

It is easy to assume the patient has come for their routine check-up … when in fact the patient has a more pressing or at least a second agenda to discuss.

Silverman et al. (2005)

© Cambridge University Press 2007

Unit 1 Receiving the patient 19

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17

18

Other opening questions might also limit the patient’s contribution.

Look back at the opening questions in Exercise 15a and circle those which require a follow-up question.

Some doctors use body language instead of an opening question.

Demonstrate to your group how you might open a session using body language only. Would this technique be appropriate in your country?

Would you use this technique? Why (not)?

Setting the agenda The patient’s opening statement is possibly the most important part of the interview.

19

Dr Patel refers Mr Mahoney to a consultant, Mr Swift. Read the opening statement that Mr Mahoney gives to the consultant, underline the important points and explain your choices to a partner.

Mr Swift Mr Mahoney

I wonder if you could tell me in your own words what’s been happening.

Well, yes, I’m sure you’ve got all this information, but … my arthritis has been playing me up1 a bit as usual – I’m having difficulty sleeping and I’m in some pain first thing in the morning. But it’s the headaches that are really getting me down, they’re so painful. Sometimes I’ve been sick2 with them … literally. I’m starting to have time off work now because of them. My wife’s really worried. She’s the one that insisted I go see Dr Patel.

20a With a partner, list the benefits of allowing the patient to make an opening statement.

Examples: Enables doctor to hear patient’s story.

Signals the doctor’s interest in the patient.

b Compare your findings with the rest of the group.

21

1.8 Listen and complete the consultant’s next phrase to set the

agenda for the rest of the interview with Mr Mahoney.

Mr Swift

the headaches that are really looking at those. the arthritis later, if that’s . Is there you want to discuss today? bothering you,

20

2

(US English) acting up, giving me trouble

2

(US English and UK English) I’ve thrown up, I’ve vomited

Unit 1 Receiving the patient

© Cambridge University Press 2007

Out & About If you are working in an English-speaking environment, listen out for the use of opening questions, as well as the speaker’s tone of voice.

Compare your findings with the rest of the class next time you meet.

COV-19 2020

Language for setting the agenda Shall we / Let’s start with [the headaches]?

Shall we start by discussing / looking at [the headaches]?

We’ll come back to [the arthritis] later / after that.

We’ll talk about [the arthritis] later / after that.

If that’s all right / OK with you?

Does that sound all right / OK?

22

With a partner, choose a set of symptoms (a or b) and practise setting the agenda with the patient. a Recurrent headaches, ingrown toenail b Eczema, diarrhoea1

Piecing it all together 23a Choose one of the situations from Exercise 13 and role-play the first part of the encounter with your partner.

Student A: Student B:

Turn to page 123.

Turn to page 129.

b Swap roles. Choose a different situation and role-play the first part of the encounter as before.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area)

1

Greeting the patient appropriately by: – introducing myself and explaining my role – obtaining the patient’s preferred form of address

1 2 3 4 5 1 2 3 4 5

Establishing rapport by: – using a welcoming tone of voice – making the patient feel relaxed – using appropriate eye contact

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Posing an opening question that is suitable for the encounter

1 2 3 4 5

Setting the agenda for the interview

1 2 3 4 5

(US English) diarrhea

© Cambridge University Press 2007

Unit 1 Receiving the patient 21

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Unit 2 The presenting complaint LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● encourage patients to express themselves in their own words ● take an accurate history of the presenting complaint ● ask about the intensity and degree of pain ● use techniques such as facilitation, repetition and clarification

With a partner, discuss these questions: 1 What do you think the differences are between a doctor-centred approach and a patient-centred approach?

2 Which approach do you think gets the best results?

A patient-centred approach to history-taking You are going to read about approaches to gathering information.

1a

Read the article below and complete the gaps with these sentences.

(There is one sentence you will not need.) a both doctor and patient had greater understanding of the symptoms b History-taking was limited to a number of closed questions

DVD clips 1 and 2

c Medical training was all about the disease. d The patient is considered expert of their own disease

Patient-centered approach to history-taking Traditionally doctors took the dominant role during consultations; for many, a doctor’s word was God and, as such, their professional expertise unquestionable. Patients were not expected, neither did they expect to, participate actively in the history-taking process; indeed, their health was entirely in the hands of their physician. Medical training was all about the disease, and the patient as victim of that disease; the disease and the patient were considered as separate entities.

1 regarding the functioning of the relevant organ or system in order to arrive at an accurate diagnosis. The impact of the disease on the patient’s life was barely considered, if at all.

George Engel, pioneer of doctor–patient relations, soon realized a deeper understanding of patients’ problems could be achieved through a bio-psychological model. Engel believed strongly in the patient as the main source of information. The patient-centered encounter therefore takes on a more holistic approach, with social, economic, and psychological factors also playing an essential role in the diagnosis.

2 ; one person’s experience of a disease is fundamentally different from the next.

So what of the benefits of such a radically different approach to historytaking? Studies in the 1970s showed that only 25% of doctors had an open, flexible consultant style; the other 75% interviewed their patients in a tightly controlled way, allowing them limited participation. Doctors attending three-day communication skills courses recently at the

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Unit 2 The presenting complaint

© Cambridge University Press 2007

COV-19 2020 Figure 1

University of Sussex, UK, were found to be significantly more patient-centered. Students showed more empathy, asked fewer leading questions, and were more responsive to patient cues. More positive still – 3 and patients were more likely to comply with treatment.

Figure 1 shows the power of the patient-centered history-taking process on the diagnosis.

b

2

The article makes reference to closed questions. What are closed questions? What other kinds of questions are there?

82% Diagnosis made on history remains unchanged after examination/investigation

Read the article again and complete this table, giving examples of the differences between the two approaches.

9% Diagnosis made on history changes after examination

9% Diagnosis made on history remains unchanged after examination, but changes after investigation

adapted from Communication Skills for Medicine, 2006

Doctor-centred approach

Patient-centred approach

• disease and patient were completely separate

• patient is expert of his/her own disease

Question type(s):

Question type(s):

3

Discuss these questions in small groups.

1 Do the statistics in the article/chart surprise you? Why (not)?

2 Are there any situations where the patient-centred approach might not be appropriate?

3 Do all patients want to be part of the patient-centred approach?

Explain your answer.

4a

Complete this questionnaire as truthfully as possible. Circle the number that corresponds to you in each case (3 = somewhere in the middle).

I do most of the talking.

I ask mostly closed questions.

I am mainly interested in problems.

It is my medical agenda that is most important.

I usually try to maintain control and guide the consultation.

12345 12345 12345 12345 12345

The patient does most of the talking.

I ask mostly open questions.

I am mainly interested in people.

It is the patient’s agenda that is most important.

I usually let my patient control and guide the consultation.

In relation to the above criteria, where are you usually on the scale below?

I am a doctor-centred consulter.

12345 I am a patient-centred consulter. adapted from The Doctor’s Communication Handbook, 2004

b

Compare your responses with a partner.

© Cambridge University Press 2007

Unit 2 The presenting complaint 23

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Think about … how you would feel about gathering information on the presenting complaint in English.

5a

Take a couple of minutes to think about this and then rate your ability to do the following from 1 (lacking in confidence) to 5 (highly competent).

1 I can ask appropriate questions to obtain an accurate history.

2 I can encourage patients to express themselves in their own words.

3 I can ask specific questions to clarify.

4 I can ask clear, unambiguous questions.

b

Discuss your responses with the rest of the group.

Using exploratory questions 6a

2.1 You overhear part of an encounter between a doctor and her patient in the next cubicle. Listen to the encounter and analyse the doctor’s general approach by circling a number from 1 to 5.

Dr Haines is a doctor-centred consulter.

b 7

12345

Dr Haines is a patient-centred consulter.

Explain your analysis in small groups.

2.1 Listen again and complete Dr Haines’s questions as you hear them.

1 Do you still

?

2 How long have you had that,

?

3 Are

?

Are you having

8

9

4 Do

?

5 You’re not suffering from achy joints as well,

?

In groups, decide if you agree or disagree with these statements.

1 Dr Haines asks appropriate questions to obtain an accurate history.

YES / NO

3 Dr Haines asks specific questions to clarify.

YES / NO

2 Dr Haines encourages the patient to express himself in his own words.

YES / NO

4 Dr Haines asks clear, unambiguous questions.

YES / NO

Categorise the questions in Exercise 7 and then discuss.

C Closed

24

?

L Leading

Unit 2 The presenting complaint

M Multiple

© Cambridge University Press 2007

O Open

T Tag

COV-19 2020

10a

2.2 You hear another encounter. Listen and analyse the doctor’s

general approach by circling a number from 1 to 5.

Dr Linley is a doctor-centred consulter.

12345

Dr Linley is a patient-centred consulter.

b Explain your analysis in small groups.

11

12

13

2.2 Listen again and complete Dr Linley’s questions as you hear them.

1 How have you

?

4 W

?

2 Can you

?

5 Any

?

3 Any

?

In small groups, discuss your impressions of Dr Linley’s consultation by saying if you agree or disagree with these statements.

1 Dr Linley asks appropriate questions to obtain an accurate history.

YES / NO

3 Dr Linley asks specific questions to clarify.

YES / NO

2 Dr Linley encourages the patient to express herself in her own words.

YES / NO

4 Dr Linley asks clear, unambiguous questions.

YES / NO

Categorise the questions in Exercise 11 and then discuss.

C Closed

14

L Leading

M Multiple

O Open

T Tag

Discuss these questions with the rest of the group.

1 Which doctor – Dr Haines or Dr Linley – has the most success?

2 What type of questioning (C, L, M, O or T) is the most effective? Why?

15a A young mother and her son are being interviewed by the Registrar. Here are some of the questions the doctor poses. Categorise them as before.

Note that more than one category may be possible for each question.

C Closed

L Leading

M Multiple

T Tag

Presenting complaint: hay-fever-type symptoms 1 Does the sneezing start when the dog is in the house?

C, L

2 Has he been wheezing as well?

3 So the symptoms are there all the time, are they?

4 Is he getting these attacks while he’s outside, too? Do they come on suddenly with no warning? What typically happens?

5 Did your son’s allergy start after you bought the dog?

6 And you’ve already taken him to see your GP about this problem, haven’t you?

© Cambridge University Press 2007

Unit 2 The presenting complaint 25

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b Rewrite questions 1–6 as open questions.

Example: 1 When does the sneezing start?

c Look again at questions 5 and 6 on page 25 and answer these questions.

1 How might the parent now feel about … a buying the dog? (Q5) b not having gone to see the GP (Q6) 2 Why should doctors avoid this type of question?

Cultural awareness Research showed that patients at a walk-in clinic in the UK were more satisfied with the information-gathering phase of the interview if they were allowed to express themselves in their own words rather than provide yes/no or one-word answers to closed questions. (Stiles et al, 1979) Would this be the case in your country?

Describing the nature of pain 16

Discuss these questions with a partner.

1 What kind of patients are more likely to do the following and why? a say the pain is greater than it is b say the pain is less than it is 2 Why is it important for the patient to be able to describe pain accurately?

3 How do you react to pain?

17a Use a good monolingual dictionary to check the meaning of these adjectives.

1 blinding

6 pounding

2 burning

7 shooting

3 cramping

8 stabbing

4 crushing

9 tingling

5 gripping

10 throbbing

b With a partner, think of an ailment that corresponds to each adjective.

Example: 1 migraine (blinding headache)

c Do you use equivalent adjectives in your own language?

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Unit 2 The presenting complaint

© Cambridge University Press 2007

Doctors start problemsolving very early in the consultation, and starting the consultation with a closed question might restrict diagnostic reasoning to an overnarrow field of enquiry.

Silverman et al. (2005)

COV-19 2020

18

Discuss these questions in small groups.

1 What do the metaphors illustrated here have in common?

Metaphors Symptoms can also be described using imagery.

Look at these descriptions of a headache: I felt like I’d been hit over the head with a hammer.

2 Do you use similar imagery in your own language? Share these with your group.

My head feels like it’s being clamped in a vice.

You may also hear some of these expressions used with the linking words as though: ‘I felt as though I’d been hit over the head with a hammer.’

19a Not all patients are capable of describing degrees of pain. In small groups, discuss how you would use this scale and write a question you might ask a patient to describe his/her pain.

Visual analogue pain scale No pain

Worst pain imaginable

b What method do you use to assess pain? Explain it to the class. How does it compare with the visual analogue pain scale above?

Patient speak 20

It is equally important to ascertain the severity of the pain. With a partner, read this patient’s description of pain and circle the correct qualifier (very / quite) in the explanation below.

Well, how can I describe it? There is this sharpish twinge every so often.

Out & About If you are in an English-speaking environment, listen out for the use of imagery when describing pain.

Compare your findings with the rest of the class next time you meet.

The suffix –ish means the pain is very / quite painful.

© Cambridge University Press 2007

Unit 2 The presenting complaint 27

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Exploring the presenting complaint 21a You are going to hear a doctor taking the first part of a patient history from a patient suffering from recurrent headaches. Before you listen, write an open question for each of these answers. a Q: How do they compare to a migraine

?

A: Oh, they’re not quite as bad as a migraine. It’s kind of that stage before. b Q:

?

A: Here, around the front, here, around the forehead. c Q:

?

A: Oh goodness, anything up to six, seven hours. d Q:

?

A: I’d say, for about three months now. e Q:

?

1

A: No, not really … but my husband reckons I’m going deaf. f Q:

?

A: Yes, it’s quite a dull pain, but there’s a constant throbbing pain as well. g Q:

?

A: Normally I lie down for a while and I turn off the light. That seems to help. h Q:

?

A: Mainly in the morning, just when I’ve woken up.

b Compare your questions with a partner.

22

2.3 Listen and compare your questions with those of the doctor.

23a Look at the questions and answers in Exercise 21a and put them in the order you would expect to hear them.

b 24

2.4 Listen and check the order. Note that the questions vary slightly from those in Exercise 22.

Here are the Seven Attributes of a Symptom. Which of them does each question from Exercise 21a refer to?

1 Location question b

5 Setting (in which it occurs)

2 Quality

6 Aggravating/alleviating

3 Quantity/severity

7 Associated manifestations

4 Timing

25a Carrying out a holistic, patient-centred encounter should also include the ‘eighth attribute’. Discuss what this might be in small groups.

1

28

(US English) thinks

Unit 2 The presenting complaint

© Cambridge University Press 2007

1

COV-19 2020

b Did the doctor ask the patient about this ‘eighth attribute’? c Write two more open questions you could ask a patient to ascertain this information.

Example: How do you feel about this?

Patient speak When describing symptoms, your patients may use a variety of expressions.

26a Write an explanation or meaning plus an example sentence for as many of these phrasal verbs as possible. build

bring

blow

clear

clog

cough

ease

up dry

flare

be

t/

mi

vo

tighten

k

sic

play puff

shoot

throw

b Compare your findings with a partner. c With your partner, practise rephrasing the expressions to be sure you have understood your patient.

Example:

Out & About If you are in an English-speaking environment, listen out for the use of other phrasal verbs when describing symptoms, e.g. verbs + out/in/of.

Sorry, just so I’m sure; by [throw up], do you mean …?

Compare your findings with the rest of the class next time you meet.

Clarification, facilitation and repetition Encouraging patients to tell the story in their own words is an important part of the patient-centred approach. The Calgary-Cambridge observation guide suggests doctors use various techniques to achieve this.

27

Match the techniques (1–3) with their definitions (a–c).

1 Clarification

a Encouraging the patient to say more, but not specifying the topic. This can be done through posture, actions or words.

2 Facilitation

b Echoing the patient’s words encourages him/her to give more details. This is useful for eliciting both facts and emotions.

3 Repetition

c Indicating that you have been listening to the patient and pinpointing what you know and don’t know.

© Cambridge University Press 2007

Unit 2 The presenting complaint 29

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28

With a partner, read audio script 2.4 on page 139 and note down one or more examples for each technique.

29

Decide whether each of these is an example of clarification, facilitation or repetition.

1 I see.

6 Lean forward (non-verbal)

2 Just let me check what you have told me so far …

7 Right.

3 Patient: I was terrified.

Doctor: Terrified?

9 Go on.

4 When you say

, do you mean … ?

5 Nod of the head (non-verbal)

30

8 Yes. 10 I’m listening, please continue.

11 Slight tilt of the head (non-verbal) 12 Could you explain what you mean by … ?

With a partner, complete this statement, then answer the question below.

Remaining silent but attentive and relaxed is a cue for the patient to continue. Silence is an example of . It could be accompanied by non-verbal signs, such as nodding the head or leaning forward slightly, to avoid making the patient feel uncomfortable.

How comfortable would you be using silence during the history-taking?

Facilitating the encounter 31a

2.5 With a partner, listen to what happens to the voice in these examples of facilitation and answer the question below.

1 Uh-huh.

2 Yes.

3 I see.

4 Go on.

Which is the odd one out?

b

2.5 Listen again and repeat the examples.

32a With a partner, read this mini-dialogue aloud. Use the most appropriate tone of voice.

Patient: I was terrified.

Doctor: Terrified?

b Compare your version with others in the group.

33

With a partner, choose a common presenting complaint. You are going to do a short role-play to establish the patient’s symptoms.

Student A: Student B:

See below.

Turn to page 129.

Student A Your patient is not very communicative, and you have to use strategies to obtain the information you need. Try using silence. Don’t forget to use an appropriate tone of voice.

You’ll be looking at other strategies such as these in Unit 3.

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© Cambridge University Press 2007

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Piecing it all together 34a In small groups, allocate roles to two students as follows.

Student A: Student B:

Turn to page 124.

Turn to page 129.

b The rest of the group are observers. Use the checklist below to rate the doctor’s questioning technique during the history-taking of the presenting complaint. ✓✓ = competent

✓ = fairly competent

✗ needs more work

Observers’ checklist Item

Rating

1

Used a patient-centred approach throughout the consultation.

2

Began with open and moved to closed questions as appropriate.

3

Refrained from employing leading and tag questions.

4

Enquired about specific features of the condition (location, quality, severity, etc.).

5

Asked about aggravating and alleviating factors.

6

Enquired about associated manifestations.

7

Used clear questions, avoided complicated medical terminology.

8

Employed appropriate tone of voice.

c Observer(s) and the patient should feed back to the doctor. d Swap roles or create another scenario and role-play it in the same way.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area) Encouraging patients to express themselves in their own words by: – employing a patient-centred approach 1 2 3 4 5 – asking mainly open questions 1 2 3 4 5 – using verbal and non-verbal facilitating techniques 1 2 3 4 5 Taking an accurate history of the presenting complaint by: – employing an appropriate questioning technique – avoiding confusing and biased questions – clarifying and checking understanding

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Asking about and understanding descriptions of the nature and intensity of pain

1 2 3 4 5

© Cambridge University Press 2007

Unit 2 The presenting complaint 31

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Unit 3

Past medical and family history

LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● request the patient’s past medical history ● discuss the family history ● take effective notes during an interview ● write an effective patient note ● structure and summarise the interview

An accurate family history is a well-established method for recognising genetic disorders and susceptibilities that may pose risks for future health problems.

It remains one of the most powerful ‘genetic tests’ to identify individuals at risk from inheritable diseases when laboratory tests are not available … Early identification of families with increased risk for chronic diseases such as heart disease, diabetes and certain cancers can often improve, delay or even prevent adverse health outcomes to individual members. taken from Family Medical History in Disease Prevention, American Medical Association, 2004 As a group, discuss these questions, then check your answers in the key on page 156.

1 Why is it necessary to ask a family history, and what are the most important aspects?

2 What problems might patients have in: a recalling their family history in general?

DVD clip 3

b discussing certain family ties (adopted siblings, extended family)? c going into the mental and physical disability of family members?

Why?

You will be looking at this aspect of information-gathering later in the unit.

Components of the past medical history Medical students are often encouraged at first to carry out a complete past medical history (PMH). You’re going to hear part of a talk at a medical conference on the pitfalls of taking the PMH.

1a b

Before you listen, with a partner, list the eight components of a past medical history. They should be in a logical order.

3.1 Listen and check your list. Then fill in the headings in the notes on

the next page.

c

3.1 Listen again and complete the notes about the different

components.

Communication Skills Patients are only human, and many people have bad memories. Unless patients visit the doctor regularly, they are unlikely to have all the information about their past medical history at their finger tips. Encourage your patients by jogging their memory: What about injuries [when you were at school]? What about [sports/DIY injuries]?

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COV-19 2020 8th International Medical Communication Conference The Hamptons Clinic, New Jersey Past medical history: the components

by Carmen María López, M.D.

1

5 Patients may recent ones. They can be adults.

but remember more , even

Be aware of repeated injuries in women (might indicate ) and the (may need help or referral to social services). Repeated injuries might possibly indicate or .

2 Childhood illnesses Patients remember childhood illnesses if or , e.g. chickenpox, mumps, measles. Also ask about unusual illnesses.

6

3

7 Important information, especially for + (toxoplasmosis/rubella). Patients don’t .

4 Some patients about surgical procedures and some may not even know for their hospitalisation or exploratory investigations.

d

Ask all about pregnancy + related problems. Difficult for some to discuss or .

Patients may not think to mention to + , but will remember hay fever, etc.

Presenting complaint may be a reaction to or .

1 8 Medications Patients forget to mention + Reluctant to mention medicines + medications prescribed by another doctor.

.

Don’t forget!

Compare your findings with a partner, then discuss these questions.

1 What problems might the patient have in giving the doctor all the information?

2 What is the connotation of the word drug for the patient?

3 Is it common in your country to ask all women of child-bearing age about pregnancies?

Think about … how you would ask questions to obtain the PMH in English.

2a b 1

Look at the components (1–8) above. Write a question for each one.

Compare your questions with a partner.

(UK English) medication

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Taking a past medical history Asking about the PMH can be done using questions or ‘openers’.

Case history: Adele Martin, 44, has just moved into the area. She presents to a family practice1 suffering from irregular bowel movements.

You’re going to hear Dr Tran interviewing Ms Martin about her PMH. (NB The doctor has already asked about the presenting complaint.)

3a

b

3.2 As you listen, number the components of the PMH as you hear them.

a Past illnesses

e Accidents and injuries

b Childhood illnesses

f Allergies

c Immunisations

g Pregnancies

d Surgical procedures

h Medication

Answer this question.

Does the doctor ask about the PMH components in the same order as in the conference notes on page 33? Why (not)?

c

3.2 Listen again and complete the doctor’s questions (1–13) in the dialogue below.

Dr Tran

Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran

34

Since this is your first visit to the practice, I’d like to have a more detailed picture of things. Could you tell me about any illnesses you 1 ?

I had my tonsils out when I was a little kid, I remember that.

2 childhood illnesses?

Don’t remember, to be honest – my mother would know, I’d expect. Mumps, measles, that kind of thing, usual stuff.

Regular childhood illnesses, then? [pause] And 3 in general since then?

No, no real problems, to tell you the truth.

Good. So, have you had any operations, 4 the tonsils?

No, no. Like I say, I’m pretty healthy.

5 visits to the hospital?

Yes, for the birth of my son, and, er, then a couple of years ago, I had to go in for some tests.

Mm-hm? What kind of tests, Ms Martin?

Don’t remember exactly.

6 when you gave birth?

Yes, it was just before my 40th – celebrated it surrounded by diapers2 that year! [smiles] Going back to those tests, Ms Martin, can I ask you to elaborate on those a little?

Oh, those, well, er, I lost my second baby, a little girl apparently.

I’m sorry to hear that. I 7 , was she stillborn?

1

(UK English) GP surgery

2

(UK English) nappies

Unit 3 Past medical and family history

© Cambridge University Press 2007

Doctor asks about general health.

Open question Patient remembers being hospitalised as a child – often a traumatic experience for a child and so easier to recall.

COV-19 2020 Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran

Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran Ms Martin Dr Tran

4a

b 5

Yep. [sighs and looks away] I understand this must be a painful memory for you. [pause] Moving on, if we can. Are you fully immunised?

I’m sorry?

What I mean is, how 8 with your shots1, Ms Martin?

I think I’m OK. I had most of those when I was at school.

9 tetanus?

Uh-uh. [shakes her head] Now, nearly finished this part. Um, have you ever suffered from allergies?

No, not that I know of. My brother always got hay fever, poor thing, but not me.

Any food allergies?

Mm … Strawberries – weird, isn’t it?

And I suppose they were your favourite fruit, too? [they laugh] 10 to any medications – some people are allergic to penicillin, for example?

No. And finally, 11 any medications at all, Ms Martin?

Ah, yes. I was taking antibiotics, but didn’t finish the course, didn’t seem to be doing anything. I’m not on anything else.

Right. 12 them for?

Oh, I’d had a very bad cold and I couldn’t shake it off.

How about medications you buy 13 ?

Ah … laxatives sometimes, you know, for the problems I’ve been having recently. Tylenol2, occasionally.

Some people believe in alternative medicine; is this something that interests you?

No, no, definitely not.

Well, some people are turning to alternative forms of treatment, and so this is a question we have to ask, in case of any possible complications. OK. [pause] So, I’d like to sum up your history briefly to make sure I have all the details correct before we proceed …

In pairs, choose one of the following to analyse. Then read the dialogue again and add comments, as in the examples on page 34, to help you with your analysis. ●

Dr Tran’s questioning technique for the PMH

●

Ms Martin’s responses in relation to the pitfalls discussed in the talk in Exercise 1

Present your findings to the rest of the group, giving examples to substantiate your points.

Discuss as a group.

Dr Tran pauses at three significant places during the encounter, but for different reasons. Why does he do this?

1

(UK English) jabs

2

(UK English) paracetamol

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Unit 3 Past medical and family history 35

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Language to request the past medical history 6

Compare these two ‘openers’ used to enquire about the PMH and then answer the question below. ●

Could you tell me about any illnesses you’ve had in the past?

●

Could you tell me about any illnesses you might have had in the past?

The history is the most important part of the patient’s assessment, as it provides 80% of the information required to make a diagnosis.

Marsh (2004)

Both ‘openers’ are polite, but which is the most appropriate and why?

7

It is important to obtain a precise medication history. Look at these examples and note the different use of past tenses and prepositions.

Past simple

in/on + exact date / ago

Doctor Doctor

Patient Carer1

When did you start taking the antibiotics?

When did he complete the course of treatment?

I started taking them two weeks ago.

He completed the course on Tuesday.

Present perfect

since + exact time / for + time period

Doctor Doctor

Patient Carer

How long have you been on the tablets?

How many years has she been on the pill?

I’ve been on them since last Friday.

She’s only been on the pill for six months.

Past continuous 1

for + time period

Doctor

Patient Patient

How long were you taking the analgesics?

I was taking them for a couple of years.2 I took them for five weeks.

Past continuous 2

exact time period

Doctor

Carer

8

How often was your husband self-injecting?

He was injecting three times a day.2

With a partner, practise asking questions about your own or an imaginary PMH, using Dr Tran’s questions from pages 34–35.

Taking a focused past medical history A complete PMH is not always appropriate, and many situations call for a more focused history.

9

With your partner, decide in which of these cases you would take a focused PMH. Why? a 28-year-old female passenger presenting to the Emergency Department with suspected whiplash following a minor car accident b 19-year-old female student complaining of a sore throat

10

c 46-year-old female referred by her GP to the gastroenterology clinic with anaemia d 85-year-old female with a persistent temperature of 39°C, suffering from diarrhoea

3.3 You are going to hear a doctor (Dr Bhaskar) taking the PMH of one

of the patients in Exercise 9. Listen to Part 1 of the PMH and say which patient is being interviewed: a, b, c or d.

1

36

(US English) care giver

2

(US English) Use of the past simple is more common.

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11a Before you listen to Part 2, with a partner, predict which components of the PMH Dr Bhaskar will focus on by ticking the boxes in this list.

Components

Dr Bhaskar The medical history has a traditional format, but it should not be considered as a rigid interrogation and checklist of questions. Although a structured approach is needed, it is important to adopt a flexible attitude, adapting your questions and differential diagnosis as information is received.

Past illnesses Childhood illnesses Immunisations Surgical procedures Accidents and injuries Pregnancies Allergies Medication

b

Marsh (2004)

3.4 Listen and check.

c With your partner, compare your findings and then answer these questions.

1 What do you learn about Mrs Wilson’s PMH? 2 How effective do you feel Dr Bhaskar’s questioning technique is?

Patient speak You might hear patients talk in very general terms about their health using these expressions. off colour run down

off low

under the weather

poorly

out of sorts

Patients might also use not + that/too + positive adjective (such as brilliant/clever/fantastic/good/great/hot) to describe how they feel.

I’ve been (feeling) out of sorts for a while now.

I’ve not been feeling too great lately.

He’s not been that good these last few weeks.

12a Decide on two ways you could encourage a patient to explain in more detail how he/she has been feeling. (NB Both verbal and non-verbal communication strategies are possible.)

b With a partner, using the expressions above, practise asking your patient to explain him/herself in more detail. Swap roles.

Signposting and summarising 13a Look back at the encounter with Ms Martin on pages 34–35. Underline examples of expressions the doctor used to do the following: ●

change direction

●

ask for more detail

●

refer to an earlier point

●

summarise

●

end

b With a partner, answer these questions.

1 What difference do these expressions make to the encounter?

2 Do you use similar techniques in your own language?

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Unit 3 Past medical and family history 37

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c In small groups, discuss why it is important to summarise before moving on to the next stage of the encounter.

14

With a partner, choose another case history from Exercise 9 and take the patient’s PMH. As you go through the history, use signposting to structure the interview. Swap roles.

Writing the patient note 15

With a partner, look at the sample of a patient note on the right and discuss the significance of the caption.

Think about … how you would feel about writing a patient note in English.

16a Take a couple of minutes to think about this and then rate your ability to do the following from 1 (lacking in confidence) to 5 (highly competent).

1 I can remain objective when writing the patient note.

2 I can maintain accurate and concise records.

3 I can write legibly (clearly).

Summary: Mrs Katorina Gajowiecka is 35 years old f. c/o pain in right breast. It began three days ago. She noticed a lump before she took a shower which she described as pain radiating to her underarm. Lump is erythematous. Patient is nulliparous and currently perusing ‘in vitro’ for fertility problems.

4 I can use standard abbreviations in English.

Writing in ‘hieroglyphics’ could have dire consequences!

b Discuss your thoughts with the rest of the group.

Standard medical abbreviations 17a Look at this table of standard medical abbreviations. Write out in full as many of the abbreviations as possible.

HTN r

m GI

b h/o

yo l

Neuro f

cig FH

CXR w

PMH ETOH

MRI ICU

Abd c/o

b Rewrite these medical notes in full.

25 yo b m presents c/o Abd pains on l side. Patient h/o GI problems.

PMH car accident – 2001 in ICU 2/12. FH father and mother A&W. No cig, ETOH 25 units/week

c As a group, share any techniques you may have for remembering some of the more commonly used abbreviations.

You will find a list of standard medical abbreviations at www.cambridge.org/elt/goodpractice.

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18a Look at this extract from a patient note. Using the criteria below, evaluate the doctor’s technique.

Unit N°

St George’s Hospital

Z29104

A&E

Date / Time

Clinical Notes

10/05 6:25pm

PC The patient is very breathless

Matherson

Surname (Block letters)

First Name(s) D.O.B./age

Michael 19/10/69

(Each entry must be signed)

Previous

1992- AP ° HTN / DM / IHD / Ep / Ren / An HPC The patient started to feel breathless two days ago, and the problem is slowly getting worse. His symptoms came on gradually and are worse at night time. He is wheezing and he says his chest feels tight. He has a history of asthma and has been prescribed a course of Salbutomol. The Salbutomol only gives minimal relief at the moment. He has been prescribed 100 milligrams of Salbutamol.

Family history Mother – she is still alive and has no significant health problems, she also suffers from asthma.

Father – died heart attack in 1992.

Drugs Salbutamol 100mg No over-the-counter medication

Allergies

Social H Office manager Office clean, no dust No cig / Alcohol – occasional ‹10 units/wk No pets Sexual history – no Signed:

Yes

No

1 The doctor has remained objective.

b Compare your thoughts with a partner.

Always maintain intermittent eye contact, and don’t give the impression that your notes are more important than what the patient is saying.

c Turn to page 121 and read the advice. Did you think of all these points?

Lloyd and Bor (2006)

2 The doctor has written accurately and concisely.

3 The doctor has signed the note legibly (clearly).

4 The doctor has used standard medical abbreviations.

d Compare your thoughts with the corrected version in the answer key (see page 159).

19

Write the PMH section of the patient note for Ms Martin (see page 34).

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Unit 3 Past medical and family history 39

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Taking a family history Taking a family history can be crucial, but it must be done sensitively and with no assumptions about a patient’s family status.

20

The Pedigree diagram (a form of note-taking) is a genetic assessment tool used to screen for certain genetic diseases. It generally includes three generations. With a partner, look at the Pedigree diagram and answer these questions.

1 What disease is possibly being transmitted?

2 For which ‘female’ genetic disorder might the Pedigree diagram be similar?

3 For which ‘male’ and/or ‘female’ genetic disorder might the Pedigree diagram be similar?

Key female male

Language for taking a family history Could you tell me about any illnesses that might run in the family?

I have to ask, how did [your father] die?

I understand this may be painful for you, but could you tell me how [your son] died?

Is there a history of [breast cancer] in your family / on the female/male side of the family?

affected male

Out & About 21

Work in pairs.

Student A: Student B:

22

Turn to page 124.

Turn to page 130.

In pairs, take your partner’s own family history and plot a Pedigree diagram.

Piecing it all together

If you are in an English-speaking environment, check the symbols in common usage for the Pedigree diagram. Compare your findings with the rest of the class next time you meet.

23a Read through this case history and look at the information on Pyrexia of Unknown Origin (PUO)1 on page 121.

Case history 85-year-old female with a persistent temperature of 39°C, suffering from diarrhoea.

Betty Jackson lives on a working farm with her son and daughter-in-law. She is of good general appearance, well dressed and looking a little younger than her years. She’s worried no one is looking after her cat while she is in hospital and her family is away on holiday.

1

40

(US English) Fever of Unknown Origin (FUO)

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b Before you role-play, as a group, decide on a focused PMH and your line of questioning, based on the case history.

c Work in pairs.

Student A: Student B:

You are Betty Jackson. Evaluate Student B’s questioning technique for the PMH. You are the doctor (see below).

Student B 1 Take notes as you interview the patient.

2 Evaluate the notes you took during the history-taking process. ✓ = happy with my progress ✗ = need to work on this

✓/✗ = room for improvement ✓

✓/✗

✗

I remained objective.

I maintained accurate and concise records.

I wrote legibly (clearly).

I used standard abbreviations.

3 Ask your partner to comment on your question-taking technique during the role-play.

d Swap roles or choose one of the other cases in Exercise 9 to create another scenario and role-play it in the same way.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area) Taking an accurate past medical history by: – employing an appropriate questioning technique – structuring and summarising the discussion

1 2 3 4 5 1 2 3 4 5

Asking about the family history

1 2 3 4 5

Developing an awareness of note-taking by: – employing standard abbreviations – being accurate and concise

1 2 3 4 5 1 2 3 4 5

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Unit 4 Social history and telephone consultations LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● enquire about the patient’s social history ● employ good telephone etiquette ● ensure an effective telephone consultation ● summarise and check information Make it a rule to know more about the patient when they leave than when they came in.

Tate (2004) How does Tate’s quotation link to the above pictures and the role of a doctor?

Think about … which aspects to consider when gathering information about a patient’s social history.

1a

Questions relating to the personal and social history should be woven throughout the interview. They allow you to identify contributory factors to the patient’s illness and help you to evaluate the patient’s sources of support, likely reactions to illness, coping mechanisms, strengths and fears.

b

1 Occupation

3

5

2

4

6

Discuss the six areas above in more detail. For each area, make notes about which factors are important to a patient’s health and why.

Example: Occupation: unemployment – known to have an effect on morbidity rates

2a

4.1 You’re going to hear part of a seminar discussion at a university.

Listen and check your notes from Exercise 1b and add any information you have missed.

b

Bickley (2003)

42

Take a couple of minutes to think of six subheadings for a patient’s social history.

Unit 4 Social history and telephone consultations

Answer these questions.

1 Why is this part of the history-taking process so important?

2 Do patients always see the medical relevance of their social history?

Explain your answer.

© Cambridge University Press 2007

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Occupational health 3a

Read this extract and underline the correct information.

In the USA, an estimated 50,000 to 70,000 deaths per year are caused by occupational factors and more than 350,000 / 95,000 new cases of occupational disease are recognised every year. These diseases involve certain / every organ system(s),

and one of the most important barriers to the accurate diagnosis of occupational and environmental diseases is the long latency between exposure and the appearance of the illness. / ignorance concerning occupation-related health problems. taken from Textbook of Physical Diagnosis, Swartz (1989)

b 4a

4.2 Listen and check your answers.

With a partner, consider the type of conditions/diseases typically associated with these occupations.

1 airport baggage handler 1

b 5a b

6a

5 farm worker

2 cleaner

6 healthcare professional

3 coal miner

7 keyboard operator

4 construction worker

8 manual worker

Add two more occupations to the list and ask another pair to comment on them as above.

It’s not enough to find out your patient’s occupation. Make a list of information you would need from a cleaner. Compare with a partner.

With your partner, write a list of questions to gather information you need from the cleaner. You may wish to begin with an open question and follow with focused, closed questions.

4.3 Listen to a GP taking Mary Stevens’ social history

and complete the doctor’s notes.

b

4.3 Listen again and note any questions that do not

1 Presenting complaint: 2 Place of work: 3 Other pertinent information:

appear in your list in Exercise 5b.

7

With a partner, choose another occupation from the list in Exercise 4a and role-play a similar dialogue between patient and GP asking about the patient’s occupational health. Remember to reassure the patient. To emphasise the importance of certain questions, you can start like this: It is important to know this because …

1

(US English) housekeeper

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Asking about lifestyle and environmental health It is impossible to separate the disease from a person’s lifestyle. It is therefore important to address a whole range of wider lifestyle issues as well as the physical symptoms when interviewing patients.

8

With a partner, look back at the pictures on page 42 and answer these questions.

1 Which of these aspects of a person’s lifestyle, if any, would a GP ask these patients on a first visit to the surgery1? Explain why. ● ●

smoking ● alcohol consumption recreational drug use ● sexual history

2 What might prompt a GP to ask about these issues in more detail?

Cultural awareness Alcohol consumption in the UK and Ireland is tolerated and considered the norm amongst men and women. Consumption, sometimes in quite large quantities, occurs across both sexes and amongst all ages and economic groups.

How is alcohol viewed in your country of origin and how is it treated by GPs? You will be working on taking a more detailed history of these aspects in Unit 8.

9a

Read the dialogue between Mary Stevens and her GP on page 141. With a partner, underline the questions the GP poses related to Mrs Stevens’ environmental health.

b

Now circle the points of her lifestyle that might cause future concern and note the question the doctor asks to establish the patient’s coping mechanism.

Here are other questions a GP might ask:

How are you managing [with your current situation]?

Is there anything causing you particular stress at the moment?

What sort of things cause you stress?

10a In groups of three, read through this case study and decide which points / potential risk areas are likely to raise questions about lifestyle and environmental health for a doctor and why.

Case study 1 Sinead Davies is a white, 22-year-old, single mother with three children (two under school age), living on a council housing estate2 in the suburbs of a large city. Sinead and her family rely heavily on welfare benefits and often struggle financially. She is currently living with a boyfriend of six months, who has a severe drink problem and a history of domestic violence. The family keeps several pets, including a parakeet and a Rottweiler.

44

1

(US English) doctor’s office

2

(US English) low-income housing

Unit 4 Social history and telephone consultations

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b Present your ideas to the rest of your group, outlining the possible risk areas.

c In your groups, role-play the interview that takes place between Sinead Davies and her GP. Student A: Take the role of Sinead Davies.

Student B: Take the role of the GP, and take a complete social history.

Student C: Take the role of observer and note the language Student B uses to take the social history of the patient.

Student B might like to start with:

d

If you don’t mind, I’m just going to ask you a few questions about your home life.

4.4 Listen to the actual interview with Sinead and work as a group to

make a note of any questions you feel useful.

Communication Skills You will have already come across patients with different educational levels in your own country. The important thing is to take your time with the patient and paraphrase your questions if necessary, without being patronising: Let me ask that in another way, …; Well, what I mean is …

e Swap roles, this time using Case study 2 (see page 122).

Student A: Student B: Student C:

Take the role of observer and note the language Student C uses to take the social history of the patient.

Take the role of Saleem Akhtar.

Take the role of the GP.

f As a group, compile a bank of possible questions for the social history based on your role-plays, including questions under each of the six subheadings you noted in Exercise 1a. You may wish to read the audio script on page 141.

g In groups of three, write notes summarising the patient history in one of the role-plays above.

Summarising the encounter You looked briefly at the benefits of summarising in Unit 3. The CalgaryCambridge observation guide suggests doctors summarise at the end of a specific line of enquiry to confirm understanding before moving on.

11

Using your notes from Exercise 10g, complete the role-plays from the previous exercise by summing up for the patient and checking you have the correct information. You may wish to use the language below.

Summarising is the key skill in the informationgathering and structuring phases of the interview … It provides intentional feedback to the patient about what you think you have heard when listening to their story.

Silverman et al. (2005)

Language for summarising Summarising the patient history Just to summarise, then. You …

I’d like to (briefly) summarise your history to be sure I have the details correct. You …

Just let me summarise to check I have everything right [before I proceed with the physical examination]. You …

So let me see if I’ve got this right. You …

1

Checking the information Is that an accurate summary, or have I missed anything out1?

Is there anything you wish / would like to add?

Is that right so far?

Have I understood you correctly?

(US English) Did I leave anything out?

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Patient speak Doctors are advised to avoid medical jargon wherever possible with their patients. However, sometimes patients are familiar with the more common Greek-based names.

12a With a partner, complete these tables by adding a definition of each suffix and then give an example of medical terminology for each.

Suffix

Definition/ Related to

–algia

pain

Example of medical terminology

Suffix

Example of medical terminology

–oma

–aemia

–osis

–uria

–pathy

–ectomy

Definition/ Related to

removal of

hysterectomy

–genic

–penia –phagia

arthritis

–itis

–plasty

–ology

–pnoea

–rrhoea

–phobia

b With a partner, practise explaining this terminology as if to a patient.

Example: Arthritis means you are suffering from inflammation of the joints.

13a

4.5 You’re going to hear a doctor explaining medical terminology to her patients. As you listen, note the condition in each case.

1 hysterectomy 2 3

Out & About

4

If you are working in an English-speaking environment, listen out for more terminology and add it to the table in Exercise 12a, as you come across it. Try to see a pattern in the stress. Compare your findings with the rest of the class next time you meet.

5 6 7 8

b

4.5 Listen again and underline the stressed syllables in each word.

Where there is more than one, use a double underline for the main stress and a single underline for the secondary stress.

c Choose four more examples from the table in Exercise 12a and read them out for your partner to write the correct word stress.

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Evaluating the potential of the telephone consultation 14

As a group, discuss these questions.

1 Do telephone consultations already exist in your country?

2 In what situations are telephone consultations used in your country?

15

You are going to read an extract from an article about telephone consultations. Before you read, with a partner, discuss the advantages and disadvantages of telephone consultations.

16a Read the article. Does it mention the advantages and disadvantages you identified in Exercise 15?

Telephone consultations Despite the possible uses for the telephone in the medical field, delivery of clinical care by this means of communication is still, for many, somewhat controversial.

Potential uses of this type of consultation range from delivery of routine and emergency care, as well as repeat prescriptions and results of investigations, transfer of information and patient education. Following discharge, the telephone consultation can also be a vehicle for informing patients of investigations and checking up on patient understanding of advice given. And for those with chronic disorders, this type of consultation could even substitute visits to the clinic.

Several studies have shown that the public are highly satisfied with this mode of communication – particularly those living in rural areas or those whose health or social situation make visits to the surgery or hospital difficult. In one study, a third of those patients who consulted a clinician by telephone would have otherwise gone to the emergency department.

Doctors, however, are more wary. While many value the flexibility that the telephone consultation provides, they are concerned about the absence of visual clues, the inability to confirm diagnosis with an examination, not being able to use touch as a communication aid, as well as the formality and relative anonymity of the method.

Studies showed that this form of consultation decreased costs and use of resources without detrimental effect to health outcomes. However, there is still concern about quality and safety. Staff training, protocols for managing common scenarios, dedicated time for telephone contacts, documentation of all consultations and a low threshold for organising face-to-face consultation may help to ensure the quality and safety of telephone consultations.

A key concern in each telephone consultation is being able to assess whether or not telephone management is appropriate. A good telephone consultation should mean that a person receives information that allows him or her to manage a disorder at home and understand when further advice should be sought.

Increased use of the telephone in health care represents just one of the range of developments in information technology that are likely to greatly alter the way in which clinical care is delivered in the future.

adapted from Information in Practice – Telephone Consultations, Car and Sheikh, BMJ vol. 326, 2003

b Look at the penultimate paragraph of the article and decide how you could conduct the telephone consultation to ensure the patient receives this information.

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Unit 4 Social history and telephone consultations 47

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Think about … how you would feel carrying out a telephone consultation in English.

17a Take a couple of minutes to think about the difference between face-toface and telephone consultations. Consider: ● ●

establishing rapport ● understanding the patient gathering information ● picking up on patient cues

b Discuss your thoughts with the rest of the group.

You will be looking at these aspects later in the unit.

Employing good telephone etiquette 18a Later in their article, Car and Sheikh suggest a framework for telephone consultations. Read through these stages and put them into the correct order in the flowchart. ●

Advise about follow-up and when to visit a doctor

●

State your name

●

Take a detailed and structured history

●

Request the caller to repeat the advice given

●

Record the person’s name, sex and age

●

Provide advice on treatment or disposition

●

Ask if the person has any outstanding questions or concerns

●

Summarise the main points covered

●

Record the date and time of the call

●

Obtain the caller’s name and telephone number

b With a partner, compare your flowcharts and answer these

Stage 2 Stage 3 Stage 4 Stage 5 Stage 6

questions.

Stage 7

1 Why should a doctor ask if the caller has any outstanding questions or concerns?

Stage 8

2 In your opinion, why do Car and Sheikh also give the following advice?

Stage 9

a Answer the telephone promptly b Let the caller disconnect first

48

Stage 1

Unit 4 Social history and telephone consultations

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Stage 10

State your name

COV-19 2020

19a

4.6 You’re going to hear a telephone

consultation carried out by Dr Marsden.

Listen to the conversation and complete Dr Marsden’s notes about the patient.

b Compare your answers with a partner. c

4.6 Listen again and complete what Dr Marsden says at each stage of the consultation. (NB Stage 3 does not require a question.)

Stage

Family Practice 26 December 2009 Date Tony Patient details Tel. 01229 DOB Presenting complaint Diagnosis Medication Make appointment with GP Follow-up if

Language

1

Good evening, I’m Dr Marsden.

2

I wonder if you

and telephone number, please, just in case we at any point or we .

3 4

… could I also

5

So, what

?

6

So what

you …

7

… if the

over the next 24 hours, then I

8

… I’d just like to

9

Now, if you

10

, please?

to see your GP.

to be sure I

.

I’ve just given, Mr Patchett.

Now, before we finish,

?

Non-verbal communication on the telephone 20

With a partner, discuss how non-verbal communication might help you during a telephone consultation.

21a It is important that the summary in a telephone consultation is clear.

Pausing at significant moments during the summary can facilitate the process. Read Dr Marsden’s summary (audio script 4.7 on page 142) and separate the different chunks of the summary with a slash (/) where you feel a pause is appropriate.

b

4.7 Listen and check by marking the script again, using a different-

coloured pen.

c With a partner, practise reading Dr Marsden’s summary aloud until you feel you have the right pacing.

d Now do the same for the summary you wrote in Exercise 11.

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22

With a partner, using the stages from the framework, role-play one of the following situations concerning the Davies family (see Case study 1 in Exercise 10a). When playing the role of the doctor, remember to use appropriate non-verbal communication, and be sure to use the correct pacing when summarising.

1 Ms Davies calls, worried about her six-month-old baby, who has a persistent cough.

2 Ms Davies calls, complaining of earache and blocked sinuses.

3 Ms Davies calls about her three-year-old son, who has been bitten by the family’s pet parakeet.

Ensuring an effective telephone consultation 23a You’re going to hear part of a telephone encounter between a patient, Mr Tomlinson, and Dr Baker. Before you listen, in small groups, discuss this case study and decide on possible presenting complaints.

Case study 3 Richard Tomlinson, 55, has been a moderate smoker for 35 years and smokes on average half a packet a day. A coal miner for much of his working life, he now runs his own off-licence1 in a busy shopping area in Collingwood, a mining town in the East Midlands. Richard is fairly active; his job is quite physical, as it requires him to do a lot of lifting, and he regularly looks after his two grandchildren following his only daughter’s very recent death in a car accident.

b

4.8 Listen and answer these questions.

1 Why has Richard called the surgery?

2 What other aspects of his life are worrying him?

3 What advice would you give him?

c

4.8 Listen again and, as you listen, tick the objectives Dr Baker achieves.

a Establishing rapport b Gathering information c Understanding the patient d Picking up on patient cues

d

4.8 Listen again and note how Dr Baker achieves her objectives. Give an example for each.

Example: b Doctor allows patient to tell his own story

e In small groups, discuss these questions.

1 Which of the patient cues does Dr Baker not pick up on?

2 How might this affect the encounter?

1

50

(US English) liquor store

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f Check your answers by reading the audio script of the encounter on page 142.

g With a partner, write the final part of the telephone encounter, summarising and advising the patient appropriately.

You will be working on telephone consultations again in Unit 9.

Piecing it all together

Careful active listening, frequent checking for understanding and an interested response are paramount if the telephone interview is to be effective.

Silverman et al. (2005)

24a In groups of three, use Case study 4 on page 122 to devise a scenario for a telephone encounter between Rosanna Fiennes and Dr Baker. You may wish to select a disease or condition from the table in Exercise 12a.

b Allocate roles. Student C is the observer and should record his/her impressions of the encounter in relation to the framework for telephone consultations on page 48. He/She may wish to give Students A and B advice following their role-play.

c Role-play the encounter. d Swap roles. Each time, try to improve on your telephone technique according to the observer’s comments. Use one of the other case studies in this unit or devise your own.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area) Taking a complete social history by: – employing an appropriate questioning technique – investigating occupational, environmental, financial, educational, family/support networks and lifestyle factors Summarising the face-to-face and telephone encounter Carrying out an effective telephone consultation by: – following a logical framework – employing techniques for ensuring rapport and reading patient cues

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1 2 3 4 5

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

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Unit 5 Examining a patient LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● prepare and reassure the patient during an examination ● explain examination procedures ● give effective instructions in a patient-friendly manner

A

B

C

DVD clip 4

Think back to the last time you were a patient and discuss these issues in small groups.

1 Can you identify with any of these patients? Which one(s) and why?

2 How do you feel before being examined?

3 As a patient, what helps you to relax before a physical examination?

Physical examination checklist Remember to: 1 wash your hands thoroughly before touching the patient 2 respect the patient’s sense of dignity at all times

Think about … how you would feel carrying out a physical examination in English.

1a

Take a couple of minutes to think about this and then rate your ability to do the following from 1 (lacking in confidence) to 5 (highly competent).

1 I can put the patient at ease before and during the examination.

3

2 I can explain instructions clearly to the patient.

4

3 I can maintain the patient’s trust during the examination.

4 I can carry out the examination while allowing the patient to remain dignified.

5

b 6

Discuss your thoughts with the rest of the group.

Procedure for physical examinations 2

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Unit 5 Examining a patient

In small groups, devise a checklist for student doctors to remind them what is expected during a physical examination, such as the one on the left. Include physical and psychological elements.

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Explaining procedures 3a

Read this article about the four techniques used during a patient examination and complete the gaps.

TECHNIQUES OF THE TRADE Regardless of which part of the body you are examining, you will use four techniques. These must be used in sequence unless you are carrying out an abdominal assessment. a

b

involves using a stethoscope to listen for different breath, heart and bowel sounds. Hold the bell of the stethoscope lightly against the patient’s skin to listen for low-pitched sounds. Close your eyes to focus while you are carrying out the technique. However, don’t carry out this technique through a gown, and wet excess hair on the patient’s chest so as to eliminate any interference.

in texture, tenderness, temperature, moisture, pulsations and masses. Always make sure that you work on tender areas last. c

can be done via smell and hearing as well as vision, in order to observe both normal conditions in a patient and deviations from the norm. If it is done correctly, it can reveal more than any other of the four techniques. Observe the patient for the following pointers: colour, size, location, movement, texture, symmetry, as well as sounds and odours.

d

requires tapping the fingers or hands quickly and sharply against parts of the patient’s body. The technique is usually used on the chest or abdomen to locate organ borders, to identify shape and position of an organ, or determine its consistency. Listen to the sounds produced: observe their loudness, pitch and duration.

entails touching the patient with different parts of the hand, using varying degrees of pressure. This technique requires you to have short fingernails and warm hands. Use a light form of this technique to assess surface abnormalities

b 4a

What is the correct sequence for these techniques?

Write the correct number (1–4) in each box.

adapted from Assessment made incredibly easy (2005)

It is important to always keep the patient informed of what you are doing. With a partner, use the information in the article in Exercise 3a to write instructions explaining the procedures in clear, simple English as if to a patient.

You may wish to start like this: If you don’t mind, I’m just going to …

You might also need to use phrases such as these: It won’t hurt at all.

If at any time you feel uncomfortable, please let me know.

It / The stethoscope might feel a little cold …

b

Compare your instructions with the rest of the group and make any necessary changes.

c

Practise explaining the procedures as if to a patient.

Remember to maintain a friendly tone of voice.

5a

With a partner, choose another technique from the article or look at the photos on the right and explain an associated procedure in clear, simple English.

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b

Rate your partner’s level of clarity – a, b or c. a The explanation is clear and simple to follow. b The explanation is fairly clear and simple, but still requires slight improvement. c The explanation is still relatively difficult to understand.

Think about … how you would give instructions to a patient in English.

6a

Write instructions for each of these situations (1–4).

1a

1b

3a

2a

2b

4a

3b

4b

b

With a partner, compare your instructions.

You will have the chance to review your instructions later in the unit.

Verbs for giving instructions 7

Look at these cartoons (A–E) and put each of the verbs / verb phrases (1–14) on the next page into the correct column. Note that some can be used more than once, and you may not need to use them all.

A

B

C

D E

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COV-19 2020 1 lie back

6 bring your knee up to your chest

11 lean back

2 lean forward

7 press down

12 press up

3 straighten

8 breathe out

13 relax

4 breathe in deeply

9 roll onto your side

14 sit up

5 bend Cartoon A

10 rest your arms by your side Cartoon B

Cartoon C

Cartoon D

Cartoon E

4, …

8a

Read these two dialogues and underline all the instructions written in a formal style. The first one is done for you.

1 Presenting complaint: check-up following a minor knee operation Patient I’m still having problems with this knee.

Doctor OK, let me have a look. Can you roll up your trouser leg1 for me? Good, now if you could recline on the bed and flex your right knee …

Patient [shows signs of being a little uncomfortable] Doctor Still seems to be causing you a little discomfort, Sean.

Patient Yeah, yeah, I know.

Doctor Gently then, just bring your knee up to your chest. That’s fine. And now extend your leg again …

2 Presenting complaint: asthma Patient [wheezing heavily] Doctor Mrs Daniels, can you sit in the upright position for me, please? I can see you’re having difficulties today. We’re going to try to make things more comfortable for you. I’m just going to listen to your chest.

Patient Sure.

Doctor Good. Now, I want you to inhale through your nasal passage. Inhale deeply … that’s it. Now exhale. And again … inhale … and exhale.

Doctor Now, I want to measure your respiratory rate … I think you’ve seen this little machine before. [shows patient a peak-flow machine2] Patient [nods]

b

Replace the formal verbs with their less formal equivalents (1–14 in Exercise 7).

c

With a partner, role-play the dialogues.

1

(US English) pant leg

2

(US English) spirometer

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Patient speak 9

Look at the illustrations of joint movements (1–9) and match them with the correct medical term to describe them (a–k) and the appropriate instruction for the patient (A–K). Note that two of the illustrations link to more than one term and instruction.

Example: Picture 1: k (retraction) + B (Tilt [your head] forwards) Joint movements 1

2

3

4

5

6

7

8

9

Medical terms a circumduction b abduction c adduction d retraction e pronation f supination g internal rotation h external rotation i eversion j inversion k protraction

10

Using patient-friendly instructions, carry out simple examinations on a partner to assess these parts of the musculoskeletal system. ● ● ● ● ● ●

56

Patient instructions A Lift [your arm] up.

B Tilt [your head] forwards.

C Move [your feet] out.

D Make small circles with [your arm].

E Rotate [your hip] inwards.

F Put [your arm] back down.

G Move [your feet] in.

H Turn [your palm] down.

I Rotate [your hip] outwards.

J Turn [your palm] up.

K Tilt [your head] backwards.

head, jaw and neck spine shoulders and elbows wrists and hands hips and knees ankles and feet

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Using indirect language for instructions 11a

5.1 You are going to hear two consultations. Listen and note the presenting complaint for both patients.

Consultation A

Consultation B

Presenting complaint: • Take off shoes and tights1 • Try to bend left knee • Stand up • Lift skirt over knee • Say if it feels uncomfortable • Lift left leg

Presenting complaint: • Hold out right hand • Stand up and put arms by side • Take off shirt • Bend elbow horizontally • Lift right arm to shoulder level • Lift and lower arm

1

1

b

5.1 Listen again and put the instructions in order by writing a

(US English) (panty) hose

number (1–6) in the boxes for each consultation.

c Compare your answers with a partner. d

5.1 Listen to Consultation A again in more detail and complete the

doctor’s instructions.

1

for me, please, Julie.

2

your foot down now.

3

lift your left leg as high as you can.

4

off your shoes and your tights …

5

your skirt over your knee?

6

if it starts to feel uncomfortable …

Cultural awareness Indirect instructions can help put the patient at ease at the beginning of a consultation and can reduce embarrassment and anxiety. Do you use instructions in the same way in your language?

e Discuss these questions with your partner.

1 Do the doctors use direct or indirect language for giving instructions?

2 Why do you think doctors tend to use this type of language for instructions in English?

3 Were the instructions you wrote in Exercise 6a direct or indirect?

Rewrite them if necessary.

Can/Could you + infinitive …

Would you mind + –ing?

Intonation for instructions 12a

Language for polite instructions

5.2 You are going to listen to two more doctors giving instructions to

↑

their patients. As you listen, mark the intonation pattern ( = voice rises, = voice falls) on the sentences below. The first one has been done for you.

If you can/could + infinitive …

I want / I’d like you to + infinitive …

↑

↑

↑

1 If you could just take off your shoes and loosen your jeans?

2 Would you mind rolling over onto your stomach for me?

3 I want you to sit up with your legs stretched out in front of you.

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b With a partner, read the sentences aloud until you are satisfied that your voice has the right intonation.

c Use the pictures in Exercise 9 to practise giving your own instructions.

Softeners 13a With a partner, complete the missing words in these sentences.

I’d

like you to lift your left leg. relax your leg.

I’m It

going to feel your shoulder for any fractures. looks like a minor fracture at this stage. one more examination left.

b

5.1 Listen to the consultations again and check your answers.

14a With a partner, read aloud and compare the examples below, then decide what effect the word just creates.

1 a I’d just like you to lift your leg. b I’d like you to lift your leg.

2 a It looks like a minor fracture. b It just looks like a minor fracture.

3 a I’m just going to feel your shoulder for any fractures. b I’m going to feel your shoulder for any fractures.

4 a One more examination left. b Just one more examination left.

b

↑

5.3 Listen to the examples and mark the intonation pattern (

↑

or

) on the word just.

c Read the examples aloud using the correct intonation on just.

15

Just in case is a common expression often used by doctors. With a partner, look at this sentence and decide what the function of the expression is.

I’m sure it’s just a slight viral infection, but I’m going to send off a blood sample, just in case.

16

Look back at the instructions you wrote in Exercise 6a. Rewrite them using indirect language and the softener just.

It is important to use softeners such as just to establish and maintain good interpersonal relations in English-speaking cultures. An absence of softeners can convey a lack of warmth and tact.

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Out & About If you are in an English-speaking environment, listen out for the use of just and note how it is used.

Compare your findings with the rest of the class next time you meet.

COV-19 2020

Piecing it all together 17a With a partner, use these notes written by a medical student to continue the dialogue below between a GP and a male patient complaining of stomach cramps. Don’t forget to use indirect language and the softener just. Notes 1, 2 and 4 have already been covered.

EXAMINING THE ABDOMEN

GP

4 5 6 7

[1] Before I examine your abdomen, you might want to go to the toilet. I need to examine you with an empty bladder.

Patient It’s OK, Doctor, I went just before I came in.

GP All right, so let’s get started, then. [2] If you could just take off your shoes and unbutton your trousers1 and lie on the bed.

Patient Yes, sure.

GP Now, if you’re comfortable, [pause] can you bring your knees up and put both feet on the bed.

[4] I’m just going to put this under your knees.

1 2 3

8 9 10 11 12 13

Ask Pt to empty bladder Ask Pt to undress as necessary Cover genitalia (m+f) and breasts (f) as necessary to preserve patient dignity Place small pillow under knees Ask Pt to keep arms at sides Warm hands Ask Pt to point to area of pain – speak softly + encourage Pt Get Pt to use imagery if uncomfortable Osculate 4 areas of abdomen Percussion Palpate area Explain procedure if Pt doesn’t understand Tell Pt examination complete

Communication Skills When giving instructions, make them easier to understand by using the phrase as if you were trying to … , e.g. Bend your knee, as if you were trying to touch your bottom2 with your heel.

b Role-play your dialogue with your partner.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area) Explaining examination techniques

1 2 3 4 5

Giving instructions using patient-friendly vocabulary

1 2 3 4 5

Giving instructions in a patient-friendly manner by: – using appropriate intonation – using the softener just – using indirect language

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

1

(US English) pants

2

(US English) behind

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Unit 6 Giving results LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● explain results to a patient ● encourage a patient to express his/her fears and concerns ● explain medical terminology to a patient ● give a prognosis

If the first half of the consultation represents the foundations of medical communication, explanation and planning are the roof.

Silverman, Kurtz and Draper (2005) Discuss these questions in small groups.

1 Why do you think the first half of the consultation, i.e. gathering information, is referred to as ‘the foundations of medical communication’?

2 Why do you think the explanation and planning stage is referred to as ‘the roof’?

1a

Write down criteria you would use to evaluate how effectively a doctor provides information to a patient during a consultation.

1 Do they give the correct amount of information?

2 3 4

b

Look at your criteria and compare them to the answers on page 163. How do they compare?

Giving and explaining new information to a patient 2a

Look at the objectives in the table below based on the Calgary-Cambridge observation guide for giving and explaining information to a patient.

Note two examples of how doctors can achieve these objectives. An example is given in the first box.

Giving correct amount and type of information

assess patient’s current knowledge

Helping patient understand and remember new information

Including patient’s perspective

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Unit 6 Giving results

Check your answers against the table in Exercise 4.

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Giving a diagnosis 3

6.1 Listen to Dr Finlay explaining the results of a test to a patient, Ben White. Evaluate how well you think Dr Finlay achieves these three objectives by ticking the appropriate box. Discuss your answers with a partner.

Very good

Good

Could improve

Giving correct amount and type of information Helping patient understand and remember Including patient’s perspective

4

This table shows how the objectives listed in Exercise 2a can be achieved during the consultation. Read the transcript below from the dialogue in Exercise 3. For each underlined phrase, put a number (1–3) in the box to indicate which objective is being addressed. One section achieves two objectives.

Objective

Ways to achieve

1

Giving correct amount and type of information

• • • • •

Give information in manageable chunks Check for understanding Ask for patient’s prior knowledge early on Use patient’s response as a guide on how to continue Ask patient what other information would be useful

2

Helping patient understand and remember new information

• • • • • •

Organise information Use signposting, e.g. firstly, …

Use visuals to help explain conditions or procedures Check patient’s understanding of new information Repeat and summarise to reinforce information Explain in a clear, concise way – avoid jargon

3

Including patient’s perspective

• Pick up and respond to verbal and non-verbal cues • Elicit how the patient is feeling • Allow patient to ask questions, get clarification

Dr Finlay

Ben Dr Finlay

Ben

OK, Ben. a) To begin with, I’m going to give you your results, and then we’ll discuss where to go from there. 2 If you recall from our last conversation, I mentioned the possibility of diabetes?

Yes, I remember.

Well, your results show that you have the early stages of diabetes. Let me explain. A reading between 100 and 125 mg/dl would indicate the early stages of diabetes, and your glucose level is 115. b) So this means that you do have a form of pre-diabetes.

A reading of over 126 would indicate you have diabetes, but we’ll need to do another test to confirm this.

Right, so if the reading comes back the same, that means I don’t have diabetes?

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Unit 6 Giving results 61

COV-19 2020 Dr Finlay Ben Dr Finlay Ben

Dr Finlay Ben Dr Finlay

Well, it’s not as simple as that … c) Before I move on, d) can I just check what you understand by diabetes?

Something to do with sugar levels in your body?

Yes, e) your body isn’t able to absorb the sugar it needs. f) Do you know anyone with this condition?

Well, I used to work with somebody who had diabetes, and he had to inject himself every day and he wasn’t allowed to eat any sweet things.

It sounds as if your colleague had quite severe diabetes. g) Does that worry you?

Could that happen to me?

Well, yours is much milder, but h) that brings me to the next point; we do need to control your condition so it doesn’t get any worse. i) There are four things you need to consider. j) First of all, you need to lose weight; secondly, you need to cut down on your drinking; thirdly, you need to cut out saturated fats and salt from your diet; and finally, you have to give up the cigarettes.

It would also help if you took up some gentle exercise. k) So, just to recap, we need to do another blood test, and in the meantime, it’s important that you make immediate l) Do you think you'll find changes to your lifestyle. that difficult?

Organising information 5

In the dialogue above, the doctor uses language to organise the way he presents information to make it easier for the patient to follow, e.g. signposting language: first of all, secondly, etc. Note two other examples of signposting that the doctor uses in the dialogue.

6a

Read this extract, where a doctor is explaining the results of an X-ray to a patient. Does the lack of signposting make it harder to follow the sequence and timescale? Do you think the explanation could be improved?

The X-rays show that the bone is broken. It’s a simple break, so we’ll only need to put it in plaster. You’ll need to wear the plaster for at least six weeks, and we’ll take another X-ray to see if it has healed. We’ll take off the plaster and you’ll have physiotherapy.

b

Complete the gaps in the expanded version of the explanation below using appropriate signposting from the box. first of all finally however then to begin with when 1 , the X-rays show that the bone is broken. 2 , it’s a simple break, so you won’t need surgery. 3 , we’ll put it in plaster. You’ll need to wear the plaster for at least six weeks. 4 we’ll take another

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X-ray to see if it’s healed. 5 we’re sure that it’s healed, we’ll take off the plaster.

6 , there’ll be physiotherapy to get the leg working properly again.

COV-19 2020

7

Look at these two scenarios. Take it in turns to play the part of the doctor. Explain what the results show and what is going to happen next to the patient, using appropriate signposting.

Scenario 1 • Results of ultrasound scan: a number of gallstones in the gall bladder • Bile ducts also dilated, possible presence of gallstones • Gallstones need to be removed • Treatments: 1 Drugs to dissolve the stones: six months for smaller stones, a year for larger ones; 50% chance of stones re-occurring within five years.

2 ERCP: a surgical technique, using small tools attached to an endoscope to release the stones. (An endoscope is a small flexible tube that is inserted into the body.) High success rate and a low re-occurrence rate.

3 Open surgery: making an incision and removing the stones directly. ERCP more successful and less invasive than open surgery.

Scenario 2 • Results from CT scan: chronic sinusitis – a viral infection • Pain caused by tissues blocking the sinus • Treatments: depends on degree of severity 1 Antibiotics: attack bacteria, but do not kill virus; condition usually clears up 2 Steroid sprays or drops to relieve blocked nose and ease breathing by reducing swollen sinuses 3 Operation needed called FESS (functional endoscopic sinus surgery) if symptoms do not improve. Common operation and high success rate. An endoscope (instrument that magnifies inside of nose and nasal cavities) is inserted into nose, shows opening of sinus drainage channel. Tissues blocking the affected area removed. Operation improves sinus drainage and helps sinus to function better.

Using do for emphasis and confirmation 8a

Look at these statements taken from the dialogue in Exercises 3 and 4.

1 You do have a form of pre-diabetes.

2 We do need to manage your condition.

Do has a different function in each example. Match each statement with one of the following functions. a Do to show emphasis b Do to confirm a point

Providing an overt structure to the consultation reduces uncertainty and anxiety which can otherwise block effective communication and reduce recall and understanding.

Silverman, Kurtz and Draper (2005)

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b

Add the appropriate form of do to these sentences, making any other changes necessary.

Do to confirm a point 1 The results confirm that he has pneumonia.

2 As we suspected, the results show that you have anaemia.

3 I told you that the treatment can cause nausea.

Do to show emphasis 4 I think it would help if you spoke to a counsellor.

5 Your condition requires careful monitoring.

6 You need to cut down on your alcohol intake.

c

With what words could you replace do in sentences 4–6 above?

Voice management 9a

6.2 Listen to the two statements from Exercise 8a. Mark where the word stress falls by underlining the word(s) that are stressed.

1 You do have a form of pre-diabetes.

2 We do need to manage your condition.

What do you notice about word stress when do is used?

b

Practise saying sentences 4–6 from Exercise 8b, using either do or really.

Make sure you stress these words.

10

Practise these situations with a partner. Take it in turns to play the role of the doctor and think of a sentence you would say to a patient.

1 The results of an investigation confirm that the patient has had a mild stroke.

2 Stress the importance to your patient of keeping an eye on his/her weight.

3 The X-ray shows that your patient has fractured a rib.

4 Emphasise to your patient the importance of taking up mild, regular exercise.

Explaining medical terminology to a patient 11a Read the extract on the next page and decide whether these statements are true (T) or false (F).

1 Bilirubin causes the yellow discoloration of the skin and of the whites of the eyes.

2 Jaundice can only be caused by damage to the liver.

3 Jaundice is likely to make the urine dark.

b 64

What difficulties do you think patients might have in understanding the extract? Underline the language that might cause problems.

Unit 6 Giving results

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Jaundice Jaundice is a yellow discoloration of the skin and of the whites of the eyes caused by abnormally high levels of the pigment bilirubin in the bloodstream. High levels of bilirubin in the blood may result from problems originating either within the liver or outside the liver. Damage to the liver, such as that due to inflammation or scarring, can impair its ability to excrete bilirubin into bile. Alternatively, the bile ducts, which carry bile from the liver to the small intestine, may be blocked, for example, by a gallstone or a tumour. Urine is often dark because excess bilirubin is excreted through the kidneys. People may have itching, lightcoloured stools or other symptoms, depending on the cause of jaundice.

For example, acute inflammation of the liver (acute hepatitis) may cause loss of appetite, nausea, vomiting and fever. Blockage of bile may result in abdominal pain and fever.

12

Match these terms (1–8) taken from the extract with their more patient-friendly equivalents (a–h).

1

originating

a a different colour to normal

2

discoloration

b coming from

3

such as that

c more than the normal amount

4

excess

d for example

5

impair its ability

e stop it from doing

6

excreted

f severe

7

acute

g stomach

8

abdominal

h passed through

Language for explaining Let me explain what _______ is/are.

Usually/Frequently/Sometimes …

In some cases, / In this case, …

What happens then is …

13

This means that …

If you look here, you will see …

As you can see, …

When this happens, it causes …

Role-play the following situation with a partner. One of you is the doctor and should explain the condition in Exercise 11 to your partner, who is the patient. Focus on the vocabulary you choose and the way you structure the information. You may want to draw a diagram to explain the condition. Invite the patient to ask any questions. Any medical terminology that you use when speaking to a patient should be followed by a brief explanation.

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14a Read these examples of doctors explaining the results of investigations to their patients (examples taken from Myerscough and Ford, 1996). The intention of the doctor in each case is to be reassuring and to indicate that there is nothing to worry about. Which word cues this?

1 It’s just a small ulcer on the neck of the womb. (to a woman who has cervical erosion) 2 It just shows some early arthritis in the spine. (results from an X-ray for a middle-aged man who has a sore back)

b In these cases, however, the patients become very anxious. What language may have resulted in the patients feeling anxious?

c How would you change the statements to ensure that the patients are likely to feel less anxious?

Picking up on verbal cues 15a

6.3 Listen to the continuation of the dialogue from Exercise 3. The

patient expresses his anxiety in a number of ways. Note two examples which show that the patient is anxious.

b One example of where the patient shows his anxiety is when he asks the doctor That won’t happen to me, will it? Why do you think the patient uses a tag question?

c

6.4 Listen to this question asked in two different ways. Which question shows greater anxiety?

1 Will that happen to me?

2 That won’t happen to me, will it?

Communication Skills When giving results, watch the non-verbal feedback you receive from your patient. Signs of anxiety, such as clasping and unclasping hands, perspiring and/or changing position frequently, may help you to pick up on areas where the patient is uncomfortable.

Indicating probability when giving results When expressing a likely prognosis, the first step is to indicate if it is positive or negative. There are a number of ways of doing this, some of which are explored on the next page. As confidence in diagnoses may vary, it can sometimes be useful to avoid definite statements and to use language which indicates probability rather than certainity.

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Patient speak Exercise 16a contains examples of colloquial questions which may be asked by a patient in response to a doctor’s initial statement of results.

16a Categorise the questions (1–10) as A or B as follows.

A Patient tries to confirm that he/she does not need more treatment.

B Patient tries to confirm that he/she needs more treatment.

1 So, this is only the first hurdle?

2 So, I’m good as ever?

3 So, I’ve got the all-clear?

4 So, it’s still early days?

5 So, I’m fighting fit1 again?

6 So, there’s some way to go yet?

7 So, I’m not out of the woods yet?

8 So, I’m on the mend?

9 So, I’m a new man?

10 So, more of the same?

b With a partner, practise how you might respond to the questions above.

You can use some of these expressions.

Well, it looks like it.

It seems so.

That seems to be the case.

There may be some way to go.

That’s what the results seem to show.

17

Sometimes, when a patient asks a specific question regarding the success of a procedure, it can be useful to objectify the situation by using percentages to express the rate of successful outcomes. Compare these two statements.

1 Statistically, 80% of these operations result in a complete recovery.

2 One in five of these operations does not result in a complete recovery.

Which sounds more reassuring?

18

In this list, the first statement indicates the highest level of probability.

Rank the rest of the statements in descending order. a It is almost certain that …

e It is unlikely that …

b It may be possible that …

f It is probable that …

c It is highly unlikely that …

g It is likely that …

d It is possible that …

1

(US English) back to normal

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Out & About

Cultural awareness When helping patients to understand the information, it is important to understand their cultural frame of reference, but at the same time not to make assumptions based on cultural stereotypes. For example, it is tempting to assume that a Chinese person may have a Chinese reference frame; but after speaking to her, you may find that she has been brought up in Australia and, as a result, her beliefs and values may be more Australian.

It is important to find out what the patient’s starting point and perspective are in order to avoid such problems.

Think about a situation where you made a cultural assumption about somebody that was incorrect. What did you base your judgement on, and how did you find out you were wrong?

Look for examples in the health columns of magazines where doctors respond to patient queries about conditions and treatments. Look at the language the doctors use to explain points to non-experts. It will help to develop your communication skills for interacting with patients.

Piecing it all together 19a Read the two extracts below, adapted from the Merck Manual (18th edition).

Underline any difficult language and write down suitable paraphrases.

b With a partner, take it in turns to explain the conditions as if you were talking to a patient.

Acute bronchitis

Erythema nodosun

In bronchitis, areas of the bronchial wall become inflamed and swollen, and mucus increases. As a result, the air passageway is narrowed. Bacteria and viruses are usually present. Symptoms lasting up to 90 days are usually classified as acute bronchitis. Infection bronchitis can be caused by infection or exposure to irritants. However, infectious bronchitis occurs most often during the winter and is most often caused by viruses. Smokers and people who have chronic lung diseases may have repeated attacks of acute bronchitis because mucus is less able to drain from their airways.

Malnutrition increases the risk of upper respiratory tract infections and subsequent acute bronchitis, especially in children and older people.

Erythema nodosun is an inflammatory disorder that produces tender, red nodules under the skin, most often over the shins, but occasionally on the arms and other areas. Quite often, erythema nodosun is a symptom of some other disease or sensitivity to a drug. Young adults, particularly women, are most prone to the disorder, which may recur for months or years. Bacterial, fungal or viral infections may also cause erythema nodosun. Erythema nodosun nodules resemble raised bumps and bruises that gradually change from pink to bluish brown. Fever and joint pain are common. Lymph nodes in the chest occasionally become enlarged and are detected with a chest X-ray. The painful nodules are usually the tell-tale sign for the doctor.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area)

68

Explain results to a patient

1 2 3 4 5

Encourage a patient to express his/her fears and concerns

1 2 3 4 5

Explain medical terminology to a patient

1 2 3 4 5

Give prognosis in a clear way, using expressions of probability and time

1 2 3 4 5

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Unit 7 Planning treatment and closing the interview LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● explain treatments to a patient ● discuss options ● describe benefits and side effects ● advise on lifestyle ● negotiate treatment ● close the interview

Compliance describes the degree to which the patient follows the prescribed regimen of medicines … Non-compliance continues to represent a serious therapeutic deficit at the core of medical practice, with consequent massive personal, societal and economic cost.

Marinker and Shaw (2003) Discuss these questions in small groups.

1 What do you think the personal, societal and economic cost refers to?

2 What factors do you think can cause poor levels of compliance?

3 What can the doctor do to improve compliance?

Explaining treatment DVD clip 5

1

7.1 Listen to a doctor outlining a treatment plan to his patient. How

likely is it that the patient will comply with the treatment? Does the doctor do any of the things you discussed in question 3 of the Lead in?

The difficulty for health professionals lies in acknowledging that it is the patients’ agenda and not their own that determines whether patients take medicines.

Think about

While compliance describes the degree to which the patient follows the prescribed regimen of medicines, concordance describes an agreement between a patient and a healthcare professional about whether, when and how medicines are to be taken … an agreement that respects the wishes of the patient.

2

Marinker and Shaw (2003)

… what differences in terms of patient communication you would expect to see between a doctor who follows a concordance-based approach (see panel on left) and one who does not.

Negotiating a plan of action Below are seven stages recommended by the Calgary-Cambridge observation guide when negotiating a plan of action with a patient.

Complete the stages with the words from the box. beliefs concerns support view

information

options

plans

support

1 Discuss .

2 Provide on action or treatment offered.

3 Obtain patient’s of need for action, perceived benefits, barriers, motivation.

4 Elicit patient’s reactions and about plans and treatments.

5 Take patient’s lifestyle, , cultural background and abilities into consideration.

6 Encourage patient to be involved in implementing .

7 Ask about patient systems; discuss other available.

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3a

Below is the audio script of the dialogue in Exercise 1. Three sentences are underlined. In each case, the doctor is missing an opportunity to use one or more recommended stages from the seven outlined on the previous page. With a partner, decide which of the seven recommendations is being missed out.

Doctor Hello, Miss Lennox. What can I do for you?

Patient The antibiotics you prescribed haven’t cleared up my chest infection.

Doctor Right. Did you complete the course?

Patient Yes, I did.

Doctor And do you feel any better after taking them?

Patient No. They’ve had absolutely no effect, apart from giving me thrush and leaving me feeling completely exhausted.

Doctor a Right. What I’ll do is try you with a different set of antibiotics.

Patient Another course? But why didn’t the other course get rid of the infection?

Doctor It’s not always easy to know exactly which antibiotics to prescribe.

Patient I feel like some kind of guinea pig.

Doctor b If you want to get rid of the infection, you’ll need to persevere with them.

Patient How long will I have to take them for?

Doctor Ten days.

Patient And what happens if there’s no improvement after a few days?

Doctor You’ll need to complete the course to allow them to take effect.

Patient I’m really not crazy about taking more antibiotics. Isn’t there anything else I could take instead?

Doctor c No, I’m afraid only antibiotics will clear this up.

b

7.2 Listen to another version of the dialogue. Do you think the patient will be more likely to accept the recommended medication? How many of the opportunities you discussed above have been taken up in this dialogue?

c

Read the audio script of the second dialogue on page 144 and underline the sections that correspond to the recommended stages of the CalgaryCambridge observation guide.

d

These phrasal verbs appear in bold in the audio script for the second dialogue (see page 144). From the context, write down what you think they mean.

1 2 3 4 5 6

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cleared up washed out drag on getting through getting rid of sort out

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e

Use the correct form of the phrasal verbs from Exercise 2d to complete these sentences.

1 It looks as though this rash has almost 2 Will these tablets

.

this infection, then?

3 This cold has left me feeling very

.

4 How much longer do you think this will

for?

5 The medicine doesn’t seem to be at all.

this cold

6 It’s so difficult just to

the morning.

Any treatment is a balance between risk and benefit. In the end, the only way to resolve the risk–benefit issue is to bring the patient into discussions about treatments, give them all the information and allow them to choose.

Marinker (2000)

Discussing options You are going to listen to a doctor describing treatments for hypertension to a patient.

4a

Before you listen, discuss these questions in pairs.

1 Explain what hypertension is, as if you were describing it to a patient.

2 List three factors which can contribute to hypertension.

b

7.3 Listen to the doctor. What three options does she outline to the patient?

c

7.3 Listen again and complete these phrases.

1 Now, there are a number of options 2 … firstly,

.

what they are …

3 … and then I’ll talk about each treatment 4 In terms of medication,

d

, OK? are available.

5

taking water pills, or diuretics.

6

beta blockers.

Work in pairs. Take it in turns to play the role of the doctor. Using the language below, outline possible options for treating hypertension.

Language for making suggestions You could consider taking …

You might want to consider taking …

You may want to think about …

One option is taking …

Another option/possibility is …

An alternative is …

Alternatively, you could think about …

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Providing information on treatments 5a b

7.4 Listen to the doctor describing three possible treatments for hypertension. What are they?

7.4 Listen again and note down the side effects or disadvantages of each treatment.

Explaining benefits and side effects of treatment 6

Here are a number of phrases that you could use to describe benefits or side effects of treatments. Put the phrases in the table below under the appropriate heading.

1 Each has its pros and cons.

2 The downside of this medication is …

3 The big plus with this type of treatment is …

4 There are risks and benefits with all these treatments.

5 The problem with this is …

6 The main benefit of this is …

7 The main advantage of this is …

8 The drawback with this medication is …

9 There are both pluses and minuses with this medication.

10 The main strength of this medication is …

11 The good thing about this is …

12 The disadvantage is …

Benefits

Side effects

Benefits and side effects

Giving advice on lifestyle 7a

7.5 Listen to the beginning of a dialogue where a doctor is advising a

patient to give up smoking. Why does the patient say that giving up smoking will be difficult?

b

7.5 Listen again and complete these sentences.

1 Patient: I know, but 2 Doctor: I understand that it’s not easy, but

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c

Work in pairs. Student A should play the role of the doctor, outlining the four treatments below using the phrases from Exercise 6. Student B should ask questions where appropriate and decide which treatment he/ she would like to try. Then swap roles.

1 NICOTINE Benefits:

PATCH

Possible side effects: Solution: 2 NICOTINE Benefits:

continuous supply of nicotine during day; relieves withdrawal symptoms and physical cravings; user friendly slight itching or redness of the skin vary position of patch when new one is applied

GUM

Possible side effects: Other points to note: 3 NASAL SPRAY Benefits: Possible side effects: 4 PRESCRIPTION Benefits:

helps control cravings; helps reduce weight gain associated with quitting smoking irritation of mouth and throat (lessens with use); can make existing stomach ulcers worse bitter taste, not suitable for those wearing dentures

good for heavy smokers / those with severe withdrawal symptoms; helps reduce weight gain associated with quitting smoking irritates nose and throat, especially at the beginning

DRUGS

Possible side effects: Other points to note:

can be taken while still smoking (smoker can set a date for quitting during the second week of treatment) difficulty sleeping, dry mouth and headache unsuitable for people who have blackouts, head injury or brain tumour taken from The New Quit Guide, So You Want to Quit?

Patient speak 8

Here are a number of phrases used by patients to express the likelihood of keeping to a doctor’s advice / prescribed drugs. Decide whether each patient: a is unlikely to comply

b may comply

c is likely to comply

1 I’ll give it a try.

6 I’ll give it my best shot.

2 I’ll try as hard as I can.

7 I just can’t see myself doing it.

3 It’s going to be a real struggle.

8 I’ll do my very best.

4 I’ll give it a go.

9 I’ll see what happens.

5 There’s no way I can do that.

10 I’d say the chances of doing that are slim.

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Negotiating treatment with a patient 9a

b

7.6 Listen to the doctor from the previous dialogue encouraging his patient to be involved in the treatment plan. What does the patient decide to do?

7.6 Listen again and complete these sentences that the doctor and patient use to negotiate treatment.

1 Patient I’m 2 Doctor two weeks?

by any of them. if you cut down your smoking for the next

3 Doctor

you think you could get by on?

4 Patient I think five

c

.

5 Doctor

a reasonable beginning.

6 Doctor

that you keep to five cigarettes a day.

Practise reading the sentences above aloud.

10

Role-play this situation with a partner.

Student A: Student B:

Turn to page 125.

Turn to page 130.

Language for negotiating treatment Proposing How about … ?

What if … ?

Instead of + –ing, you could …

Why don’t you … ?

Checking if proposal is acceptable Do you think that is manageable?

How do you feel about that?

Do you think you can manage that?

Does that sound achievable?

Inviting suggestions from patient What do you think you’ll be able to do?

What do you think is an achievable/realistic target?

What is your preferred course of action?

What treatment do you think would suit you best?

Doctors and patients may not always agree. The implication of concordance is that when this happens, the patient’s view takes precedence.

Marinker (2003)

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Communication Skills Ask your patient to summarise the plan of action that you have negotiated to ensure he/ she understands what is expected of him/her.

COV-19 2020

Cultural awareness Lifestyle changes can often mean breaking habits developed over a lifetime, so making these changes can be very difficult. However, when individual habits are part of a larger cultural framework, change is likely to be even more difficult. It is important, therefore, to establish the role that cultural factors may play in preventing a patient from following advice on lifestyle.

11a These two statements are taken from the dialogues in Exercises 3 and 7 where patients are asked to change their lifestyle. What cultural factors are involved here?

1 But having a few drinks with my friends is the only chance I get to relax!

2 I’ve been smoking since I was 12, and all my friends smoke.

b How would you respond to these statements in a way that acknowledges the difficulty of the lifestyle change?

Closing the interview According to the Calgary-Cambridge observation guide, the following points should be observed when closing the interview: ●

End summary: summarising what has taken place in the session and clarifying the plan of care

●

Contracting: agreeing next steps for patient and doctor

●

Safety-netting: what to do if the plan is not working, and when and how to seek help

●

Final checking: checking that the patient agrees and is comfortable with the plan, and there are no other issues to be discussed

12a

7.7 Listen to the doctor concluding the consultation from Exercise 3.

The patient is a 50-year-old male who has been advised to make changes to his lifestyle. Tick the stages above that are covered by the doctor in the dialogue.

b Look at the audio script on page 145 and underline the phrases in the dialogue that fulfil the four stages of the Calgary-Cambridge observation guide.

Example: OK, just to recap …

c With a partner, practise closing the interview for your earlier dialogue on smoking (Exercise 7c). Use as much of the language that you noted in Exercise 12b as possible.

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Out & About Make a list of five people you know reasonably well who vary in terms of age, gender, socio-economic and cultural background. For each person, identify any difficulties they might have in implementing the following treatments or lifestyle changes.

• • • • •

Cutting out all dairy products Cutting out red meat Cutting out all sweet foods Taking four pills a day Taking exercise for 20 minutes every day

Report your findings back to the group.

Piecing it all together 13

Work in groups of three. There are three scenarios. For each role-play, each of you should take a different role (doctor, patient or observer).

Student A: Student B: Student C:

Turn to page 125.

Turn to page 130.

Turn to page 134.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area) Explaining treatment by: – providing sufficient information – outlining benefits and side effects of treatment Negotiating treatment by: – identifying the patient’s understanding of the need for treatment – identifying possible barriers to not taking treatment – taking into consideration the needs and wishes of the patient Closing the interview by: – summarising what has been discussed – agreeing on what action is to be taken by the patient – outlining support systems available to the patient

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1 2 3 4 5 1 2 3 4 5

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

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Unit 8 Dealing with sensitive issues LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● broach sensitive issues without bias and remain nonjudgemental ● read and respond to patient cues ● employ question techniques for alcohol consumption: CAGE ● write concise and accurate notes ● update the patient note

a In small groups, decide why a patient might find these issues sensitive. ● ● ●

age ethnic origin underage sex

● ● ●

alcohol use recreational drug use weight

domestic violence sexual orientation

● ●

b As a group, compare your ideas and reasons for this. What other issues could be added to this list?

Ideas discussed in Unit 4 might help you with this.

Think about … how you would feel about discussing sensitive issues with a patient in English.

1

Take a couple of minutes to think about this and then rate your ability to do the following from 1 (totally lacking in confidence) to 5 (highly competent).

1 I can remain objective and non-judgemental.

2 I can mirror my verbal with my non-verbal communication.

3 I can recognise and respond to patient cues.

4 I can ask questions using an appropriate tone of voice.

Broaching sensitive issues 2a

Doctors are only human and not exempt from making assumptions.

Look at these three images and, for each one, make a list of possible assumptions a doctor might make.

Patient 1

Patient 2 I was wondering what I needed to do to get an HIV test.

I think I need to go on the Pill.

Patient 3 I fell while I was doing the cleaning.

Do not assume anything … Making assumptions could have a disastrous effect on the consultation.

Dalton & Noble (2006)

b

8.1 Listen and find out the real reason for each visit.

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c

Read this possible response from the doctor for Patient 1 and imagine what might happen. Discuss with a partner.

Certainly, but first I’d like to ask you how many unprotected homosexual contacts you’ve had in the past year.

d

8.2 Listen again to the encounter with Patient 1 and complete the

question the doctor actually asks to broach this sensitive issue.

Of course. Is you an HIV test?

e

8.3 Listen again to the encounter with Patient 3 and complete the

sentence the doctor uses to broach this potentially sensitive issue.

Well, telling me your drinking …

3a

78

Ensuring your question is appropriate will help you to broach issues in a sensitive way. With a partner, look at these questions (1–6) and decide the problem in each case. Complete the third column of the table.

Question

Scenario

1 a Are you married? b Are you gay?

Male/Female patient’s first visit to GP

2 Don’t you think your lifestyle is a little promiscuous?

During interview, patient divulges that he/she has several sexual partners

3 You’ve never had intercourse, have you?

Adult patient

4 Do you have a drink problem?

Patient has indicated a higher-than-average consumption of alcohol

5 I take it your wife is aware of the situation?

Patient presents with STI; doctor knows the patient is married

6 Have you taken illegal drugs in the past?

Male/Female patient’s first visit to GP

Problem with question

Improved question + rationale

Doctor assumes patient has never had intercourse.

When was the last time you had intercourse?

(More positive – some adult patients may be sensitive about not having ever had intercourse.)

b

Now complete the fourth column of the table by rewriting the questions in a more positive form. Include a rationale for your answer, as shown in the example.

c

Compare your ideas with the rest of the group and explain your rationale.

Unit 8 Dealing with sensitive issues

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COV-19 2020 Cultural awareness [In the USA] the term “homosexual” as an adjective for gender (e.g. “homosexual male”) should be avoided, as it is generally perceived to be demeaning. The term is acceptable, however, to describe the behavior (e.g. “homosexual behavior”).

Swartz (1989) Are there similar considerations in your own language? How do you deal with them?

4

Another way to broach sensitive issues is to put your questions in context. With a partner, rearrange these words to form questions for broaching sensitive issues.

1 There may be / for these symptoms, / find out more, / I’m going to / have to / various reasons / ask some rather personal questions. / but in order to 2 to ask a / a better understanding / and so I’m going / I need to have / few personal questions. / of your alcohol use, 3 possible exposure to HIV. / to ask you some questions / I’m just going / of a more sensitive nature / to assess your

5a

With a partner, act out the dialogue between Dr Staples and his patient Paul Johnson, which takes place in the local surgery.

Student A: Student B:

Dr Staples Mr Johnson Dr Staples Mr Johnson Dr Staples Mr Johnson Dr Staples Mr Johnson Dr Staples Mr Johnson Dr Staples

b

Read the doctor’s part below. You begin the interview.

Turn to page 131.

So, there’s something worrying you … of a sexual nature, perhaps? [looks nervous, fiddles with a gold chain] Don’t worry, Mr Johnson, believe me there’s nothing I haven’t heard already. *** And your wife’s aware of the situation? *** Are you gay? *** Right, so you’ve had other partners, then? *** It’s not for me to judge, Mr Johnson, but alcohol can lead to promiscuity, and you do need to be careful …

Discuss these questions with your partner.

1 What was the general attitude of Dr Staples during the interview?

2 How do you think the patient felt he was treated by Dr Staples during the interview?

c

With your partner, rewrite the dialogue using more appropriate language.

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d

Role-play your new dialogue to another pair. As they listen, they should stop the role-play at any point they feel it could be improved. Rework the doctor’s questions until you feel they are appropriate to the situation.

Reading patient cues 6a

You’re going to read an extract from an article on patient cues. Before you read, discuss with a partner possible answers to these questions.

1 In a patient-centred interview, what are the value of patient cues?

2 Why might doctors find it difficult to read patient cues?

b

Read the article and find answers to the questions.

The single most important rule is to maintain a nonjudgemental approach.

Reactions that betray disapproval, embarrassment or boredom block communication, as do behaviours that condescend, stereotype or make fun of the patient.

Bickley (2003)

Reading cues Why do doctors repeatedly fail to respond to patient cues? Perhaps it is in part due to issues of control.

Doctors have traditionally controlled the interview via closed questions which limit patients’ contributions and render them more passive. When we pick up on patient cues, perhaps we feel that we are being taken off our pre-planned flight path and are uncertain of where we might be led – we start to feel out of control.

An awkward moment ensues which is all too easy for the physician to sidestep by returning to safer ground (Epstein et al., 1998). Paradoxically, cues are usually a short cut to important areas that require our attention.

We may also fail to pick up cues to the illness framework because we are listening for cues about the disease. If the patient says, ‘It’s been difficult at home and I’ve been getting a lot more pains lately,’ it’s easy to preferentially pick up on the disease rather than the illness cue and say, ‘Tell me about the pains’ without returning to ‘You mentioned things have been difficult at home …’.

Doctors are frightened of opening a Pandora’s box of their patients’ emotions and feelings. In comparison, it is the area that other professionals such as counsellors and therapists are most encouraged to explore!

To ensure accurate interpretation of non-verbal behaviour, it is important not only to observe carefully but also to verify your perceptions verbally. Checking your interpretations and assumptions encourages patients to talk further about what they are thinking or feeling and has a double pay-off – both doctor and patient avoid possible misinterpretation and discover more information. Emotional problems only hinted at through nonverbal channels are often the root cause of physical symptoms.

taken from Skills for Communicating with Patients, Silverman et al. (2005)

c

Discuss these questions in pairs.

1 Why does the author make the distinction between the words illness and disease?

2 To what extent should doctors also think about the kind of messages they are giving their patients? Why? 3 How might a doctor check verbally if he/she is unsure about how the patient is really feeling?

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7a

Read this further extract from the article in Exercise 6b.

Without attention to your own non-verbal communication skills and the messages that you are transmitting through the non-verbal channel, many of your efforts to communicate may be undone. If your verbal and non-verbal signs are contradictory, at the very least you risk confusion or misinterpretation and at worst your non-verbal message will win out. Patients rarely ask for verbal confirmation of cues that they pick up and commonly base their impressions primarily on non-verbal messages.

b

With a partner, discuss an example, either from your personal or professional life, where you didn’t pay sufficient attention to nonverbal cues. How did you deal with the situation? What emotions are particularly difficult for you to ‘hide’ from the listener?

c

In small groups, demonstrate examples of non-verbal cues from your culture. Ask other members of the group to guess their meaning.

Discussing sexual and reproductive health

Out & About

Think about … when and why doctors might find it difficult to discuss sexual matters with their patients.

8a

Plot each of these sexual topics on the scale below in terms of how difficult it is to discuss them.

1 3 6 9

female sexual dysfunction 2 sexually transmitted infections (STIs)1 pre-marital sex 4 teenage pregnancy 5 homosexuality bisexuality 7 HIV and AIDS 8 sex between elderly people unprotected sex 10 sexual promiscuity 11 male sexual dysfunction

easy

b

difficult

Share your thoughts with the rest of the group and answer this question.

How might aspects of a doctor’s culture contribute to his/her way of thinking about sexual and reproductive health?

Consider the following: the State ● religion ● professional training ●

9a

● ●

media family upbringing

8.4 Dr Hanley has already carried out a physical examination on Jennifer, a 32-year-old who has pains in her lower abdomen, and findings suggest the need to carry out a sexual health history. Listen to the encounter and rate the doctor’s general approach on a scale of 1 to 5.

Dr Hanley remains objective and non-judgemental.

1

If you are in an English-speaking environment, watch out for the use of non-verbal cues either in professional or non-professional situations, or in the visual media, and how people respond to them. Compare your findings with the rest of the class next time you meet.

12345

The subtle hints we [doctors] give about personal values and views about lifestyles will influence patients in deciding whether to keep information secret and go elsewhere for their care.

Lloyd and Bor (2006)

Dr Hanley appears subjective and judgemental.

(US English and UK English) STDs (sexually transmitted diseases)

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b In small groups, explain your analysis and answer these questions, giving examples.

1 What do you notice about Dr Hanley’s questioning technique?

2 Why does he choose this approach?

c Read the audio script on page 145 and find examples of the following: 1 Contextualising the question

Communication Skills

2 Reassuring the patient 3 Asking permission 4 Making it possible for the patient to speak to a female doctor

When dealing with issues about sexual health, you may want to be honest regarding your own feelings about it: It may be helpful for you to know that I sometimes find this topic a little difficult to discuss as well.

10a With a partner, read this referral letter and compile a series of questions from the encounter with the patient’s family practitioner1 that might have preceded it.

MAIN STREET FAMILY PRACTICE Dear Dr. McDonald Subject: Carlos López, 01/19/1942, 1325 North Stafford Street, Arlington, VA 22201 I am referring Mr. López for prostate examination with minimum delay.

As you can see from the patient file, Mr. López visited me on June 15, 2007 complaining of hesitancy and straining to empty his bladder. After questioning, I found him to have decreased force and calibre of the urinary stream. He finds he is dribbling after micturation and has a sensation of incomplete bladder emptying. Accompanying symptoms are, as he described, a “dull pressure in his bladder area.” Some hematura present. Urine is brown in color. He has no remarkable past history of heart disease, nor prior history of bladder or prostate disease. Tonsils removed at 12 years. Patient is otherwise healthy and takes no medications2. Denies allergies3.

Married, but limited sexual activity at present. Patient does not smoke. Drinks ETOH occasionally.

Retired. Father died at age 86 of prostate cancer. Mother died of natural causes.

Despite a relatively clear bill of health to date, his father’s death as a result of prostate cancer prompted me to refer him to you for further testing and investigation.

Sincerely Rafaela Levy (M.D.)

b With a partner, role-play the dialogue between Dr Levy and Carlos López, using your questions. Take care to remain non-judgemental and objective during the interview.

11a In small groups, compile a list of dos and don’ts for taking a sexual history.

Examples: Do contextualise the questions.

Don’t make assumptions.

b Compare your list with the rest of the group and make adjustments if necessary.

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1

(UK English) GP

2

(UK English) medication

3

(UK English) No allergies reported

Unit 8 Dealing with sensitive issues

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In a well-conducted interview, the patient is likely to feel that discussing sexual matters is a natural part of the medical and psychosocial history.

Enelow et al. (1996)

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Alcohol use and abuse 12a Take a few minutes to answer this questionnaire.

KNOW YOUR DRINK 1 How many grams of alcohol does one unit represent?

4 Do different types of beer have different levels of alcohol content?

2 What are the recommended levels for safe alcohol consumption in units per week for: a) men? b) women?

5 Is it more accurate to ask: a) ‘How many bottles of spirits do you drink in an average week?’ or b) ‘How long does a bottle of spirits last?’

3 What are the equivalents in units of alcohol for: 1 a) 2 pint of beer? b) a small glass of wine? c) one (pub1) measure of spirits2? d) a 750cl bottle of wine? e) one standard bottle of spirits?

6 Patients with an alcohol problem tend to their alcohol intake. a) underestimate b) gauge correctly c) overestimate 7 Which professions are known to be more susceptible than others to alcohol abuse?

adapted from Communication Skills for Final MB, Dalton and Noble, 2006

b With a partner, compare your answers. c In small groups, discuss these questions.

1 What signs would make you suspect alcohol abuse in a patient?

2 What do you need to consider when asking a patient about alcohol consumption?

Asking about substance abuse This section of the history-taking process deals with questions about cigarettes, alcohol and recreational drug use.

13a

8.5 You’re going to listen to Part 1 of an encounter with Dave Mullins.

Listen and say whether, at this stage of the interview, you would be concerned about Dave’s alcohol intake.

b

8.6 Listen to Part 2 and decide if you need to continue any further

with the investigation.

c

8.7 The CAGE Technique is a well-known tool used to establish possible alcohol abuse. Listen to Part 3 and note the word(s) associated with each letter of the acronym CAGE in the table on the next page.

1

(US English) bar

2

(US English) liquor

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Unit 8 Dealing with sensitive issues 83

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Question d

Have you ever

?

Yes / No

A

Have people ever

?

Yes / No

G

Have

?

Yes / No

Have

?

Yes / No

C

E

o

d

8.7 Listen again and complete the questions. Then note Dave’s responses

to each question by circling the correct word. Explain your answers.

e Check your answers in pairs by looking at the audio script on page 146. f As a group, compare these questions.

Doctor:

… how much can you drink on a Saturday?

Doctor:

How much do you drink on a Saturday?

Do you think the response would be the same?

g With a partner, using the responses to the CAGE questions and the information in the questionnaire on page 83, discuss Dave Mullins’ current susceptibility to alcoholism.

Consider: ●

the patient’s feelings towards drink

●

his interpersonal relationships

●

what happens while under the influence of alcohol

●

any adverse effects the patient may suffer.

Cultural awareness Unlike those who abuse alcohol, those within the drug culture tend to exaggerate their use of recreational drugs. It is possible to broach the subject much more directly: Have you ever used drugs other than those required for medical purposes? Don’t forget to ask about prescription drugs.

Following an affirmative answer, ask about type(s) of drugs consumed before asking about frequency and route of administration.

What is your experience of the drug culture? Have you found this tendency to exaggerate to be true?

Patient speak 14

Work in pairs.

Student A: Student B:

84

Dave

Turn to page 126.

Turn to page 131.

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15

You might also hear these expressions to describe the effects of certain drugs. With your partner, circle language used to describe negative effects and underline language used to describe positive effects. bombed come down crash have a bad trip have the shakes on a high spaced out stoned wasted wrecked

16

What do the following verbs refer to in drug culture? kick the habit, detox, clean up, dry out, go cold turkey = to

17

In small groups, discuss this question.

Out & About Listen out in different contexts for slang terms for different recreational drugs – opioides, stimulants, sedatives, cannabis and psychedelics. Compare your findings with the rest of the class next time you meet.

Why is it important to have a good grasp of this jargon?

Updating the patient note Being accurate as well as specific and concise is not easy when writing in another language.

18a Read these examples taken from patient notes and strike through any words you feel are superfluous. The first one has been done for you.

1 Both right and left ears are clear.

2 Cervix is pink in colour and smooth.

3 Liver is tender to palpation.

4 Patient states there is no pain over left eye.

5 On sight, patient is thin, looks distressed and generally unwell.

6 Father died in 1999, aged 64. He died of lung cancer.

7 In the patient, there is no history of asthma or tuberculosis exposure.

8 Sexual history: this is not appropriate to the presenting complaint.

9 Lungs are resonant to percussion.

10 II/VI systolic ejection murmur (audible).

b Compare your answers with a partner, explaining your reasoning.

19a Just as the tone of your patient encounter should always remain objective and non-judgemental, so too your patient note entries. Read through the entry written about Dave Mullins (see Exercise 13) taken after a follow-up visit. With a partner, discuss why this entry would not be appropriate.

Patient arrived drunk and late AGAIN for his appointment!!

b Answer this question.

It is important to be objective. Hostile, demoralising or disapproving comments have no place in the patient’s record. Never use words, penmanship or punctuation that are inflammatory or demeaning.

Bickley (2007)

From a legal point of view, what is the issue behind this type of entry?

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Piecing it all together 20

Work in pairs.

Student A: Student B:

See below.

Turn to page 132.

Student A

a Read through your role and take a few minutes to consider the personality of your character, including environmental and social factors.

Consider also the feelings that such a person might convey through his/ her non-verbal cues.

It’s 3 a.m. on a busy night in August in the Accident & Emergency (A&E) Department1 of a small local hospital.

You are Cathy, a 35-year-old barmaid2. You’ve been working in a local pub for a number of years and know the clientele well. You receive tips that you accept in the form of shots of spirits, and at the end of your shift, you often drink with the rest of the staff before going on to a club. This particular evening, you find yourself in A&E with what you think is a broken rib. You also suspect you have an STI.

b Role-play the scenario, with Student B taking the role of the Registrar, then swap roles.

c Use the list of dos and don’ts from Exercise 11a to give constructive criticism on your partner’s sexual history-taking technique.

d As a group, decide what lessons can be learned from this activity.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area)

86

Taking an accurate sexual and reproductive history by: – broaching the subject with sensitivity – mirroring any verbal and non-verbal communication – remaining objective and non-judgemental – recognising and responding to patient cues

1 1 1 1

Asking about substance abuse

1 2 3 4 5

Developing an awareness of note-taking by: – employing a non-judgemental tone – being specific and concise

1 2 3 4 5 1 2 3 4 5

1

(US English) Emergency Room (ER)

2

(US English) bartender

Unit 8 Dealing with sensitive issues

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2 2 2 2

3 3 3 3

4 4 4 4

5 5 5 5

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Unit 9 Breaking bad news LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● deliver bad news in a sensitive way ● reassure a patient or relative ● show empathy

Why is giving bad news in a medical or non-medical context so difficult?

1a b

Write a definition of ‘bad news’.

Compare your definition with this quotation. Does it differ in any way?

Bad news is any information that changes a person’s view of the future in a negative way.

Mueller (2002)

DVD clip 6

2

Read these examples of situations where a doctor has had to break bad news to a patient or relatives. With a partner, rate them in order of difficulty (1 = most difficult, 6 = least difficult). a A 24-year-old professional pianist who is unlikely to regain full use of her left hand b A pregnant 35-year-old woman whose baby has Down’s Syndrome1 c A 75-year-old man whose stomach cancer has returned after five years d The parents of a five-year-old girl who is dead on arrival following a road traffic accident e An 18-year-old patient who has to have his leg broken to re-set it f A 42-year-old nurse whose pre-employment blood test is positive for HIV

3

With a partner, discuss factors which make it difficult for doctors to give bad news to patients.

Preparing the patient for bad news 4a b

Write down two factors that are important to consider when breaking bad news. Compare your answers with a partner.

9.1 Listen to a doctor breaking bad news to a patient in a hospital

setting. Note three ways in which the doctor could improve his communication technique.

1

(US English) Down Syndrome

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5a

Baile et al. (2000) devised a communication model called SPIKES, which provides guidelines on how to break bad news. Look at the key stages, outlined below. Each of the stages will be examined in detail in the following sections.

SPIKES – a communication model for breaking bad news The elements are:

b

●

Setting for the interview: physical surroundings, non-verbal communication

●

Determining patient’s perception of their situation

●

Doctor’s invitation to patient to indicate how much information is required

●

Giving knowledge/information to patient

●

Dealing with patient’s emotions

●

Agreeing most appropriate strategy for moving on and summarising situation 9.1 Listen to the doctor and his patient again. Which of the elements of SPIKES does the doctor include?

6

SETTING: With a partner, drawing on what you have learned about communication so far, discuss the ideal setting in which to break bad news.

7

PERCEPTION: In small groups, discuss these questions.

1 Why is it important to ask patients what they understand of their condition before you tell them the results of an investigation?

2 What type of question (open, closed, multiple) do you think is the most appropriate to find out what the patient’s perception is?

It is always important to ask patients about their understanding of the event and what difference they perceive it will make to their lives before you tell them what the situation is. ‘Before you tell, ask.’

Baile et al. (2000)

3 Write two questions to help you find out patients’ perception of their condition.

Example: What is your understanding of your condition at this stage?

Patient speak Patients may respond to the question What is your understanding of your condition at this stage? in a number of ways, according to their knowledge.

8

Look at these phrases and categorise them under these headings. a knows nothing

b knows something

c well-informed

1 I’ve seen something about it in the papers.

2 You don’t need to tell me about it, my brother …

3 I’m very familiar with the condition, as my father had it.

4 Haven’t a clue.

5 My knowledge is a bit sketchy/patchy.

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6 I’ve picked up bits and pieces from here and there.

7 No idea.

8 Not a lot.

9 I’ve got a rough idea.

10 I have a reasonable understanding.

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9

INVITATION: Before you begin to provide patients with information, it is important to determine how much detail they want, or what level of information they are comfortable with. In small groups, discuss these questions.

1 In your country, do you think it is likely that a patient suffering from a terminal illness will be given an accurate assessment of his/ her condition, or will this information be kept from the patient and given only to the family?

2 What factors would you take into account to decide how much information you should give?

Softening the question

Labelling the patient with the attitudes and outlook of a whole race or culture may be just as damaging as not being sensitive to multicultural issues at all; the doctor’s objective must be to find out each individual patient’s unique perspective and experience of illness.

Chugh et al. (1994)

10a Look at these three questions. In each case, the question is asked in two different ways. Which is the more appropriate or softer form, a or b?

1 a How much detail would you like me to go into? b How much detail do you want?

2 a Is there anything you don’t want to be told? b Is there anything you would prefer not to be told?

3 a Are there any areas you would rather I didn’t go into? b Are there any areas you don’t want me to go into?

b What is the difference in the language used in each question?

Giving knowledge and information KNOWLEDGE: The purpose of this stage is to provide the patient with knowledge and information about their condition and the likely prognosis.

It is important to use language to signal to the patient that you have to give them bad news.

11a b

9.2 Listen to a dialogue between a doctor and a patient who is about to receive bad news. Is this the patient’s first visit to the doctor?

9.2 Listen again and complete what the doctor says to prepare his

patient for bad news.

The results are back. I but

, that they were positive for HIV.

12

Write two other phrases you could use to alert patients that they are about to be given news which may be distressing. Compare your answers with a partner.

13

With a partner, take it in turns to play the role of a doctor breaking bad news to a patient. Remember to elicit the patient’s existing knowledge and ask about the amount of information he/she wants to be given.

Student A: Student B:

Turn to page 126.

Turn to page 132.

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Dealing with emotions EMOTIONS: It is important to anticipate the patient’s emotions, and acknowledge and deal with them as they arise.

14a Look at these examples of exploratory, empathetic and validating language.

Exploratory language – finding out how the patient feels Can you tell me how you are feeling?

What do you make of what I’ve just told you?

How are you feeling about this news?

b

15a

Validating language – showing the patient’s feelings are normal and to be expected I can understand why you feel like that.

Many patients experience similar feelings.

9.3 Listen to six sentences. For each one, decide if it is: a exploratory b empathetic c validating

1

c

Empathetic language – showing your understanding of the patient’s feelings I can tell you weren’t expecting to hear this.

I was also hoping for a better result.

2

3

4

5

6

9.3 Listen again to the phrases. Look at the audio script on page 146 and underline the words the doctor stresses.

9.4 Listen to the continuation of the dialogue between the doctor

and his patient diagnosed HIV positive (see Exercise 11). As you listen, underline examples of exploratory, empathetic and validating language in the audio script (page 146).

b It is important to reassure patients that they will be supported through their illness. Write two phrases you could use to offer support to a patient.

Example: We will work through this together.

c

9.4 Listen again. What phrase does the doctor use to reassure the patient that he will not be left to cope on his own?

Agreeing strategy and summarising STRATEGY: It is important to give patients a plan of the future and to summarise key points to give them some direction.

16

9.5 Listen again to the final part of the conversation in Exercise 15.

1 Does the doctor outline a plan to the patient?

2 Does he summarise key points from the interview?

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Combining empathetic, exploratory and validating statements is one of the most powerful ways of providing support. It reduces the patient’s isolation, expresses solidarity and validates the patient’s feelings or thoughts as normal and to be expected.

Baile, Buckman, Lenzi et al. (2002)

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Case study: disregarding a constraint 17

While there are many constraints on the way a doctor carries out a patient interview, sometimes a situation demands that these are set aside. Read this article, identify the constraint and decide whether the doctor is justified in his actions. Discuss with the rest of the group.

A time to listen Donald A. Barr, MD, PhD When teaching my students about what goes into a good doctor–patient interaction, I tell them about the studies that show how quickly doctors interrupt their patients.

Male physicians especially, I tell them, are notorious for stopping the patient midsentence to redirect the discussion. In one study that I came across, female primarycare physicians waited an average of three minutes before interrupting the patient to redirect the discussion toward issues more relevant to diagnosis. Male physicians waited an average of 47 seconds. How long do I wait, I wondered? I decided to try an experiment.

I would let my next patient talk as long as he or she needed to explain his or her reason for seeing me. I would watch the clock and see how long a patient might naturally take to explain the presenting complaint. I would hold my tongue.

The patient was in her 70s and greeted me with a smile when I stepped behind the curtain to be with her. “Hello, I’m Dr Barr. What’s the problem that brings you in today?”

She began to describe the past several weeks of her life. As I recall, it had to do with a co-worker noticing something, talking with her sister on the phone, and her reluctance to see doctors. The word “cough” surfaced for a second, then quickly became submerged again.

Looking at the medicines on the shelf at the drugstore and not knowing which to choose … needing to dress warmly (Wasn’t the weather we’d been having nasty?) … sometimes she had trouble sleeping … The nurse poked her head through the curtain and silently tapped her watch. The waiting room of our urgent-care center was full, and things were starting to

© Cambridge University Press 2007

back up. I wouldn’t budge, though—I turned back to the patient and nodded. However long it took, I would wait for the patient to stop of her own accord. I wouldn’t butt in.

It was the cough that was keeping her awake … She always got colds more easily than other people … Her sister was just a worrier … She finally had agreed to come in to see a doctor, just to reassure her friends and family.

Twenty-two minutes from start to finish.

The nurses were never going to forgive me.

The lungs had left-sided rales. The fever was mild, but the white count suggested infection.

The chest radiograph showed a large infiltrate on the left and what I feared was a mass.

I called the pulmonary specialist across the street and asked if he could squeeze the patient in this afternoon. He did, only to confirm the worst. It appeared the patient had a tumor causing the infiltrate, and there probably were enlarged hilar nodes as well. She probably had lung cancer, and it was probably in an advanced stage. She needed antibiotics right away to get the infection under control, after which further testing would be arranged.

The patient came back to our center for the antibiotics. The specialist had told her what he had found and had given her an indication of the grave prognosis she faced. I stepped back into the patient’s space and said with sadness, “This hasn’t been a very good day for you, has it?” She looked at me for a moment with an unmistakable smile on her face. She reached out her hand and patted me on the wrist.

“Oh, don’t worry about all that. I’ve had a good life. But I just wanted you to know—this is the best doctor visit I’ve ever had. You’re the only one who ever listened.”

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Patient speak 18

Match these questions (1–5) that patients might ask about their chances of survival with the doctor’s responses (a–e).

2 What are my chances?

a I can’t say for certain, but it looks as if you’re fighting it.

3 Am I going to make it?

b There is a fair chance that you’ll recover.

4 Don’t beat around the bush, just tell me straight.

c At the moment, I’d say 50:50.

5 Is it the big ‘C’?

e OK. I’m afraid that the tumour has spread.

1 So, what are the odds?

d Yes, I’m afraid it is cancer.

19a Categorise these questions used by a patient in response to the doctor’s prognosis by putting them under the correct heading below.

1 So, I might pull through?

2 So, this means I’ve had it?

3 So, things could be worse, I guess?

4 So, I don’t have long for this world?

5 I might be able to beat it, then?

6 Will I last the year?

7 So, it’s not all doom and gloom, then?

8 So, it’s curtains for me, is it?

9 So, there’s a glimmer of hope, then?

10 So, my time’s up, then?

11 So, my days are numbered?

12 So, I’m fighting it?

13 I’ll soon be six feet under, then?

14 So, I’ll soon be pushing up daisies?

Not going to recover

Some hope of recovery

b Why do you think patients use such language? c Do you have expressions in your own language that describe dying in a less direct way? Share your examples with the group.

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Communicating with relatives Think about … what factors need to be considered when communicating with relatives. What factors need to be considered when breaking bad news over the phone?

20

9.6 The SPIKES model can also be used for breaking bad news to

relatives. Listen to a conversation where a doctor has to inform a patient’s daughter that her mother has suffered a major stroke. As you listen, tick which stages from the SPIKES model the doctor covers.

Setting Perception of the situation Invitation Knowledge/information to relative Emotions Strategy for moving on

Communication Skills It is important to give information to a patient or relative in a slow and controlled way to allow them to take in what you are saying. Practise speaking more slowly than usual and pausing after each piece of new information.

21

9.7 You are going to listen to the telephone call made by the daughter

in the dialogue you have just heard (Exercise 20) when she learned that her mother had just been admitted to hospital. As you listen, rate the doctor’s ability to communicate with the relative using these criteria.

Discuss your answers with a partner. excellent

good

could improve

tone intonation pausing speed of delivery word stress

22

With a partner, take it in turns to play the roles of the doctor and the relative in a telephone conversation. Pay particular attention to the way you manage your voice.

Student A: Student B:

Turn to page 126.

Turn to page 132.

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Unit 9 Breaking bad news 93

COV-19 2020 Cultural awareness In some cultures, a negative prognosis is traditionally conveyed first to the family and later to the patient. They believe that informing the patient of a bad prognosis results in hopelessness and then becomes a self-fulfilling prophecy (i.e. the patient will give up and the bad prognosis will come true).

Does this apply to your culture? Discuss in small groups.

Out & About From the article on page 91, it is clear that although the doctor’s behaviour does not conform to the standard model of the patient interview, the patient (and doctor) experience seems to have been a positive one. In a healthcare setting with which you are familiar, identify one of the standard models of doctor–patient interaction. Is there any way in which this could be changed to provide more benefit to the patients?

What constraints might apply to prevent this happening? Present your example to the group in the next class.

Piecing it all together 23

Work in groups of three. There are three scenarios. For each role-play, each of you should take a different role (doctor, patient or observer).

Student A: Turn to page 127.

Student B: Turn to page 133.

Student C: Turn to page 135.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area)

94

Deliver bad news in a sensitive way by understanding the context of breaking bad news

1 2 3 4 5

Reassure a patient or relative by using appropriate verbal and non-verbal communication strategies

1 2 3 4 5

Show empathy by using appropriate: – language and voice management – non-verbal language

1 2 3 4 5 1 2 3 4 5

Unit 9 Breaking bad news

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Unit 10 Communicating with challenging patients LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● encourage a withdrawn patient to speak ● calm an aggressive or angry patient ● assert your role as a doctor

Read this quotation.

Doctors cannot be loved and respected by all of their patients all of the time, nor can they expect of themselves an ability to warm towards all of their patients.

Ford (1996) What kinds of patient might a doctor have difficulty warming to?

List your examples.

1 DVD clip 7

Ford identifies a number of patient types with whom doctors may have difficulty in establishing a communicative relationship: ●

dirty patients

●

deceitful patients

●

patients who abuse alcohol or drugs

●

patients who formally complain about their treatment

●

hostile/litigious patients

●

manipulative or sexually provocative patients

●

ungrateful patients

●

obsessive patients

Look at the list you made in the Lead in. Is it similar to Ford’s? Compare your responses with a partner.

Communicating with an uncommunicative patient Sometimes patients are uncommunicative at the beginning of an interview for a number of reasons.

Think about … why a patient might be uncommunicative.

2

Write down two strategies you would use to draw out an uncommunicative patient.

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3a

10.1 Listen to a doctor speaking to an uncommunicative patient. Write

down two aspects of verbal communication that the doctor uses to draw the patient out.

b

10.1 Listen to the recording again and write down two ways in which the doctor uses his voice to encourage the patient to talk.

c

Read the audio script. Underline examples of closed questions. Why do you think the doctor uses closed questions in this particular situation?

Doctor Patient Doctor Patient Doctor Patient Doctor Patient

Doctor

Patient Doctor

Patient

Lloyd & Bor (2004)

d

Identify the ways in which the doctor encourages the patient to tell her story.

4a

Read this dialogue. The patient is a 28-year-old new mother with twomonth-old twins. She is very withdrawn and is probably suffering from post-natal1 depression.

Communication Skills

Doctor Patient Doctor Patient Doctor Patient Doctor

When talking to a depressed patient, acknowledge the patient’s difficulty in talking by saying, for example, I can see that this is very difficult. You can also show empathy non-verbally by leaning forward and ensuring you maintain eye contact.

1

96

Tell me, Mary, how are you feeling at the moment? [her eyes fill with tears] [brief silence] This is very difficult for you to talk about, isn’t it?

Yes. [shaky voice] Are you still getting the headaches?

Yes. And do the painkillers I prescribed help? Have you been taking them, Mary?

A couple of times, but they knock me out. I can’t function properly with them. And I need to look after the family – they need me.

I know. You have a lot on your plate at the moment, don’t you? Nursing your husband, taking care of the children and looking after your mother.

Yes, I feel overwhelmed. [patient begins to cry] I’m sorry, Doctor.

You don’t need to apologise, Mary. It’s perfectly normal to cry. I understand how you’re feeling. You’re worried that if you don’t stay strong for the family, things will fall apart, aren’t you?

Yes. I can’t let that happen.

If a patient is not very responsive, it may be more appropriate to use closed questions.

So, Mrs Lyons, tell me, what can I do for you? [no response, patient stares at floor and looks very unhappy] Mrs Lyons? Why have you come to see me? [tries to speak, but no words come out] Please talk to me. I can’t help you if you don’t talk to me. [begins to cry] Now, now, Mrs Lyons, please don’t cry.

b

Work with a partner. Where appropriate, change open questions to closed questions and add examples of facilitative language to draw the patient out.

c

Practise the amended version with your partner.

(US English) post-partum

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Reading and responding to body language 5

Write down two non-verbal cues that would indicate to you that a patient is being uncommunicative.

6

Reading a patient’s body language and then asking appropriate questions may help to draw the patient out. Below are a number of questions that a doctor could ask a patient, according to his/her non-verbal communication. Put the questions under the appropriate headings.

Can I ask what you are thinking?

How are you feeling at the moment?

How do you feel right now?

I can see that you are trembling – are you very anxious?

I can see that you want to say something …

You were going to say something then?

What’s on your mind?

You look as if you are about to cry – are you very upset?

You look as if you were about to say something …

You seem very distant – why is that?

You seem very far away …

Asking why patient is withdrawn 1 Can I ask what you are thinking?

2 3 4 Encouraging patient who is trying to express him/herself 1 I can see that you want to say something …

2 3 Responding to strong physical signs 1 I can see that you are trembling – are you very anxious?

2 Asking how the patient is feeling 1 How are you feeling at the moment?

2

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7

Role-play these situations with a partner. The patient has come to see his/her doctor; the doctor needs to get as much information as possible from the patient. Doctors should pay particular attention to the body language of the patient and respond in an appropriate way, using some of the phrases in Exercise 6.

Situation 1 Student A: Student B:

Situation 2 Turn to page 127.

Play the role of the doctor.

Student A: Student B:

Play the role of the doctor.

Turn to page 133.

Expressing emotions 8

Discuss these questions.

1 When is it appropriate to cry in your culture, if at all?

2 What emotions can crying represent?

3 When expressing emotion in your culture, do gender and age make a difference in terms of what is regarded as acceptable?

9a

10.2 Listen to the dialogue between a doctor and an irate patient.

Emotional release is a healthy process which can help people both physically and psychologically. The first way to help people in this area is to allow them to express feelings.

Burnard (1990)

Tick the approach (a–d) the doctor uses in response to the patient’s behaviour. a Evaluative: The doctor disapproves of the patient’s behaviour. b Interpretive: The doctor tells the patient how he thinks he feels. c Supportive: The doctor understands how the patient is feeling and responds to him in a reassuring way. d Probing: The doctor tries to find out why the patient is angry.

b

c 10a

10.2 This dialogue has the potential for communication breakdown to occur. Listen to the dialogue again and identify two places where you think this is beginning to happen. Discuss in small groups.

If you were the doctor in this situation, what steps could you take to avoid the potential for communication breakdown?

10.3 Listen again to the doctor and patient from Exercise 9a. Which

approach (evaluative, interpretive, supportive or probing) does the doctor use this time? Identify three examples from the dialogue to support your answer.

b What do you think the underlying reason might be for the patient’s anger?

98

11

10.4 Listen to the next part of the consultation. What is the underlying reason that has caused the patient to be angry?

12

Can you think of an example from your own experience where a different underlying reason has been the cause of a patient’s or friend’s anger?

Unit 10 Communicating with challenging patients

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Anger arises in many instances as a response to loss or the threat of loss. The loss may be real – for instance, the death of a loved one – or may be perceived, i.e. the threat of loss of dignity or self-esteem.

Ford (1996)

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13

Read the script for audio 10.3 (page 148) and write down an example of where the doctor …

1 validates the patient’s emotions of anger 2 reassures the patient.

14a Work in pairs. Read this dialogue and make appropriate changes so that the doctor validates the patient’s emotions and reassures him.

Doctor What can I do for you, Mr Brown?

Patient Those antibiotics you gave me aren’t doing the job.

Doctor But Mr Brown, I only prescribed them last week. You need to take them for two weeks.

Patient But this is the third course you’ve prescribed me now.

I’m fed up taking them. They just make me feel tired and depressed, and I still have a bad chest1.

Doctor You need to give them time to run their course.

Patient But why didn’t the other ones clear up my chest?

Doctor We don’t always know which antibiotics are going to work.

Patient What, so I’m some kind of guinea pig? You’re supposed to know what you’re doing.

Doctor Mr Brown, I do know what I’m doing, you just need to be more patient.

b Now role-play the amended version.

Communicating with a manipulative patient 15a

10.5 Listen to a dialogue between a patient with a drug-abuse problem

and his doctor. What does the patient want? How does the patient try to get what he wants?

b

10.5 Listen again and write down two examples of manipulative

language used by the patient.

c

A golden rule when dealing with anger or angry complaints is to be quick to listen and slow to judge. Above all, help them to take control of the situation while showing acceptance, empathy and support.

Ford (1996)

10.6 Listen to three possible responses by the doctor in relation to the

patient’s request for a higher dose of methadone. Which heading (a–c) do the three responses come under? a assertive b non-assertive c aggressive Patient Can’t you understand, you idiot? You’ve got to up my prescription2.

1 Doctor I’m not prepared to listen to you while you’re shouting.

2 Doctor Don’t tell me what I should do. I’m not your supplier.

3 Doctor OK, I’ll increase it on this occasion, but there will have to be a review of your situation before we can do anything else.

1

(US English) cough

2

(US English) give me stronger stuff

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16a In each of the situations below, the doctor has responded in an aggressive way. In each case, make the doctor’s response less aggressive, but still assertive.

1 The patient is complaining that the receptionist has been rude to him.

Doctor

There’s no point taking your frustrations out on me.

2 The patient keeps repeating the same points which have been dealt with in the interview.

Doctor

You’re taking up valuable time that other patients need.

3 The patient has severe liver damage and is very worried that it’s going to get worse, but is still drinking heavily.

Doctor

You only have yourself to blame. If you don’t stop drinking, what else do you expect?

b Check your revised responses with a partner and practise them.

Patient speak 17

The phrases below are common expressions that a patient might use to describe his/her emotional state. Match the phrases (1–18) to the feeling (a–e) they describe. a irritable b moody c depressed in general 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

d depressed as a result of an event e anxious

I’m a bundle of nerves.

I’m down in the dumps.

I’m on a short fuse all the time.

I just keep going to pieces.

I’m up and down like a yo-yo at the moment.

It’s been a real blow for me.

I feel het up1.

I tend to fly off the handle for no reason.

I’m on a bit of a downer.

I feel very uptight.

I feel very low.

I feel on edge. / I feel edgy.

I’m really cut up2 about [losing my job].

I’m prone to outbursts for no particular reason.

I’m a nervous wreck.

I’m finding it very difficult to come to terms with [the divorce].

I have big mood swings.

I get very cranky/snappy/ratty3.

1

(US English) worked up, emotional

2

(US English) upset

3

(US English) Snappy and ratty are UK English only.

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Piecing it all together 18

Out & About

Work in groups of three. There are three scenarios. For each role-play, each of you should take a different role (doctor, patient or observer).

Student A: Turn to page 127.

Student B: Turn to page 133.

Student C: Turn to page 136.

Listen out for language which expresses the emotional state of the speaker and make a note of which emotion it relates to.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area) Encouraging a withdrawn patient to speak by: – responding to non-verbal cues – asking appropriate questions – showing empathy

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Communicating with an angry patient by: – allowing the patient to express him/herself – validating the patient’s feelings – identifying the source of the patient’s anger

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Communicating with a manipulative patient by using assertive language when necessary

1 2 3 4 5

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Unit 11 Communicating with the elderly LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● carry out an effective interview with an elderly patient ● show sensitivity and respect to an elderly patient ● communicate with depressed elderly patients

a Write three examples of common traits associated with old age. b With a partner, discuss what you think the worst aspect of getting old is.

c

11.1 When you are young(er), it is difficult to imagine what

it actually feels like to grow old. Close your eyes, listen to the visualisation exercise and think about what it must be like.

What is your reaction to the visualisation exercise? Was there any aspect that you had not considered before? Discuss with a partner.

Think about … factors you need to consider when taking an effective history from an elderly patient.

1a

What particular barriers might you experience in communicating with elderly patients in general? Write down three examples.

b

With a partner, discuss how good communication skills can help to deal with the examples you noted.

c

Discuss the potential problems when taking a medical history from an elderly patient with regard to the following:

d

●

the time needed to carry out the consultation The patient might consider the visit as a social event.

●

obtaining information from the patient

●

identifying the presenting complaint(s)

●

prescribing medication

Discuss your thoughts with the rest of the group. Think back to issues you covered in Units 1–4.

Overall wear and tear on the body will affect everyone in their later years.

Sensitivity to changes, and especially to their meaning for an individual patient’s feeling of well-being, is an avenue to respectful interaction.

Purtilo and Haddad (1996)

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Interviewing an elderly patient 2a

11.2 You’re going to hear the first part of an encounter between Dr Wadman, a GP, and one of his patients, Mr Harold Whitaker, an 85year-old widower. As you listen, tick the problem areas for this encounter.

1 sensory impairment 2 fear of being institutionalised 3 cognitive impairment 4 memory 5 lack of chief presenting complaint 6 perception of illness

b

With a partner, compare your findings.

c

Answer these questions.

1 Is the patient already known to Dr Wadman? How do you know?

2 What is/are the presenting complaint(s)?

3 To what extent do you feel Dr Wadman carries out the interview with sensitivity?

d

11.2 Listen again and complete Dr Wadman’s questions.

Dr Wadman Mr Whitaker Dr Wadman Mr Whitaker Dr Wadman Mr Whitaker Dr Wadman Mr Whitaker Dr Wadman Mr Whitaker

Dr Wadman Mr Whitaker Dr Wadman

1

[welcoming tone, friendly voice] Mr Whitaker, come in and take a seat. Nice to see you. Are you comfortable there?

Yes, Doctor, thank you. Can I leave my stick1 just here?

Of course. the fan off, it’s a bit noisy …

I’m fine, really. I’m getting used to this new hearing aid now; it cuts out most of the background noise.

Good, I’m pleased to hear it. , Mr Whitaker?

Oh, where shall I start? When you get to my age … it’s all downhill! [They laugh.]

Why the most?

Well, it’s a bit embarrassing, really. . Can you describe what’s been happening?

You can probably see – it’s my hands – they’re shaking all the time, I can’t do much with them. It’s getting worse, too.

And I’ve got problems dribbling, too – you know, that’s really embarrassing. ?

When my Kathy was alive, we had lots of friends, always going out. We liked the good life – dinner parties, theatre …

Uh-huh.

Takes patient’s hearing impairment into consideration

(US English) cane

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Unit 11 Communicating with the elderly 103

COV-19 2020 Mr Whitaker

Dr Wadman Mr Whitaker Dr Wadman Mr Whitaker

Dr Wadman Mr Whitaker Dr Wadman

Mr Whitaker Dr Wadman Mr Whitaker Dr Wadman Mr Whitaker Dr Wadman Mr Whitaker Dr Wadman Mr Whitaker Dr Wadman Mr Whitaker

Dr Wadman

Mr Whitaker Dr Wadman Mr Whitaker Dr Wadman

1

I was a member of the Rotary Club, you know, and I played tennis for the club team – men’s doubles. Kathy wasn’t much of a tennis player – but my goodness, could she dance … [smiles] Good memories? [looks warmly at patient] Wonderful memories. [slight pause] And how ?

It’s the friends, you see, Doctor. This dribbling gets me down.

I can’t face them like this, can I? Don’t get out much any more because of that. [looks down] I can see how that might get you down. We’ll look at ways to try to control this later on.

It’s another symptom of the Parkinson’s, isn’t it?

It is, yes. [pause] If I could just ask you something else at this stage … When some people cough or sneeze, they leak urine.

Does this happen to you? [sighs] Yes, my waterworks1 are playing up a bit, too. I was about to mention that. [sighs] Right. We can also discuss how you can control this. Now, what kind of support network do you have, Mr Whitaker?

Sorry? [looks confused] when you need a helping hand?

My daughter-in-law’s just down the road. with your daughter-in-law? [defiant tone] Oh, no, don’t bother ringing her, not now my son’s no longer with us, anyway.

What about neighbours?

Maggie, she’s just next door, she’s great, she gets the shopping in for me – just the bits ’n’ bobs I need.

Social services? [pause] Don’t want them coming round if I can help it. The last time they came, they took my Kathy and put her in that home, didn’t they? I know they’re doing their job, but … [looks at floor, obviously sad] Some of the services they provide could make life easier for you. ‘Meals on Wheels’, for example. You won’t have to worry so much about getting a balanced meal inside you.

You’re right, I suppose – sometimes I’m just too tired to cook properly. Don’t get me wrong, I like cooking. , Mr Whitaker?

I don’t get out much. Stick’s OK around the house, but … it just gets me down. [looks down] We’ll come back to that if you like. Any other medical issues you’d like to discuss today?

e

In small groups, discuss how Dr Wadman deals with the problem areas identified in Exercise 2a. Read the dialogue again and add relevant comments, as in the example on page 103.

f

Compare your findings with the rest of the group.

(US English) plumbing

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Patient speak 3a

Match phrases from Box A and Box B to form collocations.

Example: I’ve got a touch of indigestion.

A

b

My hearing My memory My knee My waterworks I had a bit of I have the odd I have the occasional I’ve got a touch of

B

arthritis indigestion a dizzy spell a funny turn gout pain

rheumatism spasm is going is not what it used to be is/are playing up is/are troubling me

With a partner, practise asking your patient for clarification.

Examples:

Sorry, can you just tell me what you mean by a funny turn?

When you say your waterworks are playing up, can you describe the symptoms to me?

Showing sensitivity and respect 4

Look at these key points from the Calgary-Cambridge observation guide for developing rapport. ●

Acceptance: acknowledges patient’s views and feelings; accepts legitimacy; is not judgemental

●

Empathy and support: expresses concern, understanding and willingness to help

●

Sensitivity: deals sensitively with embarrassing and disturbing topics and physical pain

Write down two topics/issues that might cause embarrassment or be disturbing for an elderly patient and which would need to be dealt with sensitively. Discuss with a partner.

5a

11.3 Listen to a doctor talking to an elderly lady. How well do you

think the doctor performs in terms of providing acceptance, empathy and support, and sensitivity?

b

11.3 Listen again and write down three reasons to justify your answer.

c

Look at the audio script on page 149 and underline examples where the doctor shows lack of sensitivity to the patient.

6a

11.4 Listen to a more sensitive version and give two reasons why this

is more sensitive.

b

The secret to respectful interaction with older people is to keep their age-related problems in mind while concentrating on their individuality.

Purtilo and Haddad (1996)

Look at the audio script on page 149 and underline the language which helps achieve this.

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7

Compare the language used in the dialogues in Exercises 5 and 6. What is it about the language used in the second dialogue that might have a more positive effect on the patient?

A Dialogue 1: Dialogue 2:

Is there something wrong with your mouth?

Your voice sounds a little different to usual. Is there something the matter?

B Patient:

Can you give me some indication when it’s likely to clear up?

Dialogue 1: It’s difficult to tell with somebody your age.

Dialogue 2: Well, it’s very difficult to say, but ulcers do tend to take longer to clear up as people get older.

8a

Look at this question taken from the dialogue in Exercise 2.

When some people cough or sneeze, they leak urine. Does this happen to you?

Compare this with the question: Do you leak urine?

What difference in language do you notice between the two questions?

Which do you think is more appropriate in this situation and why?

Language to show sensitivity Talking about physical symptoms Some people may experience …

This is quite a common occurrence in older age.

This tends to be quite common in advanced years. Have you experienced this?

There is a tendency for this to increase in later life.

It’s not unusual for this to happen with older people.

Can you just check that … ?

Talking about feelings It is understandable why some people may feel this way. Do you feel like this?

It is perfectly natural for people who may feel like this. Do you feel like this?

Suggesting courses of action This might be a good time to consider other alternatives.

I was wondering if you have considered / were aware that …

It might be a good idea to check …

I can appreciate that it’s difficult to … , but it is important.

b

Identify the four examples in the box above where indirect language has been used to avoid using the word old.

c

Read these sentences and notice how phrases from the table above have been used to show sensitivity/respect.

1 Can you just check that your hearing aid is switched on? A quick check now and again can make all the difference.

2 I was wondering if you were aware that your family are worried about you continuing to live on your own.

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d

Using phrases from the box on the previous page, rewrite these sentences to show sensitivity/respect to the patient.

1 You have to expect some loss of control over your bladder at your age. You’ll just have to get used to it.

2 You can’t just take the medicine when you feel like it. You’re supposed to take it three times a day.

3 Do you realise that you’re dribbling a lot?

9a

What aspects of non-verbal communication do you think are particularly important when you are talking to an elderly patient?

b

With a partner, compare your examples and explain your choice.

c

Imagine the type of non-verbal communication that might accompany the sentences in Exercise 8c. Then consider the same for your revised sentences from Exercise 8d.

d

With your partner, practise the revised sentences using the appropriate non-verbal communication.

Communicating with patients with hearing problems 10a

b

11.5 You’re going to listen to a doctor talking to an elderly patient who has a slight hearing problem. What two things could the doctor have done to ensure the patient heard properly the first time?

11.6 Listen to a different doctor talking to her patient. The patient

has some difficulty in hearing the doctor. Identify two ways in which the doctor tries to help the patient.

c Is there anything else that a doctor could do to make it as easy as possible for the patient to hear him/her?

11

Work in pairs. There are two scenarios. For each role-play, each of you should take a different role (doctor or patient).

Student A: Student B:

Turn to page 127.

Turn to page 134.

12a A natural inclination may be to shout when talking to an elderly patient with hearing difficulties. However, Currie (1996) recommends using a loud conversational voice, rather than shouting, with clear lip movements to assist lip-reading. With a partner, discuss why you think a loud conversation voice is more effective than shouting.

b With a partner, vary the loudness of your voice to find out what different levels your partner is comfortable with. How close is it to the volume you normally use? Try to find somewhere quiet, then somewhere more noisy, and see how much you have to adjust the volume to get it right.

© Cambridge University Press 2007

Many elderly people are embarrassed as well as isolated by the disability [deafness] and may attempt to conceal it by a mixture of lip-reading and bluff. If a patient gives unexpectedly bizarre or even just excessively bland answers, it is worth thinking about whether they have actually heard the question.

Currie (1996)

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Assessing the patient’s ability to live independently Doctors are often required to assess a patient’s ability to live independently.

Activities for Daily Living (ADL) are a series of functions to determine the level of independence shown by an elderly patient.

13a You are going to hear a medical student giving a presentation to his class. He outlines the usefulness of a tool with the acronym BATTED for assessing how well an elderly patient can carry out activities for daily living (ADL). Before you listen, with a partner, guess what word(s) are represented by each letter of the acronym BATTED. B A

Ambulation (walking)

T T E D taken from Interviewing and Patient Care, Enlow et al. (1996)

b

11.7 Listen and check.

c As a group, discuss how some of these functions can be measured through simple observation in the doctor’s surgery.

14a With a partner, using the following as an example, continue the encounter with Mr Whitaker (see Exercise 2) and re-assess his ability to function independently. Take notes.

Doctor Patient Doctor Patient

Do you have trouble with bathing?

No. How do you do it?

I wash in the sink. The bath’s too difficult to get in and out of.

b Swap roles and continue the encounter by using another acronym: SCUMM, which describes various activities related to daily living.

SCUMM Shopping Cooking/cleaning Using transportation Managing money Management of medication

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Communicating with depressed elderly patients 15

The following have been identified as significant factors in causing depression in the elderly. Think about an older person you know who may be experiencing any of these. How easy do you think it would be to identify whether he/she is depressed?

16a

●

Traumatic life events (such as bereavement)

●

Social and interpersonal difficulties (loneliness, isolation, separation from family)

●

Family history of depression

●

Poverty and poor living circumstances

●

Physical illness 11.8 Listen to a doctor talking to an elderly patient. How does the

woman react when the doctor suggests she is depressed? Why do you think she reacts this way?

Despite many public campaigns to educate people about mental health and illness, there is still a stigma about mental illness. Older patients, who grew up with different ideas about mental health, may feel this stigma even more keenly and find mental health difficult to discuss.

National Institute of Ageing (2004)

b Look at the audio script on page 150. The patient responds well to the doctor’s open questions. Underline all the open questions the doctor asks.

17

Not all patients with depression will be as responsive to open questions, and it may be necessary to use closed or simple choice questions. Look at these frameworks for simple choice questions.

Is it [your knee] or is it [your foot] which is causing the problem?

Do you want to [continue as you are] or do you want to [have some help at home]?

Think of some more examples which would fit into the gaps above.

18a Imagine that the patient in the dialogue in Exercise 16 is mainly giving one-word answers. With a partner, rewrite the dialogue to take account of this, using as many closed questions as you think are appropriate.

Remember to include empathetic and supportive language.

b Practise the dialogue with your partner.

Assessing the mental state of the patient 19

11.9 Listen to the dialogue between a doctor and a new patient. The

doctor does not go into a detailed clinical history at the start. What does he do instead?

20

11.10 Listen to a dialogue between a doctor and an elderly female

patient who has hurt her foot. Do you think the patient is confused?

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21

What do you think Purtilo and Haddad mean by ‘discern that one patient is making sense within a context not immediately evident’?

Talking about death and dying As patients grow older, it becomes harder to avoid the inevitability of death.

While many patients may not want to mention it, or acknowledge the possibility, others will want to talk about it and may want to share their fears and anxiety.

22a Read this doctor’s account of interacting with an elderly patient and then, with a partner, answer the questions below.

Some years ago, I and a nursing colleague visited a woman at her doctor’s request. She had advanced oesophageal carcinoma with considerable pain and almost total dysphagia. As is my custom, I did not immediately take a history, but rather asked the patient in what way she felt I could help her: ‘Ease my pain, show me what I can eat and reassure me that you will answer my questions honestly. I must be fit enough to do some unfinished business.’

Some weeks later, so frail that she could no longer manage at home, she was admitted to the hospice, where, again, she was asked the same question: ’In what way can I be of service to you?’ Surprisingly, she replied with a question: ‘Do you know what a platform ticket is?’ She proceeded to explain that she expected to meet a kindly companion in the near future. ‘I feel as though I am on a railway platform, bags packed, a single ticket in my pocket and (just like British Rail!) a trifle late. As if I had studied the travel brochures, I am excited about where I am going because it sounds lovely, but of course, I haven’t actually met anyone who has ever been there and I can’t help feeling a bit apprehensive. As I wait here, I would like someone to talk to, someone to advise me and possibly provide a bit of reassurance, but, most of all, I just want a companion because I am finding it a bit lonely. Will you get a platform ticket, Doctor?’

It became routine to stop at her bed and ask if it was time to buy the platform ticket, with always the same reply: ‘No, so long as you know when to get it!’ One day, scarcely looking any different, she called over and whispered that her train was coming in. I sat with her, holding her hand and marvelling that conversation seemed unnecessary, until she said ‘Thank you for being with me – you can’t come any further, but I am no longer afraid or lonely,’ and shortly afterwards she died.

1 The woman uses an unusual metaphor for death, when she compares it to waiting for a train. What effect do you think this has on the communication process?

2 How do you feel about the dying patient’s request that the doctor be someone to talk to, offer advice and be a companion? Is this compatible with what you feel a doctor’s role should be?

b What metaphors for death are used in your own country? Discuss with a partner.

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[Remember to] listen with interest and politeness to the patient.

Listening will help you to determine the depth of confusion, ascertain the wisdom of trying to correct it, and in some cases, discern that one patient is making sense within a context not immediately evident.

Purtilo and Haddad (1996)

Communication Skills Writing down any instructions you need to give a patient in a clear and simple way gives elderly patients a permanent record of what you have discussed in the interview.

taken from Talking to the dying patient, Doyle, D., 1996

COV-19 2020 Cultural awareness

Out & About

As well as notorious terms such as ‘crinklies’ and ‘crumblies’ sometimes used in geriatric wards, people are also reduced to no more than their condition: ‘We have two hips and a knee in today’ in the surgical ward, or the diminution of a human being with Alzheimer’s disease to no more than a ‘dement’.

Cayton (2006) This quotation is taken from an article which questions the way in which the NHS relates to older people in society, in some cases dehumanising them.

In your culture, how are older people viewed in general? Is this changing and in what way? Share your thoughts with the group.

Piecing it all together 23a Work in groups of three. Before doing the role-play, compile a list of

Read the health column of a popular magazine and focus on letters written by elderly patients. Before you read the doctor’s reply, think how you might phrase a reply in order to reassure the person.

Make some notes.

Read the doctor’s reply and compare his/her response with the points you have made.

criteria to be used by the observer to evaluate the doctor’s performance in terms of all the issues raised in the unit.

b There are three scenarios. For each role-play, each of you should take a different role (doctor, patient or observer).

Student A: Student B: Student C:

Turn to page 128.

Turn to page 134.

Turn to page 136.

c Swap roles or choose one of the other cases in the unit to create another scenario and role-play it in the same way.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area) Taking an effective clinical history for the elderly by: – remaining respectful and sensitive – pacing and structuring or restructuring the interview accordingly – taking into consideration sensory impairment – employing appropriate voice-management skills

1 2 3 4 5

Assessing the patient’s ability to live independently

1 1 1 1

Detecting mild depression and assessing mental state by employing the appropriate questioning technique

1 2 3 4 5

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2 2 2 2

3 3 3 3

4 4 4 4

5 5 5 5

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Unit 12 Communicating with children and adolescents LEARNING OUTCOMES

Lead in

At the end of this unit, you will be able to: ● establish and develop rapport with a child ● reassure a child ● gain a child’s consent to be examined ● explain procedures to a child ● respond to a child’s verbal cues ● communicate effectively with an adolescent

The heart is for loving and the brain is for doing sums.

The perspective of a child under seven. Taken from Eiser (1983)

a This quotation demonstrates the very limited understanding that young children have of their bodies. Think of three other ways in which you think child patients differ from adult patients. It may help if you can think back to your own childhood.

b How comfortable do you feel / would you feel working with young children? Why?

Establishing initial rapport DVD clip 8

In order to establish an effective rapport with young patients, it is important to demonstrate your understanding of how they differ from adults in the way you interact with them.

Think about … the issues involved when meeting a six-year-old child for the first time in the consultation room.

Communication Skills Asking a child to draw a picture is a good way of beginning a conversation, especially if the child is shy.

1

Write down two things that you would do to begin to establish a rapport with the child.

2

12.1 You are going to listen to the beginning of a consultation with a new patient. The doctor is talking to a six-year-old girl and her mother.

1 Does the doctor do either of the things you noted in Exercise 1?

2 Does he do anything else to establish rapport with the mother or child?

3a

Look at the stages in the Calgary-Cambridge observation guide for establishing initial rapport. How do you think a doctor might carry out stage 3 when dealing with a child patient?

1 Greets patient and obtains patient’s name 2 Introduces self and clarifies role 3 Demonstrates respect and interest, attends to patient’s physical comfort

b

What topics would you talk about to show interest in a child?

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c

12.2 Listen to another doctor who is receiving a new patient. The

doctor is talking to a seven-year-old boy and his mother.

1 Does the doctor cover each of the stages in Exercise 3a adequately?

Make brief notes next to each stage.

2 Does the doctor include the mother in the small talk?

Making a child comfortable 4a

12.3 Listen again to part of the dialogue from Exercise 3c and fill in

the missing words.

In paediatric consultations, communication takes a triangular form, involving the doctor, the child and the parent, each giving and receiving information, each observing and being observed.

Speirs (1996)

raise your chair up a bit so you can see me.

b

The doctor uses the word just when she tells the boy she needs to adjust his chair. What effect does the word just have on the sentence?

c

In the above example, the word just goes at the beginning of the sentence. It can also be placed in other parts of a sentence. Look at other things a doctor might say to make a child comfortable and write down where you would insert the word just.

1 I’m going to clear some space for Teddy to sit.

2 If I could get you to sit here next to me. That’s great. Are you comfortable?

3 Yes, it is hot in here. Let me open the window before we begin.

Paying a child a compliment 5a

A common way of paying somebody a compliment is shown in this sentence from the dialogue:

Interviews proceed better if the child’s eye level is at or even above the doctor’s.

Speirs (1996)

That’s a great football shirt, Billy.

That’s a + adjective + noun / They’re + adjective + noun (plural) Here are other things a doctor might compliment a child about. Match the adjectives (1–4) with the appropriate nouns (a–d). Note that each adjective can be used with more than one noun.

b

1

1 cool

a dress

2 lovely

b toy

3 pretty

c trainers1

4 cute

d smile

What other expressions could you use to pay a compliment?

(US English) sneakers

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Developing rapport 6a

Look at the stages for developing rapport outlined in the Calgary-Cambridge observation guide. The first three stages have been covered in Unit 11 (Exercise 4). How relevant do you think the six stages are when communicating with children? Discuss with a partner.

1 Acceptance: acknowledges patient’s feelings 2 Empathy and support: expresses concern, understanding, willingness to help 3 Sensitivity: deals sensitively with embarrassing topics and physical pain 4 Sharing of thoughts with patient 5 Provides rationale: explains why an examination is needed 6 Examination: asks for permission to examine patient

b

12.4 Listen to the continuation of the dialogue you heard in Exercise 3c.

Tick the stages above that the doctor covers in the dialogue.

c

12.4 Listen again and complete these sentences from the dialogue.

1

feeling sad?

2 I

why you’re feeling sad.

3 Oh dear, 4 You

nasty cough, _____ _____? missed that, Billy.

5 6

d 7a

is to have a look at your chest. look at your chest?

Identify which stages the sentences in Exercise 6c come under.

In this sentence from the dialogue, the doctor uses must to show empathy: You + must + present perfect: You must have missed (that) …

There are other constructions using must that can also be used to show empathy: That/You must be …

That/You must have been …

Match the halves of these sentences. (There are several possibilities for some.)

b

1 That must have been

a a lot of pain.

2 You must be

b disappointing for you.

3 That must be

c very tired.

4 You must have been

d very sore.

5 You must feel

e difficult for you.

6 You must be in

f disappointed.

What other phrases could you use to show empathy?

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c

In pairs, practise using the phrases in Exercises 7a and 7b in these scenarios.

1 A six-year-old boy has come to see you because he has a cough. He has only just got over measles and tells you that his birthday party had to be cancelled.

2 An eight-year-old girl has come to see you because she has sprained her wrist. Swimming is her passion and she had to pull out of the school swimming championship.

8

With a partner, read audio script 12.1 on page 150 and make changes to improve the consultation. Role-play the improved dialogue.

Remember to: ●

make sure the child is comfortable

●

show interest in the child, e.g. pay the child a compliment

●

show sensitivity, empathy and support.

Reassuring a child 9

In what situations might you need to reassure children?

Example: A child might be scared because he/she thinks the illness is much worse than it really is.

10a

12.5 Seven-year-old Jenny has broken her wrist. She thinks it is her fault because she didn’t go to bed when her parents told her. Listen to what the doctor says to her. How does he reassure her?

b

12.5 The way in which the doctor speaks to Jenny also helps to reassure her. Listen again and focus on the doctor’s voice. Write down two aspects of his voice which help to reassure her.

Language for reassuring a child You shouldn’t blame yourself.

I’m sure you didn’t mean to do it.

Don’t worry, it’s not your fault.

11

Look at the two scenarios on page 122 and take turns playing the role of the doctor.

Children may blame themselves for an illness, believing it is a punishment for bad behaviour. You should reassure children that sickness is not the result of naughtiness and that they are not responsible for the illness.

Lloyd and Bor (2004)

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12a Look at possible phrases a doctor might use to reassure a child. In what context might these phrases be used?

1 Don’t look so sad. We’re going to make you better very soon.

2 You’re not to blame for this in any way.

3 Don’t be scared. I promise this won’t hurt.

4 It will be very quick, you’ll hardly feel a thing.

b

12.6 Listen to the phrases above and mark which words are stressed in

each one. Practise saying the sentences aloud.

13

What would you say in the following situations to reassure the patient?

Work in pairs and take turns playing the role of the doctor and child.

1 A seven-year-old child is very frightened after having a nose bleed during a football match. He thinks he will bleed to death.

2 An 11-year-old child is about to have an injection. The child is terrified of needles.

3 An eight-year-old child has stomach cramps and is very agitated.

She ate an apple, including the core, and thinks a tree is going to grow inside her. You need to examine the child’s stomach.

4 A 12-year-old girl comes in with a first-degree burn on her hand.

She’s worried that she’s going to be scarred for life and thinks it’s her own fault because she’d been told not to play with candles.

14

What aspects of non-verbal communication can help you to gain some insight into how a child is feeling?

Examining a child 15

12.7 Listen to a doctor giving instructions to an eight-year-old girl.

The child does not co-operate. Write down at least two things the doctor does or doesn’t do which might explain why the child is not co-operating.

16a

12.8 Look at this checklist of functions that a doctor should do when

he/she is examining a child. Now listen to a different doctor giving instructions to a five-year-old boy. Tick the stages the doctor includes. ●

Asks child for permission to be examined

●

Asks the parent to remove any of the child’s clothing

●

Tells the child he/she can get dressed again shortly

●

Explains procedure

●

Demonstrates procedure on a toy

●

Checks child understands what’s happening

●

Gives clear, simple instructions

●

Praises child for co-operation

●

Tells child to put clothing back on as soon as examination has finished

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It is possible to make some judgements on how comfortable the child feels by the way in which they walk into the consulting rooms. For example, they may stride in front of the mother or refuse to leave the mother’s side.

Lloyd and Bor (2004)

COV-19 2020

b Write down two questions you could ask a child to obtain permission to examine him/her.

17

Role-play an improved version of the dialogue in Exercise 15 following the procedures listed in Exercise 16.

Giving instructions 18a Look at the two different ways the doctors instructed their patients to do something in the dialogues in Exercises 15 and 16.

Dialogue 1 No, Stacy, don’t get down yet. I haven’t finished.

Now, Stacy, come on, you must sit still.

Explain procedures before you do them.

Prepare the child for a strange noise or smell, a painful procedure, or change from a familiar routine. Toys help to establish rapport with children. They can also be used to explain procedures.

Lloyd and Bor (2004)

Dialogue 2 OK, Joe, I need to look at your chest, so can I get Mummy to take off your lovely football top for a few moments?

OK, now I need you to take a big breath for me and hold it.

What is the difference in the language they use for giving instructions?

b How would you give the following instructions in a more child-friendly way?

1 You need to open your mouth wider. (checking tonsils) 2 How can I see your eyes if you won’t open them? (presenting complaint: headaches) 3 Don’t move when I’m examining you. (checking stomach) 4 Stand on the weighing machine, please.

Responding to a child’s verbal cues Active listening means attending to the child’s feelings and responding to them appropriately.

19a Responses can be classified under the following main headings: a Evaluative (The doctor disapproves of the child’s behaviour.) b Interpretive (The doctor tells the child how he/she thinks they feel.) c Supportive (The doctor understands how the child is feeling and responds to him/her in a reassuring way.) d Probing (The doctor finds out about the child’s feelings.)

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COV-19 2020 Read this dialogue extract. There are four possible responses that the doctor could make. Match each of the responses (1–4) with one of the headings (a–d) on the previous page.

Doctor Kate

Now, Kate, I’m going to give you a little jab.

I hate needles!

1 Doctor

It’s probably the thought of them that you don’t like, rather than the actual jab.

2 Doctor

What do you hate about them?

3 Doctor

You really wish you didn’t have to have this today, don’t you? I’ll be very quick.

4 Doctor

Now, now, Kate. Even your little sister didn’t mind her injection, did she?

b Which two responses are appropriate for the doctor to make?

Patient speak 20

How would you ask a ten-year-old child these questions?

1 Do you suffer from drowsiness during the day?

2 Are your eyes sensitive to light?

3 Do you feel nauseous?

4 Do you have any abdominal pain?

21

Children will often use different words (sometimes their own special words) to describe bodily functions and body parts. It can be helpful to recognise some of the more common ones. Match the medical terms (1–3) with what a child of eight might say (a–c).

1 To open your bowels1

a To have a runny tummy3

2 To pass water / urinate

b To do a poo4

3 To have diarrhoea2

c To have a wee5

Cultural awareness When working with children, it is important to be aware that different cultures have different expectations of what ‘good’ behaviour is for children.

For example, some research suggests that Canadian mothers expect their children to be more independent and exploratory than, for example, Chinese mothers, and reward that type of behaviour. The values of the parent’s culture are likely to influence how easy it will be to get the child to respond and to win his/her trust.

Can you think of any examples of cultural expectations of children’s behaviour that might affect a consultation?

1

(US English) To have a bowel movement

4

(US English) To go poop

2

(US English) diarrhea

5

(US English) To go pee-pee

3

(US English) To go diarrhea

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22

Read these child patients’ comments of how they would like hospital to be and think about how it differs from the way you see a hospital.

‘I would like it best if it was mostly boys of all ages and there’s a train in the waiting room of the children’s hospital. (If the hospital had) a big window so they could fit lots of patients in the windows. If they’re really poorly, there’s a drink machine outside. If it’s just a little cut that’s bleeding, you can come to the entrance and press the button to make the plaster1 drop down and all the bandage – you can choose which button to press for a plaster.’

Collin, a five-year-old boy ‘(I would like the hospital to have) bunk beds, nice nurses and doctors, toys, TV, cars, cakes, lollies2, a guitar, drum, toy puppet, a watch to wear and a whole board to draw pictures on.’

Mark, a six-year-old boy

Out & About Look at one service within a medical context which is used by children as well as adults (e.g. doctor’s surgery), and note what efforts have been made to make it more appealing to children.

What other simple changes could be made to improve it?

taken from Now I feel tall: What a patient-led NHS feels like, December 2005

Communicating with adolescents 23a In establishing a rapport with adolescents, it can often be difficult to choose a suitable topic, but it is worth pursuing, as it can help overcome awkwardness. Think of three topics which you think might be generally suitable for adolescents.

b Think back to when you were an adolescent. What were the main barriers you felt existed between you and your parents/carers?

24

Wrate (1996) lists some common areas that adolescents frequently complain about when communicating with adults in general: 1 Not being listened to 2 Getting mini-lectures or advice that he/she doesn’t want to hear 3 Being patronised / treated like a child 4 Being asked intrusive questions 5 Being spoken to using complex language 6 Being treated in a humourless way To what extent do you think each of these is relevant to the medical consultation? Discuss with a partner.

1

(US English) Band-aid

2

(US English) lollipops, suckers

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Adolescents want very much to show they are mature and ‘can handle things themselves’, but at the same time, some of the medical and psychosocial issues they confront may require them to be more dependent (than an adult).

In gathering information from the patient, the Home, Education/ Employment, Activities, Drugs, Sexuality, Safety (violence and abuse) and Suicide (HEADSSS) mnemonic is very useful to remind us of important information we need to obtain from adolescent patients. This approach starts with non-threatening, openended, non-judgemental questions and progresses to more sensitive areas.

Sacks and Westwood (2003)

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25a

12.9 Listen to a dialogue between a doctor and an adolescent patient.

How well do you think the doctor has handled the interview?

b Match these extracts from the dialogue with points 1–6 in Exercise 24.

Not all are covered and some are used more than once. a Well, my dear, you certainly have grown since I saw you last. b Have you started having sex? c But you’re only a child … 16 is too early to start having sex. d There’s really nothing to laugh about, you know. e You’re not fully developed emotionally or physically yet, and you’re taking a lot of risks with your health.

c Look at these statements. With a partner, discuss where they could be fitted into the dialogue. Refer to the audio script on page 151. Then practise the dialogue.

1 It’s not my intention to lecture you, but you do really need to consider …

2 I don’t mean to pry into your personal life, but I do need to know …

3 I can assure you that I am listening to you.

Piecing it all together 26

Work in groups of three. There are three scenarios. For each role-play, each of you should take a different role (doctor, patient or observer).

Student A: Student B: Student C:

Turn to page 128.

Turn to page 134.

Turn to page 136.

Progress check Complete the Progress check for this unit.

(1 = I need more work on this, 5 = I feel confident in this area) Establishing a rapport with a child by: – greeting the child and obtaining his/her name – introducing myself and clarifying role – demonstrating respect and interest – attending to patient’s physical comfort

1 1 1 1

Reassuring a child

1 2 3 4 5

Examining a child and giving instructions

1 2 3 4 5

Responding to a child’s verbal cues

1 2 3 4 5

Communicating effectively with an adolescent by: – avoiding patronising language – not lecturing

1 2 3 4 5 1 2 3 4 5

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2 2 2 2

3 3 3 3

4 4 4 4

5 5 5 5

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Role-play and additional material Unit 3, Exercise 18c Patient note ● Date each entry and note the time using the 24-hour clock. ● Ensure each statement is objective; avoid the use of statements you cannot justify – patients and lawyers can have access to these notes. ● Use diagrams where appropriate, as they are often much more descriptive than long paragraphs. ● Make your headings clear. ● Keep your records as concise as possible. ● Records should appear in a logical order. ● Handwriting must be legible; it is not just you who subsequently needs to read your notes. ● Use only standard medical abbreviations. ● Record only relevant negatives and positives. ● Scrawled initials are inadequate; someone else has to read your notes and be able to identify who has written them.

Unit 3, Exercise 23a History of the patient with PUO This should be thorough, as the diagnosis may be difficult to obtain. Note especially: ● Foreign travel: the incubation period of many tropical diseases may mean that the fever starts some time after arrival back home ● Contact with animals ● Contact with infected people ● Sexual history and any history of intravenous drug use ● Alcohol intake ● Previous illnesses, particularly recurrent infections and/or a history of immunosuppression ● Previous surgery or accidents ● Rashes ● Diarrhea ● A full history of medication, including over-the-counter drugs ● Immunization history ● Symptoms such as weight loss, sweats, and itching ● Lumps ● Familial disorders (e.g. familial Mediterranean fever)

taken from Crash Course, General Medicine, Allen & Marsh, 2005 NB Information-gathering for sexual history and lifestyle will be treated in Unit 4. Include these questions if you feel they are appropriate.

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Unit 4, Exercise 10e Case study 2 Saleem Akhtar, 19, is third-generation Pakistani from a predominantly white, middle-class area of Manchester, where he was brought up and still lives with his mother and younger sister. He has been unemployed for six months despite having attended FE college1 and gaining a qualification in basic accountancy. He was previously a member of the local rugby team, was generally popular at school and is a practising Muslim. His mother is concerned about his lack of motivation and concentration.

Unit 4, Exercise 24a Case study 4 Rosanna Fiennes is a young professional of 25 working in investment banking. She works long hours and commutes two hours a day by train into London. Hobbies include foreign travel to South-East Asia and West Africa, where she worked following university for an NGO, as well as football2; she plays for the local women’s side. Ms Fiennes is about to be married, but due to family reluctance to accept her future partner, she spends a lot of time between two homes.

Unit 12, Exercise 11 Scenario 1 Doctor: Your patient is seven years old. He/She seems very upset. Find out why he/she is so upset and give reassurance.

Patient: You are a seven-year-old with a chest infection. You went to bed with your hair wet, ignoring your mother’s advice to dry it. You are very upset and think you are ill now as a punishment.

Scenario 2 Doctor: Your patient is a ten-year-old boy. He seems very upset. Find out why he is upset and reassure him that his arm should be better in time for the match.

Patient: You are a ten-year-old boy. You were doing stunts on your bike and you fell off and hurt your arm. Your parents are annoyed with you because they told you not to do stunts. You’re worried and upset because you might not be able to play with the school football team, where you are the highest goal scorer.

Unit 1, Exercise 13 Student A 1 Use the information on the cards on the next page to greet the patient (Student B) and put him/her at ease. You may wish to use some of the phrases from Exercise 7a. Remember to use an appropriate welcoming tone of voice and good eye contact.

1

(US English) community college

2

(US English) soccer

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COV-19 2020 Doctor’s card 1: small medical practice Name: Post: Patient: Presenting complaint:

[your name] GP1 Mr Thomas Brown DIY accident

Doctor’s card 2: hospital

Name: Post: Patient: Department: Referred by: Presenting complaint:

[your name] Student doctor Miss Claudine Mukizwa Oncology Mr Hussein Barek three-monthly check-up

2 Swap roles. You will now take the role of the patient. The doctor (Student B) will use the four objectives on page 17 to greet you and put you at your ease.

Patient’s card 3: small medical practice Patient: Mr William Ashton (you are known as Billy) Presenting complaint: hay-fever symptoms Patient’s card 4: hospital

Patient:

Mrs Francesca d’Angelo (pronounced ‘DAN-ge-lo’; but you prefer to be on first-name terms) Presenting complaint: Suspected ectopic pregnancy

Unit 1, Exercise 23a Student A You are the doctor.

Receive the patient ➔ ask the opening question ➔ set the agenda Remember to greet and establish a good rapport with your patient from the outset.

1

(US English) PCP (Primary Care Physician), doctor

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Unit 2, Exercise 34 Student A You are the emergency doctor. A female patient in her early 60s presents with pains to the left arm. She appears to be in some distress and needs calming down before you can take an accurate history. The patient had already called for an emergency doctor to attend, but the doctor failed to turn up.

Read through the information about the two conditions below and then take the history of the presenting complaint.

ANGINA

MYOCARDIAL INFARCTION

FEATURE

CHARACTERISTICS

Location

retrosternal, throat, left arm

retrosternal, throat, left arm

Quality

typically to the throat or left arm

typically to the throat or left arm

Quantity/ Severity

tight, gripping, a dull ache

tight, gripping, a dull ache – but more severe than as for angina

Timing

short, usually only a few minutes

usually longer than 30 minutes and terminated only by use of opiate analgesia

Aggravating

exertion, stress, cold, emotion

usually none, but may have similar precipitants to angina

Alleviating

rest, glyceryl trinitrate (GTN) tablets (rapid) often none except opiates

Associated manifestations

usually none

sweating, light-headedness, palpitations, nausea, vomiting, sense of foreboding

Unit 3, Exercise 21 Student A a Plot a Pedigree diagram for your patient using the information below and the symbols in the box.

Pedigree diagram symbols

↑ ■● Ca CAD

male female patient patient deceased cancer cardiac disease

A&W ↑ ↓ RTA s.b.

alive and well increase decrease road accident stillborn abortion

Patient information ●

Maternal grandparents died in a road accident, 55 and 52

●

Paternal grandfather died aged 70, heart attack

●

Paternal grandmother died aged 25, cause unknown

●

Father, 75, diabetes, broken hip

●

Mother died aged 64, stomach cancer

●

Patient, male, 47, high blood pressure

●

Brother, 45, heart attack at 40

●

Sister, 37, alive and well

●

Wife, 41, alive and well

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Son, 10, alive and well

●

Daughter, stillborn, 1999

b Interview Student B and plot his/her Pedigree diagram. Student B will interview you; answer using the patient information above. c Compare the two versions of each Pedigree diagram.

Unit 7, Exercise 10 Student A You are the doctor. Your patient is 35 years old and complains of exhaustion.

He/She is 20 kilos overweight. The consultation is coming to an end. Use the language for negotiating treatment on page 74 to advise him/her to lose weight gradually and take up some moderate exercise.

Unit 7, Exercise 13 Student A Scenario 1 You are the doctor. The patient is a 35-year-old male. He is suffering from work-related anxiety, and you need to outline three possible treatments.

Options: 1 Cognitive-based therapy: Good results, but may take months to take effect. Also long waiting list.

2 Medication (anti-depressants): Takes two weeks to take effect.

Possible side effects: nausea, feeling detached, headache, weight gain, blurred vision, dry mouth, constipation, sedation, sexual dysfunction 3 Time off from work: Immediate relief, but problem may remain unresolved.

Scenario 2 You are the patient. You are a 28-year-old married female. You have three children and don’t want any more. You want some form of birth control which is very reliable and doesn’t require too much work on your part. You are a smoker and a bit overweight.

Scenario 3 You are the observer.

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Unit 8, Exercise 14 Student A Ask your partner to help you complete these definitions by asking questions.

Example: What does ‘clean’ mean?

Jargon 1 acid head

Definition person regularly using LSD

2 clean 3 cut

mix a drug with other substances (flour, talcum powder, etc.)

4 dope 5 habit 6 freebasing

smoking cocaine

7 jack up

inject oneself with drugs

8 mainlining 9 score

obtain drugs

10 stash 11 script

prescription (methadone)

12 tools

equipment for taking drugs

13 track marks 14 user

Unit 9, Exercise 13 Student A Scenario 1 You are the doctor. A 75-year-old male/female, who has been in remission from stomach cancer for five years, has been readmitted to hospital.

Examination shows that the cancer has returned and has spread to other parts of his/her body. The prognosis is very poor.

Scenario 2 You are the patient. You are a 32-year-old nurse. You have just been offered a job and are looking forward to starting your new job, but need to have a medical before the job is confirmed. You don’t foresee any problems.

Unit 9, Exercise 22 Student A Scenario 1 You are the doctor. You need to telephone a parent to tell him/her that their child has been run over. The child is in a coma. You don’t know at this stage what damage has been caused.

Scenario 2 You receive a call from the local hospital to tell you that your partner has collapsed at work.

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Unit 9, Exercise 23 Student A Scenario 1 You are the doctor. You need to explain to a 37-year-old mother that the baby she is carrying has Down’s Syndrome. The woman had a miscarriage two years ago.

Scenario 2 Your five-year-old daughter was hit by a motorist just outside your house.

She has been rushed to hospital. She is your only child. You are distraught and are blaming yourself for allowing it to happen.

Scenario 3 You are the observer. Use this checklist to make notes of your impression of how well the doctor meets the criteria.

Communication checklist Give hope (e.g. possible treatment, lack of pain, mobility) where this is possible, but don’t minimise the severity of the condition or give false hope.

Give the patient time to ask questions.

Give information in manageable chunks, repeating key points if necessary.

Avoid jargon: explain medical terms in simple, clear language.

Show support. ●

● ● ● ●

Unit 10, Exercise 7 Student A You are the patient. You have recently been bereaved and you are on the verge of crying. You are having difficulty sleeping. You feel very detached and you avoid eye contact with the doctor when he/she is speaking to you.

Unit 10, Exercise 18 Student A Scenario 1 You are a GP. A new patient has come to see you.

Scenario 2 You are the patient. You are a 42-year-old male and are a heavy drinker. You have come to ask for medication to stop the stomach pains you have been getting. Your doctor has told you to stop drinking, as it is having a serious effect on your health, and refuses to prescribe anything until you stop. You are very defensive about your drinking, do not like being told what to do and respond very aggressively to the doctor’s questions.

Scenario 3 You are the observer.

Unit 11, Exercise 11 Student A Scenario 1 You are the patient. You are 72 years old. You have a hearing problem and give answers that are not related to the questions. However, if the doctor repeats the questions slowly and clearly, you will be able to hear him/her.

You have come to see the doctor because your right knee is troubling you.

Scenario 2 You are the doctor. The patient is 80 years old and wears a hearing aid.

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Unit 11, Exercise 23b Student A Scenario 1 You are the doctor. The patient is a 68-year-old female. This is the first time you have met the patient.

Scenario 2 You are the patient. You are a 73-year-old male. You’ve been a diabetic for the last 20 years, and your circulation is getting worse. You have a bad pain in your right foot.

Scenario 3 You are the observer.

Unit 12, Exercise 26 Student A Scenario 1 You are the doctor. Your patient is 16 years old.

Scenario 2 You are the patient. You are 15 years old and have come to see the doctor because you have very bad acne. You feel very self-conscious and are almost suicidal because your fellow pupils are making fun of you because of the acne.

Scenario 3 You are the observer.

Unit 1, Exercise 13 Student B 1 Take the roles of the patients shown on these cards. The doctor (Student A) will use the four objectives on page 17 to greet you and put you at ease.

Patient’s card 1: small medical practice

Patient: Mr Thomas Brown (prefers to be known as Tommy) Presenting complaint: DIY accident Patient’s card 2: hospital

Patient:

Miss Claudine Mukizwa (pronounced ‘mu-KI-zwa’; you prefer to be known by your surname) Presenting complaint: three-monthly check-up following cervical cancer scare 2 Swap roles. You will now take the role of the doctor. Use the information on these cards to greet the patient (Student A) and put him/her at ease.

You may wish to use some of the phrases from Exercise 7a. Remember to use an appropriate welcoming tone of voice and good eye contact.

Doctor’s card 3: small medical practice Name: [your name] Post: Locum

Patient: Presenting complaint:

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Mr William Ashton hay-fever symptoms

COV-19 2020 Doctor’s card 4: hospital

Name: Post: Patient: Department: Referred by: Presenting complaint:

[your name] Consultant Mrs Francesca d’Angelo G&O Mrs Katie Jones suspected ectopic pregnancy

Unit 1, Exercise 23a Student B 1 You are the patient. You have very high expectations of doctors and their role, and you have had bad experiences in the past. Make a mental note of how the doctor interacts with you – try to get an overall impression.

2 Feed back to Student A after the role-play, giving your overall impressions.

Unit 2, Exercise 33 Student B You will take the role of a patient presenting with symptoms of your choosing. You are not very communicative and quite shy, and in general you dislike going to the doctor’s.

Unit 2, Exercise 34 Student B You are the patient. You are 63 years old. You are suffering pains in your left arm, but don’t know what is causing it. Your fears lead you to believe you are suffering a heart attack. You have already called for an emergency doctor to attend, but no one came. Your husband has gone out fishing with your son.

Choose one of the two conditions shown in the table below. The doctor will interview you.

Characteristics Feature

angina

myocardial infarction

Location

retrosternal, throat, left arm

retrosternal, throat, left arm

Quality

typically to the throat or left arm

typically to the throat or left arm

Quantity/Severity

tight, gripping, a dull ache

tight, gripping, a dull ache – but more severe than as for angina

Timing

short, usually only a few minutes

usually longer than 30 minutes and terminated only by use of opiate analgesia

Aggravating

exertion, stress, cold, emotion

usually none, but may have similar precipitants to angina

Alleviating

rest, glyceryl trinitrate (GTN) tablets (rapid)

often none except opiates

Associated manifestations

usually none

sweating, light-headedness, palpitations, nausea, vomiting, sense of foreboding

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Unit 3, Exercise 21 Student B a Plot a Pedigree diagram for your patient using the information below and the symbols in the box.

Pedigree diagram symbols

↑ ■● Ca CAD

male female patient patient deceased cancer cardiac disease

A&W ↑ ↓ RTA s.b.

alive and well increase decrease road accident stillborn abortion

Patient information ● Maternal grandmother died aged 74, stroke ● Maternal grandfather died aged 65, pneumonia ● Paternal grandmother died aged 70, cause unknown ● Paternal grandfather died aged 57, diabetes, coronary thrombosis ● Mother died aged 66, lymphoma ● Father died aged 69, coronary thrombosis ● Patient, male, 62, stroke ● Brother died aged 52, coronary thrombosis ● Brother, 69, alive and well, history of prostate cancer ● Sons, 38 and 40, alive and well b Interview Student A and plot his/her Pedigree diagram. Student A will interview you; answer using the patient information above. c Compare the two versions of each Pedigree diagram.

Unit 7, Exercise 10 Student B You are the patient. You are 35 years old and feel exhausted. You put this down to an accumulation of long hours at work and socialising. You have gained weight as a result of having to dine out on a regular basis with clients, an important part of your job. Listen to the treatment proposed by the doctor and outline any difficulties you foresee in following such treatment.

Unit 7, Exercise 13 Student B Scenario 1 You are the patient. You are a 35-year-old male suffering from work-related anxiety. The anxiety is currently very severe, and you want a solution as quickly as possible.

Scenario 2 You are the observer.

Scenario 3 You are the doctor. The patient is a 38-year-old male who plays rugby. He has severe pain in his knee, particularly when exercising or playing.

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COV-19 2020 Options: 1 Keyhole surgery: Good results where indicated, but need to undergo surgery with long waiting list.

2 Analgesics: Should provide immediate relief, but may not have any effect on the condition in the medium/long term.

3 Physiotherapy: Good results, medium-term waiting list. May have to moderate exercise/rugby.

Unit 8, Exercise 5a Student B Dr Staples *** Mr Johnson [looks nervous, fiddles with a gold chain] Dr Staples *** Mr Johnson Right, well, it’s a problem I’m having … down there … it’s like herpes … well, I think that’s what it is.

Dr Staples *** Mr Johnson My wife? I’m not married.

Dr Staples *** Mr Johnson No, I’m not gay! I have a regular girlfriend – Kate – but no, she doesn’t know I’m here, and anyway I don’t think she gave it to me.

Dr Staples *** Mr Johnson Well, actually I’ve been seeing someone new. My relationship’s not that good at the moment … I’ve been a little out of control recently … had a couple of one-night stands …

Dr Staples ***

Unit 8, Exercise 14 Student B Ask your partner to help you complete these definitions by asking questions.

Example: What does ‘acid head’ mean?

Jargon

Definition

1 acid head 2 clean

free from drugs (in system or person)

3 cut 4 dope

generic term for drugs

5 habit

an addiction to drugs

6 freebasing 7 jack up 8 mainlining

injecting intravenously

9 score 10 stash

place where drugs are hidden

11 script 12 tools 13 track marks

sign of injecting into a vein

14 user

person taking drugs (narcotics)

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Unit 8, Exercise 20 Student B a Read through your role and take a few minutes to consider the personality of your character, including environmental and social factors. Consider also the feelings that such a person might convey through their non-verbal cues.

It’s 3 a.m. on a busy night in August in the Accident & Emergency (A&E) Department of a small local hospital. Staffing in A&E is tight, with several people on holiday. An upturned juggernaut on the motorway has brought in a series of casualties throughout the night.

You are the Registrar on A&E. You’ve been asked to interview Cathy, a 35-year-old female with a suspected broken rib. You see from her notes this is not her first visit to A&E in the past few months (a previous fall with mild concussion a month before, etc.). Blood test results are compatible with alcohol abuse (raised gammaGT).

Consider asking your patient about the following: ● her drinking habits (use the CAGE tool) ● other possible symptoms ● her PMH and general health ● her feelings towards alcohol ● her interpersonal relationships ● what happens to her under the influence of alcohol. b Role-play the scenario, with Student A taking the role of Cathy. c Swap roles. d Use the list of dos and don’ts from Exercise 11a to give constructive criticism on your partner’s sexual history-taking technique. e As a group, decide what lessons can be learned from this activity.

Unit 9, Exercise 13 Student B Scenario 1 You are the patient. You are a 75-year-old male/female who has been in remission from stomach cancer for five years and has been readmitted to hospital. You suspect that the cancer has returned.

Scenario 2 You are the doctor. A 32-year-old nurse has had a blood test for a range of possible conditions as part of her securing employment at the hospital. You need to tell him/her that the test is positive for HIV.

Unit 9, Exercise 22 Student B Scenario 1 You receive a call from the local hospital to tell you about an accident that your child has been involved in.

Scenario 2 You are the doctor. You need to telephone a husband/wife about their partner. The patient has collapsed at work. You’re not sure what’s happened, but suspect that the reason may be due to a viral infection.

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Unit 9, Exercise 23 Student B Scenario 1 You are the patient. You are a 37-year-old pregnant woman. You are at the hospital to get the results of your scan. You are delighted to be pregnant.

You had a miscarriage two years ago, which was a terrible blow to you.

Scenario 2 You are the observer. Use this checklist to make notes of your impression of how well the doctor meets the criteria.

Communication checklist Give hope (e.g. possible treatment, lack of pain, mobility) where this is possible, but don’t minimise the severity of the condition or give false hope.

Give the patient time to ask questions.

Give information in manageable chunks, repeating key points if necessary.

Avoid jargon: explain medical terms in simple, clear language.

Show support.

Scenario 3 You are the doctor. Your patient is a 75-year-old man/woman whose stomach cancer has returned after five years. The cancer has spread to other parts of the body. The prognosis for recovery is poor. ●

● ● ● ●

Unit 10, Exercise 7 Student B You are the patient. You have acute back pain and find it difficult to cope.

You are in a lot of pain and you think that you will lose your job. You grimace and sigh deeply. You feel distressed and you find it difficult to say what is on your mind. You open your mouth, but the words won’t come out.

Unit 10, Exercise 18 Student B Scenario 1 You are the patient. You are 35 years old. You have come to see the doctor because you feel very vulnerable as a result of being bullied by your boss. As a result, you have been having anxiety attacks. You feel distressed talking about the issue and make little eye contact with the doctor.

Scenario 2 You are the observer.

Scenario 3 You are the doctor. Your patient is a 35-year-old woman who is suffering from depression. You have told her previously that she has to lose weight, but notice that she has put on more weight. You are not in favour of prescribing weight-loss pills.

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Unit 11, Exercise 11 Student B Scenario 1 You are the doctor. The patient is 72 years old.

Scenario 2 You are the patient. You are 80 years old and wear a hearing aid, but sometimes you forget to switch it on. You have gout in your right foot. Only respond accurately to the doctor’s questions if he/she asks you to check that your hearing aid is on and if you can see his/her lip movements clearly.

Unit 11, Exercise 23b Student B Scenario 1 You are the patient. You are a 68-year-old female. You are suffering from incontinence following a minor stroke. This is the first time you have had incontinence, and you feel very embarrassed. This is the first time you have met the doctor.

Scenario 2 You are the observer.

Scenario 3 You are the doctor. The patient is 75 years old and you have known him for a long time.

Unit 12, Exercise 26 Student B Scenario 1 You are the patient. You are 16 years old. You are suffering from very low esteem: at times, you feel like ending things. You don’t relate well to your parents, as they only seem to be interested in you getting the right grades to get into university. You have reluctantly made an appointment to see the doctor on the advice of your friend. You feel very vulnerable, but trust your friend’s advice.

Scenario 2 You are the observer.

Scenario 3 You are the doctor. Your patient is 14 years old and is underweight for her age. The parents are concerned that their child might be anorexic.

Unit 7, Exercise 13 Student C Scenario 1 You are the observer.

Scenario 2 You are the doctor. The patient is a 28-year-old married female, with three children. She has come to find out about birth control, as she doesn’t want any more children.

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COV-19 2020 Options: 1 The Pill: Oral or injection-based combined pill; 95–99% effective. Can cause side effects such as weight change and mood swings, but these often disappear after the first few months of use. May also cause a slight rise in blood pressure with increased risk of heart attack or stroke, particularly if patient is obese, diabetic, has raised blood pressure, has family history of heart attack or stroke, or smokes.

2 IUD/IUS: Rigid contraceptive device that is inserted into the womb by a doctor; 98–99% effective. IUDs give immediate protection and last for several years. They are useful for women who have already had children and want to defer or prevent future pregnancies. The device may increase the patient’s susceptibility to infections such as pelvic inflammatory disease. There is also a slight risk that the device will be rejected from the womb, or pierce the womb and cause serious inflammation.

3 Diaphragm: Barrier device; 84–94% effective at preventing pregnancy.

It must be left in place for six to eight hours after intercourse to prevent pregnancy and removed by 24 hours. A visit to a doctor is required for a proper fitting for the diaphragm.

Scenario 3 You are the patient. You are a 38-year-old male who plays rugby. You have a bad knee from an accident on the sports field. You want to get back to playing as soon as possible because your team is very close to the final.

Unit 9, Exercise 23 Student C Scenario 1 You are the observer. Use this checklist to make notes of your impression of how well the doctor meets the criteria.

Communication checklist Give hope (e.g. possible treatment, lack of pain, mobility) where this is possible, but don’t minimise the severity of the condition or give false hope.

Give the patient time to ask questions.

Give information in manageable chunks, repeating key points if necessary.

Avoid jargon: explain medical terms in simple, clear language.

Show support.

Scenario 2 You are the doctor. A five-year-old girl has been rushed into Emergency after being hit by a car. The girl was pronounced dead on arrival. She was an only child. You need to inform the parents.

Scenario 3 You are the patient. You have been feeling unwell lately. You managed to fight off cancer five years ago, but are worried that it has come back. ●

● ● ● ●

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Unit 10, Exercise 18 Student C Scenario 1 You are the observer.

Scenario 2 You are the doctor. The patient is a 42-year-old male. You are aware that he is a heavy drinker and you have told him that he has to give up. You are reluctant to prescribe painkillers until he stops drinking.

Scenario 3 You are the patient. You are a 35-year-old woman who is suffering from depression. You have come to ask for some weight-loss pills because you are quite overweight and your weight has continued to increase since you have been on anti-depressants. The doctor has told you that you must lose weight and take up some gentle exercise, but you just can’t motivate yourself. As well as being depressed, you are angry that the doctor won’t give you the weight-loss pills.

Unit 11, Exercise 23b Student C Scenario 1 You are the observer. Use the criteria you agreed in Exercise 23a to evaluate the role-play.

Scenario 2 You are the doctor. The patient is a 73-year-old male.

Scenario 3 You are the patient. You are a 75-year-old male. You had a bit of a funny turn while you were driving. Fortunately, it happened on a quiet road, and you were able to regain your composure. You are a bit reluctant to tell the doctor what happened because you are worried that he will suggest that you give up driving. You love the independence that your car gives you.

Unit 12, Exercise 26 Student C Scenario 1 You are the observer.

Scenario 2 You are the doctor. Your patient is 15 years old and has very bad acne.

Scenario 3 You are the patient. You are a 14-year-old girl and have come to see the doctor because your parents are concerned that you are underweight. You like being thin and do not want to put on weight. You eat normal-size portions, but exercise a lot.

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Audio scripts Audio 0.1 1 Can you raise your leg as far as you can?

2 Can you raise your leg as far as you can?

3 Can you raise your leg as far as you can?

Audio 0.2 1 Why haven’t you been taking your medicine?

2 Why haven’t you been taking your medicine?

Audio 0.3 Doctor Hello, George. Please have a seat. Now, what can I do for you?

Patient My chest seems much the same, Doctor, I don’t …

Doctor Let’s have a listen … Mm, well, it sounds a lot clearer now.

Patient I’m not sure. I feel exhausted all the time and I never feel like eating.

Doctor Well, the antibiotics tend to lessen the appetite. But you’re still eating something every day?

Patient Oh, I just pick at the odd thing. This is the third course of tablets I’m taking, and they’re having no effect.

Doctor You still have another ten days before you complete the course, don’t you?

Patient Yeah.

Doctor That should really make the difference.

Patient I can hardly lift a cup of tea. I’m really fed up.

Doctor I’m sure that will improve as your chest gets better.

We’ll see how you feel on your next visit.

Audio 1.1 Actually, a lot of research has gone into this, believe it or not.

The position of the seating is very important and can go a long way towards the success, or failure, of the interview. Patients are less likely to be forthcoming if they are seated directly opposite the doctor across a desk. If their seats are placed at right angles to each other, or if they are sitting opposite each other but away from the desk, then the patient is more relaxed and so more forthcoming. These are less formal seating arrangements.

Sitting across a desk from the doctor can make the patient feel ill at ease, and certainly in most cases, it doesn’t facilitate conversation.

The actual distance between patient and doctor is also important. You don’t want to be so far away from your patient that you can’t hear them or that they feel you aren’t interested in what they’re saying. But by the same token, neither do you want to make them feel threatened by being too close. Seats should be somewhere between four and six feet apart, although in the US, as close as three feet is still considered appropriate. Are there any questions at this stage?

Audio 1.2 1 Friend So, why are you so annoyed?

Patient Well, I go in, and it was just like this big empty room, really bare, horrible. The doctor just kept on writing notes.

You know, he didn’t even look up.

© Cambridge University Press 2007

Friend Typical.

Patient Then there was this nurse on the phone in one corner, couple of younger doctors, maybe medical students, I don’t know, in the other – they were chatting about their night out.

I felt so stupid, just standing there. Goodness knows how long I was waiting. Nobody even acknowledged me, let alone asked me to sit down.

Friend No! You’re joking!

Patient I’m not. Anyway, he got me to sit down eventually, then asked me what was up.

Friend He said it like that – what’s up?

Patient Yes, and he just sounded so bored. I don’t even think he knew my name. Certainly don’t know his. Trouble is, I was getting so annoyed, I went and forgot some of my questions.

Friend What, you mean you had a list?

Patient Yeah, read it on some medical website … they advise you to do that. You know how tongue-tied I get when I’m nervous.

Friend Suppose that makes sense.

Patient Especially with the symptoms I’ve been getting, I wanted to make sure I didn’t miss anything. I know I’ve got to get this stuff checked out. Now I’m going to have to get myself another appointment … Course, that’s going to cause problems – day off work, someone to pick up the kids from school … I’ve a good mind to complain.

2 Patient Saw that nice Dr Martorelli again this morning.

Friend Ooh, I do like him, he’s lovely.

Patient Very handsome … and he always takes his time with you, not like some of the others. Lovely voice – Italian, you know.

Friend Is he? Wasn’t sure, suppose he looks …

Patient Always shakes your hand, very proper.

Friend Yes, nice that, very polite.

Patient Stares a bit, though, bit intense sometimes, I have to look away. Must be an Italian thing. My hubbie reckons it’s cultural – I think it’s just his way. But you know I get a bit embarrassed, what with my bladder problem an’ all. Problems with my waterworks for years. But I’m sure that Tanya in the next bed could hear everything.

Friend Didn’t he close the curtains?

Patient Well, yes, of course, but still, don’t want all ’n’ sundry knowing your business, do you?

Friend No, no, you don’t.

Audio 1.3 1 GP

Good evening, Jenny, come in and take a seat. What brings you here today?

2 Consultant Good afternoon, Ms Kavanagh – am I pronouncing it correctly?

Ms Kavanagh Yes, that’s right.

Consultant Dr Simpson has referred you to me for further investigations. I’d like to spend five minutes with you to ask you some questions, if that’s OK?

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COV-19 2020 3 Registrar Hello, Mr Hanks … what would you prefer me to call you?

Patient Sid is fine.

Registrar Sid, my name is Dr Evans, and I’m one of the registrars on the ward this evening. I’ve come to have a little chat about your operation tomorrow.

Audio 1.4 Registrar Good evening. Miss Staples, isn’t it? I hope I’m not disturbing you?

Patient Yes, that’s right. No, you’re not disturbing me. It’s just the lottery, I’ll turn it down.

Registrar Onto a winner?

Patient Probably not, with my luck.

Registrar Now, er, Miss Staples – sorry, what would you prefer me to call you?

Patient Sue, Sue’s fine.

Registrar Sue, I’m Dr Anderson, and I’m the registrar on the ward this evening. Your consultant asked me to drop by to see you, to see if you were in any pain after the op. Are you comfortable? Can we get you another pillow?

Patient I’m OK, thanks.

Registrar Good. So, I’m just going to ask you a few questions – five minutes or so, and then we’ll let you sleep. If you don’t mind, I’d also like to take some notes as we talk.

Patient Sure, fine.

Audio 1.5 1a Registrar Good evening. Ms Finlay, isn’t it?

Patient Yes, that’s right.

Registrar I’m Dr Cameron. I hope I’m not disturbing you?

1b Registrar Good evening. Ms Finlay, isn’t it?

Patient Yes, that’s right.

Registrar I’m Dr Cameron. I hope I’m not disturbing you?

2a Dr Patel Yep? Patient Yeah, right … Been waiting ages. You know …

Dr Patel Yes, um, be with you in a minute.

2b Dr Patel Good morning, Mr Mahoney, isn’t it? Come in and have a seat.

Patient Yeah, right …

Dr Patel Sorry to have kept you waiting, Mr Mahoney.

Patient Thank you, doctor. You know, I’ve been sitting there for nearly an hour.

Audio 1.6 1 Good morning, er, Mr Barker, isn’t it? Your consultant asked me to come and see you.

2 Anya Kaplinski? You’ve come for your six-month check-up, I see.

3 Hello? Come in? Sorry for the wait, Miss Staples, we’re running a little late this morning.

4 Mrs Khan?

Audio 1.7 Dr Patel Ah, good morning, Mr Mahoney, isn’t it? Come in and have a seat.

Mr Mahoney Yeah, right …

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Dr Patel Sorry to have kept you waiting, Mr Mahoney.

Mr Mahoney Thank you, Doctor. You know, I’ve been sitting there for nearly an hour.

Dr Patel Yes, I do apologise, we’re running a little late this morning.

Mr Mahoney That’s all right, can’t be helped.

Dr Patel Now then, any improvement in the arthritis since I saw you last?

Mr Mahoney Well, yes, it’s been playing me up as usual – I can’t sleep properly and I’m in pain first thing, you know. But it’s these headaches that are really bothering me, I just can’t seem to shake them off …

Audio 1.8 Mr Swift Good morning, Mr Mahoney. Mr Swift, Senior Consultant. Please take a seat.

Mr Mahoney Thank you, Doctor.

Mr Swift Now, you’ve been referred by your GP, Dr Patel, and I see from his letter you’ve been having some problems recently with your health. I wonder if you could tell me in your own words what’s been happening.

Mr Mahoney Well, yes, I’m sure you’ve got all this information, but … my arthritis has been playing me up a bit as usual – I’m having difficulty sleeping and I’m in some pain first thing in the morning. But it’s the headaches that are really getting me down, they’re so painful. Sometimes I’ve been sick with them … literally. I’m starting to have time off work now because of them. My wife’s really worried. She’s the one that insisted I go see Dr Patel.

Mr Swift I can see it’s the headaches that are really bothering you, so if we can start by looking at those. We’ll come back to the arthritis later, if that’s OK with you. Is there anything else you want to discuss today?

Audio 2.1 Dr Haines Good morning, Mr Jenkins, I’m Dr Haines. So I see from the notes you’ve been suffering from a high temperature? Do you still have a temperature?

Mr Jenkins Uh-huh.

Dr Haines How long have you had that, a couple of days?

Mr Jenkins Oh, no, no, no – more than that. I’d say, on and off, about two months.

Dr Haines Two months? OK. Um. Are you shaking? Are you having night sweats?

Mr Jenkins Yeah, yeah. I shake and sweat and, yes, especially at night.

Dr Haines Um, right, OK. Do you have any muscular pain?

Mr Jenkins Er, yeah, yeah …

Dr Haines And your joints? You’re not suffering from achy joints as well, are you?

Audio 2.2 Dr Linley Hello, Sarah, I’m Dr Linley. How have you been feeling?

Sarah Not so bad, but I’m still very hot.

Dr Linley Can you tell me a bit more about it?

Sarah Well, I’ve been having these hot spells … for about two months now.

Dr Linley Two months? Two months, OK. Umm … any other symptoms?

Sarah Yeah, yeah. I shake and sweat and, yes, especially at night.

Dr Linley Umm, right, OK. Do you have any muscular pain?

Sarah Er, yeah, yeah …

Dr Linley Whereabouts?

COV-19 2020 Sarah I don’t know, all over.

Dr Linley Any pain in your joints?

Sarah Yes, it flares up every so often, just here …

Audio 2.3 a b c d e f g h

How do they compare to a migraine?

Whereabouts do you get these headaches?

How long do they tend to last?

How long have you had the headaches?

Are there any other symptoms?

Can you describe the pain?

What seems to improve the situation for you?

When do they come on?

Audio 2.4 Doctor So, what brings you here today?

Patient Um, I’ve been having these really bad headaches.

Doctor Go on …

Patient Well, I keep getting them.

Doctor Ah-huh? Can you describe them?

Patient Um, yeah. I’d say it’s like a pneumatic drill.

Doctor Mm. Could you explain what you mean by ‘pneumatic drill’?

Patient Yes, it’s quite a dull pain, but there’s a constant throbbing pain as well – it builds up.

Doctor Mm. Whereabouts do you get these headaches?

Patient Here, around the front, around the forehead.

Doctor Mm-hm. On a scale of one to ten, how would you rate them?

Patient Well, that’s kind of difficult to say to be honest, but, um …

Doctor OK. Have you ever had a migraine?

Patient Yes, a couple of times.

Doctor So, how do they compare to a migraine?

Patient Oh, they’re … no, not quite as bad as a migraine. It’s kind of that stage before.

Doctor How long do they tend to last?

Patient Oh goodness, er, anything up to six, seven hours.

Doctor OK, and how long have you had them, the headaches?

Patient Mm. I’d say for about three months now.

Doctor Ah-huh.

Patient On and off.

Doctor So, if I’ve got it right, you’ve been having these headaches for about three months now and they are quite painful, like a constant throbbing sensation?

Patient Yes, that’s about it.

Doctor And what seems to … what seems to improve the situation for you?

Patient Mm. Well, normally I lie down for a while and I turn off the light. That seems to help – they generally ease up when I do that.

Doctor And when do you, when do you really notice them?

When do they come on?

Patient Mainly in the morning, just when I’ve woken up.

Doctor Yeah, I see. OK. And are there any other symptoms?

Are you getting other symptoms at all?

Patient No, not really.

Doctor No? Patient No, but my husband reckons I’m going deaf.

Doctor Right. Well, er, maybe we’ll start by taking a look at your ears …

Audio 2.5 1 Uh-huh.

2 Yes. 3 I see. 4 Go on.

© Cambridge University Press 2007

Audio 3.1 So, moving on to the past medical history. Patients of all age groups have problems retrieving information about their PMH and may need a little coaxing. You can begin with an open question, but move on to closed questions; after all, you are looking for information that is directly related to the presenting complaint. However, be careful that you’re not interrogating the patient either and bombarding them with questions; give them time to reflect before going on to the next component.

Start by asking about a patient’s past illnesses. More recent illnesses are OK, but patients are often vague about those that took place further back, unless there is some kind of landmark – a particular stage in their life or a traumatic event, a death in the family, for example.

Childhood illnesses. As a child, the responsibility was with the parents, and so the patient may not necessarily remember which of these illnesses they suffered: mumps, measles, chickenpox. A significant period of time off school would be a memory jogger, however. Aside from the common childhood illnesses, you need to be asking about more unusual illnesses.

Immunisation is the next component. It is important to know if a child has been immunised or that a woman of child-bearing age is immunised against rubella or toxoplasmosis. People associate inoculations with school age, again something they were not responsible for, and so they don’t necessarily remember the details. As an adult, we tend to think about getting immunised just before going on vacation, but that’s about it.

Surgical procedures come next. But again, be aware that people tend to be vague about hospitalisations and any operations they might have had. Some patients may have little understanding of the exact nature of an operation, or indeed why exploratory investigations were carried out.

Next, accidents and injuries. This component may be easier for the patient to recall, but read the signs. Repeated head injuries or fights may indicate possible alcohol or drug abuse. Recurrent bruising or fractures in an elderly person may be a sign this person needs help or can’t cope, is potentially vulnerable and may need to be referred to the social services. Similar repeated injuries for a woman may well suggest domestic violence. As with the initial stages of information-gathering, you need to be observing the patient’s non-verbal communication as well.

It is customary to ask women of child-bearing age about pregnancy and any problems during pregnancy, er, maternal diabetes, toxaemia, etc. Distinguishing between abortion and miscarriage may be a problem for some; this can be trauma-related or a reluctance to admit a pregnancy to a partner or a family member.

Allergies are important to ask about, too, but patients might not make the link between allergic reactions to medication or food to the concept of allergies – they might simply remember to tell you they suffer from hay fever or that they have an allergy to dust.

Finally, medications – don’t forget to ask about medications.

This, too, could have a bearing on the presenting complaint.

Most patients can tell you about their current medications, but will forget to mention over-the-counter medicines – laxatives, flu tablets, allergy medication; even vitamins should be noted. They might also not think to tell you that they are taking alternative treatments, such as herbal or homoeopathic remedies. They may be wary of mentioning non-conventional medicine, as they are uncertain of the doctor’s thoughts about it. Patients may not mention medications prescribed by another doctor either, or may assume it has been included on the patient notes. However, when talking medications, my advice to you: avoid use of the word ‘drug’, as for many people this has connotations of illicit, addictive drug-using behaviour. So, to summarise, the eight points you need to cover are …

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Audio 3.2 Dr Tran Since this is your first visit to the practice, I’d like to have a more detailed picture of things. Could you tell me about any illnesses you might’ve had in the past?

Ms Martin I had my tonsils out when I was a little kid, I remember that.

Dr Tran Any other childhood illnesses?

Ms Martin Don’t remember, to be honest – my mother would know, I’d expect. Mumps, measles, that kind of thing, usual stuff.

Dr Tran Regular childhood illnesses, then? And how has your health been in general since then?

Ms Martin No, no real problems, to tell you the truth.

Dr Tran Good. So, have you had any operations, apart from the tonsils?

Ms Martin No, no. Like I say, I’m pretty healthy.

Dr Tran Any other visits to the hospital?

Ms Martin Yes, for the birth of my son, and, er, then a couple of years ago, I had to go in for some tests.

Dr Tran Mm-hm? What kind of tests, Ms Martin?

Ms Martin Don’t remember exactly.

Dr Tran Can I ask you how old you were when you gave birth?

Ms Martin Yes, it was just before my 40th – celebrated it surrounded by diapers that year!

Dr Tran Going back to those tests, Ms Martin, can I ask you to elaborate on those a little?

Ms Martin Oh, those, well, er, I lost my second baby, a little girl apparently.

Dr Tran I’m sorry to hear that. I have to ask, was she stillborn?

Ms Martin Yep. Dr Tran I understand this must be a painful memory for you.

Moving on, if we can. Are you fully immunised?

Ms Martin I’m sorry?

Dr Tran What I mean is, how up to date are you with your shots, Ms Martin?

Ms Martin I think I’m OK. I had most of those when I was at school.

Dr Tran How about tetanus?

Ms Martin Uh-uh. [shakes her head] Dr Tran Now, nearly finished this part. Um, have you ever suffered from allergies?

Ms Martin No, not that I know of. My brother always got hay fever, poor thing, but not me.

Dr Tran Any food allergies?

Ms Martin Mm … Strawberries – weird, isn’t it?

Dr Tran And I suppose they were your favourite fruit, too? Are you allergic to any medications – some people are allergic to penicillin, for example?

Ms Martin No. Dr Tran And finally, are you currently on any medications at all, Ms Martin?

Ms Martin Ah, yes. I was taking antibiotics, but didn’t finish the course, didn’t seem to be doing anything. I’m not on anything else.

Dr Tran Right. Can I ask you what you were taking them for?

Ms Martin Oh, I’d had a very bad cold and I couldn’t shake it off.

Dr Tran How about medications you buy over the counter?

Ms Martin Ah … laxatives sometimes, you know, for the problems I’ve been having recently. Tylenol, occasionally.

Dr Tran Some people believe in alternative medicine; is this something that interests you?

Ms Martin No, no, definitely not.

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Dr Tran Well, some people are turning to alternative forms of treatment, and so this is a question we have to ask, in case of any possible complications. OK … So, I’d like to sum up your history briefly to make sure I have all the details correct before we proceed. So you had your tonsils out and most of the regular childhood immunisations …

Audio 3.3 Dr Bhaskar … blood tests show you are iron deficient. Does that sound right, Mrs Wilson?

Mrs Wilson I suppose I must be, yes.

Dr Bhaskar Now, I want to ask you a few questions to have a clearer idea of what has caused your anaemia. I have to ask you a few personal questions if you don’t mind. Do you mind if I take a few notes as well as we go along?

Mrs Wilson No, that’s fine.

Audio 3.4 Dr Bhaskar Can you tell me how your periods have been over the past two years or so?

Mrs Wilson I had a hysterectomy about eight, nine years ago – er, 1999? Yeah, it was 1999. I had those, er, oh, what do you call them … f…?

Dr Bhaskar Oh, fibroids?

Mrs Wilson Fibroids, that’s it. And so my periods were really painful till then. I’ve not had a period since, obviously.

Dr Bhaskar And can you tell me when you started your periods?

Mrs Wilson Eleven, I think. Yes, it was – I’d just started secondary school.

Dr Bhaskar Uh-huh. Have you had any abdominal pain?

Mrs Wilson No. Dr Bhaskar I’m just going to ask you some questions about your diet and your bowel habit and, um … And so, apart from your hysterectomy, have you had any other operations or illnesses?

Mrs Wilson Never been in hospital otherwise, no.

Dr Bhaskar Can I ask you about any medication you might be taking at the moment?

Mrs Wilson Well, Dr Kwame put me on iron tablets when I saw her last week. I’m taking three a day.

Dr Bhaskar So, if I can just recap on what we’ve discussed so far: the blood tests you had showed you were iron deficient, and you’re currently on iron tablets as prescribed by your GP. You had no other symptoms, and you have a good, healthy, balanced diet. Your periods started when you were eleven, you had a hysterectomy in 1999. Is that an accurate summary, or have I missed anything out?

Mrs Wilson No, I think that’s all.

Audio 4.1 Professor In your last session, we looked at the elements involved in the past medical history. Today, an area a little less obvious – social history. Evaluating a patient’s social history is equally important for various reasons, and we’ll come back to those in a while. Under the umbrella of social history, we’ll look at the six different factors that may or may not have a bearing on your patient’s health. Occupation is the first one. Anyone have a stab at the kind of issues that might need to be addressed here?

Student 1 A doctor needs to ask about the type of job – whether it’s sedentary or active, how long they’ve been in the job, what they did before, etc. Also if they’re in contact with toxic fumes or products.

COV-19 2020 Professor OK, good start. It might also be important to ask about the occupation of other members of the household.

Linked to this, of course, is finance – a well-known source of stress – I’m sure you’re all familiar with that.

Stress is linked to depression, of course, and therefore the psychological well-being of your patient. Environment is also linked – both to work and the home. Why would it be useful to know about your patient’s environment?

Student 2 It’s the proximity to factories and farmland that’s important, I think. Is the patient at risk from living close to a company producing toxic products, for example?

Professor That’s part of it, Ella. Go on.

Student 2 Um, the condition of the housing itself, maybe?

How many bedrooms compared to the number of residents, the facilities … that’s what you mean, right?

Professor Right. Moving on to education. Now, levels of education can indicate how well the patient is informed about general medical care and his or her right to free health checks, depending on the patient, as well as access to information regarding safe-sex practices, the dangers of smoking, health and safety in the home, etc. What about the family? And I’m not talking about family medical history here … anyone?

Student 3 Support networks?

Professor Can you elaborate, Reza?

Student 3 Yes, there are two types of support network. Formal, like the social services, and informal, like the family. Does the patient’s family live nearby? What’s the patient’s relationship with their family, do they help take care of the patient’s children? That kind of thing.

Professor Thanks. Lastly, there’s lifestyle. As well as asking our patients about their general level of fitness and determining their attitude towards exercise, etc., we’re also going to be asking them about alcohol consumption, whether or not they smoke, if they use recreational drugs at all. Also their sexual practices. We might also ask them about recent trips abroad.

Can anyone tell me why you think that might be relevant?

Audio 4.2 In the USA, an estimated 50,000 to 70,000 deaths per year are caused by occupational factors, and more than 350,000 new cases of occupational disease are recognised every year. These diseases involve every organ system, and one of the most important barriers to the accurate diagnosis of occupational and environmental diseases is the long latency between exposure and the appearance of the illness.

Audio 4.3 GP

I’m now going to ask you some questions about your job.

What type of work do you do, Mary?

Mary I’m a cleaner at a big hotel in town, part-time.

GP Uh-huh, if you could just describe your work for me?

Mary Well, it’s much the same as any other cleaning job, I’m afraid, Doctor.

GP Um, I understand, but it’s important to know this to give me an idea about why you’re suffering from these asthma attacks all of a sudden.

Mary Oh right. Um, I’m generally on bedroom duty, I suppose I clean about 15 bedrooms on average every morning.

GP Mm-hm. And are you exposed to any toxic products at work?

Mary Toxic? Don’t know if they’re toxic or not – they’re regulation cleaning products, so I imagine they’re OK. As I said before, I’ve only had problems with the attacks recently.

I’ve been using the same products for a couple of years now.

I … I tend to get the attacks when I’m at home, anyway.

© Cambridge University Press 2007

GP

Has anyone in your household ever worked with hazardous materials that could have been brought home?

Mary No, don’t think so. My husband’s not working at the moment, anyway.

GP I see. What about where you live, your environment. Do you live near any factories that give off potentially hazardous fumes?

Mary No, no. There’s no factories round our way, Doctor.

GP How do you and the family spend your evenings, Mary?

Mary You know, the usual – telly, I read sometimes. But then most of the time, I’ve my little girl to take care of. She’s still on chemo, so I’m up at the hospital most nights.

GP How are you coping?

Mary Well, it’s not getting any easier, I’m afraid.

GP And your husband, your children?

Mary Oh, Pete’s got the boys on the new hobby – it’s good for them to do something creative, and it keeps them occupied, stops them thinking about their little sister. But then, I think he does it for himself, really.

GP What’s that, then?

Mary Making model planes … you know, those kits you can buy with all the fiddly little pieces …

Audio 4.4 Doctor Now, if you don’t mind, Sinead, I’m just going to ask you a few questions about your home life.

Sinead OK. Doctor It’ll help me to better assess your present situation.

Perhaps you could start by telling me about your current living situation?

Sinead Yeah. I live up on the Hudson Estate; do you know it?

Doctor Going out towards the ring road, right, on the way to Stevenage?

Sinead Yeah, that’s it. I’ve been there a few years now with the three kids. It’s a bit small, but it’s all the Council could give me at the time.

Doctor When you say small, how many bedrooms do you have?

Sinead Just the two. It’s not really practical, now there’s Fred as well – my boyfriend.

Doctor How about pets, do you have any pets?

Sinead Oh yeah, the kids love their animals. They’ve got a couple of rabbits and a parakeet. And Fred’s got one of those Rottweiler things.

Doctor Ah-ha. You don’t approve of the dog, I take it?

Sinead I’m worried for the kids – I think it’s dangerous having that kind of dog around. Anyway, the place is just too small.

He’s out in the garden most of the time, but then he messes the garden and that … ugghh.

Doctor Ah-ha. What about members of your family?

Sinead My mum’s just down the road, and I’ve got my brother over in Stevenage. Mum’s great – she loves taking care of the little ones. My brother and his girlfriend are always coming over.

Doctor So you’ve got lots of support, then. And you’re currently in a relationship, if I’ve understood right?

Sinead Yes, six months now.

Doctor So, how are things there?

Sinead It’s OK, I suppose.

Doctor You don’t sound very convinced.

Sinead He’s started drinking again.

Doctor And how does that affect you and the children?

Sinead It doesn’t affect the kids much – he comes in really late and they’ve gone to bed.

Doctor And you? How do you cope with Fred’s drinking?

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COV-19 2020 Sinead I try to keep out of his way; pretend I’m asleep when he gets in. He’s got a real violent temper.

Doctor I see. And has he ever been violent towards you or the children?

Sinead No, no, he hasn’t.

Doctor Um, is there anything else worrying you at the moment?

Sinead Money. I’ve got problems with the bank, there’s loans to pay, and I owe a few people – my Mum, she’s lent me a bit, but she can’t really afford it either.

Audio 4.5 1 We need to remove your wife’s womb, Mr Singh – this is known as a hysterectomy.

2 A substance that is carcinogenic means it is likely to cause cancer.

3 Apnoea is quite a serious condition that affects your breathing.

4 Agoraphobia is the fear of wide-open spaces and can cause great distress in its sufferers.

5 Your daughter has leukaemia, which, on a very simplified level, is a cancer of the blood.

6 Arthritis means you are suffering from inflammation of the joints.

7 Neuralgia is caused by irritation of a nerve.

8 Some women suffer from endometriosis, or diseased tissue of the uterus.

Audio 4.6 Dr Marsden Good evening, I’m Dr Marsden. I wonder if you could give me your full name and telephone number, please, just in case we need to call you back at any point or we get cut off.

Tony Yes, of course. My name’s Tony, Tony Patchett – that’s P-A-T-C-H-E-T-T – and the number is 01229 845143.

Dr Marsden Good, thanks. Now, could I also have your date of birth, please?

Tony Yeah, er, 30th May 1956.

Dr Marsden So, what prompted you to call us today?

Tony Well, you see, I’ve been getting these pains in my chest, a real burning pain … too much rich food over Christmas, probably – I always overdo it.

Dr Marsden Well, it sounds as though you’re suffering from a bout of indigestion, Mr Patchett. It isn’t anything to be concerned about at this stage. So what I’m going to suggest is that you go to your local pharmacy and buy an antacid – Gaviscon, for example. I would also suggest you reduce your intake of rich food over the next few days.

Tony Ah-huh.

Dr Marsden Now, if the medication doesn’t solve the problem over the next 24 hours, then I would advise you to make an appointment to see your GP. Tony After 24 hours, OK, if that’s what you say, Doctor.

Dr Marsden Now, Mr Patchett, I’d just like to briefly summarise your history to be sure I have the details correct.

You’ve been suffering from mild chest pains since Christmas Eve and you’ve experienced some acid burning. You’ve eaten a lot of rich food over the last few days, which is unusual – your diet’s usually quite plain – and you think this might have contributed to your symptoms. You’ve no history of ulcers. You don’t have any other symptoms. No one else in your household has these symptoms. Is that right so far?

Tony Yes, think so.

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Dr Marsden My advice therefore is that you treat the symptoms with an over-the-counter indigestion remedy. You should also reduce your intake of rich food. But should the symptoms persist, you do need to see a doctor.

Tony OK. Dr Marsden Now, if you wouldn’t mind going over the advice I’ve just given, Mr Patchett?

Tony Er, treat the symptoms with Gaviscon or something like that and cut out rich food. If I’ve still got the indigestion this time tomorrow, then I have to make an appointment with my doctor at the surgery.

Dr Marsden Yes, that’s right. Now, before we finish, is there anything more you want to ask?

Tony No, no, that’s fine. I feel better knowing it’s nothing serious. Thanks.

Dr Marsden I’m pleased you feel reassured. Goodbye, Mr Patchett. Enjoy the rest of your Christmas holiday.

Audio 4.7 Dr Marsden Now, Mr Patchett, I’d just like to briefly summarise your history to be sure I have the details correct.

You’ve been suffering from mild chest pains since Christmas Eve and you’ve experienced some acid burning. You’ve eaten a lot of rich food over the last few days, which is unusual – your diet’s usually quite plain – and you think this might have contributed to your symptoms. You’ve no history of ulcers.

You don’t have any other symptoms. No one else in your household has these symptoms. Is that right so far?

Audio 4.8 Dr Baker What prompted you to call today, Mr Tomlinson?

Mr Tomlinson I’m … I’m not sure exactly. I don’t know if I really need to go in and see my doctor or not, but I don’t want to be taking time off work.

Dr Baker I can hear you’re having trouble breathing. Am I right in thinking this is what you’re calling about?

Mr Tomlinson Yes. I’ve had this all weekend, but I didn’t want to spoil it for the grandkids – they were up to stay this weekend.

Dr Baker Lovely to see them, but lots of hard work, eh?

Mr Tomlinson You’re not kidding.

Dr Baker I can sympathise; I have my own … Now, can you describe your symptoms to me in a little more detail?

Mr Tomlinson I have problems getting up the stairs these days, you know.

Dr Baker I see, go on …

Mr Tomlinson Well, that’s it. I’ve cut down on the fags these last few weeks, but I’m still having trouble. I cough up this horrible stuff all the time, too. I’m not sure what else you need to know …

Dr Baker Stuff? What does it look like?

Mr Tomlinson Stuff … I mean phlegm – yellowish phlegm.

Dr Baker Thanks. Tell me about any illnesses you might have had in the past.

Mr Tomlinson Bronchitis, I’ve had bronchitis a couple of times now. Could it be that again, do you think?

Dr Baker Hmm. And what type of work do you do, Mr Tomlinson?

Mr Tomlinson I have my own shop now – an off-licence – wines and spirits, you know.

Dr Baker OK. How do you manage?

Mr Tomlinson Well, there’s lots of lifting, that’s for sure. I’m having real trouble with that side of things … but the daily running of the place – no problems. But …

COV-19 2020 Dr Baker You sound a little worried by the situation?

Mr Tomlinson The hours at the shop are long. I’d like to spend more time with the grandchildren and help Rob out as much as I can. I want to do my best for them, you know; it’s only right after my daughter’s death, the poor lad’s got enough on his plate as it is …

Audio 5.1 A Doctor If you could stand up for me, please, Julie. I’d like you first to try to bend your left knee … very gently.

Patient Like this?

Doctor That’s right, as if you were trying to touch your bottom with your heel … Fine, thank you. You can put your foot down now. OK, I’d just like you to lift your left leg as high as you can … that’s it. How does that feel?

Patient Actually, it’s quite painful in that position.

Doctor Please, if you could take off your shoes and your tights and sit back up on the examining table. Do you need any help getting up on the table?

Patient No, think I can manage that OK … right.

Doctor Would you mind just lifting your skirt over your knee? Yes … yes, the left one. Thank you. Now I’m going to examine your knee. Just relax your leg. I’m going to press on your knee, and I want you to tell me if it starts to feel uncomfortable or if there’s any pain.

Audio 5.3 1 a b 2 a b 3 a b 4 a b

I’d just like you to lift your leg.

I’d like you to lift your leg.

It looks like a minor fracture.

It just looks like a minor fracture.

I’m just going to feel your shoulder for any fractures.

I’m going to feel your shoulder for any fractures.

One more examination left.

Just one more examination left.

Audio 6.1

B Patient I really think I’ve dislocated my shoulder this time, Doctor.

Doctor Well, let’s see. I’ll need you to do a few tests first, just in case.

Patient Sure, that’s OK. Doctor Can I ask you to take off your shirt, Keith, and sit on the edge of the bed … If you don’t mind, I’m just going to feel your shoulder for any fractures … Now, this might be a little painful.

Patient Ouch!

Doctor Right … right, that’s fine. It just looks like a minor fracture at this stage. Now, what I want you to do is to stand up and put your arms by your side … OK. Now, Keith, if you could just lift your right arm to shoulder level … yeah? … and then bend your elbow horizontally … yes, that’s it, towards me. Thank you. Just one more examination left. Would you mind just holding out your right hand?

Patient Like that?

Doctor That’s it. Now, with your palm facing up, lift your arm, as if you were pointing up to the ceiling … and now the reverse, lower your arm, till your fingers are pointing to the floor.

Dr Finlay OK, Ben. To begin with, I’m going to give you your results, and then we’ll discuss where to go from there. If you recall from our last conversation, I mentioned the possibility of diabetes?

Ben Yes, I remember.

Dr Finlay Well, your results show that you have the early stages of diabetes. Let me explain. A reading between 100 and 125 mg/dl would indicate the early stages of diabetes, and your glucose level is 115. So this means that you do have a form of pre-diabetes. A reading of over 126 would indicate you have diabetes, but we’ll need to do another test to confirm this.

Ben Right, so if the reading comes back the same, that means I don’t have diabetes?

Dr Finlay Well, it’s not as simple as that … Before I move on, can I just check what you understand by diabetes?

Ben Something to do with sugar levels in your body?

Dr Finlay Yes, your body isn’t able to absorb the sugar it needs. Do you know anyone with this condition?

Ben Well, I used to work with somebody who had diabetes, and he had to inject himself every day and he wasn’t allowed to eat any sweet things.

Dr Finlay It sounds as if your colleague had quite severe diabetes. Does that worry you?

Ben Could that happen to me?

Dr Finlay Well, yours is much milder, but that brings me to the next point; we do need to control your condition so it doesn’t get any worse. There are four things you need to consider. First of all, you need to lose weight; secondly, you need to cut down on your drinking; thirdly, you need to cut out saturated fats and salt from your diet; and finally, you have to give up the cigarettes. It would also help if you took up some gentle exercise. So, just to recap, we need to do another blood test and in the meantime, it’s important that you make immediate changes to your lifestyle. Do you think you’ll find that difficult?

Audio 5.2

Audio 6.2

1 GP

Yes, thank you for your patience today, Mr Barker, we’re running over time, unfortunately. Now, Mr Barker, if you could just take off your shoes and loosen your jeans? Would you mind rolling over onto your stomach for me?

2 GP Now then, Miss Davies, first I need to examine your back.

Patient Oh, really?

GP Yes, I’d like you to just slip off your shoes, lift up your jumper and lie down on the couch over there.

Patient OK …

GP That’s fine … now, I want you to sit up with your legs stretched out in front of you.

© Cambridge University Press 2007

1 You do have a form of pre-diabetes.

2 We do need to manage your condition.

Audio 6.3 Dr Finlay Now, is there anything at this stage that you would like to ask me?

Ben Will I need to have insulin jabs? I hate needles, they really scare me.

Dr Finlay No, you won’t. The important thing is that you follow my advice about changes in lifestyle – losing weight, cutting out fatty foods and salt, cutting back on your alcohol intake and giving up smoking. Is there anything else you’d like to ask?

Ben The person I was telling you about had to have his foot amputated. That won’t happen to me, will it?

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Audio 6.4

Doctor I can understand your concern, but antibiotics really are your best chance of getting rid of the infection quickly.

Different antibiotics affect you in different ways; I can also give you some cream which will sort out the thrush. If you need to, I can give you a doctor’s note so you can take time off work.

Patient I can’t do that. I just need to get better. [pause] OK, I’ll try some different ones.

Doctor OK, and if these don’t help, come and see me again. But I’m hopeful that these will take care of the problem for you.

1 Will that happen to me?

2 That won’t happen to me, will it?

Audio 7.3

Dr Finlay Now, please don’t get upset. I can understand your concern, but if you follow the advice I’ve given you, that isn’t going to happen.

Ben Yes, but he can’t work any more. I can’t lose my job. I’ve got my family to think of.

Dr Finlay As I explained to you before, your colleague has a very severe case of diabetes.

Audio 7.1 Doctor Hello, Miss Lennox. What can I do for you?

Patient The antibiotics you prescribed haven’t cleared up my chest infection.

Doctor Right. Did you complete the course?

Patient Yes, I did.

Doctor And do you feel any better after taking them?

Patient No. They’ve had absolutely no effect, apart from giving me thrush and leaving me feeling completely exhausted.

Doctor Right. What I’ll do is try you with a different set of antibiotics.

Patient Another course? But why didn’t the other course get rid of the infection?

Doctor It’s not always easy to know exactly which antibiotics to prescribe.

Patient I feel like some kind of guinea pig.

Doctor If you want to get rid of the infection, you’ll need to persevere with them.

Patient How long will I have to take them for?

Doctor Ten days.

Patient And what happens if there’s no improvement after a few days?

Doctor You’ll need to complete the course to allow them to take effect.

Patient I’m really not crazy about taking more antibiotics.

Isn’t there anything else I could take instead?

Doctor No, I’m afraid only antibiotics will clear this up.

Audio 7.2 Doctor Hello, Miss Lennox. What can I do for you?

Patient The antibiotics you prescribed haven’t cleared up my chest infection.

Doctor Right. Did you complete the course?

Patient Yes, I did.

Doctor And do you feel any better after taking them?

Patient No. They’ve had absolutely no effect, apart from giving me thrush and leaving me feeling completely washed out.

Doctor Right. I’m sorry to hear that. Sometimes antibiotics may not agree with patients. What I’ll do is try you with a different antibiotic and see how that goes.

Patient Isn’t there something else that I could take instead?

Doctor Unfortunately not. It’s possible that the infection may clear up on its own if we leave it, but most likely it’ll drag on.

A different antibiotic could really help here.

Patient I really want to get rid of it, but I’m not sure I can face another course.

Doctor Is that because of the thrush and feeling washed out?

Patient Yes. I’ve got a demanding job, and it’s a struggle getting through each day at the moment.

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Doctor Mm, your blood pressure is a bit on the high side, Mr Dean.

Patient Oh. Doctor Did you have to rush to get here?

Patient A bit. Er, it took a while getting a parking space, and I ended up parking a few roads away from here.

Doctor I see. Well, your blood pressure might be a bit high on account of that. I’ll take it again in a few minutes … It’s gone down a little, but it’s still a bit higher than it should be. It’s important that we control it. Do you understand why it’s important to control your blood pressure?

Patient It can cause a stroke or heart attack?

Doctor Yes, that’s right. Now, there are a number of options you could consider, so firstly, I’ll outline what they are and then I’ll talk about each treatment in turn, OK? Patient Fine.

Doctor In terms of medication, the following options are available. You could consider taking water pills, or diuretics.

These flush out excess fluid and salt in your body, which helps to lower blood pressure. Another option is taking beta blockers. Basically, these block the effects of adrenalin on the heart, reducing the amount of stress to the heart. This means the heart doesn’t have to work so hard, and therefore blood pressure is reduced. Another option you could think about at this stage is making certain adjustments to your current lifestyle – getting your weight down a bit, limiting yourself to two units of alcohol a day and doing some regular, moderate exercise may bring it down naturally.

Patient But having a few drinks with my friends is the only chance I get to relax!

Audio 7.4 Doctor One option we could look at is prescribing you diuretics.

Patient Er, don’t they make you go to the toilet a lot?

Doctor Yes, that is a downside of them, but if you take them in the morning, you should be able to sleep through the night without having to go to the toilet.

Patient Right.

Doctor Other possible side effects you may experience are weakness, fatigue, dizziness or muscle cramp, but these effects should wear off after a short while. Now, turning to beta blockers …

Patient Hm, I’m sure those are the ones my friend said made him impotent?

Doctor Well, that can happen, but it’s not very common. The advantages to this are that they can reduce anxiety as well as control blood pressure. Again, however, there are some common side effects which you should be aware of, such as nausea, dizziness and insomnia. More serious side effects might include depression or disorientation, but we’d monitor your reaction closely.

Patient Right.

COV-19 2020 Doctor The other option you could try is adopting a healthy lifestyle plan. Basically, eating a low-fat diet, increasing your intake of fruit and vegetables, avoiding salt in your food, cutting right down on alcohol and doing some form of exercise a few times a week.

Patient So I wouldn’t have to take any medication?

Doctor No, you wouldn’t. Your blood pressure isn’t very high, and simple lifestyle changes might bring it down to a normal level. We would monitor it over the next month to see if that was enough.

Patient Mm, that seems worth a try. I’d prefer not to take any medication, really, with all those side effects.

Doctor The only problem you may have is keeping to a healthier lifestyle. Some patients find it difficult to change old habits – for example, you may find that you really miss particular foods.

Patient Well, I’ll give it a go, anyway.

Audio 8.1

Audio 7.5

2 Doctor So, Dina, how can I help you today?

Dina I think I need to go on the pill. I’m still getting really bad stomach cramps, like before. Um, I’m getting them every month now. Ella in my class at school, she’s been on the Pill for a year now, and she says it’s really helped. I mean, I’m missing most of my classes the day I get my period at the moment, and it’s just really inconvenient …

Doctor It’s important that you stop smoking.

Patient I know, but it’s easier said than done. I’ve been smoking since I was 12, and all my friends smoke.

Doctor I understand that it’s not easy, but it’s making your asthma worse.

Patient I know.

Doctor OK, so I’m going to outline some ways to help you stop smoking.

Audio 7.6 Doctor OK, so I’ve outlined the options, which one do you want to go with?

Patient I’m not really convinced by any of them. I could just try to stop …

Doctor You could do, but you’ll need to have very strong willpower. Do you really think you could manage that?

Patient Well, I tried that a few years ago, but I didn’t get past the second day. But I feel much more determined this time.

Doctor How about if you cut down your smoking for the next two weeks? What’s the least you think you could get by on?

Patient I think five might be do-able.

Doctor That sounds like a reasonable beginning. OK, then, so let’s agree that you keep to five cigarettes a day.

Patient OK. Doctor I’d like you to keep a record each day. It’s important that your family and friends know what you’re trying to do, so they can help if you’re finding it difficult.

1 Doctor So what brings you here today, Mr Thompson?

Mr Thompson I was wondering what I needed to do to get an HIV test.

Doctor Of course. Is there any particular reason you feel you need to have an HIV test?

Mr Thompson Well, yes. I’m being sent by my company to Australia to head up a new subsidiary over there. It’s a great opportunity.

Doctor Sounds good, congratulations.

Mr Thompson Thanks. Yes, me and Sally – that’s my wife – we’ve been wanting to emigrate there for a couple of years.

So anyway, we’ve filled in all the paperwork, just on the last hurdle now – I need proof of a negative HIV test, so I was wondering if you could arrange this for me …

3 Doctor Mr Templeton, what brings you here today?

Mr Templeton I fell while I was doing the cleaning.

Doctor Oh. Mr Templeton Anyway, my daughter’s worried about me, Doctor.

Doctor In what way?

Mr Templeton She thinks I need to come and talk to you about my drinking.

Doctor Well, if you start by telling me how you feel about your drinking, then we can take it from there …

Audio 8.2 Doctor So what brings you here today, Mr Thompson?

Mr Thompson I was wondering what I needed to do to get an HIV test.

Doctor Of course. Is there any particular reason you feel you need to have an HIV test?

Mr Thompson Well, yes. I’m being sent by my company to Australia to head up a new subsidiary over there …

Audio 7.7

Audio 8.3

Doctor OK, just to recap on what we’ve discussed. You’re going to try to lose some weight to see how much that brings down your blood pressure.

Patient Yes, that’s right.

Doctor You’re going to follow the diet sheet for the next three weeks and then you’ll come back and see me. You’re also going to do 30 minutes’ exercise three times a week.

Patient Yes – well, I’ll give it a go, anyway.

Doctor Is there anybody who can give you support if you’re finding it difficult?

Patient My wife will help if I explain why I’m doing this.

Doctor That’s good. If you’re having trouble keeping to the diet or you feel you need some support, you can phone me at the following times during my telephone consultation hours.

Patient OK, that’s good to know.

Doctor Is there anything else you’d like to ask?

Patient No, it’s clear what I have to do.

Doctor Mr Templeton, what brings you here today?

Mr Templeton I fell while I was doing the cleaning. Anyway, my daughter’s worried about me, Doctor.

Doctor In what way?

Mr Templeton She thinks I need to come and talk to you about my drinking.

Doctor Well, if you start by telling me how you feel about your drinking, then we can take it from there …

© Cambridge University Press 2007

Audio 8.4 Dr Hanley I’m going to ask you some questions that regard your personal life, in particular your sex life, that some people find a little sensitive.

Jennifer Er, I don’t really see the relevance, Doctor …

Dr Hanley There may be various reasons for your symptoms, but in order to find out more, I’m afraid I’m going to have to ask some rather personal questions. Is that all right with you?

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COV-19 2020 Jennifer Sure, that’s fine.

Dr Hanley I see there’s something troubling you, Jennifer …

Jennifer No, no, it’s fine.

Dr Hanley When was the last time you had sexual intercourse?

Jennifer Ah, I broke up with my boyfriend not so long ago, so I guess it’d be about two months ago.

Dr Hanley OK, and could you just tell me if you’ve had any other symptoms, apart from the pains in your abdomen?

Jennifer Well, it’s kind of embarrassing …

Dr Hanley Take your time, Jennifer, there’s no rush. As I said, many people find this type of thing difficult to talk about.

Jennifer Ah, there’s this white stuff … what do you call it?

Dr Hanley Discharge.

Jennifer Right.

Dr Hanley And when did you first notice the discharge?

Jennifer Just a couple of days ago.

Dr Hanley And did you notice any pain during intercourse?

Jennifer Yes, sometimes. There was blood, too, sometimes.

Dr Hanley Have you noticed blood at any other time?

Jennifer Er, I’m not sure what you mean.

Dr Hanley Between your periods, for example?

Jennifer Oh, that! Yes, from time to time, but suppose I didn’t think anything of it. Why, is it serious? Is it something I’ve caught? I don’t remember James having anything like this.

Dr Hanley At this stage, it’s better not to speculate, but I’m going to ask you to give a urine sample and, depending on the results, we’ll be able to make a diagnosis.

Jennifer But why would I be the only one with symptoms?

That’s what I don’t understand.

Dr Hanley With some infections, some partners don’t even realise they’ve contracted it – they don’t have any noticeable symptoms. I suggest you make another appointment for next Thursday, but if you’d prefer to speak to a female doctor, I can refer you to Dr Stevens.

Audio 8.5 Doctor I’d like to ask you now about your drinking habits. Do you drink alcohol, Dave?

Patient Yeah, course, but you know, it’s just a social thing – out with my mates sometimes of an evening. The usual.

Doctor Uh-huh … go on …

Patient Well, that’s it, really, Doctor.

Audio 8.6 Doctor So, how often do you drink with your friends – let’s say, in an average week?

Patient Average week? Well, that’d be two or three nights after work before I go home, and then Saturday night, of course, with the lads.

Doctor Mm-hm. And so how much would you tend to drink after work?

Patient Two or three pints. My girlfriend wouldn’t be happy if she knew.

Doctor Hmm … and on a Saturday, how much can you drink on a Saturday?

Patient Ah, Saturday, that’s probably a little more.

Doctor A little more?

Patient Five, six, sometimes more …

Doctor Do you ever drink at home at all?

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Patient Sunday night – I tend to stay in with my girlfriend and watch a DVD. We’ll generally share a couple of bottles of wine between us, but that’s it. Well, I say we split it – she only has a couple of glasses. But no spirits – used to drink spirits when I was at college, but, let’s say, they don’t agree with me. [pause] Makes me go a bit mad – not nice to know, if you get what I mean.

Audio 8.7 Doctor OK, Dave, I’d like to ask you a little more about your drinking, if you don’t mind.

Patient Yeah, but I’m not sure I know where you’re going with this?

Doctor I just need to have a better understanding of your drinking habits.

Patient Right.

Doctor Have you ever felt the need to cut down on your drinking?

Patient Cut down? Well, I did after college. But not now – think I’m fine now.

Doctor Have people ever annoyed you by criticising your drinking?

Patient Like I said, my girlfriend gets a bit edgy when I drink too much – but that’s just how she is. Bugs me sometimes – maybe she’s got a point.

Doctor Have you ever felt guilty about your drinking?

Patient Missed my mum’s birthday this year ’cos I’d drunk too much the night before – I couldn’t get out of bed the next day. But she was fine about it. Didn’t get on my case – not like my girlfriend, anyway. She’s cool, my mum.

Doctor Have you ever needed an ‘eye opener’ first thing in the morning – to steady your nerves or get rid of a hangover?

Patient An eye opener – is that what they call it? No, I’m not at that stage yet, Doctor. Not quite needing the ‘hair of the dog’ just yet!

Audio 9.1 Doctor Apologies for not having a quieter spot to talk, my office is being used by somebody else.

Patient I just want to get it over with.

Doctor I can understand that. Well, we’ve just had your tests back from the lab, and I’ve had a quick look.

Patient And? Doctor It looks as if the tumour has spread.

Patient Right, so, um, what happens now?

Doctor Well, there are a couple of other options we can try, which we can discuss in your next appointment …

Audio 9.2 Doctor Hello, James. Please have a seat.

James Thanks.

Doctor So, tell me, how have you been feeling since I last saw you?

James Not too good. I’ve been feeling really flu-ish. I have to change my T-shirt a few times a day because they’re soaked with sweat, and walking up the stairs really catches my chest.

Doctor I’m sorry to hear that. You know those blood tests we did last visit?

James Yes? Doctor Well, we’ve had the results back. I was hoping to have better news for you, but I’m afraid that they were positive for HIV.

COV-19 2020

Audio 9.3

Audio 9.6

1 2 3 4 5 6

Doctor Hello, Deborah, I’m Dr Naylor. I spoke to you earlier on the phone.

Deborah Hello.

Doctor Would you like to come with me? We have a quiet room at the end of the corridor. … It’s good you could get here so quickly. I’m very sorry about your mother. I can see that this is a terrible shock for you.

Deborah I can’t believe it.

Doctor OK, so before we go in, I just want to update you on your mother. We examined her, and she’s had a severe brain haemorrhage. Unfortunately, there is very little chance of her pulling through.

Deborah But how did it happen?

Doctor It would have happened very quickly – she might have had a bit of a dizzy spell or a bit of a headache. She would have gone into a coma immediately. The most important thing now is that she’s peaceful and that we’re doing everything to make her comfortable. I just want to explain that there are a number of tubes and wires attached to her.

Just try to ignore them. She’s on a ventilator, as her own breathing was weak.

Deborah Oh, I feel terrible that nobody was there when it happened.

Doctor It’s normal to feel guilty in a case like this, but you mustn’t. This was waiting to happen, but nobody could have predicted when. Now, I understand other members of your family are on the way?

Deborah Yes. Will they get here in time?

Doctor Well, I can’t say for sure, but at this stage, I’d say she has about three days. It’s important that she has her family around her. Do you have any other questions you’d like to ask me?

Deborah No. Doctor I’ll speak to you again when you’re all here. Once again, I’m very sorry about your mother.

It’s only normal to feel like that.

How does that make you feel?

I know this is not good news for you.

Can you tell me what you’re worried about?

I know this must be very hard for you.

Anybody would react in the same way.

Audio 9.4 James So, I’ve got AIDS? Doctor Well, you’re HIV positive, which means that you have been exposed to the HIV virus, which causes AIDS. It can take a long time to develop into AIDS, but from the symptoms we observed on your last visit, there is the possibility that it’s happening already.

James Right.

Doctor Can you tell me how you’re feeling, James?

James [pause] I’m really scared. One of my friends died of AIDS two years ago.

Doctor It’s only natural that you feel scared.

James So, can it be treated?

Doctor There are drugs that can help. Would you like me to tell you about them?

James Not right now, Doctor. I’m not able to take much in at the moment.

Doctor I can understand that. We can go through it at your next appointment.

James OK. [pause] What are my chances?

Doctor I realise how difficult it must be for you to ask that question. I can’t really say at this point, but we’ll do everything we can. Do you have a friend or relative you can talk to about this?

James I’m really close to my sister.

Doctor That’s good. [pause] I could arrange an appointment with our counsellor here if you’d like to talk to someone else?

James Yes, that would be helpful.

Doctor Is there anything else you’d like to ask?

James Not at the moment.

Doctor OK. So, we’ll go through the options available next time. In the meantime, I’ll make an appointment with our counsellor for you.

Audio 9.5 James So, can it be treated?

Doctor There are drugs that can help. Would you like me to tell you about them?

James Not right now, Doctor. I’m not able to take much in at the moment.

Doctor I can understand that. We can go through it at your next appointment.

James OK. [pause] What are my chances?

Doctor I realise how difficult it must be for you to ask that question. I can’t really say at this point, but we’ll do everything we can. Do you have a friend or relative you can talk to about this?

James I’m really close to my sister.

Doctor That’s good. [pause] I could arrange an appointment with our counsellor here if you’d like to talk to someone else?

James Yes, that would be helpful.

Doctor Is there anything else you’d like to ask?

James Not at the moment.

Doctor OK. So, we’ll go through the options available next time. In the meantime, I’ll make an appointment with our counsellor for you.

© Cambridge University Press 2007

Audio 9.7 Receptionist Hello, District Hospital.

Deborah Hello, I’d like to enquire about my mother, Mrs Maureen O’Sullivan. She was admitted to your hospital about 30 minutes ago.

Receptionist Just one moment, please.

Doctor Hello, this is Dr Vincent Naylor speaking from A&E. Who am I talking to, please?

Deborah I’m Deborah Taylor, Mrs O’Sullivan’s daughter.

Doctor OK, Deborah. Let me explain the situation. I’m sorry to tell you this, but your mother has had what would appear to be a stroke. Her response rate was very poor when the ambulance arrived.

Deborah Oh, no!

Doctor Now, she’s in the intensive care unit. She’s on a ventilator, and we’ve made her as comfortable as possible.

We’re taking her down to the CRT in about 20 minutes to examine her more closely.

Deborah Right.

Doctor Now, I need to ask you a few questions, if you wouldn’t mind, about your mother.

Deborah Um, yes, of course.

Doctor Now, when was the last time you spoke to your mother?

Deborah Two days ago.

Doctor OK and did you notice anything different in her voice then? Did she seem confused in any way?

Deborah Er, no, she was the same as usual.

Doctor Do you know if she was taking any medication?

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COV-19 2020 Deborah No, she wasn’t, but I know she finished a course of antibiotics recently for a chest infection.

Doctor OK. Now, I understand that she was living alone. Was she totally independent?

Deborah Yes, she was very active – gardening, painting …

Doctor OK, Deborah, that’s been very helpful.

Deborah But is she going to pull through?

Doctor I’m afraid it’s very unlikely. She’s very ill … But we’re doing our best for her. So that’s the situation. If you could notify any other members of your family, and I’ll speak to you again when you get to the hospital.

Audio 10.1 Doctor Tell me, Mary, how are you feeling at the moment?

Patient [her eyes fill with tears] Doctor This is very difficult for you to talk about, isn’t it?

Patient Yes. Doctor Are you still getting the headaches?

Patient Yes. Doctor And do the painkillers I prescribed help? Have you been taking them, Mary?

Patient A couple of times, but they knock me out. I can’t function properly with them. And I need to look after the family – they need me.

Doctor I know. You have a lot on your plate at the moment, don’t you? Nursing your husband, taking care of the children and looking after your mother.

Patient Yes, I feel overwhelmed. I’m sorry, Doctor.

Doctor You don’t need to apologise, Mary. It’s perfectly normal to cry. I understand how you’re feeling. You’re worried that if you don’t stay strong for the family, things will fall apart, aren’t you?

Patient Yes. I can’t let that happen.

Audio 10.2 Doctor Hello, Mr Adams, sorry for the delay. Er, please have a seat.

Patient Do you realise I’ve been waiting for over an hour to see you? I was here ten minutes before my appointment.

What’s the point of me arriving in good time when you keep me waiting? I had to rearrange a meeting to come here today and …

Doctor I’m sorry, Mr Adams, but we’ve been very busy today.

Patient That’s not my problem. If everybody came at the right time, you wouldn’t be running late, would you? Why do I have to put up with other people’s incompetence?

Doctor Mr Adams, everybody has had to wait. You’re not the only one.

Patient So I’m the only one who’s complained, am I? Doctor Mr Adams, I think you are being unreasonable. You’ve made your point. Can we get on?

Audio 10.3 Doctor Hello, Mr Adams, sorry for the delay. Please have a seat.

Patient Do you realise I’ve been waiting for over an hour to see you? I was here ten minutes before my appointment. What’s the point of me arriving in good time when you keep me waiting? I had to rearrange a meeting to come here today and I had to phone my secretary to cancel another meeting.

Doctor I’m very sorry for the delay and I appreciate the problems this has caused you. We’ve been exceptionally busy today. One of the other doctors is ill, so I’ve been dealing with some of his patients as well. I’m doing all I can.

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Patient OK, but it’s not fair to keep your patients waiting for ages, is it?

Doctor No, you’re right, it isn’t. [pause] Do you think we can move on now and look at the reason for your visit?

Patient I suppose so.

Audio 10.4 Doctor OK, so can you tell me what seems to be the problem?

Patient I’m finding it very difficult to cope at work at the moment.

Doctor I see. Can you tell me exactly why you’re finding it so difficult?

Patient It’s hard to put a finger on it. I just feel inadequate.

Doctor Try to give me an example. It’ll help me get a better picture.

Patient I don’t seem to be able to concentrate on my work.

I just sit there for ages not getting anything done. I never seem to be able to finish a task properly.

Audio 10.5 Doctor Hello, Steve. Er, come in. Have a seat. What can I do for you today?

Patient I’m not feeling too good. The medication isn’t enough.

Doctor But we agreed on your last visit that that level was right.

Patient No, you told me that it was enough for me, and it’s not enough, Doctor. I’m in pain most of the time. I need a higher dose.

Doctor We agreed that you need to use less methadone, not more, and you agreed to that, too.

Patient But I wasn’t so sick then. I’m sick now and I need to up the dose. Do you want to see me in pain?

Doctor No, of course I don’t. But we agreed that it was better for you to reduce your intake.

Patient You agreed, not me. Please can you give me some more?

Doctor You know I can’t.

Patient You really like seeing me in pain, don’t you? You’re meant to help me, not let me suffer. I’m not leaving here until you increase the prescription.

Audio 10.6 Patient Can’t you understand, you idiot? You’ve got to up my prescription.

1 Doctor I’m not prepared to listen to you while you’re shouting.

2 Doctor Don’t tell me what I should do. I’m not your supplier.

3 Doctor OK, I’ll increase it on this occasion, but there will have to be a review of your situation before we can do anything else.

Audio 11.1 Imagine you begin a day with your eyes blindfolded, your ears plugged, your mouth gagged and your legs tied together.

Audio 11.2 Dr Wadman Mr Whitaker, come in and take a seat. Nice to see you. Are you comfortable there?

Mr Whitaker Yes, Doctor, thank you. Can I leave my stick just here?

Dr Wadman Of course. Shall I turn the fan off, it’s a bit noisy …

Mr Whitaker I’m fine, really. I’m getting used to this new hearing aid now; it cuts out most of the background noise.

COV-19 2020 Dr Wadman Good, I’m pleased to hear it. So, what brings you here today, Mr Whitaker?

Mr Whitaker Oh, where shall I start? When you get to my age … it’s all downhill!

Dr Wadman Why don’t you start with what’s been bothering you the most?

Mr Whitaker Well, it’s a bit embarrassing, really.

Dr Wadman Take your time. Can you describe what’s been happening?

Mr Whitaker You can probably see – it’s my hands – they’re shaking all the time, I can’t do much with them. It’s getting worse, too. And I’ve got problems dribbling, too – you know, that’s really embarrassing.

Dr Wadman How is this affecting you?

Mr Whitaker When my Kathy was alive, we had lots of friends, always going out. We liked the good life – dinner parties, theatre …

Dr Wadman Uh-huh.

Mr Whitaker I was a member of the Rotary Club, you know, and I played tennis for the club team – men’s doubles. Kathy wasn’t much of a tennis player – but my goodness, could she dance …

Dr Wadman Good memories?

Mr Whitaker Wonderful memories.

Dr Wadman And how does this relate to the problems you’ve been having recently?

Mr Whitaker It’s the friends, you see, Doctor. This dribbling gets me down. I can’t face them like this, can I? Don’t get out much any more because of that.

Dr Wadman I can see how that might get you down. We’ll look at ways to try to control this later on.

Mr Whitaker It’s another symptom of the Parkinson’s, isn’t it?

Dr Wadman It is, yes. If I could just ask you something else at this stage … When some people cough or sneeze, they leak urine. Does this happen to you?

Mr Whitaker Yes, my waterworks are playing up a bit, too.

I was about to mention that.

Dr Wadman Right. We can also discuss how you can control this. Now, what kind of support network do you have, Mr Whitaker?

Mr Whitaker Sorry?

Dr Wadman Who can you call on when you need a helping hand?

Mr Whitaker My daughter-in-law’s just down the road.

Dr Wadman And you get on well with your daughter-in-law?

Mr Whitaker Oh, no, don’t bother ringing her, not now my son’s no longer with us, anyway.

Dr Wadman What about neighbours?

Mr Whitaker Maggie, she’s just next door, she’s great, she gets the shopping in for me – just the bits ’n’ bobs I need.

Dr Wadman Social services?

Mr Whitaker Don’t want them coming round if I can help it.

The last time they came, they took my Kathy and put her in that home, didn’t they? I know they’re doing their job, but …

Dr Wadman Some of the services they provide could make life easier for you. ‘Meals on Wheels’, for example. You won’t have to worry so much about getting a balanced meal inside you.

Mr Whitaker You’re right, I suppose – sometimes I’m just too tired to cook properly. Don’t get me wrong, I like cooking.

Dr Wadman How are you coping otherwise, Mr Whitaker?

Mr Whitaker I don’t get out much. Stick’s OK around the house, but … it just gets me down.

Dr Wadman We’ll come back to that if you like. Any other medical issues you’d like to discuss today?

© Cambridge University Press 2007

Audio 11.3 Doctor Hello, my dear.

Patient Hello, Dr Griffith.

Doctor Is there something wrong with your mouth, dear?

Patient I broke my dentures, and they won’t be repaired until the end of the week. I feel so foolish without them – I didn’t even go to my art class today or my coffee evening ’cos I didn’t want people to see me. It’s so frus…

Doctor Right, my dear, but it’s not your mouth that you’ve come to see me about, is it?

Patient Er, no, it’s that ulcer on my ankle. It still hasn’t cleared up.

Doctor Right. You are taking your medication like I told you to?

Patient Yes! Doctor Well, these things do take longer to clear up at your age, dear. Nothing to worry about, though. Is there anything else?

Patient When do you think it’s going to clear up?

Doctor It’s difficult to tell with somebody your age. Tell you what, come back and see me in two weeks, and we’ll have another look at it.

Audio 11.4 Doctor Hello, Mrs Fry. Patient Hello, Dr Griffith.

Doctor Your voice sounds a little different to usual. Is there something the matter?

Patient I broke my dentures, and they won’t be repaired until the end of the week.

Doctor Oh dear. You must be finding it difficult without them.

Patient Yes, I feel so foolish without them. I didn’t even go to my art class or my coffee evening ’cos I didn’t want people to see me. It’s so frustrating. You must think I’m very vain!

Doctor Not at all, Mrs Fry. I remember losing two of my front teeth in a rugby match. I can perfectly understand you want to look your best, and it’s hard to do that without your teeth.

Patient Oh, thank you, Doctor. I don’t feel so bad now.

Doctor So, what can I do for you today?

Patient I was just wondering about this ulcer I have on my ankle. It still hasn’t cleared up.

Doctor I’m sorry to hear that. Are you still taking the medication I prescribed?

Patient Oh, yes.

Doctor That’s good. It should help with the healing. Is the ulcer still causing you a lot of pain?

Patient Not exactly, but it feels very tender.

Doctor Yes, it will do, it’s in such an awkward area.

Patient When do you think it’s going to clear up?

Doctor Well, it’s very difficult to say, but ulcers do tend to take longer to clear up as people get older. We’ll keep a close eye on it. Is there anything else?

Patient No, Doctor.

Doctor OK, Mrs Fry, shall we make an appointment for two weeks’ time to see how it’s responding?

Audio 11.5 Patient Eh? What did you say, Doctor?

Doctor Mrs Mason, I asked you when did you get this funny turn?

Patient You don’t need to shout. If you keep your hand away from your mouth, I can hear you perfectly! I got it yesterday morning.

Doctor And what were you doing at the time?

Patient What’s that noise?

Doctor Sorry, that was my printer. Just let me turn it off.

Right, so what were you doing at the time?

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COV-19 2020 Patient I had just got out of bed.

Doctor And how long did it last?

Patient Oh, about five minutes …

Patient I’ve got this awful rash, Doctor.

Doctor I see, so where is it, Mrs Ross?

Patient What’s that?

Doctor Where is it?

Patient It’s all over my arms and it’s really itchy.

Doctor I see. And is it itchy now?

Patient Not so bad. It’s not so bad during the day, but I’m finding it very difficult to sleep at night.

Doctor Mm, I can give you some cream to put on it.

Patient What’s that you’re saying about dreams?

Doctor No, I was talking about treatment. I can give you some cream, for your arms to relieve the itch.

Patient Oh, I see. That would be good.

Doctor What things do you look forward to?

Patient When my children come to visit. But that doesn’t happen very often.

Doctor Right. Well, from what you’re saying, it may be that you’re suffering from mild depression. It would explain the loss of energy, the sleeplessness and loss of appetite.

Patient Rubbish! I’m not depressed. There’s no history of that in my family.

Doctor It doesn’t have to be in your family. What I’m talking about is something that happens to a lot of people, and there are a number of treatments that can be helpful.

Patient I don’t care what you say, I’m not depressed. I keep my house and myself in order.

Doctor Well, you’ve come to me because you don’t have any energy and you’re not sleeping or eating very well. We’ve done a lot of tests, and you’re physically in great shape. The most likely explanation for your symptoms is mild depression.

Patient Well, if it is depression, what can I do about it?

Audio 11.7

Audio 11.9

Audio 11.6

Trainer So, Pradeep, if you’d like to start …

Pradeep Thanks, Dr Kapinsky. I’m going to talk today about some of the issues surrounding the history-taking process of older patients. Enlow talks about the fear felt by a great many older people of losing their independence, which is sometimes greater than the illness itself. We need, therefore, to look at the ADL, the activities of daily living, used to assess the level of independence in an older patient within their environment. You can also gauge the patient’s own perception of their independence using this tool. The acronym BATTED can help us remember the different functions we need to ask about. Has anyone heard of BATTED – B-A-T-T-E-D? BATTED basically represents all those everyday functions that we take for granted but that patients over 75 may or may not experience some amount of difficulty with. Bathing is the ‘B’, followed by Ambulation, or walking – how easy is it for the patient to get around unaided. Then comes using the Toilet – do they need assistance in using the toilet. The next ‘T’ is for Transfer, making transfers – how easy is it for your patient to make the transfer from his or her chair to, let’s say, the kitchen? ‘E’ – that’s easy – eating. Are they able to feed themselves or do they need some help? Finally, ‘D’ – dressing: can they manage to dress themselves, or again do they need help in doing this – putting on socks or tights can cause problems for people with back problems, arthritis, etc.

Audio 11.8 Doctor Hello, Mrs Cox. What can I do for you?

Patient Oh, I don’t seem to have much energy. I have this dragging feeling in my body.

Doctor Well, we did a lot of tests last time you came in, and you seem to be fine physically. Are you sleeping OK? Patient No, I stay up half the night watching TV and tend to nod off for a while.

Doctor I see … and what about your appetite?

Patient Oh, I’m not really interested in food, I just pick at the odd thing.

Doctor Right, and what about your social life? Do you get out and about much?

Patient I go to church most mornings, do a bit of housekeeping and read the paper. That kind of thing. My friend takes me for a drive sometimes, but I’m not often in the mood.

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Doctor OK, Mr Jones, could you just tell me how old you are?

Patient I’m 82, Doctor.

Doctor Right. And what year were you born?

Patient 1925.

Doctor OK, fine, and can you tell me what year is it now?

Patient It’s 2007.

Doctor Thank you, Mr Jones, that’s lovely. So, tell me, what’s brought you here today?

Patient I wanted to see you to talk about these pills I’ve been put on. It’s the side effects; they’re starting to get me down, you see …

Audio 11.10 Doctor OK, Mrs Jackson, can you tell me when this happened?

Patient I’ve had it for a week.

Doctor Right, and can you tell me how it happened?

Patient Er, I stood on the rake when I was gardening yesterday.

Doctor Yesterday?

Patient Yes, yesterday afternoon.

Doctor But I thought you said it started a week ago?

Patient Oh, I did hurt it last week, but it was really only a scratch. It was only when I stood on the rake yesterday that it got really sore.

Doctor Right. So you hurt your foot yesterday afternoon …

Audio 12.1 Doctor Hello, Mrs Long. Hello, Sara.

Mrs Long Hello, Doctor.

Doctor Please take a seat.

Mrs Long Thanks. Sara, sit here next to me, sweetheart.

Doctor Right, so can you tell me what seems to be the problem?

Mrs Long Um, Sara has been complaining of stomach cramps and she’s off her food.

Doctor I see. And when did the cramps begin?

Mrs Long Yesterday. She felt poorly in the morning, didn’t you, Sara?

Doctor Any idea what might have caused the cramps?

Mrs Long I think it might be some kind of bug. A few of the children in her class have the same thing.

Doctor Right, well, I’ll have a look at her. Sara, could you lie on the bed and I’ll look at your tummy.

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Audio 12.2

Audio 12.8

Doctor Hello, Billy. Hello, Mrs Jones. My name’s Dr Gordon.

I’m one of three partners who makes up this family practice.

Now, Billy, do you want to sit here next to your mummy, and I’ll sit here. Just let me raise your chair up a bit so you can see me. That’s better. That’s a great football shirt, Billy. So, you’re a Manchester United supporter?

Billy Yes. Doctor And do you support Manchester United as well, Mrs Jones?

Mrs Jones Oh yes. The whole family does.

Billy My dad is their biggest fan.

Doctor And does he take you to any matches?

Billy Yes, I’ve been to three matches this year.

Doctor You’re very lucky. And who’s going to win the league?

Billy Man U, of course!

Doctor OK, Joe, I need to look at your chest, so can I get Mummy to take off your lovely Bob the Builder T-shirt for a few moments? Will you let me have a look? … Ah, thank you, Joe. I won’t be long, and then you can put it back on.

This is called a stethoscope, Joe. It’ll help me to find where your cough is coming from. I have teddy here to show you what I’ll do. I put this part in my ears and then I put this part on teddy’s chest to hear his breathing. It won’t hurt you in any way. It’ll feel a bit cold, but I’ll warm it up. Do you understand what I’m going to do, Joe? Joe Yes. Doctor OK. Now I need you to take a big breath for me and hold it. That’s great, Joe … once more … and hold it. That’s fine. Thank you, Joe. You can put your top back on now.

Audio 12.3 Just let me raise your chair up a bit so you can see me.

Audio 12.4 Doctor OK, Billy, now your mummy tells me that you have a nasty cough and it keeps you awake at night. Is that right?

Billy Yes. Doctor Are you feeling sad?

Billy Yes. I’m tired.

Doctor I can understand why you’re feeling sad.

Mrs Jones And you can’t eat your favourite cereal in the morning at the moment because it makes you cough, doesn’t it, darling?

Billy Yes. Doctor Oh dear, that is a nasty cough, isn’t it? How long have you had it for?

Billy I got it on Friday and I couldn’t play football all weekend.

Doctor You must have missed that, Billy. Well, what I need to do is to have a look at your chest to find out where that nasty cough of yours is coming from. Will you let me look at your chest, Billy?

Billy OK.

Audio 12.5 Jenny, you mustn’t think this is your fault. It was an accident.

Lots of boys and girls break their wrists.

Audio 12.6 1 2 3 4

Don’t look so sad. We’re going to make you better very soon.

You’re not to blame for this in any way.

Don’t be scared. I promise this won’t hurt.

It will be very quick, you’ll hardly feel a thing.

Audio 12.7 Doctor Can you turn your head to the side so I can see your ear?

Stacy No! Doctor No, Stacy, don’t get down yet. I haven’t finished.

Father Stacy, do as the doctor tells you.

Stacy No. I want to go home.

Doctor Stacy, please sit still. I only want to look at your ear.

Stacy No! Doctor Now, Stacy, come on, you must sit still, otherwise I can’t look at your ear.

© Cambridge University Press 2007

Audio 12.9 Doctor OK, Catherine, if you’d like to come through to my office. Your mother can come in later. … Take a seat, Catherine. What age are you?

Patient Almost 17.

Doctor Well, my dear, you certainly have grown since I last saw you. What seems to be the problem?

Patient I’ve been having headaches and stomach pains quite a bit lately.

Doctor I see. How severe are the headaches?

Patient Mm, they’re not too bad. I’ve had them regularly since I started having my periods, but they’ve got worse over the last six months.

Doctor Mm. And the stomach pains?

Patient About the same.

Doctor Have you started having sex?

Patient Um, will you have to tell my mum what I tell you?

Doctor No. It will be between ourselves.

Patient Oh. Um, I started to have sex with my boyfriend Tom about six months ago, when I turned 16. My parents would kill me if they knew …

Doctor But you’re only a child … 16 is too early to start having sex. You’re not fully developed emotionally or physically yet, and you’re taking a lot of risks with your health.

Patient That’s what my parents are always telling me.

Doctor There’s really nothing to laugh about, you know. It’s a serious matter.

Patient Can’t you just listen to me without lecturing me?

Doctor Do you think the pains got worse because you’ve started having sex?

Patient Um … oh, I … I don’t know.

Doctor But you are worried about what might be causing them?

Patient I’m not too worried about the pains, to be honest, but I think I might be pregnant.

Doctor Do you use any form of contraception?

Patient Sometimes we use condoms, but not always.

Doctor You should always get your partner to wear a condom.

Otherwise there’s no telling what kind of venereal diseases you might pick up. Anyway, we can do a test to find out if you’re pregnant. Is there anything else you’re worried about?

No? OK, I’ll just ask your mother to come in, then.

Audio scripts 151

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Answer key Introduction to communication Lead in a The author means that communication takes place at a sub-conscious as well as conscious level. b Examples of transmission model: being paged in a hospital; where a doctor gives instructions to a patient who has not fully understood and does not ask for clarification Example of interactional model: in the patient interview where the doctor takes steps to check that the patient has understood the message 2 Verbal communication, non-verbal communication, listening, voice management, cultural awareness 3 The context (formal or informal), relationship of speakers to each other, gender, age, level of education, whether the other person is a native speaker or non-native speaker 4 a The expression that caused the misunderstanding was cardiac arrest. The doctor should have said heart attack. b The doctor should clarify what he means, e.g. he could say I’m sorry, that’s not what I meant. I want to know if there is a history of heart attacks/disease in your family.

5 Intonation, word stress, speed, loudness of voice, pitch 6 a 2 b 1 c 3 7 The second question is more inviting. The emphasis on why in the first question sounds as though the doctor is demanding an explanation, whereas the emphasis on the word medicine in the second question makes it sound more objective.

8 See Exercise 9 for ideas.

9 1 b 2 h 3 g (c) 4 f (e) 5 c (g) 6 e (f) 7 a 8 d 10 There is no set answer to this. However, generally speaking, some of them are more difficult to control than others, though this can be improved through awareness-raising and practice.

The following tend to be easier to control: environment, clothing and accessories, eye contact, proximity, orientation, touch.

The following tend to be more difficult to control: posture, facial expressions, movement.

11 It is important because non-verbal cues allow verbal messages to be delivered more accurately and efficiently by reinforcing the verbal message.

12 1 Hearing is passive, but listening is active.

2 Barriers to hearing: external noise, if the speaker mumbles, speaks very quickly, has a strong accent, stresses words in the wrong place.

3 Barriers to listening: thinking about what you are going to say next, day-dreaming, filtering out only certain words that you want to hear, making a judgement in advance that prevents you from listening objectively, predicting what the speaker is going to say.

4 Suggested answers ● Showing you are prepared to listen, i.e. not giving the impression that you are in a hurry. ● Listening to verbal cues, observing non-verbal cues.

152 Answer key – Unit 1

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Showing your understanding by making utterances, such as uh-huh, or using phrases like I see, Right. ● Using communication strategies, e.g. clarifying, to show that you are following what the person is saying, summarising what the person has said. ● Using appropriate body language, e.g. eye contact, orientation (the way in which you position yourself in relation to the speaker). ● Pausing before you ask further questions. a The patient is concerned that the antibiotics he has been taking for a chest infection are not working. b The doctor is accurate insofar as he collects information about the condition which the patient has already been diagnosed with. However, he does not attend to other possible conditions. Overall, the consultation is not as effective as it could be, as the doctor has not explored the patient’s concerns completely. He has not given any reason why the patient has had to take three different types of antibiotics, or any real counter to the fact that the patient does not feel better. There is the possibility that the patient will not continue the course of antibiotics. In addition, there are signs that the patient may be suffering from depression or anxiety (symptoms are: fatigue, sleeping badly or too much, significant change of appetite, low self-esteem and lack of hope for the future). By failing to observe, or choosing to ignore this, the doctor is reducing the effectiveness of the consultation, as the patient is likely to be back. a 1 Language, religion, beliefs, values, customs/habits, festivals, art, literature, music c High levels of personal responsibility, high status, clear code of ethics, specific body of knowledge and use of language, need for evidence/logic a Class, ethnicity, national culture, political beliefs, religious beliefs, influence of media It is in the middle because all communication at all levels is culture bound.

1 S 2 E 3 S 4 A 5 E ●

13

14

15 17 18

Unit 1 Lead in Osler’s quotation is highly relevant, even today, especially as many doctors are still not engaging in the most basic of relationship-building skills with their patients.

This initial contact with the patient is vital. Doctors who don’t take the time to greet their patients risk alienating them from the outset. Patients may or may not understand much about their condition, but what they do understand and appreciate is warmth and empathy, which can so easily be conveyed by the doctor, and can be reassuring and will eventually facilitate the encounter.

1 Suggested answer Patients are likely to be more frightened than the doctor (even during a first consultation) or to think their condition is more serious than the doctor says. They may even be afraid of the doctor. Patients may be even more anxious in a hospital because: of the unfamiliar environment; they don’t know the doctor; it’s busy and noisy; they might have to wait longer.

COV-19 2020 2 b Suggested answers 1 Administrative and nursing staff keep you waiting and are unfriendly; doctor too hurried and impatient; doctor interrupts; surroundings are stark or depressing (not geared for the best comfort); lack of privacy.

2 A doctor may not relate well to patients of different ages or may be more dismissive of certain age groups.

Others may find it difficult to build rapport with different genders. Appearance may also play a role – a doctor may be unconsciously judgemental, depending on how a person is dressed or his/her general appearance. These aspects could be blocking factors in the relationship-building process with the patient.

Medical students are encouraged to take these into consideration when interviewing their patients.

4 a Seating arrangement 1. b 1 Because the patient is more relaxed and therefore more forthcoming if the seats are placed at right angles to each other, and the doctor is not behind a desk.

2 c 3 Because you don’t want to be so far away from your patient that you can’t hear them or that they feel you aren’t interested in what they’re saying; neither do you want to make them feel threatened by being too close. c 2 To reassure the patient / show empathy if the patient is upset.

3 To ensure that he/she is on the same level as the patient, e.g. by pulling up a chair to carry out the encounter. He/She shouldn’t lean over the patient, as this might be intimidating.

5 a/b Consultant 1 (outpatients) 1 needs improvement (didn’t acknowledge patient or ask her to sit down) 2 needs improvement (didn’t greet patient) 3 needs improvement (sounded bored) Consultant 2 (ward round) 1 fairly competent (took his time with patient, but stared at her and didn’t suggest more private place for interview) 2 competent (polite / shook hand) 3 competent (not mentioned, but can assume was appropriate, as patient described him as having a lovely voice) 6 1 GP’s surgery (Familiarity – use of first name with patient might indicate the doctor already knows the patient.)

2 specialist’s office (This is a referral for further investigation.)

3 hospital ward (The doctor introduces himself as being the registrar on the ward this evening.)

7 a Suggested answers Objective 1 Greet the patient and obtain his/her preferred form of address (unless already known).

Objective 2 Introduce yourself and clarify your role.

Objective 3 Explain the purpose and agenda of the interview.

Objective 4 Obtain permission for special circumstances (e.g. for another doctor to attend, to take notes).

8 1 With some patients, the use of the verb chat might encourage patients to talk; it lessens the formality and makes them feel more at ease.

2 The verb chat for some patients reduces the seriousness of the situation, so it should be avoided if the doctor has

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9 a b 11 a

b

12 a

14 b

c

15 a

b

to break any kind of bad news, for example. The doctor needs to try to gauge his/her audience.

The doctor achieves all the objectives in order (1, 2, 3, 4).

The doctor also makes sure the patient is at ease by asking if she is comfortable / would like another pillow.

Encounter 1, Version A: welcoming Registrar is lively and friendly.

Encounter 1, Version B: unwelcoming Registrar speaks in a monotone.

Encounter 2, Version A: unwelcoming Dr Patel is abrupt and doesn’t respond to the patient’s frustration at having been kept waiting.

Encounter 2, Version B: welcoming Dr Patel apologises for the situation.

In English, the rising and falling intonation, speed, pitch and tone of the voice determine if a voice is welcoming or not.

1 Specialist visiting patient in a hospital ward. (This is the most likely answer, as the doctor refers to the patient’s consultant.)

2 Woman coming to surgery/clinic. (A six-month checkup might be in the case of a patient with a particular condition that needs checking regularly by his/her GP, e.g. dermatological conditions.)

3 Patient attending appointment at surgery/clinic. (In the UK, patients can either be called in to the doctor’s consultation room by the doctor him/herself or sent to the room by the receptionist, depending on the size of the practice.)

4 Doctor calling in next patient at surgery/clinic.

The doctor’s opening question invites the patient to explain the reason for his/her visit. The question needs to be sufficiently open and not exclude non-medical concerns the patient may have. From the response, the doctor will be able to set the agenda for the interview.

So, what’s the problem?: This could be perceived as very negative. It assumes the patient has a problem (or what could be perceived as a problem) and that what the patient fears (with or without reason) could be a problem.

What’s up?: This may come across as being very rude and is too colloquial a register for this setting.

Suggested answers a 2, 5, 7, 9 b 2, 4, 6, 7 c 2, 4, 5, 6, 7, 9, 10 d 2, 3, 5, 9, 10 e 1, 2, 5, 7, 8, 9 Suggested answers 1 Doctor refers to the patient’s GP, so the most likely answer is (e).

2 This question is a very general question that a doctor in any situation would use to open up the discussion in a patient-centred approach.

3 (d) is the only possible situation, as the doctor refers to a baby, and carers of newborns are required to attend surgery for routine check-ups.

4 The patient might have been given a course of tablets on a previous visit and is on his/her follow-up visit to the surgery (c) or he/she has been hospitalised and is being followed up on by the registrar/doctor during the ward round on a course of treatment (b).

5 Only (b) would be an inappropriate situation for this question, as the doctor would already know why the patient is in his/her care if currently in the ward.

6 As for question 4.

Answer key – Unit 1 153

COV-19 2020 7 Only (d) would be inappropriate, as the doctor is asking about the patient’s health (and not that of a baby).

8 As for question 1.

9 Only (b) would be inappropriate, as this question assumes the doctor is not aware of the patient’s reason for visiting. A doctor/registrar during a hospital round would know the reason for the patient being on the ward.

10 The doctor could quite possibly be referring to a small child or a baby, and so either (c) or (d) would be appropriate. The doctor appears to know the child and therefore (c) is possible.

16 a 1 Any improvement in the arthritis since I saw you last?

2 Recurring headaches 3 It was not the most appropriate opening question, as Dr Patel assumes Mr Mahoney wants to talk about his arthritis and doesn’t allow for Mr Mahoney’s own agenda. This type of question is therefore limiting and doesn’t encourage the patient to express him/herself in his/her own words. The doctor shouldn’t assume anything. b Am I right in thinking you’ve come about the arthritis?

17 3, 4, 6, 8, 10 18 Suggested answer In Anglo-Saxon countries, the following body language can be used to open the interview: open seating position (no crossed arms/legs), slight inclination of the head, sitting slightly forward, eye contact and a smile.

19 Well, yes, I’m sure you’ve got all this information, but … my arthritis has been playing me up a bit as usual – I’m having difficulty sleeping and I’m in some pain first thing in the morning. But it’s the headaches that are really getting me down. They’re so painful, sometimes I’ve been sick with them … literally. I’m starting to have time off work now because of them. My wife’s really worried. She’s the one that insisted I go and see Dr Patel …

20 a Suggested answers ● Enables the doctor to hear the patient’s story. ● Prevents the doctor from making premature hypotheses and chasing down blind alleys. ● Reduces late-rising complaints. ● The doctor doesn’t have to think of the next question (which blocks listening capacity of the doctor). The patient, who is mostly answering questions, tends to be more passive. ● Gives the doctor an indication of the patient’s emotional state. ● Enables the doctor to observe more carefully and pick up on verbal and non-verbal cues. ● Is helpful to patients for whom it is not easy to define problems – allows them time to clarify what they want to discuss. ● Signals the doctor’s interest in the patient.

21 I can see it’s the headaches that are really bothering you, so if we can start by looking at those. We’ll come back to the arthritis later, if that’s OK with you. Is there anything else you want to discuss today?

Unit 2 1 a 1 b 2 d 3 a b Closed questions are questions where the response is either Yes/No or another one-word answer. When used appropriately, they can determine specific information.

154 Answer key – Unit 2

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Used inappropriately, they can be quite restrictive, as the doctor is trying to control the encounter and not allowing the patient to express him/herself.

Other kinds of questions are: ● open: These questions require an answer of more than one word (as opposed to closed questions). They typically start with a question word, such as who, where, why, when, how, etc. ● multiple: This is where several questions are asked at the same time, making it harder to focus on the answer required, e.g. Does the itching always occur in the same place, and how bad is it? ● leading: This is where the question is phrased to elicit a particular answer, e.g. Does the itching always start first thing in the morning? (as opposed to When does the itching start?). ● tag: These are a form of closed and leading question, characterised by the ‘tag’ at the end of the sentence.

The tag is formed by the opposite form (positive or negative) of the auxiliary verb in the sentence (e.g. have, do, must, etc.) and the subject, e.g. The itching doesn’t bother you at night, does it?

2 Doctor-centred approach

Patient-centred approach

• disease and patient were completely separate

• patient is expert of his/her own disease

• tightly controlled

• patient is the main source of information

• doctors take the dominant role • patients have limited participation • patients not expected to participate actively

• holistic approach • social, physical and economic factors are important • doctors show more empathy

• patients’ health is entirely in the hands of the doctor

• patients are more likely to comply with treatment

• doctors ask leading questions

• doctors are more responsive to patient cues

• impact of disease on patients’ life barely considered Question type(s): closed questions / leading questions

Question type(s): open questions

3 2 A&E department (emergency situations), patients with respiratory problems, patients with learning difficulties, etc.

3 Some patients prefer doctors to take the lead; difference in cultural attitudes may play a role; it also depends on the emotional/physical state of the patient as to whether he/she wants to / is able to participate so fully in the encounter.

6 a Dr Haines is more of a doctor-centred consulter, although there are some positive aspects to her approach.

Rating: 2/5 Positive aspects: friendly and polite; introduces herself Negative aspects: interrupts patient; asks too many closed questions; doesn’t allow patient to express himself in his own words; asks tag, multiple and leading questions; confuses patient; answers for the patient; interrogative style

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9 10

11

12

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14

Do you still have a temperature?

How long have you had that, a couple of days?

Are you shaking? Are you having night sweats?

Do you have any muscular pain?

You’re not suffering from achy joints as well, are you?

NO Dr Haines doesn’t allow the patient to tell the story from his own point of view, referring instead to his patient note. She interrupts the patient.

2 NO As above. Also, she asks closed questions where the patient can only answer yes or no, or tries to put words in the mouth of the patient.

3 YES She asks about muscular pain.

4 NO She sometimes asks two questions at the same time, and this is not always clear for the patient.

1 C 2 C, L 3 C, L, M 4 C 5 C, L, T a Dr Linley begins with an open question and encourages the patient to tell her own story. He then uses closed questions appropriately to obtain specific information.

Rating: 4/5 1 How have you been feeling?

2 Can you tell me a bit more about it?

3 Any other symptoms?

4 Whereabouts?

5 Any pain in your joints?

1 YES All of his questions.

2 YES How have you been feeling? / Can you tell me a bit more about it? / … any other symptoms? / Whereabouts?

3 YES Do you have any muscular pain? / Any pain in your joints?

4 YES Any pain in your joints? / Do you have any muscular pain?

1 O 2 O (literally closed, but rising intonation makes it open) 3 O (see 2) 4 O 5 C, L (used appropriately to obtain specific details) 1 Dr Linley has the most success in obtaining a history.

2 The ‘cone technique’ moves from open to closed questions. It ensures that the doctor obtains a picture of the problem from the patient’s perspective by opening up the discussion. With the need to confirm specifics and narrow down the cause of symptoms, etc., he/she then follows with more closed questions. It is important for the doctor to become more focused as the interview progresses, investigating specific areas that may not emerge from the patient’s story.

Open questions allow patients to express themselves and follow their agenda. The first complaint is not necessarily the most important or the only one. The consultation could go in a completely different direction, as doctors usually have their own agenda based on previous experience. Open questions also give doctors time to think about the next question and to listen to important points.

Leading questions are those that, in effect, put words into the mouth of the patient and ‘lead’ the patient towards a particular answer.

Multiple questioning can be confusing and stressful for patients. Better to ask one question at a time.

Closed questions asked in a facilitating manner can encourage patients to tell more of their story; good non-verbal communication can turn closed into open questions. With patients in certain states – respiratory problems / A&E / stressed – it is better to use closed questioning.

Tag questions tend to guide patients in their response – the ‘tag’ reinforces the question in a particular direction.

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15 a 1 C, L 2 C, L 3 C, T 4 M 5 C, L 6 L, T b Suggested answers The child can be addressed directly if he/she is old enough to give accurate responses.

1 When does the sneezing start / do you start sneezing?

2 Does he suffer from / Do you have any other symptoms at all?

3 How often does he experience the symptoms / do you sneeze?

4 Can you explain what typically happens when your son has / you have an attack? / (Tell me,) what usually brings on the attacks?

5 Tell me how your (son’s) allergy started.

6 How have you been treating your (son’s) allergy till now? c 1 a The parent may feel some amount of guilt at having bought the dog following the son’s reaction. b The parent will feel guilty because he/she didn’t go to see the GP sooner.

2 Doctors need to avoid making patients/carers feel guilty for their actions or appearing judgemental.

Biased/‘loaded’ questions can make patients feel as though they are being judged.

16 1 a Children are more likely to say the pain is greater. b Elderly patients especially tend to underestimate the level of their pain, often due to the fact that they have learnt to tolerate pain / don’t want to bother the doctor, and are more stoical, etc.

2 To enable the doctor to arrive at an accurate diagnosis.

Different kinds of pain can lead to different diagnoses.

17 b Suggested answers 1 migraine (blinding headache) 2 urinary infection (burning sensation) 3 period pain (cramping pain) 4 chest pain (crushing sensation) 5 heart attack / angina (gripping pain) 6 headache (pounding feeling) 7 sciatica/toothache (shooting pain) 8 indigestion (stabbing pain) 9 pins and needles (tingling sensation) 10 tension headache (throbbing pain) 18 1 The metaphors are both related to DIY/tools.

19 a Put a cross on the scale to show me how bad the pain is. b The following are examples of other methods used to assess pain. ● Ask the patient to rate the pain on a scale of one to ten. ● Ask the patient if he/she has ever experienced a migraine, bad toothache or a broken leg and then ask him/her to compare the current pain to that.

20 –ish means ‘quite’.

21 a Suggested answers a How do they compare to a migraine? b Whereabouts do you get these headaches? c How long do they tend to last? d How long have you had the headaches? e Are there any other symptoms? f Can you describe the pain? g What seems to improve the situation for you? h When do they come on?

23 b f, b, a, c, d, h, g, e 24 a 3 b 1 c 4 d 4 e 7 f 2 g 6 h 5

Answer key – Unit 2 155

COV-19 2020 25 a The eighth attribute involves understanding the beliefs or thoughts of the patient regarding their illness, worries about what the symptoms might mean, expectations about how the doctor might help, emotions that the problems might induce, etc. This is to validate the patient’s viewpoint (an important aspect of the patientcentred approach) and involve the patient. Doctors may also find out extra information at this stage. b No c Suggested answers How has this made you feel? / You say you’ve been worrying …? (asking about the patient’s concerns) Tell me what you think is causing this pain. (asking about patient’s belief) What do you think might be the best plan of action? (asking about the patient’s expectations) 26 a ● bring up (transitive): vomit / be sick My little girl was coughing so much, she brought up some yellowish phlegm. ● build up: increase I’ve been having headaches – the tension builds up, and I feel as though my head is going to explode. ● blow up: swell You say your stomach blows up after meals – you have a bloating feeling – is that right? ● clear up: heal The eczema seems to have cleared up; the hydrocortisone must have done the trick. ● clog up: block His ears are a little clogged up with wax, which is why he’s been having problems hearing recently. ● ease up: improve You’ll probably find the pain will ease up when you lie down and relax. ● flare up: erupt, get worse Doctor, the rash has flared up again. I was wondering if I could have a prescription for some of that cream I had last time. ● tighten up: become tighter Ms Singh says her chest has tightened up; she’s also having difficulty breathing. ● throw up (intransitive): vomit / be sick He threw up last night; he must have eaten something that disagreed with him. ● shoot up: rise dramatically, inject The pain just shoots up my arm; I don’t know what I’ve done. ● puff up: swell Kieran’s eyes keep puffing up – I think he’s got conjunctivitis again. ● play up: cause a problem Dad says his arthritis is playing up again; he’s had a lot of pain in his joints. ● dry up: dehydrate Every winter, my face really seems to dry up, especially my forehead – the skin is all flaky. ● cough up (transitive): eject from the lungs by coughing The patient coughed up a little bit of blood this morning, but seems fine now.

27 1 c 2 a 3 b

156 Answer key – Unit 3

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28/29 Technique

Examples

Clarification

Could you explain what you mean by ‘pneumatic drill’?

So, if I’ve got it right, …

2, 4, 12

Facilitation

Go on … , Uh-huh?

1, 5, 6, 7, 8, 9, 10, 11

Repetition

No? 3

30 facilitation 31 a 3 is the odd one out (in 1, 2 and 4, the intonation rises gently; in 3, the intonation falls on the word see).

Unit 3 Lead in 1 Patient may be suffering from a genetically determined disease; patient’s concerns about presenting complaint may be linked to experience of other family members (e.g. parent died from same condition).

It must be done sensitively. Explain the significance of taking the family history and the patient will realise its importance.

Access to medical care, patient’s family culture, economic/ educational background and adopted status (in certain cases) may affect how much a patient knows about his/ her family members’ medical history.

2 a Patients may have greater difficulty recalling family history than their own PMH, especially beyond two generations. Recent events are obviously easier for them to recall. b Patients may be estranged from members of the family who may hold the key to certain genetic diseases.

There may be difficult family issues involved, and patients may be reluctant to discuss these. c Similar to b, plus fear of genetic susceptibility.

1 b 1 Past illnesses 2 Childhood illnesses 3 Immunisation 4 Surgical procedures 5 Accidents and injuries 6 Pregnancy 7 Allergies 8 Medication(s) c 1 Past illnesses: Patients may forget some illnesses, but remember more recent ones; they can be vague about the details, even adults.

2 Childhood illnesses: Patients remember childhood illnesses if they were traumatic or if they took a long period off school, e.g. chicken pox, mumps, measles.

Also ask about unusual illnesses.

3 Immunisation: Important information, especially for children and women of child-bearing age (toxoplasmosis/rubella). Patients don’t remember details.

4 Surgical procedures: Some patients understand little about surgical procedures, and some may not even know the reason for their hospitalisation or exploratory investigations.

5 Accidents and injuries: Be aware of repeated injuries in women (might indicate domestic violence) and the elderly (may need help or referral to social services).

Repeated injuries might possibly indicate drug or alcohol abuse.

6 Pregnancy: Ask all women of child-bearing age about pregnancy and related problems. Difficult for some to discuss abortion or miscarriage.

COV-19 2020

d

3 a b

c

7 Allergies: Patients may not think to mention allergies to medication and food, but will remember hay fever, etc. Presenting complaint may be a reaction to food or current medication.

8 Medication: Patients forget to mention over-thecounter medications and vitamins. Reluctant to mention alternative medicines and medication prescribed by another doctor.

1 Many patients find it difficult to recall exact details, names of conditions/diseases, as well as dates and surgical intervention. They sometimes choose not to remember traumatic experiences.

2 People tend to associate the word drug with illicit/ addictive drug-using behaviour. a 1 b 2 c 6 d 3 e 4 f 7 g 5 h 8 He doesn’t ask in the same order because he often allows the patient to control the interview and so some components are discussed as they come up naturally.

Dr Tran Since this is your first visit to the practice, I’d like to have a more detailed picture of things. Could you tell me about any illnesses you 1 might have had in the past?

Doctor asks about general health. Open question Ms Martin I had my tonsils out when I was a little kid, I remember that.

Patient remembers being hospitalised as a child – often a traumatic experience for a child and so easier to recall.

Dr Tran 2 Any other childhood illnesses?

Ms Martin Don’t remember, to be honest – my mother would know, I’d expect. Mumps, measles, that kind of thing, usual stuff.

Difficult to recall – responsibility was with the parents, and children don’t necessarily remember which of these illnesses they suffered.

Dr Tran Regular childhood illnesses, then? [pause] And 3 how has your health been in general since then?

Doctor tries to get back to the question of adult past illnesses.

Ms Martin No, no real problems, to tell you the truth.

Dr Tran Good. So, have you had any operations, 4 apart from the tonsils?

Doctor demonstrates he has been listening – mentions tonsils.

Ms Martin No, no. Like I say, I’m pretty healthy.

Dr Tran 5 Any other visits to the hospital?

Doctor needs to find out about accidents, injuries.

Ms Martin Yes, for the birth of my son, and, er, then a couple of years ago, I had to go in for some tests.

Question leads to pregnancy automatically.

Dr Tran Mm-hm? What kind of tests, Ms Martin?

Ms Martin Don’t remember exactly.

Could be that the patient doesn’t remember – patients tend not to remember details of tests. She is uncomfortable – maybe she’s blocking something.

Dr Tran 6 Can I ask you how old you were when you gave birth?

Ms Martin Yes, it was just before my 40th – celebrated it surrounded by diapers that year!

Dr Tran Going back to those tests, Ms Martin, can I ask you to elaborate on those a little?

Doctor acknowledges joke. He reads the patient cues and decides to probe, but asks an open question – still not wanting to assume anything – he wants to get the patient’s story.

Ms Martin Oh, those, well, er, I lost my second baby, a little girl apparently.

Patient possibly in denial having lost baby. Patient in mid-40s and possibly wanting more children.

© Cambridge University Press 2007

Dr Tran I’m sorry to hear that. 7 I have to ask, was she stillborn?

Doctor needs to confirm and so poses a closed question to have exact information. He acknowledges patient’s distress and apologises as he asks the question (I have to ask, …).

Ms Martin Yep. Patient upset by the line of questioning.

Dr Tran I understand this must be a painful memory for you. [pause] Moving on, if we can. Are you fully immunised?

Empathises with the patient. Doctor wasn’t able to ask PMH in the logical order, but was allowing patient to lead the encounter.

Ms Martin I’m sorry?

Patient has not understood the word immunised.

Dr Tran What I mean is, how 8 up to date are you with your shots, Ms Martin?

Doctor rephrases using patient-speak: shot.

Ms Martin I think I’m OK. I had most of those when I was at school.

People associate shots with school age, not something they were responsible for and so don’t necessarily remember the details.

Dr Tran 9 How about tetanus?

Doctor needs exact information – closed question.

Ms Martin Uh-uh. [shakes her head] Dr Tran Now, nearly finished this part. Um, have you ever suffered from allergies?

Doctor asks focused, but not closed question to give patient options.

Ms Martin No, not that I know of. My brother always got hay fever, poor thing, but not me.

Patient is sure she’s not allergic, but hasn’t made the connection with food or medications.

Dr Tran Any food allergies?

Doctor needs to be sure – closed question.

Ms Martin Mm … Strawberries – weird, isn’t it?

Patient may feel a little embarrassed by this – it’s an unusual allergy.

Dr Tran And I suppose they were your favourite fruit, too?

Humour is appropriate here.

10 Are you allergic to any medications – some people are allergic to penicillin, for example?

Doctor gives an example of medication to which people commonly have an allergic reaction.

Ms Martin No. Dr Tran And finally, 11 are you currently on any medications at all, Ms Martin?

Doctor avoids using the word drug.

Ms Martin Ah, yes. I was taking antibiotics, but didn’t finish the course, didn’t seem to be doing anything.

I’m not on anything else.

Patient hasn’t thought about over-the-counter drugs or alternative treatments.

Dr Tran Right. 12 Can I ask you what you were taking them for?

Patient hasn’t specified, and doctor needs more accurate details of medication.

Ms Martin Oh, I’d had a very bad cold and I couldn’t shake it off.

Dr Tran How about medications you buy 13 over the counter?

Ms Martin Ah … laxatives sometimes, you know, for the problems I’ve been having recently. Tylenol, occasionally.

Answer key – Unit 3 157

COV-19 2020 Dr Tran Some people believe in alternative medicine; is this something that interests you?

Doctor phrases the question by allowing patient to feel it is OK to discuss these options – even if doctor may be against use of alternative treatments/homoeopathic medicine.

Ms Martin No, no, definitely not.

Patient rejects usage.

Dr Tran Well, some people are turning to alternative forms of treatment, and so this is a question we have to ask, in case of any possible complications.

Doctor reconfirms need to ask the question and explains rationale for doing so – to validate in the eyes of patient his line of questioning.

OK. [pause] So, I’d like to sum up your history briefly to make sure I have all the details correct before we proceed …

Doctor summarises and allows patient to add or correct if necessary. Not all concerns are mentioned at the beginning of the encounter.

4 b An analysis is not expected of each and every stage of the encounter, but the comments above show fairly typical responses, how the doctor deals with them and his line of questioning.

5 Pause 1: used as a facilitating technique to encourage the patient’s story (see Unit 2).

Pause 2: sign of respect, doctor acknowledges pain the patient appears to be feeling at mention of death of baby.

Pause 3: indicates doctor is about to summarise patient story.

He uses it as a signpost.

6 The second opener is the most appropriate; might have had is a modal past perfect. The doctor does not assume anything or suggest the patient has suffered any illness through the use of modal might. It therefore opens up the dialogue more. This is a subtle use of language, but one that is important. NB Use of modal might does not indicate something that the patient might not know about.

9 Patients a and c A focused PMH would be taken in the following cases: A&E, patient suffering respiratory problems, asthma, road traffic accident, acute chest pain, patient having difficulty responding due to pain, etc.

10 Patient c 11 b Dr Bhaskar focuses on: ● past illnesses ● surgical procedures (illnesses and operations were asked about, but briefly) ● medication Note: although he doesn’t ask about pregnancies, the doctor asked about gynaecological issues, but not pregnancy exactly, to eliminate this area as a possible cause of the anaemia; the patient has since had a hysterectomy, so there is no need to go into any further detail. As this is a focused PMH, it is normal for the doctor to interview the patient in this way. c 1 Hysterectomy in 1999 due to fibroids, periods started at age 11, no other operations or illnesses, no abdominal pain, good diet, prescribed iron tablets for a week.

2 Doctor Bhaskar takes a very focused history, but it is an appropriate line of questioning. He starts with open questions, then uses the cone technique to determine exact information related to the symptoms. For more information on the cone technique, see Unit 2.

158 Answer key – Unit 3

© Cambridge University Press 2007

12 a You could ask an open question or use non-verbal communication strategies to encourage a patient to tell his/her own story: Uh-huh? + eye contact or lean forward Could you tell me in a little more detail how you’ve been feeling / how you feel?

In what way ‘under the weather’?

13 a change direction = moving on refer to an earlier point = going back to ask for more detail = elaborate on summarise = to sum up end = finally b 1 They give more structure to the interview for both doctor and patient.

15 The content of the patient note summary is accurate, but as the entry is totally illegible, there are obvious difficulties for the next doctor who needs to make use of these notes.

The fact that the patient is perusing ‘in vitro’ treatment is vital information, for example. Other vital information: the name of the patient, especially the spelling; the fact that the pain is in the right breast and not the left; the time delay (three days), etc. Hence hieroglyphics literally could have dire consequences.

17 a HTN hypertension m male black b yo year(s) old Neuro neurologic cig cigarettes CXR chest X-ray PMH Past Medical History MRI magnetic resonance imaging Abd abdomen r right GI gastrointestinal h/o history of l left f female FH family history w white ETOH alcohol ICU intensive care unit c/o complaining of b A 25-year-old black male presents complaining of abdominal pains on his left side. The patient has a history of gastrointestinal problems. Past Medical History: the patient had a car accident in 2001 and was in an Intensive Care Unit for two months. Family History: the patient’s father and mother are alive and well. The patient is a nonsmoker and drinks on average 25 units of alcohol a week.

18 a 1 yes 2 no 3 no 4 no d A full evaluation of the patient note would be: ● The doctor has not indicated the full date (no year) nor used the 24-hour clock. ● She did not write the surname in block letters as required. ● She has not added the age of the patient. ● She has not signed the note and printed her name in block capitals. It is a legal requirement to sign each and every entry. ● Entries should be clearly spread out for ease of reading. ● Not all the headings are clear: Previous should be past medical history or PMH; Drugs should be written as Drug history.

COV-19 2020 The patient note has not been written in a logical order: past medical history (PMH) appears before history of presenting complaint (HPC). ● The presenting complaint (PC), HPC and FH are not written clearly and concisely, making it more difficult to distinguish salient points. ● She also repeats information that should appear later on in the drug history. ● She does not always use standard medical abbreviations: AP and Ren are not standard abbreviations for Appendectomy (UK English: also Appendicectomy) and Renal disease (AP stands for Anteroposterior). ● She has not indicated she has asked about allergies to medication (NKDA = no known drug allergies). ● She doesn’t indicate the age at which the father died, which is more significant than the year of his death. ● She doesn’t use standard abbreviation for alcohol (ETOH), although it is still clear. ● She does not use diagrams, but this is not appropriate here. They would be more useful later on in the Examination section.

For any abbreviations you are not sure about, see the list at www.cambridge.org/elt/goodpractice.

A better version of the notes would look something like this: ●

St George’s Hospital

A&E

Date / Time

Clinical Notes

10/05/07 18:25

PC Breathlessness

Unit N° Z29104

Surname (Block letters) First Name(s) D.O.B./age

MATHERSON Michael 19/10/69

38 years

(Each entry must be signed)

HPC Started 2/7 Onset gradual Slowly worsening Worse during night Wheezy and chest feels tight Salbutomol gives minimal relief H/o asthma PMH 1992- Appendicectomy ° HTN / DM / IHD / Ep / Renal / An FH Mother – A&W, asthma Father – died heart attack aged 61 DH Salbutamol 100mg No over-the-counter medication

Allergies NKDA

Social H Office manager Office clean, no dust No cig / ETOH – occasional ‹10 units/wk No pets Sexual history – not appropriate Signed: Annabella Davies ANNABELLA DAVIES

© Cambridge University Press 2007

19 FAMILY PRACTICE Smithston Family Practice 134 Main Street Long Island New York State

Unit N° X18887

Date / Time

(Each entry must be signed)

_______ _______

PC Irregular bowel movement

Surname MARTIN (Block letters) First Name(s) Adele D.O.B./age 6/23/63 44 years

Clinical Notes

HPC PMH Child – tonsils Childhood illness – patient not exact 2 children – 1 stillborn FH DH Antibiotics – currently taking Laxatives Tylenol occasionally

Allergies NKDA

Social H Signed: ___________________

20 1 Colour blindness or Haemophilia A 2 Breast cancer 3 Neurofibromatosis (also known as von Recklinghausen’s disease), dystrophia myotonica (muscle-wasting disease)

Unit 4 Lead in The idea is that we shouldn’t judge someone by their appearance; doctors are not exempt from this human failing.

It is important that doctors avoid stereotyping their patients and making assumptions based on appearance, race, gender, sexual preference, etc. They should also remember that a patient’s health is affected by social factors. In a holistic, patient-centred model of health care, it is impossible to separate the social factors from the medical condition or disease. They could all possibly play a role – on the general morale or appearance of the patient if nothing else.

1 a/b Occupation Sedentary or active work, unemployed (Unemployment is known to have an effect on morbidity rates.)

Environment The physical environment, proximity to factories and farmland, condition of housing, toilet and bathroom facilities, stairs, number of rooms, number of residents Financial issues Well-known cause of stress and psychological wellbeing of the patient.

Education This can determine patients’ potential access to medical information and how well informed they are in terms of medical care itself, as well as, for example, safe-sex practices, the dangers of smoking, right to health checks, etc.

Family Number of immediate members, support networks Lifestyle Substance use: cigarettes, alcohol, recreational drugs; general fitness; rest and relaxation (holidays, sleep patterns, hobbies, etc.); sexual practices 2 b 1 As for Lead in. It is impossible to separate the illness from the social aspects of a patient’s life.

Answer key – Unit 4 159

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3 a 4 a

5 a

b

6 a

b

2 Some patients don’t automatically see the relevance of this aspect of the history-taking process, especially if they are not used to the holistic approach to medicine.

They might not see the link between the physical illness itself and their social and environmental situation.

350,000; every; the long latency between exposure and the appearance of the illness 1 airport baggage handler: hearing problems, back injuries 2 cleaner: dermatitis (through working with detergents) 3 coal miner: chronic lung disease, physical injuries related to the daily responsibilities of such an occupation 4 construction worker: possible exposure to asbestos (lung disease, skin cancer), lead (neurotoxicity), abdominal pain, physical injuries related to the daily responsibilities of such an occupation 5 farm worker: respiratory problems, prostate cancer (exposure to pesticides), physical injuries related to the daily responsibilities of such an occupation 6 healthcare professional: back strain, exposure to contagious diseases 7 keyboard operator: repetitive eye strain, repetitive strain injury (RSI) 8 manual worker: ischaemic heart disease / rheumatoid arthritis, physical injuries related to the daily responsibilities of such an occupation Ask about working hours; how many jobs (cleaners are paid by the hour generally, and so are likely to have several contracts); where they work and in what type of environment they carry out their work (e.g. office cleaning / industrial cleaning, etc.); exposure to hazardous products and length of time been exposed; working conditions; whether they are required to climb or exert physical effort in order to carry out their job; how much exposure to lead-based or asbestos products or toxic products or fumes, etc. they have; safety conditions (supplied with safety goggles, etc.). Should also ask about other members of the household and their possible exposure to products the cleaner might bring home.

Possible questions for gathering information about occupational health: ● What type of work do you do? ● Please describe your work. ● Have you ever worked near any factories, shipyards or other potentially hazardous facilities? ● Has anyone in your household ever worked with hazardous materials that could have been brought home? ● Have you ever had environmental or occupational exposure to [asbestos/chemicals/lead/fumes]? ● Are you exposed to any hazardous materials in your workplace? ● Do you ever have any contact with toxic products / glues, fumes, etc.?

1 Presenting complaint: mild asthma attacks 2 Place of work: hotel 3 Other pertinent information: Patient only suffers attacks at home / no exposure to toxic products at work / no hazardous environment or fumes / kids’ hobby – making model planes The GP asks the following questions: What type of work do you do, Mary? … if you could just describe your work for me?

And are you exposed to any toxic products at work?

160 Answer key – Unit 4

© Cambridge University Press 2007

8 1

2

9 a

b

10 a

Has anyone in your household ever worked with hazardous materials that could have been brought home? * (environmental health question) Do you live near any factories that give off potentially hazardous fumes? * (environmental health question) How do you and the family spend your evenings, Mary? * (lifestyle question) * These questions are not strictly about ‘occupational health’ and will be dealt with later in the unit.

Doctors should ask about all of these during an initial visit. Smoking is important, as it is a risk factor for numerous diseases. Sexual history is not only related to sexual dysfunction, etc. but is also often a contributor to depression, etc. Alcohol use in the UK and Ireland is commonplace, and there is an increasing problem.

A person’s health is determined by a balance between physical, psychological and social factors. A number of lifestyle factors may influence a person’s view of their health; they include factors such as education, occupation, employment status, relationships, hobbies and so on.

The doctor might decide to go into more detail if the patient shows evidence of alcohol abuse or recreational drug use or if there is the possibility of a sexual health issue.

Has anyone in your household ever worked with hazardous materials that could have been brought home?, Do you live near any factories that give off potentially hazardous fumes?

Husband is unemployed, which may cause stress in the family, as well as low esteem for the husband, which may have a knock-on effect for the patient, etc.

Patient works part-time only. Cleaning work means the patient earns the lowest minimum wage. As a result, there may be financial worries for the family.

The patient’s daughter has cancer and is going through chemotherapy. This is likely to cause unnecessary stress and concern for all the family members.

It is tiring for the patient to go back and forth to hospital every day, plus look after two other children, whom we imagine are school age – possibly primary.

Doctor’s question: How are you coping?

Potential risk areas: Occupation: Unclear if partner is in employment or receiving welfare benefits Environment: housing / number bedrooms in order to house two adults + three children + large, dangerous dog (in UK/Ireland, people tend to gauge size of accommodation by number of bedrooms, as opposed to total area, etc.) / facilities – toilet/running water, etc. / housing estate – could be run down / unsafe Financial: cause of stress / lower standard of living might result in inadequate nutrition / stigma of living off welfare benefits, etc. Potential to lead to depression.

Education: three children at 22 years old (one of the children is at least five years old) indicates Sinead possibly doesn’t have a high level of education and therefore access to medical education Family: social services (formal support network) are possibly already involved with this family.

Lifestyle: partner: alcohol abuse + violence have obvious consequences + negative role model for children / disruption of family life, etc. Ask patient about own drink habits – it is common for alcoholics to set up home together / domestic violence is big issue in terms of safety for woman and children.

COV-19 2020 Pets: hygiene in both cases / possible respiratory problems and allergies / potentially highly dangerous dog Some of the questions from Case study 1 could also be used in Case studies 2 and 3: ● Openers Perhaps you could start by telling me about your current living situation?

Are you currently in a relationship? ● Coping questions How does that affect you?

So, how are things there?

How do you cope with …?

Is there anything else worrying you at the moment? ● Asking for permission Now, if you don’t mind, I’m just going to ask you a few questions about your home life. ● Giving a rationale It’ll help me to better assess your present situation. ● Facilitating questions (picking up on cues) You don’t sound convinced?

You don’t approve of the dog, I take it?

f

12 a Suffix

18 a 1 2 3 4 5 6 7 8 9 10

State your name Obtain the caller’s name and telephone number Record the date and time of the call Record the person’s name, sex and age Take a detailed and structured history Provide advice on treatment or disposition Advise about follow-up and when to visit a doctor Summarise the main points covered Request the caller to repeat the advice given Ask if the person has any outstanding questions or concerns b 1 The patient may not have mentioned all the points he/she wishes to discuss, as in any face-to-face consultation. The most important reason for the call may not be the first point the patient mentions.

2 a In case of emergency / good customer service (people are more stressed in such situations) b To ensure all the points the patient wanted to mention have been covered.

19 a Date: 26 December 2009 Patient details: Tony Patchett / Tel. 01229 845143 / DOB 30/5/56 Presenting complaint: burning pains in chest Diagnosis: indigestion Medication: over-the-counter antacid (Gaviscon) Follow-up: Make appointment with GP if pain not gone in 24 hours c

Definition/Related to

Example of medical terminology

–algia

pain

neuralgia

–aemia

blood

leukaemia, anaemia

–uria

urine

polyuria

–ectomy

removal of

hysterectomy

–genic

origin of

carcinogenic

–itis

inflammation

arthritis, colitis

–ology

study of

psychology

–rrhoea

flowing

diarrhoea

3

–oma

tumour/growth

fibroma

4

… could I also have your date of birth, please?

–osis

diseased state

endometriosis, thrombosis

5

So, what prompted you to call us today?

6

So what I’m going to suggest is that you …

7

… if the medication doesn’t solve the problem over the next 24 hours, then I would advise you to make an appointment to see your GP.

8

… I’d just like to briefly summarise your history to be sure I have the details correct.

9

Now, if you wouldn’t mind going over the advice I’ve just given, Mr Patchett?

10

Now, before we finish, is there anything more you want to ask?

–pathy

disease

uropathy

–penia

lack of / deficiency

osteopenia

–phagia

swallowing

dysphagia

–plasty

repair

rhinoplasty

–pnoea

breathing

apnoea

–phobia

fear

agoraphobia

13 a/b

Some of the words have a main stress and a secondary stress; here, main stress is shown by double underline; secondary stress by single underline.

1 hysterectomy 2 carcinogenic 3 apnoea 4 agoraphobia 5 leukaemia 6 arthritis 7 neuralgia 8 endometriosis 15 Possible advantages: reduce costs, reduce numbers in emergency departments, allow doctors to treat larger number patients with minor problems, allow patients in remote areas to be treated from home, etc.

Possible disadvantages: lack of human contact, possibility of misdiagnosis and increased margin of error, etc.

© Cambridge University Press 2007

Stage

Language

1

Good evening, I’m Dr Marsden.

2

I wonder if you could give me your full name and telephone number, please, just in case we need to call you back at any point or we get cut off.

20 Even if the caller is unable to see you, using non-verbal communication, such as smiling and showing warmth with the eyes, is proven to have a very positive effect on maintaining a good relation with a caller, even during difficult situations. Also, standing up while talking can lead to rushed conversation and also a feeling of superiority. On the other hand, lounging back in the chair might lead to the doctor being more casual and less attentive.

Answer key – Unit 4 161

COV-19 2020 21 b Now, Mr Patchett, / I’d just like to briefly summarise your history / to be sure I have the details correct. / You’ve been suffering from mild chest pains since Christmas Eve / and you’ve experienced some acid burning. You’ve eaten a lot of rich food over the last days, which is unusual – / your diet’s usually quite plain – / and you think this might have contributed to your symptoms. / You’ve no history of ulcers. / You don’t have any other symptoms. / No one else in your household has these symptoms. / Is that right so far?

23 b 1 He is suffering from breathlessness.

2 Lifting things at work, long hours, not being able to help take care of his grandchildren. He is also possibly suffering from grief after the recent death of his daughter.

3 Could suggest Mr Tomlinson make an immediate appointment with his GP to be examined and possibly sent for a chest X-ray. c ✓ Establishing rapport (Using tone and supporting statements to ensure rapport develops) ✓ Gathering information (Encouraging patient to speak – often done through nonverbal / Listening actively) ✓ Understanding the patient (Asking for clarification / repetition regularly throughout the interview) ✓ Picking up on patient cues (Listening for change of pace and intonation in patient) d Establishing rapport Doctor creates good rapport with patient from outset – both have grandchildren.

Doctor’s tone of voice is calm and friendly and not rushed.

Gathering information Doctor allows patient to tell his own story.

Doctor doesn’t assume the patient is calling about breathlessness. (Am I right in thinking …?)

Doctor uses verbal facilitation and repetition to encourage the patient. (I see, go on … / Stuff?)

Doctor asks what patient can see (What does it look like?)

BUT fails to ask about hospitalisation and current medication or past occupation, all of which might have a serious bearing on the diagnosis.

Doctor fails to give patient opportunity to ask questions.

Understanding the patient Doctor asks for clarification on a couple of occasions.

(Now, can you describe your symptoms to me in a little more detail?)

Picking up on patient cues Doctor picks up on effect of symptoms on lifestyle (through change of pace in patient’s voice) – patient wants to spend more time with grandchildren. (You sound a little worried by the situation?) e 1 Doctor fails to ask about past work; patient indicates this is a second career (I have my own shop now), and as an ex-miner, he could possibly have traces of coal dust in lungs, etc.

She also misses the fact that the patient has already self-diagnosed. He recognises the symptoms, having previously suffered from bronchitis. The doctor could then have continued this line of questioning and might have arrived at a diagnosis earlier in the consultation.

162 Answer key – Unit 5

© Cambridge University Press 2007

2 If the cues had been picked up, the doctor would have advised the patient to visit his GP as soon as possible – diagnosis requires physical examination – and continued taking more detailed history before summarising and giving advice. g Suggested answer Now, Mr Tomlinson, let me see if I’ve got this right: you’ve been having trouble breathing, especially when lifting or climbing stairs. You’ve been coughing up yellowish phlegm and you’ve had a couple of bouts of bronchitis in the past. You’re concerned because you feel you should be helping your son-in-law more with the care of your grandchildren, but you don’t always feel able to do so, and you’re worried about the physical side of your job. Is that an accurate summary?

Right, well, Mr Tomlinson, I’d suggest you make an appointment to see your GP. He or she will be able to carry out the relevant tests to find out the reason for your breathing difficulties.

Unit 5 Lead-in Suggested answers 2 Patients may be having a variety of feelings prior to the examination, ranging from mild anxiety to fear. These thoughts may be quite irrational.

However, some examinations can be both painful and embarrassing. Patients might feel overexposed and, in most cases, not particularly relaxed.

2 Suggested answers Think about: cleanliness, lighting, comfort and privacy, respecting the patient’s sense of dignity at all times, washing your hands thoroughly before touching the patient, keeping the patient covered, warming hands before touching the patient, preparing the patient, explaining different examinations to the patient, not repeating painful manoeuvres, requesting permission before removing clothes or touching the patient, explaining findings when appropriate, not discussing findings fully with the patient until he/she is fully dressed, asking the patient to tell you when he/she feels pain, watching facial expressions for signs of pain or discomfort, explaining where and why you are palpating a patient, offering help getting on and off the examination table, always keeping the patient informed.

3 a a Auscultation b Palpation c Inspection d Percussion b a 4 b 2 c 1 d 3 5 a The medical instruments shown are: ● penlight (top left): a small electric torch the size of a pen used to examin eyes, ears, etc. ● reflex hammer (top right): a small hammer typically with a triangular rubber head used for testing reflexes ● tuning fork (bottom left): a steel instrument with a stem and two flat prongs which vibrates and produces a sound, used to assess a patient’s hearing, as well as in the examination of the peripheral nervous system ● nasal speculum (bottom left): a speculum is a surgical instrument used for dilating orifices (such as the nasal passage), facilitating examination or operation 7 A 1, 10, 13, 14 B 2, 4, 8 C 4, 8, 13 D 3, 5, 11, 13 E 1, 3, 5, 6, 7, 12, 14

COV-19 2020

↑

↑

↑

8 a 1 Patient I’m still having problems with this knee.

Doctor OK, let me have a look. Can you roll up your trouser leg for me? Good, now if you could recline on the bed and flex your right knee …

Patient [shows signs of being a little uncomfortable] Doctor Still seems to be causing you a little discomfort, Sean.

Patient Yeah, yeah, I know.

Doctor Gently then, just bring your knee up to your chest. That’s fine. And now extend your leg again …

2 Patient [wheezing heavily] Doctor Mrs Daniels, can you sit in the upright position for me, please? I can see you’re having difficulties today. We’re going to try to make things more comfortable for you. I’m just going to listen to your chest.

Patient Sure.

Doctor Good. Now, I want you to inhale through your nasal passage. Inhale deeply … that’s it. Now exhale. And again … inhale … and exhale.

Doctor Now, I want to measure your respiratory rate … I think you’ve seen this little machine before. [shows patient a peak-flow machine] Patient [nods] b recline – lie back; flex – bend; extend – straighten sit in the upright position – sit up; inhale – breathe in; nasal passage – nose; exhale – breathe out 9 1 kB 2 dK 3 gE 4 hI 5 aD 6 iC+jG 7 eH 8 f J 9 bA+cF 11 a A: knee injury B: suspected dislocated shoulder b Consultation A ● Take off shoes and tights 4 ● Try to bend left knee 2 ● Stand up 1 ● Lift skirt over knee 5 ● Say if it feels uncomfortable 6 ● Lift left leg 3 Consultation B ● Hold out right hand 5 ● Stand up and put arms by side 2 ● Take off shirt 1 ● Bend elbow horizontally 4 ● Lift right arm to shoulder level 3 ● Lift and lower arm 6 d 1 If you could stand up for me, please, Julie.

2 You can put your foot down now.

3 I’d just like you to lift your left leg as high as you can.

4 (Please,) If you could take off your shoes and your tights …

5 Would you mind just lifting your skirt over your knee?

6 I want you to tell me if it starts to feel uncomfortable … e 1 Doctors use indirect language to give instructions.

2 Indirect language is used to soften the instruction so that it comes across more like a request and less like a command. As a result, it is considered polite. Patients may be feeling anxious, frightened or agitated. Use of a more direct language would further aggravate their feelings.

12 a 2 Would you mind rolling over onto your stomach for me? ↑

↑

3 I want you to sit up with your legs stretched out in ↑

front of you.

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13 a The missing word in all the examples is just.

14 a Just softens the instruction and as a result renders it more polite. It can also be used to reassure the patient or diminish the seriousness of the situation. b In each case, intonation rises on the word just.

15 The expression just in case means ‘in the event that something may (not) happen’ and is used to reassure the patient that the doctor is looking at every possible potential cause, even though the chance of there being a serious problem is slight.

Unit 6 Lead in 1

Gathering information about the patient can be regarded as the building blocks of the consultation.

2 It is important, after building (on) the foundations of the patient interview by discussing patient’s wishes, history-taking and being knowledgeable, that you add the roof, i.e. make a joint management plan that the patient understands, feels comfortable with and is prepared to follow.

(Silverman, Kurtz & Draper, 1998) 1 a 2 Do they deliver information in a way which helps the patient understand it?

3 Do they deliver the information in way which helps the patient recall it accurately?

4 Do they deliver the information in a way which includes the patient’s perspective and achieve a shared understanding with the patient? (taken from the Calgary-Cambridge observation guide) 3 Very good Giving correct amount and type of information

✓

Helping patient understand and remember

✓

Including patient’s perspective

✓

Good

Could improve

4 a 2 b 1 c 2 d 1 e 1 f 1 g 3 h 2 i 2 j 1, 2 k 2 l 3 5 To begin with, I’m going to give you your results, and then we’ll discuss where to go from there Let me explain. … that brings me to the next point There are four things you need to consider 6 a Adding signposting means that the patient has got a better chance of taking in what the doctor is saying, given that he/she likely to be in a state of shock following the break. b 1 To begin with 2 However 3 First of all 4 Then 5 When 6 Finally 7 Suggested answers Scenario 1 Firstly, let me give you the results of the ultrasound test.

They show that you have a number of gallstones in your gall bladder. In addition, your bile ducts have dilated, which may mean that there are gallstones present there. We need to remove the gallstones to make you feel better. Now, there are three ways in which we could do this. Firstly, we could use drugs to dissolve the stones. However, this could take six months for smaller stones and around a year for larger Answer key – Unit 6 163

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8

9

10

11

12 14

stones. I’d like to point out that with drugs, there is a 50% chance of stones re-occurring within five years.

Moving on to the second method, which is a surgical technique called ERCP. Let me briefly outline what this involves. This is where small tools are attached to an endoscope, which is a small flexible tube that is inserted into your body, to release the stones. This method has a high success rate and a low re-occurrence rate.

The final option is to try open surgery, which means making an incision and removing the stones directly. However, compared with ERCP, this method is more invasive and patients tend to heal less quickly.

Scenario 2 Let me begin by giving you the results of the CT scan. You have a condition called chronic sinusitis, which is the result of a viral infection. The pain you are experiencing is due to tissues blocking your sinuses. Now, there are a number of treatments which I will outline. Firstly, antibiotics, which usually clear up the condition. Although they don’t actually kill the virus, they attack the bacteria that can make the sinuses very painful.

Another option is using steroid sprays or drops, which help to reduce inflamed sinuses. However, if these treatments don’t work, there’s an operation called functional endoscopic sinus surgery, which is a very common operation and has a very high success rate. Let me explain what this involves.

An endoscope, which is an instrument that magnifies the inside of your nose and your nasal cavities, is inserted into your nose. This allows the surgeon to see the opening of your sinus drainage channels, and any tissues blocking the affected area can be removed. Following the operation, the drainage of your sinus will be more efficient, and your sinus will function better. a 1 b (Confirming that the patient has diabetes) 2 a (Stressing the need to manage the condition) b 1 The results do confirm that he has pneumonia. / The results confirm that he does have pneumonia.

2 As we suspected, the results do show that you have anaemia. / … the results show that you do have anaemia.

3 I did tell you that the treatment can cause nausea.

4 I do think it would help if you spoke to a counsellor.

5 Your condition does require careful monitoring.

6 You do need to cut down on your alcohol intake. c 4 really, definitely, certainly 5 definitely, certainly 6 really, definitely, certainly a 1 You do have a form of pre-diabetes.

2 We do need to manage your condition.

The word do is stressed in each example.

Suggested answers 1 The results of the investigation do confirm that you have had a mild stroke. / that you did have a mild stroke.

2 It’s important that you do keep an eye on your weight.

3 The X-ray shows that you did fracture a rib. / The X-ray does show that you fractured a rib.

4 It’s important that you do take up some mild, regular exercise. a 1 T 2 F (It can also be caused by blocked bile ducts.)

3 T b No visuals, long sentences, little signposting, some difficult vocabulary 1 b 2 a 3 d 4 c 5 e 6 h 7 f 8 g a just b Because the doctor used the words ulcer and arthritis. In both cases, the patient had a different perception to the doctor of the seriousness of the condition.

164 Answer key – Unit 7

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15

16 17

18

c 1 It’s just a small, harmless growth on the neck of the womb.

2 It just shows some wear and tear on your spine, which is normal for a man of your age. a I hate needles, they really scare me.

The person I was telling you about had to have his foot amputated.

I can’t lose my job. I’ve got my family to think of. b The patient is seeking reassurance from the doctor. c The second question shows greater anxiety. a 1 B 2 A 3 A 4 B 5 A 6 B 7 B 8 A 9 A 10 B Statement 1 is more reassuring, because it stresses the positive outcome. Eighty per cent sounds like a high figure, so this is emphasised, rather than the remaining 20 per cent of operations which don’t result in a complete recovery. a, g, f, d, b, e, c (or a, f, g, d, b, e, c: likely and probable are near synonyms)

Unit 7 Lead in 1 Personal cost: The patient does not get better and/ or quality of life is not as good as it could be.

Societal cost: The time wasted by healthcare professionals in treating patients with ongoing conditions when they could be treating others.

Patients may be underperforming at work, which affects others. Emotional strain on relatives/carers.

Economic cost: Cost of drugs prescribed and not used; cost of wasted time of professionals; cost of sick pay for employers.

2 The quality or the quantity of information may be insufficient.

The impact of the medication on the patient’s daily life.

Physical or mental incapacity of patient.

Patient may not see the value of taking pills and prescriptions.

Social isolation.

3 Involve the patient in the decision-making process.

Find out about the patient’s beliefs.

Explain clearly why it is important to follow treatment or advice.

Be supportive.

1 Not very likely. The doctor simply tells the patient what to do without considering the patient’s perspective.

Think about Where a doctor uses a concordance-based approach, the communication is more likely to be interactive.

The doctor elicits the patient’s perspective on the proposed treatments, giving him/her an opportunity to raise any concerns. If the doctor does not follow a concordance-based approach, he/she is more likely to simply tell the patient what to do, without finding out if the patient can see any difficulties in following the instructions.

2 1 options 2 information 3 view 4 concerns 5 beliefs 6 plans 7 support; support 3 a a 1 b 4 c 6 b There is a better chance that the patient will accept the recommended medication, as the doctor has addressed the patient’s concerns. c Doctor Hello, Miss Lennox. What can I do for you?

Patient The antibiotics you prescribed haven’t cleared up my chest infection.

Doctor Right. Did you complete the course?

Patient Yes, I did.

Doctor And do you feel any better after taking them?

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d

e 4 a

b c

5 a b

Patient No. They’ve had absolutely no effect, apart from giving me thrush and leaving me feeling completely washed out.

Doctor Right. I’m sorry to hear that. Sometimes antibiotics may not agree with patients. [stage 2] What I’ll do is try you with a different antibiotic and see how that goes.

Patient Isn’t there something else that I could take instead?

Doctor Unfortunately not. [stage 1] It’s possible that the infection may clear up on its own if we leave it, but most likely it’ll drag on. A different antibiotic could really help here.

Patient I really want to get rid of it, but I’m not sure I can face another course.

Doctor Is that because of the thrush and feeling washed out? [stage 3] Patient Yes. I’ve got a demanding job, and it’s a struggle getting through each day at the moment.

Doctor I can understand your concern, but antibiotics really are your best chance of getting rid of the infection quickly. Different antibiotics affect you in different ways; I can also give you some cream which will sort out the thrush. If you need to, I can give you a doctor’s note so you can take time off work. [stage 7] Patient I can’t do that. I just need to get better. OK, I’ll try some different ones.

Doctor OK, and if these don’t help, come and see me again. But I’m hopeful that these will take care of the problem for you.

1 made better 2 tired/drained 3 go on for a long time 4 surviving/lasting 5 no longer having 6 find a solution to 1 cleared up 2 sort out 3 washed out 4 drag on 5 getting rid of 6 get through 1 Suggested answer Hypertension (or blood pressure) is basically the pressure of blood in your arteries. Your heart pumps blood around your body through a network of tubing called arteries. The higher your blood pressure, the greater your risk of developing narrowed arteries, which can lead to heart problems, kidney disease and strokes. (raised blood pressure ≥160/100mmHG.) 2 Smoking, excessive alcohol consumption, diet that is high in salt and processed foods, being overweight, lack of exercise, genetic predisposition Diuretics / water pills, beta blockers, change to lifestyle 1 you could consider 2 I’ll outline 3 in turn 4 the following options 5 You could consider 6 Another option is taking Diuretics, beta blockers and lifestyle changes Side effects / Disadvantages ● Diuretics: frequent urination, weakness, fatigue, dizziness or muscle cramp ● Beta blockers: nausea, dizziness, insomnia; depression or disorientation and impotence ● Changing lifestyle: keeping to a controlled eating and exercise plan, e.g. it can be difficult to cut out particular foods from the diet.

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6 Benefits: 3, 6, 7, 10, 11 Side effects: 2, 5, 8, 12 Benefits and side effects: 1, 4, 9 7 a The patient has been smoking for a long time, and he is surrounded by people who also smoke. b 1 I know, but it’s easier said than done.

2 I understand that it’s not easy, but it’s making your asthma worse.

8 a Is unlikely to comply: 3, 5, 7, 10 b May comply: 1, 4, 9 c Is likely to comply: 2, 6, 8 9 a The patient decides not to try any of the options outlined by his doctor. He decides to use willpower. b 1 not really convinced 2 How about 3 What’s the least 4 might be do-able 5 That sounds like 6 So let’s agree 11 a Suggested answers 1 Social environment 2 Social environment, peer pressure b Suggested answers 1 I understand that having a few drinks with your friends is really important to you.

2 I can appreciate that it’s going to be difficult making these changes.

12 a All the stages are covered. b Doctor OK, just to recap on what we’ve discussed. […]

You’re going to follow the diet sheet for the next three weeks and then you’ll come back and see me. You’re also going to do 30 minutes’ exercise three times a week.

Patient Yes – well, I’ll give it a go, anyway.

Doctor Is there anybody who can give you support if you’re finding it difficult?

Patient My wife will help if I explain why I’m doing this.

Doctor That’s good. If you’re having trouble keeping to the diet or you feel you need some support, you can phone me at the following times during my telephone consultation hours.

Patient OK, that’s good to know.

Doctor Is there anything else you’d like to ask?

Patient No, it’s clear what I have to do.

Unit 8 Lead in a Any particular patient might consider any one of these issues sensitive, depending on that particular person. People’s attitudes to different issues depend on background, religious or spiritual beliefs, the media, self-image, past experiences and social attitudes. b Any particular patient might consider any one of these issues sensitive, depending on that particular person. People’s attitudes to different issues depend on background, religious or spiritual beliefs, the media, selfimage, past experiences and social attitudes.

Physical and mental disabilities could also be added to this list.

2 a Patient 1: Assumptions can be made about style of clothing and manner of the patient’s appearance relating to preconceived ideas about particular social groups, e.g. the male gay community is known for being very fashion conscious.

Answer key – Unit 8 165

COV-19 2020 Patient 2: May assume patient is already in a sexual relationship. Underage sex is common in the UK, with the highest rate of teenage pregnancies in Europe.

Patient 3: May assume patient has been attacked in some way: mugged, or abused by carer, etc. b Patient 1: Needs proof of negative HIV test for immigration form to Australia.

3 a/b

Patient 2: Suffering from bad period pains.

Patient 3: Daughter concerned about his drinking. d Of course. Is there any particular reason you feel you need to have an HIV test? e Well, if you start by telling me how you feel about your drinking …

Question

Scenario

Problem with question

Improved question + rationale

1 a

Male/Female patient’s first visit to GP

The doctor is making a judgement about the patient’s sexual orientation and/or the nature of the patient’s relationship by assuming the patient is married/gay.

Are you currently in a relationship? is a more appropriate question.

Until the nature of the patient’s relationship is established, doctors should refer to the patient’s partner – a more neutral term. Also, a patient might not tell the doctor he/she is gay immediately – he/she might feel the need to gain some amount of trust in the doctor first. Patient might be in a heterosexual relationship, but not married – again, this version avoids any judgemental attitude about marriage. Avoid asking Are you married? Someone who is divorced, depending on the culture, might feel some stigma to this. Some may be married but separated – the doctor might need to establish this. A recent widow(er) might find the question distressing.

The patient could also be bisexual, and there may at some point be a need to establish if this is the case: Do you have sex with both men and women or just (wo)men? This is a simple question that is not judgemental.

2 Don’t you think your lifestyle is a little promiscuous?

During interview, patient divulges that he/she has several sexual partners

The doctor deems the patient’s behaviour to be promiscuous.

How do you feel about your lifestyle?

An open-ended question allows the patient to reflect and might divulge further information relative to the patient’s situation. The doctor is not being judgemental of the patient’s behaviour.

3 You’ve never had intercourse, have you?

Adult patient

Doctor assumes patient has never had intercourse.

When was the last time you had intercourse? (If it is reasonable to think that the patient is sexually active.)

This is more positive – some adult patients may be sensitive about not having ever had intercourse.

Have you ever had sexual relations? (If it is reasonable to think that the patient has never been sexually active.)

Tag questions (see Unit 2) should be avoided, as they tend to lead the patient to a particular response.

4 Do you have a drink problem?

Patient has indicated a higherthan-average consumption of alcohol

Patient might perceive question as doctor’s criticism of drinking habits.

How do you feel about your drinking? is a more open-ended question and takes the approach from the patient perspective first.

5 I take it your wife is aware of the situation?

Doctor knows the patient is married

Doctor assumes that the patient is only having sexual intercourse with his wife. There is also a judgemental edge to the question – I take it … – assuming there is something wrong in his behaviour if he hasn’t already spoken to his wife about the situation.

Is there anyone else who needs to be aware of this situation?

The doctor cannot rule out the possibility that the patient is having extra-marital sexual relationship(s). This question also gives the chance for the patient to divulge the relevant information to the doctor, i.e. that his wife might also require treatment, etc.

6 Have you taken illegal drugs in the past?

Male/Female patient’s first visit to GP

Emphasising the illegal nature of the patient’s behaviour is judgemental – it is not the doctor’s place to make that kind of judgement, even if it is, in effect, the case.

Have you ever taken recreational drugs?

There may or may not be some indication in the encounter that this is an issue for a particular patient. The doctor, as part of the questions on lifestyle, has to ascertain whether or not the patient uses drugs. Although a little direct, the above question can be asked if this is the case (see later in unit).

b

Are you married?

Are you gay?

166 Answer key – Unit 8

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COV-19 2020 4 1 There may be various reasons for these symptoms, but in order to find out more, I’m going to have to ask some rather personal questions.

2 I need to have a better understanding of your alcohol use, and so I’m going to ask a few personal questions.

3 I’m just going to ask you some questions of a more sensitive nature to assess your possible exposure to HIV. 5 b 1 Insensitive and judgemental.

2 Insensitively and dismissively.

Often Dr Staples makes assumptions about the patient and his lifestyle, including in his initial question, where he automatically assumes the patient wants to discuss a sexual issue, simply because the patient looks nervous.

Then at the end of the encounter, Dr Staples comes across as being disapproving of Mr Johnson’s alcohol consumption, although his intention was probably simply to warn the patient of the dangers of alcohol. c/d Suggested answers Dr Staples There seems to be something worrying you, Mr Johnson.

Mr Johnson [Looks nervous, fiddling with a gold chain] Dr Staples Take your time, Mr Johnson.

Mr Johnson Right, well, it’s a problem I’m having … down there … it’s like herpes, well, I think that’s what it is.

Dr Staples I will need to ask you some personal questions, but first, I’d like to examine you. If you could just take off your trousers and underpants and pop up on the examination table. [pause] If you could get dressed now, thank you (once patient is dressed) You were right in thinking it was herpes, what is known as herpes simplex. As I said, I’d like to ask you a few questions about your sex life, if you don’t mind? … Are you currently in a relationship?

Mr Johnson Well, actually, I’ve been seeing someone new. My relationship’s not that good at the moment …

I’ve been a little out of control recently … had a couple of one-night stands with girls I met in the local bar.

Dr Staples I see. And can I ask, when was the last time you had intercourse?

Mr Johnson Just last night, I’d been drinking.

Dr Staples Do you and your girlfriend currently have a sexual relationship?

Mr Johnson Well, yes, off and on.

Dr Staples And do you practise safe sex?

Mr Johnson Not always … well, not at all, in fact.

Dr Staples I’d like to suggest you take a look at these leaflets on safe-sex practices … and as you may be aware, herpes is contagious, so your girlfriend will need to be aware of the situation so that she can get herself checked out …

6 b 1 Patient cues serve to indicate to the doctor any underlying concerns / the emotional aspects of the illness. They could be a short cut to the real/ underlying issues for the patient, beyond the physical aspects of the illness.

2 Doctors are trained to listen for the physical aspects of the illness as opposed to the emotional. Doctors are often reluctant to deal with emotional aspects traditionally treated by counsellors or therapists. c 1 Disease refers to the purely medical aspect of what the patient is feeling, while illness is the impact of the illness on the patient’s life as a whole.

© Cambridge University Press 2007

8 b

9 a b

c

10 a

2 Taking into consideration the doctors’ own verbal and non-verbal messages is also important – sometimes more so, as patients don’t ask for any confirmation of a doctor’s feelings, i.e. they don’t tend to check these verbally as a doctor might do (with a patient) by making observations such as You sound stressed / You seem to disagree with my analysis of the situation, etc.

3 By asking clarifying questions, e.g. You sound [stressed]. / You don’t seem to agree with my analysis of the situation. / Your son looks a little unhappy/worried/apprehensive about …

It’s important to note that these will overlap. ● The State: In countries where there is a State religion, this would have repercussions on the legal requirements for doctors and the medical services.

In countries where there are unequal rights for women, doctors might be heavily influenced, and this may be reflected in their practice. ● Religion: See below ● Media: In countries where the media promote (actively or not) gay role models, for example openly gay TV presenters/actors, or allow access to discussion on these types of health issues via talk shows / e-forums, etc., the media could be said to have a particular influence on the way a doctor might think or how open he/she may be.

Censorship in the media is still highly prevalent in some countries (linked to religion and State) in which case the opposite of the above might happen. ● Professional training: As a result of the State religion in those countries where doctors only treat patients of the same sex, these issues may be entirely new and could cause embarrassment (linked to State/religion).

A predominantly Catholic country (but not a State religion) might hold certain attitudes towards certain sexual practices and reproductive health. The result of this may be that doctors may be required as part of their profession to give advice that might differ from that promoted within the UK/US medical services. ● Family upbringing: Regardless of national culture, the way a person is brought up and the values of the family may well differ and have a strong influence on a person’s beliefs as an adult (possibly linked to religion), e.g. beliefs on traditional medicine, abortion rights, etc.

Dr Hanley remains objective and non-judgemental throughout the encounter, so should rate a score of 1 or 2.

1 Dr Hanley uses the cone technique (as highlighted in Unit 2): beginning with open-ended questions before moving on to focused, closed questions. Dr Hanley tends to ask when, how and where questions.

2 Why questions might be perceived as being judgemental.

1 There may be various reasons for your symptoms, but in order to find out more, I’m afraid I’m going to have to ask some rather personal questions.

2 Take your time, Jennifer, there’s no rush. As I said, many people find this type of thing difficult to talk about.

3 Is that all right with you?

4 … but if you’d prefer to speak to a female doctor, I can refer you to Dr Stevens.

Suggested answers ● Can you describe to me the symptoms you’ve been experiencing, Mr López? ● What seems to have brought on these symptoms? ● Is there anything that alleviates or worsens your symptoms?

Answer key – Unit 8 167

COV-19 2020 Could you tell me about any illnesses you might have had in the past? ● Any surgical interventions or hospitalisations I might need to know about? ● Do you take any medication(s)? ● Have you ever suffered from allergies to medication at all? ● Could you tell me about any illnesses that might run in your family? ● Tell me about your parents. ● Any siblings? ● Are you currently in a relationship? ● Are you working at the moment? ● Do you smoke? ● Do you drink alcohol? ● How much do you drink in an average week? ● I’m going to ask you some questions that regard your personal life, in particular your sex life, that some people find a little sensitive. ● When was the last time you had sexual intercourse? ● How regularly do you have intercourse? ● Are there any questions you would like to ask at this stage? ● I’m going to refer you to a urologist at the hospital.

She’s a woman, but if you’d prefer to speak to a male doctor, I can refer you to another hospital.

11 a Suggested answers ●

Do …

Don’t …

Do contextualise the questions.

Do use clear, unambiguous, openended questions.

Do start with a general, nonthreatening question.

Do address relationships.

Do discuss sexual behaviour by asking how/what/where.

Do ask direct questions (once rapport established with patient).

Do ask about sexual partners.

Do establish patient knowledge about safe-sex practices (and lead into education).

Do use the patient’s words and language.

Do remain professional.

Do ask when you don’t understand a sexual term or activity.

Don’t make assumptions.

Don’t stereotype.

Don’t judge people.

Don’t use the question word why – it can be judgemental.

12 a 1 1 unit = 10g alcohol 2 a 21 units b 14 units 3 a, b, c 1 unit d 6–7 units e 32 units.

4 Yes. Home-brewed beer often contains higher levels of alcohol, and certain brands of shop-bought beer are stronger than others, e.g. Special Brew (a brand of lager popular in the UK) has four times the level of alcohol of standard beer.

5 b (The time in which it takes the patient to consume the bottle gives doctors a more accurate idea about the possible degree of alcoholism.)

6 a (By up to 100%) 7 armed forces, doctors, entertainment industry, publicans 168 Answer key – Unit 8

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c 1 Invariably, doctors are presented with a complication of a patient’s alcohol abuse, as opposed to a patient who admits he/she has a problem with alcohol.

Possible complications are numerous, including: fits, falls/trauma (broken ribs, head injuries, etc.), road traffic accidents (driving under the influence of alcohol), acute pancreatitis, liver disease, pulmonary tuberculosis, chest infections, etc.

2 The time of day the patient drinks / drink pattern / whether the patient drinks alone or socially / whether the patient drinks pub or home measures / type of particular alcohol consumed / patient attitude and intentions towards alcohol / past history of related disorders + past treatment / the patient’s social circumstances and family history (There is a predisposition for alcoholism if it is already present within the patient’s family, especially amongst firstdegree relatives (parents).)

13 a From the response Dave gives in Part 1 of the dialogue, he appears to be a ‘social drinker’ and so therefore his drinking habits are not of much concern. However, this could also be a mask, as we see in Part 2. Dave is able in Part 1 to give the ‘right’ responses that mask the real issue. c/d Question

Dave

C

Cut down

Have you ever felt the need to cut down on your drinking?

Yes (previously, but not now)

A

Annoyed

Have people ever annoyed you by criticising your drinking?

Yes (girlfriend regularly gets annoyed)

G

Guilty

Have you ever felt guilty about your drinking?

Yes (missed his mum’s birthday)

E

Eye opener

Have you ever needed an ‘eye opener’ first thing in the morning?

No (doesn’t feel he’s quite hit that level)

f

The response would probably be different. How much do you drink? implies there is a problem and suggests the doctor is being judgemental; the patient is likely to become defensive, a fairly typical reaction amongst alcoholics. g Two or more positive responses on the CAGE questionnaire are said to indicate problem drinkers.

Four positive responses are a definite sign of alcoholism.

Patient’s feelings towards drink: Dave feels his current level of alcohol intake is fine and is not outwardly concerned about it.

His interpersonal relationships: Dave does mention his girlfriend ‘might have a point’.

What happens under the influence of alcohol: This has not yet been investigated/discussed, but Dave indicates that drinking spirits can change his personality negatively.

Any adverse effects the patient may suffer: This has not yet been investigated/discussed, apart from the reference to missing his mother’s birthday.

To investigate Dave’s consumption in more detail and have a clearer understanding of the above, the doctor might use other question techniques, such as: The ‘FATAL DT’ questions Is there a Family history of alcohol problems?

COV-19 2020 Have you ever been a member of AA? Do you Think you are an alcoholic?

Have you ever Attempted or had thoughts of suicide?

Have you ever had any Legal problems related to alcohol consumption?

Do you ever Drive while intoxicated?

Do you ever use Tranquillisers to steady your nerves?

You might also decide to advise Dave Mullins on his level of consumption and indicate where and how he might be able to get help / refer him to the local chapter of Alcoholics Anonymous, give out educational materials on the subject of alcohol abuse, etc.

15 Language used to describe negative effects

Language used to describe positive effects

bombed come down crash have a bad trip have the shakes

on a high spaced out stoned wasted wrecked

16 All mean to give up drugs without any form of treatment, e.g. course of methadone, etc.

17 A good knowledge of the jargon will help to engage with the patient and increase communication in what might be a tense and sensitive encounter. Asking the patient to repeat or explain his/her chosen form of expression might lead to unnecessary aggressive behaviour, etc.

18 a 1 Both right and left ears are clear.

(The word both is sufficient to mean left and right.)

2 Cervix is pink in colour and smooth.

(Pink is obviously the colour and so superfluous.)

3 Liver is tender to palpation.

(It is assumed the doctor palpated the liver area in order to determine it is tender.)

4 Patient states there is no pain over left eye.

(The reader assumes the patient is the source of information unless otherwise stated, so it is not necessary to indicate this.)

5 On sight, patient is thin, looks distressed and generally unwell.

(As the doctor is observing the patient, it is not necessary to reiterate the fact – use of on sight is superfluous.)

6 Father died in 1999, aged 64. He died of lung cancer.

(The year of the father’s death is less important than what he died of and at what age.)

7 In the patient, there is no history of asthma or tuberculosis exposure.

(It is taken for granted the doctor is referring to the patient.)

8 Sexual history: this is not appropriate to the presenting complaint.

(It is sufficient to note that sexual history is not appropriate – it is taken as read that the doctor is referring to this particular presenting complaint.)

9 Lungs are resonant to percussion.

(As for sentence 3.)

10 II/VI systolic ejection murmur (audible).

(A murmur is always audible, so doesn’t add anything to the meaning of the entry.)

19 a This is a subjective observation of the patient’s health and criticism of the patient’s attitude and is therefore unprofessional, not objective and judgemental.

© Cambridge University Press 2007

b Patient records can be viewed by both patients and lawyers. It may be difficult to defend this type of entry in a court of law.

Unit 9 Lead in Suggested answer Awareness that you are causing others to be disappointed or emotionally distressed 3 Suggested answers ● Fear of being blamed by patients ● Fear of not having answers to all the questions a patient may ask ● Fear of inflicting pain on the patient ● Doctor’s own fear of illness and death ● Lack of time to deliver the news ● Awareness of lack of training in breaking bad news ● Difficulty in deciding which doctor is responsible for delivering the bad news 4 a Suggested answers ● Show empathy. ● Speak to the patient in a quiet place where possible. ● Check what the patient understands and believes about his/her illness. ● Find out what the patient wants to know. b Suggested answers ● Could show more empathy. ● Could use language to warn the patient that the news is not good. ● Could reassure patient that he will be supported.

5 b The doctor includes setting, emotions and strategy.

6 Suggested answers Privacy; no physical barriers between patient and doctor; seated; maintain eye contact / touch patient if comfortable with it; ask patient if he/she would like somebody to be present; tell patient if you are expecting any interruptions 7 1 Eliciting patients’ perception of the situation is very important, as it helps you to gauge their understanding of their illness. It also allows you to clear up any misinformation patients may have.

2 Open questions 3 Suggested answers What have you been told already about your condition/ situation?

How much information do you have about your condition at this point?

What do you know about this condition?

8 1 b 2 c 3 c 4 a 5 b 6 b 7 a 8 b 9 b 10 c 9 2 Age, mental health, emotional state, level of education 10 a 1 a 2 b 3 a b The present tense is used in the examples that are more direct. The use of the conditional makes the question softer.

11 a No, it isn’t. The doctor refers to his previous visit. b The results are back. I was hoping to have better news for you, but I’m afraid that they were positive for HIV. 12 Suggested answers I’m sorry to say that …

I’m sorry to have to tell you …

Unfortunately, …

It’s not as good as we had hoped.

It’s not the result we were hoping for.

14 b 1 c 2 a 3 b 4 a 5 b 6 c c 1 It’s only normal to feel like that.

2 How does that make you feel?

3 I know this is not good news for you.

Answer key – Unit 9 169

COV-19 2020

15

16

17 18 19

4 Can you tell me what you’re worried about?

5 I know this must be very hard for you.

6 Anybody would react in the same way. a Exploratory: Can you tell me how you’re feeling, James?

Empathetic: I can understand that.

Validating: It’s only natural that you feel scared.

I realise how difficult it must be for you to ask that question. b Suggested answers So, let’s see how we can go forward from here.

You won’t be left to cope on your own. c I could arrange an appointment with our counsellor here if you’d like to talk to someone else?

1 Yes. He says they will discuss options in the next consultation.

2 Yes. He says he will make an appointment with the counsellor.

The constraint is time.

1 c/b 2 b/c 3 a 4 e 5 d a

Not going to recover

Some hope of recovery

2, 4, 6, 8, 10, 11, 13, 14

1, 3, 5, 7, 9, 12

b To avoid talking directly about death and dying.

Think about …

Factors to be considered when communicating with relatives: ● no previous contact, therefore no existing rapport ● relatives may not understand fully the condition and the implications ● differences of opinion between relatives ● relatives may have different understandings of the patient’s wishes Things to consider when communicating over the phone: ● can’t read body language cues ● no time to prepare the listener – the call could come out of the blue ● voice management – pausing to give listener time to take in news, using a reassuring tone of voice, checking that the listener has a clear understanding of the situation 20 Setting

✓ Moves to quiet room.

Perception of the situation

Doctor does not give relative an opportunity to express her perception of the situation.

Invitation

Doctor does not invite relative to indicate level of information required initially. However, towards the end, he does ask if any more information is required.

Knowledge/ information to relative

✓ Doctor does give information regarding condition and likely prognosis.

Emotions

✓ Doctor is empathetic – I can see this is a terrible shock for you – and validating – It’s normal to feel guilty in a case like this, but you mustn’t.

Strategy for moving on

✓ Doctor indicates that there will be further consultation when all family members are present.

170 Answer key – Unit 10

© Cambridge University Press 2007

21 excellent tone

✓

intonation

✓

good

could improve

pausing

✓

speed of delivery

✓

word stress

✓

Unit 10 2 A patient might be uncommunicative because he/she is very shy, depressed, embarrassed or in pain. The following strategies may be effective: using gentle tone of voice, giving patient your full attention, giving patient time to respond.

3 a He uses closed questions, facilitative language, before he moves on to the next question; he shows empathy and paraphrases what the patient says: You’re worried that if you don’t stay strong for the family, things will fall apart? b The doctor pauses, uses a gentle tone of voice and speaks quite slowly to mirror the patient’s voice. c The doctor uses closed questions to encourage the patient to respond more fully. The patient is depressed and doesn’t respond to the open question at the beginning.

Doctor Tell me, Mary, how are you feeling at the moment?

Patient [her eyes fill with tears] Doctor [brief silence] This is very difficult for you to talk about, isn’t it?

Patient Yes. [shaky voice] Doctor Are you still getting the headaches?

Patient Yes. Doctor And do the painkillers I prescribed help? [pause] Have you been taking them, Mary?

Patient A couple of times, but they knock me out. I can’t function properly with them. And I need to look after the family – they need me.

Doctor I know. You have a lot on your plate at the moment, don’t you? Nursing your husband, taking care of the children and looking after your mother. [pause] Patient Yes, I feel overwhelmed. [patient begins to cry] I’m sorry, Doctor.

Doctor You don’t need to apologise, Mary. It’s perfectly normal to cry. I understand how you’re feeling. You’re worried that if you don’t stay strong for the family, things will fall apart, aren’t you?

Patient Yes. I can’t let that happen. d He uses closed questions appropriately, he uses silence and empathy, and he paraphrases what the patient says (e.g. You’re worried that if you don’t stay strong for the family, things will fall apart) to show understanding.

4 b Suggested answer Doctor So, Mrs Lyons, tell me, what can I do for you?

Patient [no response, patient stares at floor and looks very unhappy] Doctor You look very sad, Mrs Lyons. Are you finding it difficult to cope?

Patient [nods her head] Doctor Do you have any help?

Patient No.

COV-19 2020 Doctor That must be very difficult for you. This is a big change in your life, and it’s normal to feel overwhelmed, especially if you don’t have any support.

But I’m here to help you.

5 Suggested answers Staring into space, avoiding eye contact, looking at the floor 6 Asking why patient is withdrawn 1 Can I ask what you are thinking?

2 What’s on your mind?

3 You seem very distant – why is that?

4 You seem very far away …

Encouraging patient who is trying to express themselves 1 I can see that you want to say something …

2 You were going to say something then?

3 You look as if you were about to say something …

Responding to strong physical signs 1 I can see that you are trembling – are you very anxious?

2 You look as if you are about to cry – are you very upset?

Asking how the patient is feeling 1 How are you feeling at the moment?

2 How do you feel right now?

9 a a) Evaluative b When the doctor says to the patient you’re not the only one and when the he says you’ve made your point, can we get on?

The doctor hasn’t acknowledged the patient’s feelings sufficiently. c Acknowledge the patient’s feelings, explain why you are running late 10 a Supportive: I appreciate the problems this has caused you, No, you’re right, it isn’t b Stress, anxiety, irritability due to another reason 11 Anxiety 13 1 I appreciate the problems this has caused you.

2 I’m doing all I can.

14 a Suggested answer Doctor What can I do for you, Mr Brown? You look troubled.

Patient Those antibiotics you gave me aren’t doing the job.

Doctor Right. Can I ask you why you think they’re not working?

Patient Well, they just make me feel tired and depressed, and I still have a bad chest.

Doctor I’m afraid antibiotics can have that effect, but it doesn’t mean that they aren’t working. You still have another week to go.

Patient I know, but this is the third course you’ve prescribed me now. I’m fed up taking them. Why didn’t the other ones clear my chest up?

Doctor I can understand your frustration, but sometimes we need to try different antibiotics before one hits the spot.

Patient What, so I’m some kind of guinea pig? You’re supposed to know what you’re doing.

Doctor No, you’re not, Mr Brown, but I can see why you might feel that way. However, you need to understand that, with so many different infections going about, it’s not always easy to choose the most effective antibiotic first time. Please bear with me.

15 a The patient wants to increase his prescription. He tries to do this by making the doctor feel guilty. b Do you want to see me in pain?

You really like seeing me in pain, don’t you?

© Cambridge University Press 2007

c 1 a 2 c 3 b 16 a Suggested answers 1 I’m sorry you feel that she was rude to you, but I can’t imagine it was intentional. Reception has been incredibly busy this morning, and it may be that she was under pressure and couldn’t give you as much time as she normally would.

2 I’ve spent quite a long time explaining the situation and I can’t add anything more; there are other patients waiting to be seen.

3 I know it’s difficult for you, but there isn’t anything we can do until you get your drinking under control.

17 a irritable: 3, 8, 14, 18 b moody: 5, 17 c depressed in general: 2, 9, 11 d depressed as a result of an event: 6, 13, 16 e anxious: 1, 4, 7, 10, 12, 15

Unit 11 Lead in a Problems with hearing, physical weakness/frailty, forgetfulness / being repetitive (dementia), problems with speech (dysarthria), cognitive impairment (dysphasia: problems with processing information and responding to it), depression, loneliness 1 a Problems with speech, problems with hearing, patient could be depressed, patient could be embarrassed b Problems with speech: helped by patience, sympathy and lack of embarrassment. Doctor becomes more familiar with problem areas and speech becomes more comprehensible Problems with hearing: check if patient can hear you, check if hearing aid is working, check there is no loud background noise, articulate words clearly, be aware of non-verbal communication – make sure hands are away from mouth, as patient may rely on lip-reading Depression: identify possible causes of depression by asking about patient’s routine and degree of social interaction Embarrassment: show sensitivity and respect Loneliness: establish patient’s support network and contact with others c Suggested answers ● The time needed to carry out the consultation: seeing visit as social event; sensory impairment; reminiscing; needing more time to think; tiring more easily ● Obtaining information from the patient: memory; not being used to patient-centred approach, so needing closed questions; not as comfortable with sensitive issues as younger people; fear of being institutionalised, so may keep information back ● Identifying the presenting complaint(s): having multiple complaints; perception by patient and/or doctor that some conditions are just ‘sign of old age’ and therefore not given due attention; underplaying pain and ill health; may be suffering from depression, but not identified by the patient ● Prescribing medication: more medications; possibility of overmedication through confusion; forgetting to take medication 2 a 1 sensory impairment: ✓ Doctor asks if he should turn the fan off as it might be too noisy and make it difficult for the patient to hear. He knows the patient and is aware he might have problems.

Answer key – Unit 11 171

COV-19 2020 2 fear of being institutionalised: ✓ When doctor mentions social services, the patient reacts negatively towards their possible inclusion in his treatment following the hospitalisation of his late wife.

3 cognitive impairment: ✗ There is no evidence of this in the patient’s discourse.

4 memory: ✓ The patient does start to reminisce when he talks about his late wife (Kathy).

5 lack of chief presenting complaint: ✓ Patient suffers from Parkinson’s; also has hearing difficulties and incontinence.

6 perception of illness: ✗ Patient seems to be fully aware of the nature of this disease. c 1 Yes, the patient already knows the doctor, as he refers to his new hearing aid: I’m getting used to this new hearing aid now.

2 Presenting complaints: dribbling, incontinence 3 Dr Wadman shows sensitivity on several occasions (see below) and talks in a friendly, welcoming tone of voice. d/e Dr Wadman Mr Whitaker, come in and take a seat.

Nice to see you. Are you comfortable there?

Welcoming. Checks patient is comfortable.

Mr Whitaker Yes, Doctor, thank you. Can I leave my stick just here?

Dr Wadman Of course. Shall I turn the fan off, it’s a bit noisy …

Takes patient’s hearing impairment into consideration.

Mr Whitaker I’m fine, really. I’m getting used to this new hearing aid now; it cuts out most of the background noise.

Dr Wadman Good, I’m pleased to hear it. So, what brings you here today, Mr Whitaker?

Shares patient’s pleasure at improvement. Poses open question. Doctor knows patient is OK with patient-centred approach.

Mr Whitaker Oh, where shall I start? When you get to my age … it’s all downhill!

Doctor empathises with patient and laughs with him. Humour is appropriate here. This is a common expression in UK English to comment on age.

Dr Wadman Why don’t you start with what’s been bothering you the most?

Acknowledges possibility of multiple complaints, considering age of patient.

Mr Whitaker Well, it’s a bit embarrassing, really.

Dr Wadman Take your time. Can you describe what’s been happening?

Reassures patient and encourages him to tell story in his own time.

Mr Whitaker You can probably see – it’s my hands – they’re shaking all the time, I can’t do much with them. It’s getting worse, too. And I’ve got problems dribbling, too – you know, that’s really embarrassing.

Dr Wadman How is this affecting you?

Asks about how condition affects daily life.

Mr Whitaker When my Kathy was alive, we had lots of friends, always going out. We liked the good life – dinner parties, theatre …

Dr Wadman Uh-huh.

Facilitates patient story. Allows patient to continue, accepting reminiscence. Gives patient time to tell story in own time.

Helps patient to put current situation into context.

172 Answer key – Unit 11

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Mr Whitaker I was a member of the Rotary Club, you know, and I played tennis for the club team – men’s doubles. Kathy wasn’t much of a tennis player – but my goodness, could she dance …

Dr Wadman Good memories?

Demonstrates active listening.

Mr Whitaker Wonderful memories.

Dr Wadman And how does this relate to the problems you’ve been having recently?

Tries to put patient back on track and structures the interview.

Mr Whitaker It’s the friends, you see, Doctor. This dribbling gets me down. I can’t face them like this, can I? Don’t get out much any more because of that.

Dr Wadman I can see how that might get you down.

We’ll look at ways to try to control this later on.

Empathises with patient. Ensures patient aware will return to subject later.

Mr Whitaker It’s another symptom of the Parkinson’s, isn’t it?

Dr Wadman It is, yes. If I could just ask you something else at this stage … When some people cough or sneeze, they leak urine. Does this happen to you?

Doesn’t try to gloss over or give false hope.

Mr Whitaker Yes, my waterworks are playing up a bit, too. I was about to mention that.

Dr Wadman Right. We can also discuss how you can control this. Now, what kind of support network do you have, Mr Whitaker?

Doctor makes reference to fact he will return to this issue – gives increased structure to interview.

Mr Whitaker Sorry?

Dr Wadman Who can you call on when you need a helping hand?

Doctor phrases the question in a way to show patient it is OK to accept help and not diminish his sense of independence.

Mr Whitaker My daughter-in-law’s just down the road.

Dr Wadman And you get on well with your daughterin-law?

Tries to evaluate level of informal social support.

Mr Whitaker Oh, no, don’t bother ringing her, not now my son’s no longer with us, anyway.

Dr Wadman What about neighbours?

Mr Whitaker Maggie, she’s just next door, she’s great, she gets the shopping in for me – just the bits ’n’ bobs I need.

Dr Wadman Social services?

Tries to establish formal social support system, if any.

Mr Whitaker Don’t want them coming round if I can help it. The last time they came, they took my Kathy and put her in that home, didn’t they? I know they’re doing their job, but …

Dr Wadman Some of the services they provide could make life easier for you. ‘Meals on Wheels’, for example. You won’t have to worry so much about getting a balanced meal inside you.

Tries to reassure patient with idea that social services provide help to facilitate and does not mean loss of independence.

Patient’s response already suggests he understands this, but just needs an outlet for frustrations over wife’s death.

Mr Whitaker You’re right, I suppose – sometimes I’m just too tired to cook properly. Don’t get me wrong, I like cooking.

Dr Wadman How are you coping otherwise, Mr Whitaker?

COV-19 2020 Re-opens discussion to see if patient has any other issues he wants to discuss.

Mr Whitaker I don’t get out much. Stick’s OK around the house, but … it just gets me down.

Dr Wadman We’ll come back to that if you like. Any other medical issues you’d like to discuss today?

Acknowledges patient cue and sees the need to move away from subject, but confirms will return to it later in interview.

3 a My hearing is going. is not what it used to be. is playing up. is troubling me.

My memory is going. is not what it used to be. is playing up. is troubling me.

My knee is playing up. is troubling me.

My waterworks are playing up. are troubling me.

I had a bit of arthritis. indigestion. a dizzy spell. a funny turn. gout. rheumatism.

I have the odd pain. spasm.

I have the occasional pain. spasm.

I’ve got a touch of arthritis. gout. rheumatism. indigestion.

4 Suggested answers Incontinence, knowing they have a hearing problem, lameness/incapacity, moving into an old people’s home (US English: assisted living) 5 a Not very well. b ● He doesn’t call the woman by her name; he refers to her as dear or my dear. ● He doesn’t acknowledge how upsetting it is for her to be without her dentures. ● He is dismissive of the patient and puts her complaint down to old age. c Doctor Hello, my dear.

Patient Hello, Dr Griffith.

Doctor Is there something wrong with your mouth, dear?

Patient I broke my dentures, and they won’t be repaired until the end of the week. I feel so foolish without them – I didn’t even go to my art class today or my coffee evening ’cos I didn’t want people to see me. It’s so frus…

Doctor Right, my dear, but it’s not your mouth that you’ve come to see me about, is it?

Patient Er, no, it’s that ulcer on my ankle. It still hasn’t cleared up.

Doctor Right. You are taking your medication like I told you to?

Patient Yes! Doctor Well, these things do take longer to clear up at your age, dear. Nothing to worry about, though. Is there anything else?

© Cambridge University Press 2007

6

7

8

9

Patient When do you think it’s going to clear up?

Doctor It’s difficult to tell with somebody your age. Tell you what, come back and see me in two weeks, and we’ll have another look at it. a ● He shows sensitivity when the woman speaks in an awkward way. ● He shows empathy when he asks if she is finding things difficult without her dentures. b Doctor Hello, Mrs Fry. Patient Hello, Dr Griffith.

Doctor Your voice sounds a little different to usual. Is there something the matter?

Patient I broke my dentures, and they won’t be repaired until the end of the week.

Doctor Oh dear. You must be finding it difficult without them.

Patient Yes, I feel so foolish without them. I didn’t even go to my art class or my coffee evening ’cos I didn’t want people to see me. It’s so frustrating. You must think I’m very vain!

Doctor Not at all, Mrs Fry. I remember losing two of my front teeth in a rugby match. I can perfectly understand you want to look your best, and it’s hard to do that without your teeth.

Patient Oh, thank you, Doctor. I don’t feel so bad now.

Doctor So, what can I do for you today?

Patient I was just wondering about this ulcer I have on my ankle. It still hasn’t cleared up.

Doctor I’m sorry to hear that. Are you still taking the medication I prescribed?

Patient Oh, yes.

Doctor That’s good. It should help with the healing. Is the ulcer still causing you a lot of pain?

Patient Not exactly, but it feels very tender.

Doctor Yes, it will do, it’s in such an awkward area.

Patient When do you think it’s going to clear up?

Doctor Well, it’s very difficult to say, but they do tend to take longer to clear up as people get older. We’ll keep a close eye on it. Is there anything else?

Patient No, Doctor.

Doctor OK, Mrs Fry, shall we make an appointment for two weeks’ time to see how it’s responding?

In the extracts from Dialogue 2, the doctor is being more objective about what has happened to the patient and about her age. By using the phrase as people get older rather than somebody your age, he is making the information more objective and less threatening for the patient. a The first is more appropriate, as referring to some people makes it sound like a common problem, therefore less embarrassing. b in older age, in advanced years, in later life, older people d 1 Some loss of control over the bladder tends to be quite common in later life. It can be quite distressing, but there are ways to help manage it.

2 I can appreciate that it’s difficult to remember to take medicine three times a day, but it is important.

3 I notice that you are having a bit of trouble with your saliva. a Watching facial and lip movements plays an important part in understanding what others are saying. For those whose hearing is declining, it is even more important.

Make sure that you face elderly patients when you are speaking to them so that they can benefit from reading your lips and your facial expressions.

Answer key – Unit 11 173

COV-19 2020 10 a 1 Moved his hands away from his face. Sometimes, particularly when discussing difficult or sensitive issues, there is an instinctive movement to cover the mouth with a hand. This is something to be aware of, particularly with patients who are hard of hearing, as it can make it more difficult for them to understand what is being said.

2 Checked there was no background noise. b 1 She stresses key words.

2 She speaks more slowly at the point where the patient misunderstood the first time. c ● Check hearing aid is working. ● Use signposting. It is easier for patients to recognise words if they know what the context is. Tell the patient when you are moving on to a new subject. It may also be helpful to give clues that the context is changing within the conversation by pausing briefly, speaking a bit louder, and using gestures as much as possible to amplify what is being said. ● Face the patient and ensure mouth is clearly visible.

12 a Shouting distorts language.

It can give the impression of anger.

A higher-pitch voice can make it harder to hear.

13 a B Bathing A Ambulation (walking) T using the Toilet T making Transfers E Eating D Dressing c Through observation during the encounter in a surgery, the doctor is able to see how mobile his/her patient is by how easy it is for them get out of the chair / how easy it is for them to dress (before/after examination) / if they require help going to the toilet.

16 a She denies it. She regards depression as something shameful and doesn’t want to admit to it. b Doctor Hello, Mrs Cox. What can I do for you?

Patient Oh, I don’t seem to have much energy. I have this dragging feeling in my body.

Doctor Well, we did a lot of tests last time you came in, and you seem to be fine physically. Are you sleeping OK? Patient No, I stay up half the night watching TV and tend to nod off for a while.

Doctor I see … and what about your appetite?

Patient Oh, I’m not really interested in food, I just pick at the odd thing.

Doctor Right, and what about your social life? Do you get out and about much?

Patient I go to church most mornings, do a bit of housekeeping and read the paper. That kind of thing.

My friend takes me for a drive sometimes, but I’m not often in the mood.

Doctor What things do you look forward to?

Patient When my children come to visit. But that doesn’t happen very often.

Doctor Right. Well, from what you’re saying, it may be that you’re suffering from mild depression. It would explain the loss of energy, the sleeplessness and loss of appetite.

Patient Rubbish! I’m not depressed. There’s no history of that in my family.

Doctor It doesn’t have to be in your family. What I’m talking about is something that happens to a lot of people, and there are a number of treatments that can be helpful.

174 Answer key – Unit 12

© Cambridge University Press 2007

19

20 21

22

Patient I don’t care what you say, I’m not depressed.

I keep my house and myself in order.

Doctor Well, you’ve come to me because you don’t have any energy and you’re not sleeping or eating very well.

We’ve done a lot of tests, and you’re physically in great shape. The most likely explanation for your symptoms is mild depression.

Patient Well, if it is depression, what can I do about it?

He does a quick check for any signs of mental impairment first, as there is no point in going into a detailed clinical history until he knows.

No. She confuses the doctor initially, but then it becomes clear that she is not confused.

They mean that it’s important to listen and allow the patient to finish what he/she was saying. The patient may not appear to answer the doctor’s question immediately, but it may transpire that they do in fact give an answer, as in Exercise 20. a 1 It removes some of the awkwardness of the topic for her and for the doctor.

Unit 12 Lead in a

1

● ● ●

● ●

●

2 2 3 a

b

c

4 a b

A child does not make the decision to go to the doctor’s. ● A child has a different understanding of illness, treatment and prevention. ● A child has different perceptions of a doctor, e.g. he/she may think the doctor is deliberately going to hurt him/her. ● A young child is more unpredictable. ● A child has a different vocabulary.

Be at the same physical level as the child.

Say hello to the child and call him/her by name.

Compliment the child, e.g. admire something they are wearing or praise them for something they are doing, e.g. a drawing.

Use a gentle tone of voice.

Repeat a word(s) used by the child to show you are listening.

Smile at the child.

No ● Include the child in the conversation. ● Pay the child a compliment. ● Ask the child a question about him/herself, e.g. favourite subject at school, hobbies. ● Check if the child is comfortable / if child wants to sit next to the parent/carer. ● Use a gentle/friendly tone of voice. ● Paying the child a compliment, e.g. admire article of clothing/toy. ● Asking about the school they go to, their favourite subject. ● Asking about hobbies. ● Questions about family, school, personal interests and career intentions can usually be relied on.

1 Yes (1 Hello, Billy. Hello, Mrs Jones.; 2 My name’s Dr Gordon. I’m one of three partners who makes up this family practice.; 3 Just let me raise your chair up a bit so you can see me. That’s better. That’s a great football shirt, Billy. So you’re a Manchester United supporter?)

2 Yes (And do you support Manchester United as well, Mrs Jones?)

Just let me Just is used for reassurance. The doctor is telling the child that there is nothing to worry about when he is adjusting the seat. ●

COV-19 2020

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6

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9

10

12

13

14

15

c 1 I’m just going to clear some space for Teddy to sit.

2 If I could just get you to sit here next to me. That’s great. Are you comfortable?

3 Yes, it is hot in here. Let me just open the window before we begin. a 1 b/c 2 a/d 3 a/d 4 a/b/d b I like your + noun (e.g. I like your T-shirt) What a + adjective + noun (e.g. What a cute teddy bear!) a They are all relevant. b All the stages are covered. c 1 Are you 2 can understand 3 that is a; isn’t it 4 must have 5 What I need to do 6 Will you let me d Acceptance: 2 Empathy and support: 1, 3, 4 Examination: 5, 6 a 1 b/d/e 2 c/f 3 e/b/d 4 f/c 5 a/c/d/f 6 a b I’m sorry to hear that.

I know.

I understand.

A child might be frightened of instruments.

He/She might think the illness or injury is much worse than it really is.

When you have to give a child an injection.

He/She might think the illness is his/her fault because he/she has been naughty.

He/She might be nervous of doctors.

He/She may be in pain / tired / in shock. a By telling her that her injury was an accident and that she’s not to blame. b ● He stresses key words. ● He uses a gentle tone of voice. a 1 Child is worried that they are very ill.

2 Child feels guilty.

3 Child is about to be examined, perhaps with an instrument, or have an injection.

4 Child is about to have an injection. b 1 Don’t look so sad. We’re going to make you better very soon.

2 You’re not to blame for this in any way.

3 Don’t be scared. I promise this won’t hurt.

4 It will be very quick, you’ll hardly feel a thing.

Suggested answers 1 It must have been frightening for you when you started bleeding. But please don’t worry, any little bump can make your nose bleed.

2 I know injections aren’t very pleasant, but I promise that I’ll be very quick. It might help if you look at the picture on the wall over there while I do it.

3 So, you’re worried that a tree is going to grow inside you? That won’t happen because your tummy eats it up, just like the rest of the apple.

4 Your hand will be very sore at the moment. Don’t worry, it will clear up completely. It may look bad, but the skin is protecting itself by making a blister to help it heal faster.

You mustn’t think it was your fault, it was an accident. ● Eye contact ● Whether the child sits still or moves about ● Facial expression ● Proximity to adult ● He does not explain what he is going to do. For example, he could shine his torch in the ear of a teddy bear first so the child can understand what is going to happen. ● He has not reassured her that the examination is not going to hurt. ● His voice has become agitated rather than remaining calm.

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He is issuing commands (e.g. to keep still) rather than asking for co-operation. ● He has not involved the parent in the preparations for the examination. a The doctor includes all of these stages and gains the full co-operation of the boy. b Suggested answers Are you going to let me look at (your chest)?

I need to look at (your chest). Is that OK? Do you think I could look at (your chest)?

Can I look at (your chest)? a Dialogue 1: The doctor is being more forceful by using commands and must.

Dialogue 2: The doctor uses the phrase I need to and then asks the child for permission for the mother to remove his shirt. In the second sentence, she uses the phrase I need you to rather than can you. b Suggested answers 1 I need you to open your mouth a bit more so I can see better.

2 I need you to open your eyes so I can see what’s causing your headaches.

3 I need you to lie as still as possible when I’m looking at your tummy.

4 I just need you to stand on the weighing machine, please. a 1 b 2 d 3 c 4 a b Sentence 2 is appropriate, as the doctor is trying to determine what the barrier is.

Sentence 3 is also appropriate, as the doctor is validating the child’s fears and offering reassurance.

Sentence 1 is not helpful, as the doctor is putting thoughts in the child’s mind.

Sentence 4 is not helpful, as the doctor is putting the child under pressure by comparing her with her sibling.

Suggested answers 1 Do you feel sleepy during the day?

2 Does light hurt your eyes?

3 Do you feel sick?

4 Does your tummy/stomach hurt?

1 b 2 c 3 a a School, careers, hobbies, music, films, friends, pets b Not being listened to / different interests / being overcontrolled They are all relevant. a Not very well, because the doctor is rather patronising, e.g. Well, my dear, you certainly have grown since I saw you last.

He is also intrusive when he asks Have you started having sex? He should have used more tentative language such as I don’t mean to pry, but … b a 3 b 4 c 2, 3 d 6 e 2 c Doctor OK, Catherine, if you’d like to come through to my office. Your mother can come in later. … Take a seat, Catherine. What age are you?

Patient Almost 17.

Doctor Well, my dear, you certainly have grown since I last saw you. What seems to be the problem?

Patient I’ve been having headaches and stomach pains quite a bit lately.

Doctor I see. How severe are the headaches?

Patient Mm, they’re not too bad. I’ve had them regularly since I started having my periods, but they’ve got worse over the last six months.

Doctor Mm. And the stomach pains?

Patient About the same. ●

16

18

19

20

21 23

24 25

Answer key – Unit 12 175

COV-19 2020 Doctor I don’t mean to pry into your personal life, but I do need to know – have you started having sex?

Patient Um, will you have to tell my mum what I tell you?

Doctor No. It will be between ourselves.

Patient Oh. Um, I started to have sex with my boyfriend Tom about six months ago, when I turned 16. My parents would kill me if they knew …

Doctor But you’re only a child … 16 is too early to start having sex. You’re not fully developed emotionally or physically yet, and you’re taking a lot of risks with your health.

Patient That’s what my parents are always telling me.

Doctor There’s really nothing to laugh about, you know. It’s a serious matter.

Patient Can’t you just listen to me without lecturing me?

Doctor I can assure you that I am listening to you, Catherine. Now, the pains: do you think they got worse because you’ve started having sex?

Patient Um … oh, I … I don’t know.

Doctor But you are worried about what might be causing them?

Patient I’m not too worried about the pains, to be honest, but I think I might be pregnant.

Doctor Do you use any form of contraception?

Patient Sometimes we use condoms, but not always.

Doctor It’s not my intention to lecture you, but you do really need to consider the risks you are taking.

You should always get your partner to wear a condom.

Otherwise there’s no telling what kind of venereal diseases you might pick up. Anyway, we can do a test to find out if you’re pregnant. Is there anything else you’re worried about? No? OK, I’ll just ask your mother to come in, then.

176 Answer key – Unit 12

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978-0-521-75590-0 McCULLAGH & WRIGHT: Good Practice (Student’s Book Inside Cover). Black

COV-19 2020

Acknowledgements The authors and publishers acknowledge the following sources of copyright material and are grateful for the permissions granted. While every effort has been made, it has not always been possible to identify the sources of all the material used, or to trace all copyright holders. If any omissions are brought to our notice, we will be happy to include the appropriate acknowledgements on reprinting.

For extract on p. 8 from Communication and Language, Thompson N., Macmillan, 2003. Reproduced by permission of Palgrave Macmillan; Thomson Publishing Services on behalf of Taylor & Francis Books (UK) for adapted extracts on p. 9, from Fiske J., Introduction to Communication Studies 2nd edition, 1990, and from Fiske J., ‘General Editor’s Preface’, in Key Concepts in Communication and Cultural Studies, O’Sullivan et al, 1994; Blackwell Publishing for the extracts by Bickley, L. S. on p. 11, from Bates Guide to Physical Examination and History Taking, Lippincott Williams & Wilkins, 2003, for the extract on p.11, from Intercultural Communication: a discourse approach by Scollon, R. and Scollon, S., for the extract on p. 53, from Assessment made incredibly easy, Andre et al, Lippincott Williams & Wilkins, 2005, and on p. 119, ‘An approach to interviewing adolescents’ by Sacks, D. and Westwood, M. from Journal of Paediatrics and Child Health, November, 2003, Vol. 8, Number 9; The National CASA Association for the adapted text on p. 12, from Developing Cultural Self Awareness by Harry, B. in CASAnet Library: Cultural Competency; Elsevier Health Science for the material on pp. 13. 39, 81, 96, 118, ‘Communication Skills for Medicine’ by Lloyd and Bor, Churchill Livingstone, 2004, on p. 40, for the adapted text from Crash Course, General Medicine, ed.

Parker, Sharma, Elsevier Mosby, 2005, on p. 58, text from The Sociolinguistics of Learning and Using a Non-native Language by Loveday, Pergamon, 1982, on p. 79, extract from Textbook of Physical Diagnosis, History and Examination, ed. Swartz, W. B. Saunders, 1989, and on p.102, extract from ‘Respectful Interaction’ by Purtilo, P. and Haddad, A. in Health Professional and Patient Interaction, 1996, © Elsevier; Radcliffe Publishing Ltd for the texts on pp. 19, 26, 63, 80, from © Silverman, J, Kurtz, S., Draper, J., Skills for Communicating with Patients 2nd ed. Oxford, Radcliffe Publishing 2005, and for the text on p. 42, © Tate, P. The Doctor’s Communication Handbook 4th ed. Oxford: Radcliffe Medical Press, 2003. Reproduced with the permission of the copyright holder; Oxford University Press for adapted material on p. 66, ‘Talking with Patients’ by Myescough, P. and Ford, M., on pp. 98–99, ‘Testing topics’ by Myescough, P. and Ford, M, on p. 110, ‘Talking to the Dying Patient; by Doyle, D., on p.113, ‘Talking to Children’, Spiers, A., ‘Talking to Adolescents’ by Wrate,

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R. from Talking with Patients by Myescough, P. and Ford, M., and for text on p. 82 and p. 108 from Interviewing and Patient Care, (1996) ed. Enlow et al. By permission of Oxford University Press; BMJ for the adapted extract on p. 47 ‘Information in Practice – Telephone Consultations’, BMJ Vol. 326, 2003, and for the text on p. 69 ‘Not to be taken as directed’ by Marinker and Shaw, from BMJ Vol. 326, 2003, with permission from the BMJ Publishing Group; QUIT for the adapted material on p. 73, The New Quit Guide, So You Want to Quit Smoking, www.quit.org.uk; Vendome Group LLC, for the text on p. 87, ‘Breaking Bad News to Patients’ by Mueller, P., Postgraduate Medicine, Vol. 112, No. 3, September 2002; American College of Physicians (ACP) for text on p. 91, ‘A Time to Listen’

by Barr D. A., Annals of Internal Medicine. 2004; 140: 144; American Academy of Family Physicians for the extract on p. 94 , ‘Cross Cultural Medicine’ by Juckett, G., Journal of American Family Physicians, December 2005; National Institute on Ageing for the extract on p. 109, ‘Working with the older patient: talking about sensitive subjects’ from Talking with your Doctor: A Guide for Older People; for the text on p. 111, Cayton, H., ‘The Alienating Language of Health Care’. Reproduced from Journal of the Royal Society of Medicine 2006, 99 (10) 484, with permission from Royal Society of Medicine Press, London; for the text on p. 119, ‘Now I feel tall – what a patient-led NHS feels like’, Department of Health, London, 2005 © Crown Copyright.

Photo acknowledgements Alamy/Avatra Images p10 (7), Alamy/David Bartlett p42 (l), Alamy/Kolvenbach p10 (5), Alamy/Nick Emm p42 (c), Alamy/Profmedia International sro p42 (bl); Corbis/ Graham Bell p10 (3), Corbis/Heide Benser/Zefa p10 (4), Corbis/Image Source p10 (8), Corbis/L Clarke p10 (1), Corbis/LWA-Stephen Welstead p53 (tl), Corbis/Michael Prince p42 (br), Corbis/Michelle Penone/Zefa p10 (6), Corbis/Shine Pictures p10 (2), Corbis/Southern Rock/ Brand X p53 (tr), Corbis/Visual Unlimited p53 (bl); John Birdsall p42 (tr); Superstock/Image Source p42 (tl); Wellcome Institute p53 (br).

Author acknowledgements We would like to give special thanks the following people for their guidance in the conception and production of this project: Clare Sheridan, Catriona Watson-Brown and Nick Robinson.

Publisher’s acknowledgements The authors and publishers would like to thank the following people who reviewed and commented on the material at various stages: Dr Jonathan Silverman, Dr Sue Nelson, Dr Richard Wong, Leslie Wong, Janina Wiertlewska, Judy Wick, Nick Hillman, Sylvie Gautier, Deborah Saari and Lynne Rustecki.