A GP asked a patient for his consent to me taking a history and carrying out an examination on him. The patient agreed and the GP assured the patient that he would return in a few minutes.
T.P., a 55 year old man had a past medical history of temporal arteritis, hypertension and hyperlipidaemia. He was presenting with stiffness, weakness and some pain around his shoulder joints.
Following my history and examination, I thanked the patient for his time. As time elapsed and there was still no sign of the GP, T.P. became discontent and vented his frustration on me. He told me that he was “a busy man and didn’t have time to be used as a guinea pig with a student who was inexperienced”. I apologised to the patient and again reassured him that the GP would be coming soon.
Once the GP arrived, the patient relaxed. Through out the consultation, it transpired that the patient was under financial pressure and therefore was worried that these symptoms would progress and force him to quit work.
Feelings
At the outset, I was a little nervous but overall I felt comfortable with the history taking aspect of the consultation and I was happy with how it progressed. However, when the patient expressed his frustration, I became very uncomfortable. I could feel my face redden and I had no idea how best to handle the situation. I felt as if I was a total inconvenience to the patient. I felt foolish in the eyes of the patient as I was unable to diagnose his problem or offer a management plan. I was also trying to prove myself to the GP and I was worried that the patient would complain about me. The atmosphere in the room became very awkward until the GP arrived. When I realised that I had failed to ask about the patient’s concerns, I felt embarrassed that I had ignored this area of the consultation.
Evaluation
The positive aspects of this consultation were that I took a good structured history from the patient. I was respectful to the patient in that I thanked him for his time and patience. I also feel that I tried to understand the patient’s point of view even though I found his comments harsh and a little insulting.
The negative aspects included the fact that I completely missed the patient’s main concern about the effect these new symptoms would have on his ability to work. I didn’t address the patient’s concerns or expectations during the history meaning the patient would leave unsatisfied. I feel that my actions could potentially taint this patient’s good impression of the practice and he may be unwilling to interact with students in the future.
Analysis
This was an invaluable learning experience for me. It addressed the learning outcome “to take and present a focused history”. I realised that as part of my history taking technique, I never focused on the patient’s concerns and expectations. This consultation highlighted this flaw in my technique and I looked into this learning need by researching the Calgary Cambridge Model of history taking. I was happy that it was noted so early in my rotation as it afforded me the opportunity to improve. This consultation also underlined the importance of another learning outcome to “demonstrate good communication skills” especially when faced with challenging patients. The GP discussed the importance of trying to understand the patient’s point of view as often their annoyance is masking another feeling. In hindsight, perhaps the patient’s worry and concern played at role in his eruption of frustration at me.
Conclusion
After reviewing the case from many dimensions, discussing the case with the GP and reviewing literature on history taking, I think TP’s frustration may have stemmed from the fact that I never showed any interest in his concerns. Perhaps, I appeared disinterested in his well being as I focused solely on the “disease agenda” and ignored the “illness agenda” as outlined in the Calgary Cambridge Model. My inexperience was clearly evident and I have potential to significantly improve in this area. I now realise that making mistakes as a student is inevitable but it is important to reflect on and learn from them.
Action Plan
In future consultations, I will always explore the fears and concerns of the patients as I now realise that a consultation without addressing the patient’s ideas, concerns and expectations is futile. This will improve both patient’s and doctor’s satisfaction levels.

EXAMPLE 2
Description
On one of the days during my second GP placement I was assisting the practice nurse when a 42 year old lady came in to have surgical staples removed. The patient was one week post open laporotomy to remove an ovarian cyst. The patient chatted jovially and seemed to be in good spirits. While the nurse was out of the room I began to enquire about the history of the patient’s diagnosis and surgical management. While having this conversation the patient disclosed that pathological analysis of the removed cyst had shown malignant cells and she would now be undergoing chemotherapy.
Feelings
The patient’s disclosure came as quite a shock. I had made the false assumption that the removal of the cyst had been the resolution of the matter. The possibility of the patient requiring further treatment had not entered my mind.
As stated earlier the patient was in good spirits and I couldn’t help but admire this given the fact she was facing into such an arduous treatment. Despite this, my approach to the conversation changed. I began to wonder what is expected of me as a medical student in a scenario such as this? Should I offer my condolences to the patient? Should I offer words of encouragement? I wanted to show empathy, but the concept of being given a cancer diagnosis was so alien to me that I found it difficult to comprehend what the patient may be going through. Ultimately, I was relieved when the nurse returned to the room and the procedure could be continued with.
Evaluation
The situation was a novel one and certainly threw me out of my comfort zone. It was positive that I wanted to empathise with the patient and that I was asking questions of myself relating to patient interactions rather than assuming that I knew best.
However the situation also highlighted that I shouldn’t jump to conclusions relating to patient’s diagnoses. Despite the fact that I wanted to empathise with the patient I was found wanting in this regard. In my own estimation I struggled to best convey my feelings of sympathy.
Analysis
The primary learning need which I identified from this case is the need to improve my patient interactions when faced with a difficult or unexpected situation. I believe this can be related to the learning outcome to display professionalism.
I think my reaction to the situation was reasonable. It one of the first times as a medical student I’d encountered such a difficult and emotive case. The questions which entered my mind as the patient was explaining her diagnosis were rational. Unfortunately I didn’t possess the clinical experience necessary to address these questions adequately. However, formative experiences such as the present one are essential ingredients in developing professionalism.
Conclusion
I consulted my GP tutor. He offered me tips and advice on how to approach such situations in the future. I also referred to the ‘Breaking Bad News’ lecture on Moodle. One particular slide within the lecture concerns addressing patients’ emotions with empathy. It advises to let the patient talk and not to offer false reassurance. This was particularly informative as I almost felt compelled to offer reassurance.
Particularly useful also was a blog by Dr. Kate Granger-­‐ a doctor who is terminally ill with a rare form of sarcoma. The blog offers an interesting and insightful view into how best to approach bad news situations from the perspective of both a patient and doctor.
Action Plan
Having gone through this reflective process I feel I am better prepared for a similar scenario in the future. Ideally I would allow the patient to talk and express his/her concerns while listening attentively. I would avoid the urge to offer false reassurances while at the same time addressing the patient’s concerns and providing support.
The nature of medicine presents difficult scenarios when one is called upon to provide advice or reassurance in emotive circumstances. This case was one of my first experiences of such a scenario and will undoubtedly from an integral part in the development of my professionalism.

EXAMPLE 3
Description
During the GP rotation we were allocated to an ATP tutor, with whom we had a clinical teaching session during the 1st week. Our tutor had arranged for one of her patients with diabetes to meet with me and two other students who were in my group. I was asked to take a history from this patient and then to present it.
I took the history, starting off with asking the patient to tell me about her diabetes, when and how was she diagnosed, her diabetic control and the issues around the complications of diabetes. Our tutor came back after a few minutes and asked me to present back my findings.
When I began I immediately realised I had forgotten to ask her name and introduce myself. I apologised for this and continued to present the history as best I could. However, I was thrown and I did not present the history well. In addition, I realised I had failed to focus on some of the important aspects of diabetes.
Feelings
When I was asked to take a history I felt slightly nervous, having been on a psychiatric rotation for 6 weeks I felt that my clinical knowledge was not what it should have been. I felt pressurised and neglected to introduce myself and obtain the patients name. When I realised my omission I felt embarrassed. I wondered what the other students and ATP tutor would think of my mistake and then following that my history taking and presentation skills. In addition I was concerned that the patient would think I wasn’t very professional.
Evaluation
I believe that making mistakes are good learning experiences because it means you are less inclined to make them again. This was fortunately not an exam situation and was just a relaxed teaching session from which I took comfort. While I was critical about my history taking the tutor said that overall I had taken a good history and included most of the salient points required in a diabetic history.
The main negative thing from this experience was that I omitted a fundamental part of the clinical interview by failing to initiate the interview properly. A mistake that I should not have made at this stage in my training. Additionally I was slightly thrown for the rest of the history presentation and did not present in a clear and succinct manner.
Analysis
The learning needs I identified are related directly to the 1st learning outcome ‘to take and present a focused history’ and to the fifth, ‘to demonstrate good communication skills’.
Establishing initial rapport is a key part of each consultation as a student and a future doctor. It
involves greeting the patient appropriately and introducing yourself as well as demonstrating respect to the patient. This is something that I am more than aware of but feeling slightly uncomfortable in this situation led me to forget to do this.
As well as referring to the Calgary Cambridge model for medical interviews I have begun to revise how to take a history for each system by using moodle and sources in the library. In addition during my second GP rotation, the GP recorded me taking histories and subsequently gave me feedback.
Conclusion
Having discussed this with my GP tutor, familiarised myself with the proper structure of history taking and revised history taking for each system I feel more confident that I will not make this mistake again. I realise that it was because I felt unsure of my ability to take a proper history that I forgot the proper proforma for taking a history. This mistake then led to my subsequent poor presentation. I am glad that I made this mistake because I learned a lot from it. Going forward I believe that I will be a better student and in the future a better doctor.
Action Plan
I plan to continue to familiarise myself with the elements of history taking again and also the relevant questions necessary for each presenting complaint. In addition I plan to practise taking and presenting histories at every available opportunity in order to improve my history taking, presenting and communication skills.

EXAMPLE 4
Description
X is an elderly lady who attends her GP for many co-morbidities including chronic obstructive pulmonary disease, a long-standing history of depression and gynaecological malignancies. She has recently been experiencing excessively low mood and anhedonia. I thought she would be an interesting patient to obtain a history from, therefore I asked the GP if I could speak with her with her consent.
As I proceeded through the patient’s history, she began to provide me with an in-depth social history which included sexual assault. I spoke with her at length regarding her experience, however I was unable to redirect the conversation to complete her medical history. At the end of the conversation, the patient told me that she hasn’t told the doctor her story. She asked me to ‘pass on’ this information to her GP.
Feelings
When X first began to tell me about her past sexual assault I was taken aback. I had never spoken to a patient before regarding such an intimate matter. I initially felt uncomfortable and unsure of how to respond. I was afraid of saying the wrong thing or not presenting the right response. I felt empathetic and I wanted her to know that I was concerned about her experience, however I was at odds with the professionalism required – a so called one step of separation. At the same time, I wondered why she would tell me her story. After exhausting her social history, I knew it was necessary to complete her medical history. I didn’t know how to redirect the conversation which was frustrating. I was so worried that she would feel I was neglecting the sensitive information that I’d just received, that I avoided completing the history and concluded the consultation. I was also concerned that my GP would question my ability to perform a history as it was incomplete.
Evaluation
During this interview, I think I successfully put the patient at ease and provided her with a comfortable environment to share her story. I realized that as a stranger I served two purposes, first I provided her with an opportunity to share something that was troubling her and secondly I acted as a means to gather and relay her social history to the GP without the constraints of a busy practice. I was unsuccessful in my task to complete a detailed medical history. By avoiding completing the history I could have missed valuable information that would be necessary in providing her with the optimal care. In doing so, I disappointed myself and felt I let down both the patient and my GP.
Analysis
From this experience, I learnt that I needed to improve my patient interactions and adapt my communication skills in unfamiliar and sensitive situations. Therefore, I identified two learning outcomes which were important areas for improvement throughout my rotation. These were to develop ‘effective communication skills’ and ‘perform a focused history’, both vital to practicing good medicine. To try to gain some insight, I consulted literature and observed different GPs’ communication with patients in intimate situations. I found that both verbal and non-verbal cues as well as outlining a consultation agenda were beneficial in directing the interview. In this experience, reflecting on statements, the patient’s feelings and summarising would have helped provide closure of the initial topic before proceeding with the agenda.
Conclusion
After reanalysing my experience with X I realized that the more opportunity and exposure I am given in history taking, the better I will become. My inability to overlook my own personal discomfort and lack of experience inhibited my ability to communicate with the patient and return to the important task of completing a detailed medical history. I also identified the importance of ensuring sufficient consultation time to give patients adequate opportunity to explore additional complaints. This was an important factor in X’s inability to address her social history with the GP.
Action Plan
I discussed X with the GP and it was decided that he will explore her history at her follow up appointment in 2 weeks and take it into account when addressing her depression. I will encounter many different situations in the future requiring me to adapt my communication skills. In these situations it is important that I react appropriately to sensitive information and encourage patients to discuss their complaints. In addition, I will ask for feedback from those around me including clinicians, nurses, my peers and most importantly the patient.

EXAMPLE 5
Description
My first GP placement was a small rural practice in X. Despite only being placed there for 2 weeks, I was able to meet many of the patients, and had spoken to them quite extensively.
One morning, a patient I had met before came in enquiring about her brother, who was also a patient at the practice. I had met her brother the previous day when he had presented with a two week history of nausea, vomiting and painless jaundice.
She was quite distressed and emphasised that her brother would not approve of the fact that she had made an appointment to discuss his symptoms. She mentioned that she was very worried about him and described her concerns about his loss of appetite, lethargy and vomiting. While describing this she burst into tears and asked for a paper napkin, which the GP went to get. While he was in the next room, the patient turned to me, knowing that I had met her brother, and asked me if I knew anything about what was going on and whether I thought it was something serious.
This question definitely took me by surprise. Aware of patient confidentiality and seeing her so upset, my initial instinct was to reassure her. I told her that it must be very difficult for her seeing her brother ill and that I’m sure everything will be okay.
Feelings
At the end of the consultation, I felt like I had handled the situation inappropriately by falsely reassuring her to ease her distress. Even though the GP had explained patient confidentiality to her, and emphasised how he was not able to provide information about her brother in his absence, I felt like I should have communicated this to her too. Perhaps the fact that I had met her before and was quite fond of her clouded my judgement. I felt like when put under pressure, I failed to put into practise what I had learnt regarding communication with distressed patients and had let myself down.
Evaluation
Good
This experience has given me the opportunity to experience a medical ethical circumstance in practise, and re-evaluate communicating with a distressed patient.
I used it as a learning opportunity and spoke to my GP tutor about what had happened during the consultation. He was very supportive, explaining that some reassurance is necessary. He then gave me advice on communicating with patients in similar situations.
Bad
As that was one of my last days in the practice, I was not able to follow up with the brother’s diagnosis or apologise to his sister for my very superficial response to a loaded question; perhaps explaining to her the reasons why I could not go into any detail about her brother’s symptoms.
Analysis
My learning need was to put into practice skills learnt in the communication and consultation skills tutorial (related to GP learning outcome “Demonstrate good communication skills”). Being exposed to this challenging situation, I found it difficult to clearly explain to the patient my role as a medical student and how it was important that I maintained patient confidentiality. I would have also liked to support her through this difficult time and suggest possibilities such as accompanying her brother to a consultation, with his consent, or making him aware of her genuine concern.
My GP tutor helped me come to a conclusion about how to tackle similar situations and I will always remember this as a valuable learning experience.
Conclusion
Through this I realised the difficulty in communicating with acutely upset patients. By reflecting on what had happened, and discussing it with my GP tutor, I was able to pick up on things that I would have done differently, giving me a skill that I strongly believe will prove useful in my future career.
Action Plan
I have learnt that if a similar situation were to arise in the future, I would first give the patient a chance to talk and express their emotions. I would support the patient with empathy rather than giving false reassurance. I would explain my role, summarise the situation and give suggestions with regards to how the patient can potentially solve their current problem. I would feed back to the patient what they have told me as hearing it from someone else could help them see it in a different light. Finally, I would tell the patient that I am willing to listen to any concerns they may have in the future.

EXAMPLE 6
Description
During week one of my GP rotation, we had a communication teaching session involving videoed OSCEs with patients, which were then critiqued.
My patient was a mother who was not vaccinating her baby. The root of her concern about vaccines was that her son experienced side effects from the MMR. I explained that the MMR was a live vaccine, and it was likely her son was mounting a response to the viruses, meaning his transient malaise was not a bad thing in the long term.
During the critique afterwards, the patient said she felt like she was “battling” me and that the consultation felt “confrontational.” I noticed I had interrupted the patient and demonstrated other poor communication skills that I hadn’t realised before.
Feelings
Initially, before watching the video, I felt happy with the consultation. I knew there were areas to improve on, and I hadn’t done a good job of convincing her to vaccinate her child, but I was confident in my communication skills.
After watching the video, I was embarrassed by some of my behaviours, like interrupting the patient, and speaking at length without letting the patient talk. I thought I had demonstrated some good skills though; I thought I had addressed her concerns and displayed empathy, and used engaging body language. I felt pleased that my classmates picked up on these good points during the critique.
I was surprised at the patient’s reaction to our exchange. What shocked me was that she thought I was being confrontational, especially when I had thought it went well. What shocked me even more however was how skewed my perception of the situation was compared to the patient’s. I was disappointed that I had made the patient feel that way, and that I had been oblivious to it.
Evaluation
I was made more aware of my communication style and areas I need to improve on, and also that there are areas of the history taking in which I do well. I also considered that differences in personality contributed to different perceptions of my performance, as one of my classmates praised my overall style, while the patient criticized me, and some thought there were equally good and bad points.
However, I was unsuccessful in encouraging the patient to get her child vaccinated, and I made the patient feel like she was in a confrontation. I also exhibited other poor communication skills such as interrupting and asking to many questions at the same time.

Analysis
My learning need was to improve my interpersonal and communication skills. This addresses the first learning outcome: Demonstrate appropriate and effective communication skills with patients and staff. The video consultation was an extremely useful learning exercise for me. It identified areas that need improvement, and has made me more aware of my own style. My feelings around this experience changed from initial disappointment to a more positive personal development goal. It prompted me to have more awareness of the patient’s reactions during the consultation, to ensurethat I am adapting to the patient’s feelings. In the words of Norfolk et al.1, I need to increase my “empathetic accuracy.” To achieve this learning need, I studied the Calgary Cambridge Model2 of history taking, and also studied Flanagan’s Model, which highlights the “Golden Minute” in GP consultations3, 4, as well as Norfolk’s paper1, “The role of empathy in establishing rapport in the consultation: a new model.”
Conclusion
I am glad that I was made aware of this learning need before starting my GP attachment, it made me want to improve my “empathetic accuracy” and am more mindful of this going forward. I realise that perceptions of the same consultation can vary greatly, but it is important to try to ascertain the perception of the patient to guide the consultation. I learned that I can appear argumentative, and I must try to avoid this approach in future consultations.
Action Plan
I hope to not make patients feel like a consultation is confrontational, even when difficult subjects are being discussed. I will try to put what I’ve learned about demonstrating empathy and facilitating patient communication into practice, and I’ll also observe how GPs communicate in these situations when I am on my clinical attachment.
References

1. The role of empathy in establishing rapport in the consultation: a new model. Norfolk T, Birdi K, Walsh D. Med Educ. 2007 Jul;41(7):690-7.
2. http://www.gp-training.net/training/communication_skills/calgary/calgary.pdf
3. The consultation hill: a new model to aid teaching consultation skills. McKelvey I. Br J Gen Pract. 2010 Jul 1; 60(576): 538–540.
4. Flanagan’s CSA Consultation Model. http://www.pennine-gp-training.co.uk/res/flanagans-csa- consultation-model_basics.doc

EXAMPLE 7
Description
Our ATP session provided an opportunity to interview a patient (with consent) under video surveillance. My patient was a 70 year old gentleman with a history of prostate cancer and TURP. Half way through the interview he opened up about a deep personal issue. He mentioned that there was one thing he found extremely difficult. There was a pause. “Down below doesn’t work any more”. I gave him time to elaborate on his erectile dysfunction and its impact on his life, thinking all the while that I was doing an ok job.
Later I was able to watch my consultation on the TV screen. My performance was not as spectacular as I thought.
Feelings
During the consultation, I noticed a change in how I was feeling as the patient brought up the issue of erectile dysfunction. I felt an element of panic. How was I going to respond? The inner tension began to build. But it didn’t stop there. The panic led to a feeling of stress. I began to feel as if I didn’t have any suitable method for approaching this issue. The stress began to build and then my confidence dropped. I began to second-guess myself. Was he definitely referring to erectile dysfunction? This was an unusual feeling, an unusual “second guess” as I had sufficient knowledge to know that erectile dysfunction was one of the side effects of TURP.
Evaluation
Looking back at my performance on the screen allowed me an opportunity to begin evaluating my interviewing skills.
Negative: As soon as my patient began to approach the awkward topic of erectile dysfunction I noticed a change in my body language. I crossed my legs and brought my hands closer to my body. I stopped using hand gestures. I brought my feet under my chair. All the inner tension and fear that I felt on the inside was being released through my body position and movements. My facial expression also changed. I looked almost angry. I noticed my forehead creasing and my eyebrows narrowing down. Of course, at the time I was unaware of this. But my patient, well he was aware, very aware. At the beginning he had been sitting in a relaxed fashion with outstretched legs. As soon as my posture and body language changed so did his. He bent forward, almost as if trying to curl himself into a ball. He lost eye contact. The volume of his voice dropped.
Positive: However it wasn’t all negative. After all, the patient did open up to me about a deeply personal topic. Up to that point I had created an environment where he felt, safe, comfortable and at ease. My tone of voice, posture, eye contact and good use of hand gestures all helped in the creation of this endearing atmosphere.
Analysis
My experience alerted me to an important learning need – My inner feelings can have an unconscious impact my outward portrayal of social cues. How I am feeling internally can affect my body language, gestures and facial expressions. In a sort of “transference type” interaction, my patients pick up on this and their feelings, levels of anxiety and levels of comfort change accordingly. This learning need is addressed in learning outcome 5 of the GP module which conveys the need to “demonstrate good communication skills”. My experience has enlightened me to the importance of non-verbal modes of communication. I need to be more aware of my inner thoughts, conflicts and emotions so that I can control how they affect my outward body language. As this incident has showed me, my positive non-verbal communication was the initial impetus for the patient opening up and my negative non-verbal communication was the initial impetus for the patient closing down.
Conclusion
While I have developed good communication skills over the past 4 years in medical school I need to move outside of my comfort zone and get more practice in communicating around embarrassing topics. I’ve documented my weaknesses, noted my strengths and now I must find a way of turning my weaknesses into change.
Action Plan
In order to improve my non-verbal communication skills I plan to take a second or two during every consultation to focus part of my conscious awareness on my body language and what it may be suggesting to the patient. I can do this while taking notes during breaks in the conversation.

EXAMPLE 8
Description
My GP tutor and I reviewed a nursing home resident, X, an elderly lady with advanced dementia who was receiving antibiotics for a lower respiratory infection. On examination, she was bright and responding well to treatment. However, thirty minutes later we were called back to her room and found her semi-­‐conscious, cyanosed, with evidence of vomiting and double incontinence.
She failed to respond adequately to our treatment of supplemental oxygen and suctioning. The GP tutor confirmed that X was dying and was not for cardio-­‐pulmonary resuscitation. Her next of kin was informed but within ten minutes of responding to the emergency X had passed away.
Feelings
Initially, there was an overall sense of shock and disbelief. I had seen this lady on the ward round earlier and she appeared to be improving. There was no indication of her impending death forty minutes later.
As the incident unfolded, I felt inadequate and uncertain of what to do. I was unprepared for this situation. When X passed away, I was relieved that she did not have to suffer for long and died with dignity. Surprisingly, at time of her death I did not express any emotion. But as we debriefed later, I had a rising sense of sadness both for the patient and her family, thinking of the grief and pain this loss would cause them.
Evaluation
This was a formative event but not without emotional and professional difficulty. On one hand, this was a valuable learning opportunity. I observed how professionals care for a gravely ill patient, ensuring as much as possible a death with dignity and comfort. Also, I realised that I could remain professional in this situation and I was able to assist the team when requested.
On the other hand, it was a distressing to witness a previously well patient die so suddenly. Her death was so unexpected and quick that it was difficult to ensure she had a fully peaceful death. Even with my training to date, I really felt lost and uncertain of how to cope with this event.
Analysis
It is understandable to have feelings of shock and sadness with an unexpected death. Nevertheless, I believe my feelings of uncertainty and inadequacy reflected a lack of awareness of care plans and ‘do not resuscitate status’ (DNR) in guiding end of life treatment. As such, I feel this is my primary learning need for my reflection. It addresses two key learning outcomes, the ability to ‘demonstrate professionalism’ and ‘effective communication skills’, specifically in relation to end of life care.
When I asked my GP tutor about X’s care plan and how it was devised, she explained that DNR status and a comfort measures care plan were agreed upon collaboratively by the medical team and the family in advance. The process involved weighing up the potential benefits and burdens of invasive interventions, bearing in mind her current quality of life and ultimately deciding what was in the patients best interests. To understand this process further, I reviewed the ‘principle of proportionality’1 and ‘End of Life Care for the Older People in Acute and Long-­‐stay Care Settings in Ireland,2008’.2
From a professionalism perspective, the IMC: ‘guide to professional conduct and ethics for registered medical practitioners,2009’3 and the ‘Palliative Care Competence Framework 2014’4 provided an excellent resource in end of life care.
I now understand how X’s care plan and DNR status spared her from distressing and invasive interventions in her last moments. Furthermore, effective communication and professionalism displayed by the team regarding end of life care ensured X passed away with little suffering.
Conclusion
I believe my inexperience and lack of knowledge about end of life care explains my feeling of inadequacy at the time. This experience challenged me to confront the issue of death both professionally and emotionally, resulting in a greater insight into end of life care. I learnt how effective communication and care plans could guide end of life decision-­‐making, ensuring a dignified death for patients. I have a need to develop my communication skills and professionalism further around palliative care.
Action Plan
Through the use of Gibbs reflective cycle5, I feel better prepared for a similar scenario in the future. I have a greater understanding of care plans and DNR status, which will guide me managing this situation in my future professional practice.
To improve my skills of communication and professionalism with regards to end of life care, I need to further my background knowledge and gain more practical experience. Therefore, I plan to take advantage of future opportunities to observe and partake in the management of terminally ill patients.
References

1. McCarthy J, Donnelly M, Dooley D, Campbell L, Smith D (2010) An Ethical Framework for End-­‐ of-­‐Life Care, Module 6, Dublin: Irish Hospice Foundation. Available from: http://www.hospicefriendlyhospitals.net/ethics [Accessed 29/10/2015].
2. Hospice Friendly Hospitals Programme, Irish Hospice Foundation (2008) End of-­‐ Life Care for Older People in Acute and Long-­‐Stay Care Settings in Ireland. Dublin Available at: http://www.ncaop.ie/publications/research/reports/443_2008.pdf [Accessed 39/10/2015].
3. Irish Medical Council: guide to professional conduct and ethics for registered medical practitioners, 2009. Available at https://www.medicalcouncil.ie/News-­‐and-­‐ Publications/Publications/Professional-­‐Conduct-­‐Ethics/Guide-­‐to-­‐Professional-­‐Conduct-­‐and-­‐ Behaviour-­‐for-­‐Registered-­‐Medical-­‐Practitioners-­‐pdf.pdf [Accessed 29/10/2015].
4. Palliative Care Competence Framework Steering Group. (2014). Palliative Care Competence Framework. Dublin: Health Service Executive. Available at http://www.hse.ie/eng/about/Who/clinical/natclinprog/palliativecareprogramme/Resources/ competencyframework.pdf [Accessed 29/10/2015]
5. Gibbs G (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.

EXAMPLE 9
Description
A 34-year-old woman with a learning disability came to the GP to discuss weight loss options. The GP asked me while she left briefly to record the patient’s weight. The GP left and I asked the patient to step onto the weighing scale. She looked anxious and hesitant, but eventually stepped on the scale and I took the measurement. She began to become more distressed and asked, “Is there anyway you can tell the doctor I’m a stone lighter?”. I was stunned by her question, and didn’t know what to say, I pretended to take some time to record the measurement then finally looked at her to say “ Uhm, well”, with no plan as to what I was going to say next. The GP returned and asked me “ What did you get?” I answered the GP with the correct weight that the scale recorded. The patient became very upset, started to cry and stormed out of the room.
Feelings
When the patient asked me to tell the GP a lesser weight, I was caught by surprise. I felt awful for her because I know it can be embarrassing to be weighed. I wondered if I should do as she says. Besides, one stone less may not change her management, and may establish trust with the patient. However, I was scared that the GP would disappointed if she found out I falsified results. When the patient stormed out, I was devastated, and felt that I had made the patient very sad and uncomfortable. I felt maybe the truth wasn’t worth what it had resulted in. Additionally, I could see the GP was confused, and maybe even doubting leaving me alone with this patient. Overall, the situation made be feel really uncomfortable, and unsure of my decision.
Evaluation
I was able to tell the truth even when I was pressured by a patient. I realize now how tempting it can be for patients to make you consider altering results on their behalf. Integrity and honesty is important in medicine, and while it was difficult at the time, I realize it was better that I told the GP the truth.
Unfortunately, I failed to explain to the patient why telling the GP the real reading was important. I should have mentioned it was important for her health and tracking her progress. Additionally, I should have ensured her that even if her weight had increased, no judgement would have been made, and that we were here to help her. In my failure to communicate this to the patient, she may have been hurt by my actions, or felt like she had no support. For these reasons, the patient was upset and very reserved for the rest of the consultation.
Analysis
I may have done the right thing, but for the wrong reasons. I told the GP because I was scared she would be angry if I falsified results. As a student, I sometimes find senior doctors intimidating. However, by acting on this fear, I failed to consider what was best for the patient. The patient may have understood my actions if I had explained to her the importance of accurate documentation, and ensured her that she would not be criticized or punished for her weight gain. This experience helped me identify my need to demonstrate good communications skills. It is not only about what is being said, but how it is communicated. Additionally, it may have been helpful to mention the incident to the GP after the consultation. She could have provided some insight about how to communicate with patients in such a difficult situation. She may also have suggested others ways to communicate results I obtain, perhaps by writing it down on a paper rather than saying out loud, which may embarrass patients.
Conclusion
Overall, this experience helped me realize that patients may ask you to do something that you don’t believe is right. In these situations, appropriate communication is of utmost importance. Effective communication includes appropriate words, execution and timing. As a future physician, I want to ensure patients understand my stance even it is against their wishes, and make sure they know that it is in my best interest to do what is right for their health.
Action Plan
In the future, I plan to ask senior colleagues how they handle patients asking them to do something that is not right. I will think to myself “what is best for the patient?”. Even if it means doing something out of my comfort zone, I will make the patient my top priority. I realize that communication in this setting will take practice. However, I am hoping that now that I am aware of it, if I can seek help, and keep it in mind next time it happens, I will improve with time.

EXAMPLE 10
Description
During the first week of my first attachment one of the patients I met candidly discussed his heroin addiction with me, sharing some very personal insights. The clinical encounter was congenial and concluded with mutual thanks.
That weekend, while walking to lunch with my partner, I noticed a man walking in our direction on the other side of the street. I vaguely recognized this person but it did not register who it was until he had passed. Because of this I did not make eye contact or acknowledge him in any way, only realizing after he had passed who it was; I wondered if it had seemed to the patient that I had pointedly ignored him in front of my partner.
The next week the same patient came in again to the clinic, and although he did not raise the subject of the weekend encounter, I still felt uncertain of my handling of the situation so discussed with the GP after he left.
Feelings
Immediately after the encounter, I felt guilty that I might have been interpreted to have ignored the patient, or to have been judging him, by not acknowledging him; I realized I was uncertain about what I should have done if I had recognized him immediately. I was also apprehensive about seeing him the next week in clinic, as I knew he had an appointment.
During his subsequent appointment I was anxious that he might be offended or upset that I had not acknowledged him. He recognized and greeted me normally, and did not mention the encounter; after he left I felt slightly relieved but wanted to discuss with my GP to sort through my thoughts on the encounter.
Evaluation
On the positive side, the patient seemed satisfied with both clinical encounters, and I felt that we had established a good, nonjudgmental rapport. This provided an opportunity to discuss with my GP a very practical subject – how to interact with patients appropriately outside of a clinical setting.
The negative aspect is that I became quite stressed over the situation; additionally, if I had been conducting his clinical visit this may have distracted me and impeded our communication.
Analysis
In line with the learning outcomes #1, “Demonstrate appropriate and effective communication skills with patients and staff” and #13, “Demonstrate professionalism including the ability to reflect on experiences in order to identify and address learning needs,” I have learned from this experience. I realised that there is always a portion of one’s profession which takes place outside the workplace, and that situations in which this happens can arise unexpectedly and without warning. Communication in these settings is particularly important, as a positive or negative experience could significantly impact the doctor-patient relationship regardless of the context not being one of a doctor-patient, clinical encounter.
My GP and I discussed encounters that she had had with patients outside the clinical context and she suggested to let the patient take the lead in such situations (with particular reference to body language cues). She pointed out that during my encounter, the patient had not made an obvious effort to attract my attention or initiate contact, which may have indicated that he preferred not to interact in that context. Therefore it was unlikely that he felt judged or rebuffed by my lack of initiation of contact, and may have been made uncomfortable if I had done so.
Conclusion
After discussion with my GP tutor as well as reading articles about doctor-patient communication[1] and body language[2] identified from PubMed, I think that the subconscious processing of nonverbal cues by both myself and the patient was effective and adequate (although not to be relied upon) to avert a potentially uncomfortable or awkward encounter. It will be important for me to consciously recognize and react to these in the future.
Action Plan
I will continue active learning in communication skills, through discussion with peers and superiors, as well as engaging with literature on doctor-patient interactions. In future encounters, I will note patients’ nonverbal and verbal cues, attempt to mirror those while respecting professionalism and patient confidentiality, and actively reflect on what went well and poorly in each encounter to apply to future encounters.
References:

1. Ha JF, Longnecker N: Doctor-Patient Communication: A Review. The Ochsner Journal 2010,
   10(1):38-43.
2. Robinson JD: Getting Down to Business Talk, Gaze, and Body Orientation During Openings of Doctor-Patient Consultations. Human Communication Research 1998, 25(1):97-123.

EXAMPLE 11
Description
MM is a 69-year-old lady who I met during the 1st week of my attachment whilst sitting in with the GP. She looked rather emaciated, has Type II Bipolar Disorder and a history of secondary hypertension. After a long pause during which she directed a couple of unsettling glances toward me, MM acknowledged the GP’s greeting and told her she had been feeling dejected lately. The GP apologised and said she had to make a quick visit to the toilet, thereby leaving me alone in the room with the patient.
After a brief period of uncomfortable silence, I felt the onus was on me to fill it and hence proceeded to ask MM about her day, in response to which she told me she tried to commit suicide earlier that morning. Taken aback by her candor, I fell silent momentarily and stuttered trying to find my words before acknowledging her confession and encouraging her to elaborate – which she did whilst I listened sympathetically. The GP returned shortly after and completed the consultation assuredly, referring the patient for an urgent psych assessment.
Feelings
I felt very uncomfortable during the consultation, even before MM’s revelation. Her demeanour had me at the edge of my seat the entire time, and whilst I am fairly relaxed conversing with a patient – I felt rather inept at doing so with MM.
Initially, I was quite unsure how to handle the information rendered to me by MM. My predicament was thus – If I acknowledged her suicidal ideations and asked her to expand further, the GP could return at any moment and the patient would have to recap the information. However, if I chose to ignore what she said, it would come across as very insensitive.
I think the time lapse in making my decision was quite blatant to MM, but once I asked her to elaborate, my instincts kicked in and I felt at ease during the conversation that ensued.
Evaluation
Good
I think I was right to acknowledge MM’s statement. I was physically and verbally sympathetic and understanding whilst she recounted details of the ordeal earlier that morning – which put her at ease too. Looking back now, I did well to maintain my composure, and I think I successfully managed to manoeuvre my way through a difficult consultation despite my inexperience at handling mental health patients.
Bad
In retrospect, I shouldn’t have been so noticeably indecisive and should have acknowledged MM’s statement sympathetically regardless of where the conversation was headed or if the GP was in the room or not.

Analysis
I learnt vastly from this incident, about myself and patients. I am very inexperienced at reacting to and conversing with mental health patients, especially suicidal ones – and that is my learning need here. This relates to one of the GP learning outcomes enlisted as ‘Demonstrate good communication skills’. I’ve since reflected on the incident with my GP tutors at length and am glad to have recognised a weakness which I can improve on.
The first thing I did after the incident was have a discussion with my GP, which highlighted not only the value of being visibly compassionate to the patient, but also emphasised the significance of assessing the suicidal intent of a patient. I researched this learning need further in the Oxford GP and Psychiatry handbooks, which gave me better insight in dealing with a similar situation with regard to the direct questions to ask and also the appropriate management of low and high risk suicide patients.
Looking back, I appreciate the stress MM was under that day, which would account for what I perceived to be her strange demeanour. I do wonder however, if the GP realised what was going on and perhaps left me in the room with MM intentionally to expose me to a situation I had never experienced before?
Conclusion
I was presented with a challenging situation,which initially stumped me but I managed to manoeuvre my way through it. This helped me realise my inexperience at interacting with suicidal patients and compelled me to research and thereby better it. It was a learning experience with no detrimental effect on MM as the GP assessed and managed her accordingly.
Action Plan
In the future, I will endeavour to tackle such an incident by exploring the degree of seriousness of a patient conveying suicidal ideations, i.e. ask questions about their general mood, planned method of suicide, what prevents them from going through with it and what arrangements, if any, have they made for their affairs after death, but doing so in a gentle manner, and always being mindful of the gravity of what the patient is saying.
(767 words)

EXAMPLE 12
Description
On my first day of my GP rotation, I was asked to accompany my GP tutor during the consultation of a 72-year-old lady (X). It was evident that X was concerned regarding her presentation, as her quiet voice was shaky as she consented to me taking the history.
She then explained to me that she had recently developed worsening urinary frequency. She reported that she has always had a “sweet-tooth” and had worked in a chocolate factory for 38 years. On questioning, X added that 4 of her immediate family have Diabetes Mellitus Type 2. I was empathetic in my approach throughout and acknowledged her concerns.
My GP tutor then asked me to perform a dipstick urinalysis of the X’s urine, which she had brought into the room earlier. Eager to impress, I dipped a fresh stick into her urine before quickly interpreting the results against those on the side of the bottle. Without delay, I uttered “sugars” before showing the GP tutor. I watched as X looked on in terror.
The GP tutor then reassured X that these readings usually take 90 seconds to be read accurately. After casually chatting to X, she then confirmed that her urine was negative for Glucose. The GP tutor concluded the consult by kindly advising X to cut back on her consumption of chocolate.
Feelings
To be honest, I initially felt a little bored during the consult; it was late in the day and it sounded like a textbook history of Diabetes Mellitus.. When asked to perform the dipstick, I felt confident in my ability and was moderately proud that I was being trusted to do so.
I noticed that the atmosphere in the room had completely changed on my premature announcement that there was glucose in X’s urine. I was mortified as the GP tutor rightly corrected me for my error, and I began to feel droplets of sweat on my forehead as my face flushed scarlet. I felt foolish until X left. In hindsight, I was rather relieved when it was drawn to a close.
Evaluation
To look at positive aspects of this experience, I had taken a fairly comprehensive history and had acknowledged the patient’s concerns to put her at ease. The GP tutor felt I was capable of performing the dipstick despite it being my first day in the practise; I had performed it with confidence.
However, I would also say are a number of more significant negative aspects of my involvement in this consultation. For one, my relaxed attitude led to an easily preventable error, which resulted in a moment of shock for X. This confidence led to poor professionalism on my part as I blurted out incorrect information in the presence of an already concerned patient; falsely confirming her fears.
Analysis
I learned a number of lessons from this experience. I now realise that despite taking a comprehensive history, I cannot afford to ‘switch off’ during consultations as this leads to poor communication and simple avoidable errors. On reflection, I failed to demonstrate “effective communications with patients and staff”.
My knowledge base must also be improved vastly before I attempt to “perform appropriate core clinical skills” as it is not at the high standard that I assumed it was before starting this rotation.
Whilst debriefing on this experience with my GP tutor, she explained to me that all patients must be reassured in times of distress, and that I should never rush in in delivering a diagnosis to a patient, regardless how insignificant it may seem.
Conclusion
I reflected on this case both personally as well as in conversation with the GP tutor, and I now feel that my urge to impress was indeed a lapse in professionalism on my part, which led to a horrific moment for X. Communication with all parties is crucial and I now understand that one breach in this could have serious negative implications on the doctor-patient relationship.
However, I’m now also aware no matter how confident I am, be it as a student or physician, I must always be aware of how my words and actions can affect the patient; and I can now improve on this. Therefore, I now can see the significance of reflecting on events when errors occur, in order to learn on them and become a better doctor in future.
Action Plan
In future, I will ensure that I don’t let lose focus on the significance of communicating effectively when dealing with apprehensive patients. I now understand the importance of asking for a second opinion if unsure of anything in medicine, most importantly before imparting such knowledge on a patient.
(757 words)

EXAMPLE 13
Description
A young gentleman presented with testicular pain. I took the history, and then the GP informed the patient that he would like to perform a testicular examination. The patient tentatively made his way to the examination table and undressed. I observed my GP perform an examination; before being requested to perform it myself – the patient consented.
I remembered studying testicular examinations in intermediate cycle, yet had not performed intimate examinations on male or female patients to date. Cognisant of the patient’s anxiety and my own, I was reluctant to proceed. However, I knew in order to gain experience in this essential skill now would be a good opportunity.
So I proceeded – albeit unsure as to what exactly to do. I palpated both testicles in an unsystematic manner, without much confidence. Not knowing what I was doing I was quick to reach for assistance, asking my GP to identify the lesion- only then the tender, swollen epididymis became apparent.
The examination ended, I thanked the patient and he left with an antibiotic for acute epididymitis. I knew the development of this examination technique needed addressing.
Feelings
This was my first intimate examination and I was nervous. I knew this was an embarrassing and anxiety- provoking situation for my patient, but I too felt anxious. I was uncertain if it was not feeling confident in my skills or the intimacy of the examination that had thrown me off.
I felt well versed in the anatomy. The patient was anxious but pleasantly agreeable and my GP enthusiastic to teach, thus the environment for learning new skills – ideal. Yet I felt uncomfortable and thought asking for help would bring to a prompt end both the patient’s and my own embarrassment.
After my unsuccessful attempt, I felt guilty. Had I done the patient a disservice? Perhaps I prolonged his embarrassment, to practice an exam technique I did not know much about.
Evaluation
Good
Despite how I felt at the time I am glad I had this opportunity, which had not presented itself in the past. Importantly it allowed me to identify a weakness in my skill set. I was able to think about what had made me uncertain/uncomfortable and how to address this. I was reminded of the privilege we as medical students have, as patients demonstrate absolute selflessness in vulnerable situations to facilitate our learning.

Bad
I was thankful this uncomfortable experience occurred in a safe non-judgemental environment fostered by the patient’s willingness to consent and my GP’s desire to teach. However, I felt that the learning opportunity was not fully taken advantage of as a result of the reticence I demonstrated when placed outside of my comfort zone.
Analysis
I identified a learning need relating to Learning outcome 3: Perform appropriate physical examinations of patients.
The challenge was to find a way in which I could be more confident in my technique so that I can competently assess and diagnose testicular pathology in the future. I took the time to reflect on why I had performed to a substandard level: What was different to palpating and abdomen versus the scrotum? Why did I have no problem, for example, taking a history and asking about urethral discharge or sexual activity? Therefore the intimacy of the examination was not the real issue. What had made me comfortable when examining the shoulder or auscultating the chest earlier that morning? Answer: practice but also having a systematic method of doing things. That evening I reviewed Tally&O’Connor and McLeod’s Clinical Examinations. Then I formulated a purposeful approach.
Conclusion
I became aware that I lacked the appropriate methodology for performing a thorough male genital examination. Through self-reflection, communication with my GP and the selflessness of my patient I identified this deficiency in my clinical repertoire and made efforts to improve this skill.
Action Plan
I felt more confident in my abilities when I arrived at practice the following morning when a gentleman with a urological complaint presented. I approached the testicular examination systematically. I felt that my own confidence this time helped put the patient at ease. Although there was no pathology on examination I believed the manner in which I approached the exam was methodical, purposeful and comfortable for myself but importantly for the patient.
Word count: 698

EXAMPLE 14

Description

I was sitting the the GP’s office with the doctor and we were interviewing a patient. The patient was over 50 and had been suffering from anorexia for most of her life. The doctor I was with had been seeing the patient for about 10 years and despite all the appropriate advice, medications, and referrals for additional help, this patient was continuing to deteriorate physically and making no progress with the eating. Kidney failure was starting to set in and she had many fractures due to her weak bones.

Feelings

I felt bad. I was worried for her health. I felt helpless. It was hard to consider
that after 10 years of working with the patient and trying everything that things weren’t getting better. What’s more, thinking about continuing to try to treat this patient in vain for the next 10 years sounded incredibly disappointing and frustrating. The idea of watching this person slowly dying over time and suffering more and more complications as a result of their condition was hard to think about.

Evaluation

It was a good example of experiential learning. The doctor handled the patient well and it was a condition I hadn’t seen much of before, and certainly never the long-term sequelae. It was also good experience for future practice.

I certainly felt a variety of “negative” emotions. It was sad to see, and sadder knowing that this person will likely die of complications related to their malnutrition. It was also hard for me to think that there are some people who can’t really be helped, that no matter what you do, no matter how much motivational interviewing or referrals to psych services or medications, sometimes you just don’t “win” and solve all the patients problems.

Analysis

Learning needs, other perspectives, what do I think of my feelings? I think my feelings are reasonable considering the situation. I’m not particularly happy with them though. I think for the sake of my own wellbeing it would be better to not be as invested in the patient’s outcome. Not personally invested anyway, of course I still want to want the best for my patients.

I wonder what the patient thinks of the situation. They must be frustrated as well, I’m sure they want to be well. Unfortunately I wasn’t able to get a good feel for the patient’s level of insight in the time I had, but either way, they must know something is wrong, either with their eating or with their body, considering the number of fractures.
I think the doctor I was with had accepted the patient’s situation. She still put in every effort and cared for the patient as if it were the first day, but I think she was able to accept that this person probably won’t make much progress. It is a delicate balance to still deliver a level of care that is personal and honestly invested without leaving yourself too vulnerable.

I think this ties in well with communication, illness experience, and management plans including lifestyle changes. There is a lot that can be done, or at least attempted, with a patient such as this and while not everyone will necessarily respond to treatment, I will surely have better chances if I have a good rapport with the patient built on honest and clear communication. Additionally, all of the other support services should be considered, psychiatry referrals, eating disorder groups, psychology, and lifestyle changes are all different options for the patient and some may work better than others for one person or another. Making a good, comprehensive management plan and factoring in the patient’s social and cultural background is the best way to give a patient the best care possible.

Conclusion

I feel like I learned that you can’t necessarily “save” everyone, but if I’m a competent doctor and do everything I can to help someone, then I shouldn’t allow myself to get brought down too much. Burnout is high in the medical profession and there is only so much a person can do.

Action Plan

The effect of this experience won’t change my actions outwardly necessarily, but
I think moving forward I can strike a good balance of caring about my patients while watching out for my own feelings as well. I will strive to be wary of my own emotional state and ensure I maintain proper self-care and be ready to seek out help if necessary.

EXAMPLE 15
Description

The patient, Mr. X is an 83-year-old man who came into get his driver’s license reinstated. It had been suspended because he had been found sitting on the side of the road after attempting to walk home because his car would not start. I watched as the doctor performed a mini mental state exam (MMSE) and the patient scored a 13/30. Mr. X’s license was not reinstated.

Feelings

The whole experience was hard to watch. The patient struggled with almost every question, at one point he got so nervous he started shaking and his voice began to tremble. I felt terrible for the patient, but there was nothing I could do so I just sat there and watched the encounter. Completely helpless to do anything for the patient. In my head I rooted for him to get the right answer but by the 5th question it was clear that he did not have the mental capacity to safely drive anymore. I wished the doctor would stop the assessment because the patient was distressed, and I did not see the benefit of completing the exam.
Evaluation

The good thing about the experience is that I experienced it. Medicine is full of moments where there is very little you can do to help the patient, or there is no way of giving the patient what they want. In this case there is nothing anyone can do for the patient to make him road worthy, so the hope that comes in referring a patient to another person that will help them was not there. Accepting that there was nothing that could be done to help this patient be able to drive again and sitting with that helpless feeling is hard to do.

The bad thing is that I identified too much with the patient. I kept thinking how I would feel if I struggled with such basic questions, or if someone told me that I could not drive anymore. Driving is such a big part of being independent when you live in a rural area. I would feel awful if I lost that bit of independence.

Analysis

One of the most important roles of a primary care doctor is to keep patients healthy and safe. Not allowing Mr. X to drive was keeping in line with that role of a primary care physician. My judgement could have been swayed because I felt bad for the patient instead of focusing on what is best for the patient long term. At the time if did not feel like the MMSE needed to be done to completion because it was clear by half way through that the patient did not have the mental faculties to safely drive on the road. The MMSE can be used to track the patient’s disease progression. It was short sighted to stop the assessment because the patient was struggling with it.

Conclusion

It is okay to sympathize for the patient but empathising too much with a patient should be done with caution. The patient has feelings about what is going on with their disease progression and understanding their feelings can be helpful in communicating with the patient. Taking on the patient’s feelings can cloud my judgement and may lead me to make decisions that alleviate the patients discomfort but could be detrimental in the future. I want that patient to get his license back. Not allowing what I want for the patient interfere with what is best for the patient was an important lesson.
Action Plan

If the incident where to happen again I would emotionally take a step back. I would sympathize with the patient but minimize empathising with the patient. If I did feel like I was having strong emotions about a patient’s case I would go through my action plan a second time to make sure it contained the best interests of the patient.

EXAMPLE 16

Description

During my rural GP rotation, I was taking the MSK history of an elderly woman about her shoulder pain. I asked her “how have you been doing recently?” towards the end of my history, which I like to do with all the patients I talk to. Within a few minutes she was sobbing and explained how she has lost her husband suddenly last year and nothing was the same. She described how she watched him collapse, saw the paramedics give him CPR and how traumatizing the whole experience had been for her.

Feelings

I felt surprised, as I had not expected the conversation to take a turn but tried my best to stay calm and nod my head to verbal cues, so she knew I was listening to her. Personally, it is difficult for me to understand what loss must mean as I have never experienced it myself, but I knew the best thing for me to do was just listen. I was determined to remain as focused as I could on being empathetic. However, I was not feeling confident about what to say in between the pauses. The unfamiliarity of the situation was overwhelming with the question of “What if I say the wrong thing?”. My fear was that she would leave today very unhappy and tell other people “about that medical student that was terrible at comforting her” if I said the wrong thing. In summary, I felt surprised, overwhelmed and uneasy during the conversation.

Evaluation

Good: As a student, I felt that I had excelled active listening during the conversation. I offered her tissues and when she left; told her to take care of herself and push herself to pursue hobbies, as she lived alone and was retired. As the patient, she must have felt like it was a welcoming place for her to mourn openly and have a sympathetic ear to talk to without interruption.

Bad: There is a possibility that I had come off awkward and uncomforting while she was upset; this was most likely due to not being able to understand completely what she was going through and also having never been in such a situation where someone I has just met was telling me something so emotional. The patient might have felt like I wasn’t comforting beyond just listening to her grieve, and may have left the room feeling uncomfortable and embarrassed.

Analysis

The learning need I gained from the conversation was displaying professionalism. I didn’t do terribly for a first encounter, but I would like to be someone who is more effortless at handling emotional patients. In the past, I have been tearful with my own doctor but luckily; I have perceived her to be very empathetic towards me. Unfortunately, as someone on my doctor’s side of the situation now, I was overwhelmed with how uncomfortable I was feeling and this is something I hope to work on.

Looking into some resources; I came upon a blog post on KevinMD.com1 about an upset patient’s story. The story offers a simple explain of what to say to a crying patient as a medical professional. A simple thing I could have done was provide validation for the patient’s feelings. This meant I could have said something like, “I’m sorry about your loss. You have lost someone important in your life and it is understandable what you are going through.”
Conclusion

The most important part of any reflection for me is to see how I can improve the next time something like this happens to me and never be overwhelmed with it. Looking back, I could have said something to reassure her. By the end I could sense she felt embarrassed about getting upset in front of me and crying in front of a stranger.

Action Plan

In the future, I can offer more validation for the patient feeling upset. As someone interested in going into psychiatry, there is an important learning need of verbal empathy I would like to develop. Lastly, I understand that experience is always the best teacher and even though I felt overwhelmed today, I believe I have enough knowledge now for the next time a grieving patient walks into the room. Therefore, I’d like to push myself to be more interactive with patients no matter their history and improve with experience in the future. Continuing to reflect on uncomfortable experiences like this one is what will help me to become a caring and empathetic doctor.

Reference:

1. Ubel, P. (2016). When patients cry, please don’t do this. [online] KevinMD.com. Available at: https://www.kevinmd.com/blog/2016/05/when-patients-cry-please-dont-do-this.html [Accessed 2 Dec. 2018].

EXAMPLE 17

Description

A seven year-old boy presented with his mother to the clinic. The GP asked that I initiate the consultation. I introduced myself and before I could ask any clinical questions, the patient’s mother revealed her sons rash that had been there for two weeks. At the same moment, obviously distressed, his mother began explaining how she had been searching the internet yesterday for a diagnosis and was awake all night worrying that her son might have Lyme disease.
After taking a very quick glance, I saw an erythematous rash that I suspected to be a cellulitis. Without further questions, I felt obliged to reassure the child’s mother that she did not need to worry about Lyme disease, as it was probably a ‘simple’ cellulitis. We discussed this together for several minutes. We both laughed and I agreed when she said that she “knew it was probably ridiculous to think it was Lyme disease”. She seemed to have calmed down greatly after this.
Shortly after, I confidently told the GP that it was probably ‘just’ a cellulitis. He told me to take a closer look at the rash and showed me the erythema marginatum pattern that I had missed on examination. He informed the patient and his mother that it could possibly be Lyme disease. Both were visibly upset and arguably more anxious than on arrival.
Feelings

Initially, I was extremely satisfied that I was able to comfort and reassure the patient’s mother that she needn’t worry about Lyme disease. They were visibly less anxious than on arrival, which pleased me.
When the GP told the patient of the possibility of Lyme disease, I was highly embarrassed and regretful about reassuring the patient incorrectly. I felt awkward that I had essentially made the news more upsetting by falsely reassuring them. I felt foolish that I had missed a seemingly obvious clinical sign but at the same time, I was slightly annoyed that his mother had distracted me. After, I wondered whether both the patient and GP would feel that I was incompetent.
Evaluation

I built a good rapport in the brief consultation, which was satisfying. Both the patient and his family seemed comfortable with me. If I had diagnosed correctly, I would have felt positively with the way I addressed and eased the patient and family concerns. Where I faltered was overlooking the illness to address his mother’s concerns. It is natural for a mother to express concern for her child but I dealt with it incorrectly. I let myself be distracted from the patient’s issue and then proceeded to address concerns that I didn’t have sufficient knowledge to address. My brief consultation was insufficient to identify the problem. Unknowingly, I provided reassurance without any knowledge of whether my information was correct. This was inappropriate and led to worse anxiety for the patients following the GPs advice.

Analysis

I believe that it was completely reasonable for me to want to address their emotional response and attempt to ease concerns, but I identified the learning need to address these concerns in a manner that reassures a patient, but not to the extent where the presenting complaint is overlooked or undervalued. This relates to the learning outcome ‘Demonstrate appropriate and effective communication skills with patients and staff’. After speaking to the GP, he advised that I should listen to the patients worries actively and address them empathetically with simple, non-conclusive language until the concern can be fully addressed with the support of clear and accurate information. This seemed logical and is supported further by guidelines I discovered online. This experience won’t deter me from addressing patient’s concerns but will change the manner in which I do it.

Conclusion

Patients’ worries are not to be overlooked but dealt with in a professional and empathetic manner. Although it is said to ‘treat the patient and not the disease’, in this case, I treated the patients worries regarding the disease without addressing the disease properly which resulted in emotional strain for the patient. It is essential to carry out a proper history, physical exam and deal with patient concerns together in a consultation.

Action Plan

When a similar situation presents itself, I will feel more comfortable when dealing with the worries of patients and families. I now understand how to address concerns in a professional way, which won’t lead to heightened disappointment or worry. The presenting illness and patients concerns are intertwined. It is important to address them both to properly to address them individually.

EXAMPLE 18

Description

During my GP attachment, X attended his doctor complaining of a one-month history of persistent lower back pain following spinal decompression surgery. As the GP began the consultation, he was called out of the room. I was asked to continue the consultation and complete a mental health questionnaire. The patients mood was poor. After some of the questions the patient seemed worried. When asked about his concerns he began to speak about the difficulties he had been faced with in the past month. He spoke about the loss of his daughter and his partner’s poor cancer prognosis. As X discussed the worries and stressors that had been taking a toll on his mental health, time slipped away. The GP soon returned and asked why I hadn’t finished the questionnaire. The GP completed the consultation and agreed that X was suffering from a depressive episode and trazadone 50mg OD was prescribed.
On leaving, X shook my hand and thanked me for listening. Following the consultation, I apologised to the GP for not completing the questionnaire. Expecting to be advised that consultations should be kept shorter, instead the GP told me not to worry about it. He remarked that X had never shown such appreciation following consultations before.
Feelings

During the consultation, I sensed X’s low mood and felt the need to give him the opportunity to offload. My heart broke as he explained his situation. I was concerned for the patient’s wellbeing and swayed slightly from the instructions I was given from the GP, as I felt was appropriate. I was unsure of myself having never taken a similar history before, but tried my best to empathize with the patient. As X left the office, I was proud of myself when he smiled and shook my hand, thanking me for listening. He seemed grateful that he had the opportunity to voice his concerns. At the back of my mind, I still worried that the GP would be mad that I hadn’t finished the questionnaire on time. I had caused a further delay in an already chaotic morning, understandably frustrating. Instead he appreciated that I had listened to X. I was relieved that I had followed my instinct rather than rushing to stick to the time slot.
Evaluation

Good
Looking at the positives of this consultation, the patient seemed to leave satisfied that his concerns had been addressed and empathized with.
Bad
I did not manage to observe the allocated time slot. The patient presented with back pain, so this had to be investigated entirely. When red flags for depression were identified it left little time for investigation.

Analysis

This interaction has proven to be an invaluable learning opportunity. It addressed the learning need ‘to demonstrate good communication skills.’ Despite feeling professionally challenged throughout the consultation, it seemed to go well. To consolidate my learning, I reviewed relevant texts on history taking in such situations. This case reminded me that depression can present with pain related or somatic symptoms, making it difficult to diagnose. I reviewed some of the patient health questionnaires available (PHQ-9, WHO-5). I now understand their value as screening tools in the clinical environment and know when it is appropriate to use them. I am aware of the importance of enquiry about patient ideas, concerns and expectations.
Through this patient interaction, I have also become more aware of the role of the general practitioner as well as the time constraints they experience. Despite of this, overall patient wellbeing remains priority.
Conclusion

Following reading of the literature and having spoken to my GP tutor with regard to the case, X’s satisfaction seems to have arisen from enquiry about his ideas, concerns and expectations. Seeing beyond the physical pain was important in this case. The things that have been playing on the mind of a patient can be a significant burden. Allowing a patient time to voice these concerns can influence the course of the consultation.
Action Plan

In future I will continue to enquire about the ideas, concerns and expectations of the patient. I understand the bearing this can have on both patient and doctor satisfaction.

EXAMPLE 19
Description

One morning in the office in my X practice, the GP I was with received a call from one of the nursing homes. An elderly man was febrile, had shortness of breath and had an oxygen saturation of 70%. The GP explained that he had a full schedule of patients in the waiting room and he would not be able to come in to see the nursing home patient until lunchtime, but given his vital signs, he said that he needed immediate attention and should be brought to hospital. The nurse passed the phone to the elderly man’s daughter who was briefed on the situation. My GP explained explicitly that the man should be sent to the hospital or he will most likely die, but the daughter was adamant that she didn’t want to send him. A few hours later, we went over to the nursing home and found out the patient had indeed died. The GP asked if I wanted to help confirm that the patient was dead, which I agreed to because I thought it would be important for my own learning. After we had taken the necessary steps, we went to talk to the patient’s family, of which there 5 6 of them present now, and my GP debriefed them on what happened.

Feelings

This entire situation caused me to feel a variety of emotions, but overall, I felt very uncomfortable. When the GP was initially explaining to the patient’s daughter that her father was going to die, this blunt exchange left shocked me and made me feel immediate sadness. This is the first time I’ve encountered death up close like this my medical career. Moreover, I was confused and angry that the daughter refused to send her father to the hospital, knowing that he could be saved if she did. When we arrived at the nursing home and had heard the patient had died, I immediately felt this deep pitting in my stomach as if I was on the top of a roller-coaster about to go over. As we entered the room, I saw the man lying there exanimate but not quite as lifeless as the cadavers I had previously seen in anatomy. As we went through the steps to confirm his death, I felt very uncomfortable.
Prior to this moment, I’ve always had to examine someone listening for heart sounds, breaths etc. Now however, I was doing the opposite: listening to confirm the absence of these signs and this felt very strange.

Evaluation

As much as this was a sad and uncomfortable experience for me, I believe that it was very important for my own professional development. I plan to go into neurosurgery, a field where outcomes are often poor and death is a common occurrence. It was inevitable that I was going to see death, but I’m glad I had the opportunity to do it with my GP tutor who took things slow and supported me through the process. While I would say the overall experience was a good one for my long term development, the acute mental stress of the event left me quite shaken up and I had trouble sleeping for the next few nights.

Analysis

Upon reflecting on my experience, I arrived at one major take-away lesson. We can’t save every patient and death is not always a negative outcome. After reviewing the man’s

chart, I saw that he had late-stage Alzheimer’s and recurrent debilitating illnesses such as pneumonias. I can now understand why the daughter did not want him to be saved. He had been put through a lot of pain and had become alienated from his family due to his illness. This highlights the importance considering a patient’s illness experiences and family, cultural and social context when making decisions about their care.

Conclusion and action plan

The next time I encounter death, I will be more emotionally prepared to handle the situation. In the future, I do think that I will still be uncomfortable dealing with death, but I will also try to remember that death is natural and is not necessarily always a bad thing. I will try to remember this event for the rest of my life to put the inevitable deaths that I will encounter over the course of my career into perspective.

EXAMPLE 20

Description
During my first GP rotation in March, I encountered X, a 35-year-old woman who was undergoing chemotherapy for breast cancer. She had come in to collect her prescription and the GP asked her consent for me to take her history. She agreed and the GP left us alone to talk.
She was diagnosed with stage II breast cancer in January, underwent a mastectomy and was now receiving chemotherapy. As the conversation progressed, she told me how frightened she was about the coronavirus outbreak, as she had heard on the news about the dangers posed by the virus for immune-compromised patients such as herself. She worried for her 2 children and her husband. She began to cry and said she was terrified the virus would take her from them.
My initial instinct was to reassure her. I tried my best to console her but was unsure of what to say. I wasn’t really aware of the guidelines at the time but told her that she should stay at home as she was at risk any time she left the house. She said she understood this but seemed to get more and more upset as the conversation progressed. As the weeks went by and the COVID-19 situation here worsened, I couldn’t help but think about X, and other patients in similar situations.
Feelings
I felt great sympathy towards X as she told me about her fears. I was honoured she felt she could be so honest with me and I tried to empathise with her. However, I felt slightly uncomfortable as I did not know how to respond to her. I was embarrassed at my own inexperience and lack of knowledge and felt completely helpless when she started to cry. I felt guilty that she left the practice still upset and was angry that I didn’t do more to comfort her.
Evaluation
The positive aspects of this consultation were that I maintained a good rapport with X and created a safe space where she felt she could talk. I wanted to empathise with her. I was certainly out of my comfort zone, and was questioning myself rather than assuming I knew best.
However, I think I found it difficult to best express my feelings of sympathy. My lack of experience and knowledge of dealing with such serious cases hindered my ability to comfort her.
Analysis
This was an invaluable learning experience for me, and I relate it experience to the 6th learning outcome of my GP rotation – “Consider patients’ illness experiences and contextualise their care with respect to family, cultural and other social factors.” The COVID-19 Pandemic is a unique situation that none of us could have expected. Patients like X experience an all-consuming fear that cannot be escaped. It is on the news, the television, the radio every hour of every day; a constant reminder of the danger they are in. I didn’t know how to comfort X during this encounter. I didn’t realise that all she really needed was someone to listen to her concerns.
The experience also highlights the importance of the 1st learning outcome – “Demonstrate appropriate and effective communication skills with patients and staff”. Empathy is an essential quality to possess as a doctor that enables us to maintain rapport. It is paramount to have awareness of patients’ reactions and to understand their perspective on their own problems1.
I have addressed these learning needs of communication and listening by consulting literature on both empathy and approaching patients’ ideas, concerns and expectations. I also asked my GP Tutor how he managed patients like this and discussed the importance of trying to understand the patient’s point of view.
Conclusion
After reanalysing my encounter with X and reflecting on the evolving COVID-19 situation, I have realized that in order to reassure a patient, I do not always need to have an answer, but just need to listen and empathize. I allowed my inexperience and lack of knowledge prevent me from comforting this patient. After discussion with my GP tutor, reading the literature and reflecting, I have learned how to prevent this from happening in the future.
Action Plan
Having gone through this reflective process I feel I am better prepared for a similar scenario in the future. I endeavor to understand patients’ fears and concerns from their perspective, maintain a rapport with the patient and always show empathy.
References:

1. Norfolk T, Birdi K, Walsh D. The role of empathy in establishing rapport in the consultation: a new model. Medical Education. 2007;41(7):690-697.

EXAMPLE 21
Description
I had a wonderful experience at my GP clinic, where staff were willing to teach and clinicians I admired.
COVID19 was topical from the beginning. Most patients and staff were making efforts to adhere to public health advice and change their behaviour e.g. avoiding hand-shaking and proper cough etiquette. However, it was still not uncommon for people to proffer a hand when called into the room by the GP.
Initially, I would just shake their hand to avoid an awkward situation. I then began trying to refuse the offer by using humour to deflect, which was mainly successful. The GP behaved in a similar way. I figured I could mitigate any risks by being extremely strict about my hand hygiene, but I still thought that hand-shaking was now inappropriate due to COVID19 and PH advice.
After two days of these awkward exchanges and some internal conflict about whether I should say it, I raised the issue with the GP – I felt we/he could be more forceful and definitive in refusing to shake hands, and that not doing so was taking an unnecessary risk and setting a poor example. It turned out that he felt similarly. From then on, we both politely but firmly refused any handshake and asked patients to do so outside of the clinic also.
Feelings
The predominant feelings were of an awkwardness and discomfort, both in response to the patients proffered hands and when I debated whether to mention my concern to the GP. I was worried I would look silly or overly serious.
There was even an element of shame, as I would be someone who would take a degree of pride from being straight-talking regardless of who I am speaking to, so staying quiet felt hypocritical.
I felt a deep sense of relief after eventually talking to the GP.
Evaluation
On the one hand, these were uncomfortable experiences and I did poorly to let the issue somewhat fester. Although a minor issue in the grand scheme of things, I was not as assertive as I think should be.
Looking back, I think my desire to be liked by someone I admired made me act differently to how I would have liked and stopped me from speaking up for a while.
On the other hand, it was good that I was forced to confront this and challenge my own assumption that I am someone who is not swayed by this desire to be liked. I am now more aware of that potential blind spot of mine.
Analysis
Mastering the art of speaking up is going to be an important skill throughout my career and one I would like to put to good use. This experience helped me uncover the need to learn more about barriers to speaking up and how to overcome them.
I found some material from the GMC1 to be particularly helpful and applicable to my own experience. For example, I recognised that I am prone to using “mitigated language” – downplaying something through deferential or indirect speech – and that whilst it does have its place, it can be maladaptive if overly relied upon.
Conclusions
Critiquing my behaviour and exploring what drives it can be a powerful tool, even if it reveals some uncomfortable truths. I learned that I am not immune to letting a desire to be liked by others get in the way of doing the right thing, but that this is a common issue. I hadn’t considered that the GP I was with might feel the same way as I did, and that I was possibly being too harsh on myself when I felt ashamed.
Despite usually feeling comfortable being assertive, it is good that I learned I still have blind spots in this area and now appreciate the importance of actively seeking out those weaknesses.
Action Plan
There’s no doubt that I will be faced with similar situations throughout my career, even if they may not look exactly like this. To that end, I will continue to work through the “speaking up” resources I found from the GMC and Medical Council and try to put what I learn into practice on my clinical placements.
I’ll also keep a log of my use of mitigated language and whether it served a useful purpose or not. Introspection is useful, but I also find it can be mentally draining as I tend to focus on weaknesses, so it can be great to see evidence that I have made progress.
References:
1) Speaking up about raising concerns. The General Medical Council. https://gmcuk.wordpress.com/2019/09/05/speaking-up-about-raising-concerns/

EXAMPLE 22
Description
I was taking a history from a 20 year old lady who had come to the GP practice for the first time. I asked her why she had made and appointment and she replied “I found out that I’m pregnant today”. I was startled by her revelation and prompted her to tell me more. She had taken five home-pregnancy tests that morning that were all positive. My initial reaction was to ask her if she was upset. I assumed that because of her age that the pregnancy was unplanned, and that she would be panicking about the situation. She assured me that she was not at all panicked and appeared happy with the news. Her partner was waiting outside and she couldn’t wait to tell him. I immediately regretted my astonishment and hoped that I hadn’t made her uncomfortable.
Feelings
During the consultation I felt at ease as the patient was open and talkative. When she disclosed her pregnancy I was shocked; I imagined how I would feel in her situation and I felt immediately sympathetic towards her.
Her reaction to the pregnancy astounded me, she was not anxious as I had expected her to be.
My initial feeling after the consultation was shame. I had made an assumption about her feelings based on my own and I let this impact my actions. I was worried that she might think that I had judged her, and I regretted this. I was disappointed in myself that I had jumped to the conclusion that she would be upset, rather than asking her directly about her feelings.
Evaluation
There were some positives. I had good rapport with the patient and she felt comfortable confiding in me. I maintained eye contact and appropriate body language in order to encourage her to talk. This was a learning experience for me. It helped me become aware of how my feelings can impact my judgement and that I should be more aware of this in the future.
On the other hand, I reacted negatively to the patient’s pregnancy. She may have noticed my surprise and felt embarrassed by this, or felt that I was judging her. I asked her a closed question about her feelings which may have been leading. The word “upset” had implied that her pregnancy was not a good thing. Ultimately, I had made a false and biased assumption about the patient because she was a similar age to myself.
Analysis
Upon reflection of this scenario, I have become more aware of my preconceptions and biases. When taking a history I must put these aside so that my judgment is unclouded. I have learned that each patient is unique and will have an individual reaction to an event that may surprise me. This particular patient was thrilled with her pregnancy, however a different person may react negatively. As a physician I will require the skills to deal with each of these scenarios appropriately.
Following the consultation, I discussed with my GP tutor how to approach pregnancy consultations. The HSE provide information regarding the services that are available for unplanned pregnancies 1. It is important to make mothers aware of these resources in the case that they require additional support. Almost 1 in 4 women in Ireland have experienced an unplanned pregnancy 2 . This is undoubtedly something I will encounter in the future.
Conclusion
In summary, I have identified that my personal beliefs can impact upon my clinical judgement. Having an awareness of my biases will help prevent them from interfering in the future. Also, This scenario has highlighted to me the importance of basic history taking skills – to avoid using closed questions in the beginning which may narrow the consultation.
Action Plan
I plan to read the ICGP guidelines on crisis pregnancy 3 so that I am equipped to deal with a possible future scenario. Also, I will strive to remain unbiased when faced with a challenging situation. In order to do this, I must challenge my preconceived ideas and practice treating each patient as an individual regardless of their demographics. I will avoid using leading questions that may misdirect the conversation and rather use open questions which allow the patient to have more control.
References:

1. www2.hse.ie. 2020. Unplanned Pregnancy. [online] Available at: [Accessed 31 March 2020].
   2020. [online] Available at: https://www.ucd.ie/issda/t4media/ICCP%20Report.pdf [Accessed 31 March 2020].
2. Irish College of General Practitioners, 2017. Crisis Pregnancy: A Management Guide For General Practice. Quality in Practice Committee.

EXAMPLE 23
Description
I attended the nursing home with my GP for a routine visit. While at the nursing home, my GP instructed me to take a history from one of the newly admitted palliative cases. I proceeded to attempt to take his history; however, the man remained silent throughout the entire consultation and did not respond to me once. I continued to attempt to converse with him, asking him how he was doing and if he needed anything. After a few minutes, I acknowledged that he might be tired and that the doctor would be in to see him shortly, and politely excused myself.
After the consultation, I reviewed the patient’s chart and realised that on one of the discharge forms it noted that the man was deaf and required written communication on a whiteboard.
Feelings
Initially I felt confused and awkward, as it was very uncomfortable to have him ignore me. Upon further reflection, I realised that I felt rejected by the patient and that I tend to internalise these types of interactions as the patient perceiving me as inadequate and specifically refusing my care, which made me feel insecure.
Once I discovered that he was deaf, I felt horrible. I felt guilty that I had been disturbing him in his final hours and that he couldn’t understand me or the GP at any point during the consultation.
Evaluation
The positive aspect of the interaction was that on reflection of a seemingly uncomfortable consultation, I believe I handled the situation well. I don’t recall my behaviour becoming awkward despite how I was feeling and continued to speak softly to him, trying to inquire as to what he needed to see if that may be the cause of his silence. In addition, when he continued to be unresponsive, I was conscientious of his cues and appropriately excused myself.
The negative aspects were that it demonstrated a situation where it would have been beneficial to have checked the chart prior to the consultation. Furthermore, it highlights the issue of informed consent, as I believe it had gone unrecognised by many of the staff in the nursing home that this patient was deaf, which bodes the question of how long has this patient gone on without understanding any information we have been giving him.
Analysis
This experience highlighted many key learning needs: 1) communication and 2) informed
consent. Primarily, the learning outcome of patient communication was key in this situation. It may be easy to assume that the patient can’t understand and thus potentially lack competence, however this is not the case. It is in our role a practitioner to further explore a patient’s understanding and ensure that they have all the information, whether that means altering the mode of communication to benefit the patient ie. Written, translator etc.
Secondly, with the lack of effective communication in this scenario, it highlights the issue of informed consent. There are many elements at play with regards to informed consent, specifically disclosure of information, patient competency and understanding and lastly voluntary decision-making. The assumption was that this patient could understand all information verbally; however, that was not the case, and this compromised his informed consent.
Conclusion
After reanalysing this situation, I am more aware of the difficulty and intricacies of this specific scenario. It may be easy to assume an elderly patient who is not responding may be confused and may lack competence, but this may not always be the case and it highlights the importance of being aware of the many different modes of communication. In addition, the responsibility of being conscious of checking your patient’s understanding and being mindful of any disabilities they may have.
Plan for future action
Following this encounter, I notified all relevant staff that this man was deaf so hopefully all future interactions can be conducted via writing. For my own learning, I reviewed the supplemental resources provided on Moodle for effective communication, specifically, I revised the Calgary Cambridge communication model workshop. Notably, the learning aid mentioned active listen in the sense of hearing what is said verbally, hearing what is said non-verbally and hearing what is not said. Moreover, if the patient appears confused, exploring their comprehension further and doing everything possible to maximise their understanding. I feel this is very fitting to this specific scenario and I hope to assimilate this skill into my practice in the future. Additionally, I reviewed the workshops on breaking bad news and acknowledging medical error, both of which I feel are extremely important and equally difficult to do in practice.

Sample Solution

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