nf0621: welcome today we're talking about communication skills it's the core part of what you learn if you want to become a doctor ninety-five per cent of doctors spend most of their days talking to people one way or another ninety- eight per cent of doctors have to be able to consult even if you're a pathologist you have to talk to the relatives of the people you cut up and you have to be able to talk to other doctors as well so this is absolutely crucial now one of the first things about communication skills that we teach you all is that first of all you should introduce yourselves and so we're going to introduce ourselves because in the next few years you're going to become fairly familiar with all these names that are in front of you here and we thought we'd give you this opportunity to find out who we are and we're all going to introduce ourselves to you so that all of you will be taught by us probably most of us before you qualify even if not directly in the next few months so we thought you'd like to know who we are so this is our Department of Undergraduate G-P Education at the moment we have two senior lecturers namex and namex and as of two weeks' time we have ten part-time G-P lecturers all of us are more than half-time more than two-third time G-Ps in the week and all of us spend most of our time actually at the coalface so if my people could come up please and we'll let namex now the most important members of our team as far as you're concerned are namex who's our undergraduate administrator and namex her assistant who's i think officially called the secretary these two ladies are the heart of our department and they run everything and you will be going to see them and phoning them lots and lots [laughter] but now namex all yours nm0622: i'm the director of G-P Undergraduate Medical Education at namex Medical School and we're all members of the Department of Undergraduate General Practice Education namex asked us to give er an amusing theme about ourselves and a message therefore about communication my wife says that my interest in cricket has become an obsession and this is myself actually on a very rare occasion going out to bat and i wanted my communication theme to er surround cricket because to be successful in cricket requires teamwork it can't be a solo effort and if you think of the team it's more than just the players if you make the analogy with you as doctors in the future you're going to be the major players in the N-H-S but there are a lot of other players as well there's the ground staff the umpires the scorers the fixture secretary publicity those who make the teas and many others so there are many others in the N-H-S team as well as doctors and we'll all have different skills which namex's just alluded to some of us may be pathologists some of us may be G-Ps so similar to the cricket team there are those that are good at batting some at bowling some at fielding but success is not through individuals for us to be successful we've got to communicate and thinking particularly of the university we have teamwork in teaching that's why we're introducing ourselves as a team in order to make it a success we've got to communicate for you as students during your four years to be successful you've got to be able to communicate both as pairs and within groups during seminar work particularly in relation to problem based learning that requires teamwork and similarly when you go into practice people don't work on their own nowadays they work in teams both in the community and in hospital so effective teamwork depends on good communication to enable mutual understanding of needs whether on or off the field so the amusing bit for me is i have the long walk out from the pavilion on to the [laughter] cricket square a relatively short time at the crease depending whether i'm facing to begin with or whether i have a few balls while my partner at the other end is facing and then unfortunately the long walk back to the pavilion [laughter] pass on to namex nf0623: thank you er i'm namex's sort of other half in the academic department in that er i'm codirector er i haven't made you a beautiful slide because as my group from this morning will know i'm i'm rather keen on art and i have a new digital camera and i haven't quite got my act together er i've been here since January er and i was at U-C-L prior to that er my major interest is obviously in communication and consultation skills er which is also a research interest for for many years i was head of the international unit which is involved in primary care development projects abroad er and that i think has made me more aware of of of communication it's it's brought a lot of lessons back for me to the U-K which i use in my daily practice er these projects are quite expensive and it's led me to reflect on er looking at what we've actually done whether we've actually done anything in fact for the patients er in terms of primary care development and i've been looking at patient centred instruments er which is a research interest i intend to pursue er along with a little bit of international work that that i'm doing here er so hopefully er you'll see more and more of that as as the course progresses thank you nf0621: okay here you are namex we'll leave it there nm0624: okay [laughter] well will the miracle happen when i need to press it nf0621: yeah [laughter] nm0624: yeah nf0621: yes it will nm0624: okay thank you er my name is namex and er i'm one of the part-time lecturers here yes i do believe in miracles er because for one i became a doctor er [laughter] if i can do it i think anybody can [laughter] i mean clearly er talking about communication skills i mean that's the theme er you obviously have some attributes in communication because that's what we test in the interview but the course is and our aim is in particular to develop some of those attributes and fine tune them so that you become very successful doctors right now miracles do happen and one of them happened to me very recently i was on holiday in Toronto and after twenty-five years i met a drinking partner [laughter] now can you believe that two people could be attending two different weddings in at the same venue and be outside the hall at the same time across the road so a very quiet sort of voice says namex and i thought nobody knows me here so i ignored it [laughter] a slightly louder one came namex and there was a guy smiling across the way and it made my day i have to say it made my year i suppose to see somebody after twenty-five years who you were so close and it's amazing that sometimes you let go of your relationships and relationships are very important for G-Ps thank you nm0625: i'm namex i'm a G-P in er namex and as as namex's sort of outlined er you'll come across me both in the Communication Skills module which is what you're doing in this phase one and then later er we get involved in Clinical Methods which again is er departmental and practice based the reason i've sh-, selected this slide to show you is is partly to illustrate that we do have lives outside this building but also to er sort of highlight that communication is not always verbal and it is important to be able to recognize and appreciate non-verbal communication er and also recognize that different things mean different er different things depending on the circumstances that that you find yourself in i mean does does anybody here go diving or scubaing or so the people who don't what i mean the message there is sf0626: go up nm0625: go up yes er [laugh] not having a great time [laughter] which is more represented by that [laughter] okay thank you nf0627: first er bad communication error is i work in namex not in namex so [laughter] nf0621: i'm sorry nf0627: i apologize for that nf0621: oh that's my fault nf0627: [laughter] don't worry nf0621: er nf0627: i was going to say the should we put the the photograph up at this stage now this will give you a laugh [laughter] the [laughter] my husband said the way to get a laugh is show a wedding photograph and you're bound to get one with that hat on so [laughter] it is actually me er a hundred years ago [laughter] on my wedding day and i thought it might be interesting especially for the girls in the audience because i got married as a medical student and some of you might have been wondering about marriage and children and the rest of it er so now i then i was a medical student and getting married now i'm a daughter still and a wife and a mother as well as being a G-P and a lecturer so you really can have everything that you want it's quite possible and i thought when i looked at that if you look at the eyes and it my me-, my communication message is eye contact is really important and if you look at my eyes i'm looking in the right direction [laughter] and i and i think that is the story of my life [laughter] i really do ss: aah nm0628: hello i'm er i'm namex this here is my little new daughter namex who's now sixteen weeks old ss: aah nm0628: and that was the day she was born there [laughter] so er i was just about i'm i just er wanted to illustrate some non-verbal communication can anybody what what's what am i thinking here do you reckon [laughter] oh by the way that is my wife not [laughter] can anybody read what my face is thinking there i this is why i use this i think sm0629: well it's how did we both get into the same shirt nm0628: yeah [laughter] it's it's it's very sad isn't it y-, yeah it it's especially with my size as well [laughter] isn't it yeah any any other offers [laughter] it's a mixture of extreme p-, pride and absolute terror if you notice [laughter] the sort of a grimace on my face as well so er anyway this is what actually happens to you if you have a kid [laughter] ss: aah nf0621: so there's Homer Simpson i A-K-A me with little namex absolutely blotto on my lap it's absolutely knackering but er [laughter] but anyway that's me er i am a human being er by the way the way not to get a stomach like that is not to put a stone a year on in medical school [laughter] that's what i did it's it's mainly the curry every night after the beer avoid it like the plague [laughter] but er but anyway i'm a G-P in namex up the road a little village and one of the part-time lecturers here and i teach mainly the commu-, er the Clinical Method course a little bit later on so you'll be coming across me so it's nice to meet you all and i'll pass on thanks a lot nf0621: this is me and i thought i wasn't going to overload it with too many er bytes of information so i just [laughter] thought we'd er we'd go back to the necessity for verbal skills in consultation and just to remind you and now nf0630: i'm namex i'm the only lecturer here that has to ask you not only is the microphone working and can you hear me but can you actually see me over the lectern [laughter] 'cause i am quite short er as it said i'm a G-P in namex as well which probably a lot of people have just moved to namex and you don't know where it is it's actually the little village outside namex which is very famous obviously for a chap who used to write plays and things er and he's also very famous er for acting so i thought it was only fair that perhaps me and one of the partners at work should do a little sketch for you now this is even more humiliating than doing G-P videos so [laughter] when you come and whinge to me about having to do videos just bear in mind what i've had to go through to do this okay nf0621: right our next lecturer [laughter] nm0631: hello er my name's namex i'm a G-P in south namex at a place called namex and which is why i was a bit late so i apologize for that that's me [laughter] er i don't really have any teaching points about that i just thought that was quite sweet [laughter] although i guess er if there is anything to learn about it it's if you do have any bad habits er try and lose them as early as possible 'cause i'm still suffering from my family affliction [laughter] of supporting er Wolverhampton Wanderers and as [laughter] you might know er they're appalling [laughter] so er that's all i've got to say really [laughter] nm0632: hi my name is namex as you can read [laughter] er basically i've been appointed recently as a lecturer here so i've not had all the er experiences all these lecturers who managed to er get these fantastic slides but basically when i was studying for my M-R-C-G-P that's what i looked like er and just to let you know that if you're getting really er pissed off with doing intensive study for medicine [laughter] then you can produce a child like that which is [laughter] what i did afterwards thank you [laughter] nm0633: hi m-, my name is namex i've got B but probably in future i'll get a O-B-E or M- B-E [laughter] but that's an that's an example of er communication i haven't put my slides or anything there because Powerpoint is always a distraction and er i'm trying to provide a kind of a visual communication [laughter] so they can look at me [laughter] and i for a long time i was at the other end of er er the where you were sitting and listening to other people but i'm just r-, i've just recently joined as namex as a lecturer here and i'm a G-P in er namex okay thank you [laughter] nf0621: okay so now you know who we all are and a little bit about it so i thought we'd get ourselves back to the basics of this and er the first thing to know is that this bit of the course is part of your Clinical Skills module don't worry about writing things down nothing there are no notes to be taken from this lecture okay it's a practical course it's not theoretical there is no knowledge to be learned it's taught by practising doctors with simulated and real patients communication skills are skills and you can't learn skills by writing about them you can write about Beethoven's piano concerto till the papers are this big you can talk about it till people's ears drop off and it will not let you be able to play it to be able to play it you must play again and again and so this is not for you to write and us talking about it that makes you think that the real learning happens with the patients so why teach communication nf0621: well i like that because it's got so many examples of communication cock-ups later on when you watch it you'll actually be able to spot them and you'll say ah he's using a word that he thinks he means something different from this one does and he's d-, you know but the whole of that Carry On film is about the misunderstanding that happens in that consultation and although that is a film and you've probably seen it before i will say that i have seen worse consultations happen in real life so perhaps there is some point in teaching communication good communication has rewards and bad communication has punishments if you communicate well you know why the patient has come you can make a diagnosis the patient can understand your explanation the patient might take your treatment and the patient will like you on the other hand if you can't communicate you miss the real reasons that they've come to see you you miss important diagnoses and the patient does not understand you or what is going on patients don't then do what you want them to do and you get complaints so on a very real and practical level being able to communicate well is absolutely crucial for what we do as doctors so what is good communication well we've seen it can be non- verbal i can by the way i use my body or not give completely different impressions to people your body language your expression your posture wasn't the patient's expression marvellous when the doctor was talking looking at the X-ray non-verbal communication can also be paralinguistic things like the tone of your voice and your voice quality can communicate important things recently got a new curate in my church and she goes on about the love of Christ [laughter] and i think [laugh] every time she does it i'm i know it's wrong but [sigh] i just wish somebody had taken her an-, aside and said you can learn how to make your voice more relaxing [laughter] good communication can also be verbal what you say matters enormously the precise words that you use how you say it and the way you respond to the people er has said so let's have a think about these skills these are the skills that you're going to be practising but before we get on to that i think we ought to have another video nf0621: so the first and most important skill is listening questioning how to ask questions it's quite frightening at first going up to a complete stranger and asking them questions about when they had their bowels open and what their mother did and oh all sorts of personal things about pain and bodies responding knowing what to say and how to say it when somebody gives you a bit of themselves and how to explain how to explain things so that people understand not the way you understand it but the way they will understand it so let's have a little look at these skills w-, one at a time just briefly because we don't want to waste too much time on this so listening you have to give patients space and time to express themselves it's actually quite difficult to hear what patients are actually saying we take it for granted but very often you know there's family arguments where i told you about so and so no no you didn't you didn't say that you said something el-, it's very difficult to hear what people say because very often you're expecting an answer and you get dragged b-, off by your expectation and practising listening to the story that patients really tell you is very important you have to overcome the barriers to disclosure they're always there they'll be worse for you when you're feeling insecure when you're only a first year medical student and you feel like this but even the most experienced doctor has to overcome barriers in order to be able to help as well as they can if i've got one message that i'm going to give you above all others it's to value the patient's contribution as equal to your own in fact it's not just equal to your own it's probably everything and by the time you qualify we hope you will have the knowledge and the skills to process what the patient says to be able to make this magic thing called a diagnosis but more than that not just a label a real insight into that patient's world something that will make sense to them as well as you so you're going to be doing this by listening but also by questioning anybody know anything about questions anyone yeah sm0634: er basically not to ask leading questions to keep them open nf0621: brilliant yeah sounds very easy doesn't it not to ask leading questions but there are basically two sorts of questions there are closed questions these are ones that can be answered by yes and no things like do you have you are you and there are open questions which actually allow a patient to answer in their own words they can't be answered by yes and no and they usually start with words like who what where why and when learning how to ask open questions to ask questions in a way that allow patients to answer the way they want to is actually quite difficult and in your groups you'll all say ooh i'm going to ask these open questions and then you find you open your mouth and you say do you think it's so and so and you've asked a closed question again and it's so easy to get into habits of asking these closed questions and you have to practise to to become better at it i've got these slides in the wrong order but we'll deal with it explaining giving a good explanation i haven't put any detail on the slide because at this point we're not going to be concentrating on h-, the precise nuts and bolts of how you do it but the essential is to be able to use the right language and that is a skill that you can practise being able to use the words that patients understand and in the way that that patient understands it so you then can get a shared understanding and we teach you in order to get that shared un-, understanding you're going to use the patient's ideas the patient's concerns what's bugging them and their expectations and you'll be practising this by the time you get to the Clinical Methods course you'll actually know ideas concerns and expectations as ICE it will be something i hope that you'll be so familiar with thinking do i know their ideas do n-, i know what what they are worried about do i know what they want from us and responding what do you do when somebody bursts into tears what do you do when are there some useful things that you'll get used to d-, using things like tell me about tell me about encourages the narrative of a consultation it gets people talking it's a wonderful tool that experienced doctors use you don't usually tell your friends t-, tell me about this do you but it's something that as a professional you'll learn reflection to be able to just repeat back something that a patient has said and not to feel ridiculous about it summarizing to take a long complicated story that a patient has told you and to create it into a nice neat whole so that they can check that you've got all the important data and empathizing how to say naturally easily i'm so sorry if somebody tells them you that y-, their father's died or something like that and to be able to feel comfortable about giving that empathy so these are all very practical things and me talking to you about them isn't going to help them happen is it so how does our DISC course here help you to develop these skills we start out with three seminars each of the seminars takes place here it's about an hour and a half long you'll be in small groups there'll be about ten of you and you'll have a G-P tutor with you in that group you'll also have a thing called a simulated patient we use simulated patients quite a bit both in exams and in training and i know that there's a tendency for students to think oh it's only an actor well if you call a simulated patient an actor a lot of them get very offended but these are people who have an alter ego as a person who comes to see a doctor and they know how to be that person and they give you a chance to practise to dry run like going on a dry ski slope you know it's it's easier although it isn't easier when you actually try it you find it feels just like talking to any other patient and of course these are real patients often they have real illnesses but the advantage is that if you say the wrong thing if you laugh when they say my father died you won't have really hurt somebody in a way that can't be undone and if you find that the patient doesn't understand what you're going on about you can say ah i'm sorry shall we try that again and reel back like a videotape and have a g-, go using different words for us experienced doctors we love having a chance to use simulated patients and we f-, we find that the work that we can do with them is immensely valuable to us but these seminars that you have are a chance to actually practise your first attempts at talking to patients in a safe environment it's also an environment where you can experiment it's often quite difficult to find out why the patient has come if you're in a group the group can give you ideas how you can ask the right questions to actually find out why these particular patients have come and they also enable you to be able to find out the background to the problems that the patients have at this stage we don't expect you to make medical diagnoses but it's never too se-, soon to start practising the actual nuts and bolts of talking to patients finding out what their story is why have they come to the doctor's today what is it they want what is the real problem those skills you need right from day one we then follow it up with real patients because that's what life is a-, going to be about for all of you and you then have three sessions in the G-P practice of your group tutor so you will be with the tutor who's been with you in the seminars and you go out in pairs and you'll spend an afternoon or a morning in their surgery and you'll see real patients with real problems and even your tutor won't know anything about them because they'll come in and they'll have something new he and he won't know what it is and you'll be able to talk to them before any other doctor or nurse or anyone has actually spoken to them about this problem and have a go at finding out why the patient has come finding out the background to the problem and then as a pair you can think about the difficulties you find and you can learn to recognize what you do naturally easily and what you're going to have to work at and the most important thing here is that your G-P tutor is going to be giving you feedback every time you talk to a patient your G-P tutor will be watching and listening to what you do and they will give you feedback on how you did it well what worked why it worked and they'll give you suggestions for things to try so it's not knock you feedback it's useful feedback and even more importantly at the end of the course they should give you some structured written feedback as well so that you can take that and put it in your portfolio and you've got a record of that work you've done so that structured written feedback how do we do it i'm going to rush through this bit because it's it's important but it's also something that probably not er you'll want to know all the details very at some stage but not here here we use a thing called we call it the LAP it's called the namex Assessment Package this is the the assessment tool that's used in all the exams in the namex Medical School and it's a way of measuring how you perform when you're talking to a patient now nf0621: of you has got i hope a blue book a coursebook if you haven't got one don't fret now don't read it now just make sure you've got one in that book all the details of the assessment that's used for this is recorded and this tool with minor changes is used in all the OSCEs that you get it's used in your intermediate clinical exams that's halfway through your phase two it's used in the Clinical Methods course that we teach later on where you do two months hospital and general practice and s-, concentrated work on how you make diagnoses and how you make management plans and for you the important thing nf0621: assessment tool is how you will be measured in your final clinical exams so becoming familiar with this assessment package is useful to you and i'm going to briefly flick through the criteria that are used in the communication skills part of that assessment package now we only look at what you do in two parts of talking to patients we're not going to be judging you on how you make a diagnosis at this stage but we do look at your behaviour and relationship with patients and your tutor will tell you whether you are maintaining a friendly but professional relationship with patients whether you are conveying sensitivity to the needs of patients and whether you are communicating an awareness that their attitude actually matters towards creating a shared approach you'll also be being judged or being given feedback on your interviewing and history taking skills and there are a lot of criteria here so i'll it's on to the next slide and it's a rather crowded slide and i apologize for that you're expected to become fluent at introducing yourself putting patients at ease allowing a patient to tell their story checking out words that the patient uses that you're not sure quite what that patient means so that you don't get the sort of mismatches that happened in the Carry On film phrasing your questions simply and clearly being able to sit on your hands and shut up when needed finding out why the patient has come their ideas concerns and expectations and looking at the whole problem as it affects the patients not just their bodies that the whole of them as a a functioning individual in society in a family and although we do test on we tell you if you're getting the right sort of information in your questioning and we'll give you praise if you're well organized at this stage we don't expect people to be starting to get a really controlled history because it's is-, it's difficult it is a skill it's every bit as complicated learning to consult with patients as it is learning to drive and if it seems a bit daunting most of you have learned to drive by now in fact i hope all of you have but if you're feeling a bit daunted when you're talking to patients and thinking it's difficult just remember how awful it was the first time you actually let the clutch out and it went down the road [laughter] so where do we go from here the seminars are on Thursday afternoons the group dates and times will be on the noticeboards namex are they actually on the noticeboards at the moment nm0625: have to be up by Friday nf0621: they'll be up by Friday so you will know who your G-P tutor is where they're based who else is in your group and what time your sessions are your tutor is going to be the G-P whose practice you will be visiting you can start visiting your G-Ps after the second seminar now the first first seminar is on the twenty-fifth of September so in about a week's time and the last third seminar is on the sixth of November so all of you should have been out to your general practices sometime during the month of October or November and you then have until the following June to complete your three visits and please read your clinical skills workbook read it and read it and read it and don't lose it because you'll need it later on in your Clinical Skills module that starts in November as well have we got any questions or queries anywhere sf0635: are there any leftover workbooks nf0621: yeah we've got a wave over there one over there sf0636: are there any leftover workbooks down at the front 'cause there aren't any at the back nf0621: there are two-hundred workbooks and there are slightly fewer than two- hundred students so there should be enough to go round yes some are going your way sf0636: thank you nf0621: any others short right if we all make sure that anyone who hasn't got one gets one before they go yes now before you go before you go l-, namex who's your administrative your ad-, the G-P undergraduate G-P administrator is going to introduce herself nf0637: i'm in room one-one-three and extension number seven-three-eight-o- eight okay our secretary is namex she's in the same room and she's on extension seven-four-o-four-four er namex put up here that attendance is compulsory i will know within an hour if you've not turned up at your practices okay er it's not acceptable to not be there if you know that you can't make it phone me in advance and let me know let your doctors know and it has to be y-, er er a good reason why you're not going to be there okay er other than that if you've got any issues any problems you can come and see me any time at the moment i have got hours posted on my door but for the moment while you're sort of getting used to things come and see me any time you like thank you nf0621: right now namex wants to have a brief word after me i just want to basically say namex is in her office most of the time nearly always if you've got a problem with any of this part of the course she's there and namex if y-, if namex isn't there namex is and they are fantastic they you know they really do help and they help us as well so you'll you'll all get to know her really well by the end from my point of view that's the end of the lecture namex wants to have a quick word but thank you very much for being so quiet and listening thanks nm0622: i i ju-, just wanted to say enjoy very much being at namex University and the medical school for the next four years if you do have any problems or concerns now you've met us all i'm sure we'd be all very happy to an-, to answer any queries that you may have er the next lecturer Dr namex has suggested i think quite rightly you have a break for the next three or four minutes just to stretch your legs outside and then please come back in the lecture theatre in the next five minutes thank you very much