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Careers - Core skills series: Communication

In this series Charlotte Hudson explores the key risk areas in general practice 

At a glance

In general practice communication has to extend to a greater number of people, so there are more opportunities for it to fail. Communication between primary, secondary, voluntary and social care should be viewed not as a chain, but as a communication net.

Colleagues

You and your colleagues should be aware of who is doing what, and understand the part they play. This will involve sharing patient information, which is entirely appropriate as long as continuity of care is balanced with the need to maintain confidentiality.

The Medical Council’s Guide to Professional Conduct and Ethics states: “Doctors working in multidisciplinary teams should ensure that there are clear lines of communication and systems of accountability in place among team members to protect patients.”

Working as a locum GP, your colleagues should provide all the relevant details of the patients for whom you are responsible. Practices should have in place protocols for the transfer of relevant information between doctors. However, many do not cater for the nuances of working as a locum, so locums should have in place their own systems to ensure adequate clinical handover.

Consultations

Average consultation time in Ireland is about 15 minutes per consultation. In this time you will need to establish a good relationship with the patient, communicate effectively, and make an accurate diagnosis.

Research shows that a focused history and examination will indicate the diagnosis in about 75-80% of cases. Good communication with patients during a consultation is your first line of defence in warding off complaints and potential clinical negligence claims. Effective interpersonal skills are particularly important for locum GPs because they often have only one chance to make a good impression.

Patients who are denied the opportunity to explain their concerns or reasons for presenting may feel alienated, frustrated or resentful. Patients who are kept informed about their condition, and who are actively involved in deciding on the appropriate treatment, are more likely to comply with suggested treatments and are less likely to complain if things go wrong.

Tips for an effective consultation

  • Let the patient talk first. An uninterrupted history aids diagnosis.
  • Use non-verbal communication to encourage patients to talk, eg, nodding, making and maintaining eye contact. 
  • Well-aimed open questions can help “lead” the consultation. 
  • Allow patients enough time to ask questions and clarify things. 
  • Use patient information leaflets or factsheets. www.patient.co.uk is a useful resource.

Prescribing

Good communication is particularly important when it comes to prescribing. Patients need to be made aware of, and recognise, adverse side effects. It is vital that prescriptions are written clearly and accurately, and computer-issued prescriptions are properly checked.

The Irish Medicines Formulary (IMF) offers some good advice on this. It is also important that the patient understands clearly what the medication is for, and how they should take it. Check what other medication the patient is taking, and whether there are any contraindications with the current prescription.

Using computers

It is important that the patient feels that they are receiving your full attention. Two helpful approaches are:

  • listen – if the patient speaks, stop what you are doing and turn your attention to them – providing a useful opportunity for the patient to reflect and tell you any information they have forgotten. 
  • explain – tell the patient what you are doing.

You should ensure that other people cannot overlook your screen and make sure that when you are talking to a patient you have their records displayed and not someone else’s. There is nothing to prevent you letting a patient see their own records, unless these display harmful information relating to a third party.

Telephone consultations

Studies show that public satisfaction with telephone consultations is high, and patients increasingly wish to have this option. Talking to a patient on the phone, however, exaggerates the difficulties of a face-to-face consultation because there are fewer cues to pick up on.

  • During telephone consultations, the Medical Council warns: “Doctors must pay attention to issues such as record-keeping and confidentiality.” Be cautious about revealing your identity until you have confirmed that you are speaking to the patient. You should only discuss details with a friend or relative if you are sure that the patient has given their consent. 
  • Empathise with the caller. 
  • When gathering information on the caller’s problem, make sure you: ask some open questions and closed questions, ensure that you are in a position to reach a sound clinical judgment, agree a plan of action with the patient, and check that they agree with it and understand it. 
  • Ask the patient to repeat the advice given several times throughout the consultation.
  • Document the consultation accurately.
  • Follow-up: check existing medication when prescribing new medication, explain to patients what they should expect by way of improvement, ask about significant symptoms to report, and advise when to phone back if they are not getting better.
  • Be aware that a common error is to record information or prescribe in the wrong patient file as another file has been called up during the consultation – always check.

Being open when things go wrong

Sometimes, in spite of your best efforts, patients will be unhappy with the care they have received. The Medical Council, in Guide to Professional Conduct and Ethics (2009), states: “Patients and their families are entitled to honest, open and prompt communication with them about adverse events that may have caused them harm.”

An apology goes a long way in defusing a situation, and is not necessarily an admission of liability. Where there are differences of opinion between you and a patient, or a patient’s relatives, there is much to be gained and rarely anything to be lost by the expression of regret by the doctor.

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