Practical Prescribing for Medical Students

Helen Bradbury, Barry Strickland Hodge, Helen Bradbury, Barry Strickland Hodge

• Publisher: Learning Matters
• Year: 2013
• ISBN:
  9781446297537
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Education

Learning to prescribe is an essential part of medical training. Due to various high profile serious prescribing errors, the GMC have introduced stricter prescribing standards which medical students must meet in order to graduate. This book helps medical students learn the essentials of safe prescribing practice, and is aimed directly at their needs. It covers all the aspects of prescribing required by the GMC, including principles of prescribing, law and ethics, professional responsibilities, patient communication, at-risk groups, avoiding common errors and what to do when things go wrong. Key features:

• Directly linked to the prescribing competencies in the GMC?s Tomorrow?s Doctors and Good Practice in Prescribing Medicines
• Real-life prescribing case studies and scenarios relate the principles to actual practice and placement situations
• Activities throughout each chapter for testing prescribing knowledge and skills
• Test questions for the new Prescribing Skills Assessment to help students prepare and be confident that they can pass.

chapter 1

Communication and Patient Collaboration

Catherine Gill and Monica Murphy

Achieving your medical degree

This chapter will help you begin to meet the following requirements of Tomorrow’s Doctors (General Medical Council (GMC), 2009):

Outcome 2: The doctor as a practitioner

13. Carry out a consultation which elicits patients’ questions, their understanding of their condition and treatment options, and their views, concerns, values and preferences: (a), (b), (f), (g).

15. Communicate effectively with patients and colleagues: (a), (b), (c), (f), (g), (h).

17. Prescribe drugs safely, effectively and economically: (a), (c), (d), (e), (f), (h).

It will also link to:

Good Medical Practice (GMC, 2013a)

and

Good Practice in Prescribing and Managing Medicines and Devices (GMC, 2013b), particularly paragraphs 14, 16, 21–24 and 25–29.

A Single Competency Framework for all Prescribers (National Prescribing Centre, 2012) 2:12, 21, 23, 24 3: 25-37, 4:45, 5:49, 8: 66, 9:70.

Chapter overview

This chapter provides an outline of the essential communication and consultation skills that you will need to master in order to achieve the minimum standard expected of a prescriber. The application of these skills will help you not only in the detective work involved in clinical supposition and differential diagnosis but also in choosing correct treatment options. In more cases than not, the treatment options you choose will involve the prescribing of medicines; and, as you will learn elsewhere in this book, can result in adverse effects for patients regardless of whether this was the correct treatment option. Research shows that if you gather quality information which includes the patient’s concerns, ideas and expectations, and negotiate treatment and management options, and warn regarding possible unwanted drug effects, then the likelihood of you being able to help the patient is greatly increased (NICE, 2009).

After reading this chapter you will be able to:

• describe the different models of consultation;

• explain how using bio-psycho-social models which take account of cultural and existential dimensions can positively influence medicine-taking behaviours;

• distinguish between the concepts of compliance, adherence and concordance;

• discuss the attitudes, knowledge and communication skills involved in patient-centred practice;

• recognise how the application of these skills can help patients take medicines safely.

ACTIVITY 1.1 DECIDING WHAT COMMUNICATION IS

This may seem elementary, but think about communication and what it is. Write a short list of the key principles of effective communication. You will discover a discussion of these in this chapter. When you have finished reading the chapter, look back at what you have written and see how what has been discussed compares to your initial list.

In Tomorrow’s Doctors, the GMC states: Medicine involves personal interaction with people, as well as the application of science and technical skills (GMC, 2009, p. 4). This statement may surprise you – that an apparent fundamental in the practice of medicine needs to be articulated. Except in circumstances where a patient is unconscious, the application of science and technical skills cannot occur in a vacuum and communication with the person who needs medical attention, and/or next of kin, is essential. It seems sensible that medical practice involves a tripartite process of good communication, reasoning skills arising from scientific knowledge and clinical abilities. In an earlier GMC Standards document, Good Medical Practice, there is reference to the new world of partnership with patients and colleagues (GMC, 2006, p. 6). This suggests that, in the old world of medicine prior to 2006, partnership with patients, often referred to as a good ‘bedside manner’, was considered desirable but not essential.

The idea that good communication can improve patient health outcomes is not new and in the last 30 years of the twentieth century a strong body of work emerged exploring the rich potential of holism in healthcare. Much of the research undertaken since, to substantiate or disprove the validity of a holistic approach, has demonstrated better outcomes for patients (Edlin and Golanty, 1992; Department of Health, 2005; UKCCC, 2006). What occurs during a patient and doctor/clinician interaction – the consultation (to seek counsel) – has been extensively studied and what constitutes a successful consultation according to the patient can vary from the viewpoint of the clinician.

The consultation can be understood as a problem-solving process. The problem is something that needs consideration by the clinician. Consideration is a thought process of analysis and discernment (diagnostic process), with the endpoint being a judgement (diagnosis).

The remit of this chapter is to help you develop communication skills that will enable you to undertake a holistic consultation which is efficient and effective, yet caring and well rounded (Pietroni, 1987). The technicalities and reasoning skills related to thorough information gathering and information sharing are covered extensively, with little reference to the review of the biophysical systems and the physical examination, since these aspects are commonly covered in other medical texts.

What components make up an effective consultation?

Efficient and thorough information gathering influences the precision of diagnosis and therefore treatment by 80%. Studies repeatedly indicate this; however, patients think it is the opposite – that the laying on of hands (examination) is the most influential, along with investigations such as blood tests and X-rays/scans. The success of the consultation hinges on clinical knowledge and interview/planning skills and on the nature of the relationship that exists between clinician and patient. Your behaviour and attitude are just as important as what you say (Gray and Toghill, 2000; Bub, 2004; Deveugele et al., 2004).

What is communication?

According to the Oxford Dictionary (2012), communication can be defined in a number of ways, but for the purposes of this chapter it is:

• the exchange of information, between people by means of speaking, writing or using a common system of signs and behaviours;

• a spoken or written message;

• rapport: a sense of mutual understanding and sympathy.

The patient needs to feel sufficiently confident in your abilities, and this perception may be based on your behaviour as observed by the patient: how you greet, whether you smile, do you present as rushed or stressed? Do you seek permission on how to address the patient – given name, title and family name? Once in the consultation room or by the bedside, your opening gambit can influence first impressions. How you invite patients to disclose their problem(s) is fairly influential (a number of useful opening phrases are listed in Table 1.1, below); what is more powerful, however, is how much time you give patients initially to explain what is worrying them. This is referred to as the ‘golden minute’. Allowing patients to speak without interruption can give you almost all the information you need to unpick their problem. It also has the psychological benefit of helping patients to feel you understand them (Moutlon, 2007, p. 23). Given the quality of information you can gather from the patient perspective, their narrative and the patient-centredness that can be fostered, it would seem like time well spent. The urge to drill down with questioning to get to the bottom of the patient’s problem, as you perceive it as the clinician, can be quite irresistible and may lead to premature and inaccurate assumptions.

A Patient is the most important person in our Hospital. He is not an interruption to our work. He is the purpose of it. He is not an outsider in our Hospital, he is part of it.

We are not doing him a favour by serving him; he is doing us a favour by giving us an opportunity to do so.

(Bombay hospital motto, adapted from a quotation of Mahatma Gandhi)

ACTIVITY 1.2 HOW TO OPEN THE CONSULTATION

Before looking at Table 1.1 which details some useful opening phrases, put yourself in the position of a patient and think about what invitation phrase would induce you to share your problem(s) and what might turn you off.

If you have already adopted an opening phrase, what made you choose it?

How might age, gender and cultural background affect the opening phrase?

When is silence uncomfortable, and why?

Discuss your thoughts with a colleague and if possible a more experienced clinician. See if there are similarities and/or differences.

Table 1.1 Opening questions for the consultation

The following phrases are useful to invite patients to disclose their problem(s) and begin their narrative. They can be used after greeting the patient and introducing yourself. Whichever you use will be dependent on the healthcare setting; all can be used in general practice settings whereas questions 4–9 are more suitable for the hospital setting:

1. ‘How can I help you today?’

2. ‘What can I do for you today?’

3. ‘What would you like to discuss with me?’

4. ‘What has been happening to bring you here today?’

5. ‘Would you like to tell me what’s been going on?’

6. ‘Tell me a little about why you have come today.’

7. ‘If you’d like to tell me all about what’s bothering you; when did it start?’

8. ‘Could you start at the beginning and tell me how this all began?’

9. ‘What has brought you here today?’

Non-verbal communication

In the general practice setting, opening/inviting phrases can actually distract from what the patient may have rehearsed to say and the use of silence with non-verbal communication following greeting and introductions can be more effective. These are referred to as non-verbal cues and involve active listening. Active listening includes observable behaviours of smiling, making and then maintaining eye contact, nodding and using facial expressions that indicate interest and understanding on your part. Other non-verbal communications that create or represent meaning are your body movements and gestures, often known under the mnemonic SOLER: sitting square on to the patient with an open position, leaning slightly forward with eye contact in a relaxed posture (Power, 1998) all imply a more interested and caring attitude.

Take care when using verbal expressions such as ‘OK’ as this can potentially present as impatience rather than interest. Better verbal encouragers include ‘I see’; ‘ah-ha’; ‘yes’; ‘go on’; ‘uh-huh’; ‘umm’.

Other lines of enquiry and exploration

When patients have fully exhausted what they have to say, you should then ask, ‘Is there anything else?’ This process is known as screening and can be used a number of times in the information-gathering stage. It is a deliberate method of checking back with patients regarding any other important symptoms and perceptions they may not have mentioned. You can now move the narrative thread on with open questions or open enquiry.

Open questions do not suggest an answer or bias the patient towards replying ...

Table of contents

• Cover Page
• Halftitle
• Titles in the Series
• Title
• Copyright
• Contents
• Foreword from the Series Editors
• Author Biographies
• Abbreviations
• Introduction: The Challenge of Prescribing
• 1  Communication and Patient Collaboration Catherine Gill and Monica Murphy
• 2  Law, Ethics and Professional Responsibilities in Prescribing Practice Monica Murphy and Catherine Gill
• 3  Evidence-based Practice and Keeping Up To Date Andy Hutchinson and Jonathan Underhill
• 4  Working with Others Greg Heath and Helen Bradbury
• 5  Medicines Requiring Particular Care Natalie Bryars
• 6  Prescribing for Specialist Patient Groups Daniel Greer
• 7  Common Errors David Alldred
• 8  Adverse Drug Reactions Barry Strickland-Hodge
• 9  Drug Interactions Barry Strickland-Hodge
• Appendix 1 Drug Calculations
• Appendix 2 Answers to Drug Calculations
• References
• Index