MLACases

[Ethics]

All-In-One Approach:

Declining Patient Requests - Saying No Politely

Scope (Find the scenarios here: SRP 2.0)

• Request for a Sick Note 
  • Malingering Drink Driver: Whiplash Injury 
  • Child with Chicken Pox: Childcare Issue 
  • Husband Travelling Abroad: Childcare Issue (NEW) 
• Request for Antibiotics 
  • For Viral Upper Respiratory Tract Infection 
  • Prior to Travel to Thailand (NEW)
• Request to Change Notes 
  • Ankle/Wrist Sprain: "Say I fell down at work" 
• Request to Receive Information about Relative 
  • Talk to mother - Finding Contraception under 15y/o daughter’s bed 
  • Talk to mother - Daughter with Depression 
  • Talk to son - Surgeon asking about mother’s CT scan results with suspected colonic cancer 
• Request to Withhold Information from Relative 
  • Talk to son - Don't tell my dad about colon cancer 
  • Talk to daughter - Don't tell my mum about colon cancer with metastasis 
• Request for Nursing Home Discharge for Relative
  • Talk to son – Wants mum to be discharged to nursing home 
• Request for Assisted Death for Relative
  • Talk to son - Discussion with Son in Switzerland 
• Request for Sex-Selective Abortion 
  • Preconception counselling: wants abortion if not male child 
    

Data Gathering

1) GRIPS Type 2 (Position & Presenting complaint)  

• In some cases, you may be asked in the task directly to “negotiate with the patient”, which provides a clue that the patient is coming with a request that you can not meet. 
• You will usually be briefed with some information about the situation, so it is good practise to acknowledge what you know so far before asking your open question. For example:
  • “I understand that your husband has travelled abroad for a couple of weeks and that you have some concerns…How can I help?” 

Note:

• Change my notes (ankle/wrist sprain) – this case is a bit of a misfit requiring an additional management step before the real issue comes. 
• They may tell you that you have already assessed the patient and that you’ve sent her for an x-ray and are tasked now with explaining the x-ray results and discussing management so do not start introducing yourself as if you’ve just met. 
• The x-ray (normal – no fracture), diagnosis (ankle/wrist sprain) and management (self-care advice – PRICE) should only be addressed briefly because they are not key themes. 
• Once that’s done, the patient is likely to ask you for a ‘favour’, and you can proceed with step 2.

2) Acknowledge Request + Transition into History

• Be prepared for the patient to make the request directly in their opening sentence in some cases. In such cases, you should briefly acknowledge the request and swiftly transition into explaining that you will need to gather some more information before you can advise them or disclose any details. Avoid the temptation to jump straight into explaining or managing the situation with inadequate information. For example:
  • → “Doctor I need a sick / fit note.”
    • “Yes sometimes as healthcare professionals we do issue sick notes, but I’ll first need to assess your fitness to work before I can consider whether that’s something I can do for you.”
  • → “Doctor I need antibiotics.”
    • “Yes sometimes as healthcare professionals we do prescribe antibiotics, but I’ll first need to assess you medically to see if antibiotics will be suitable for you.”
      
  • → “Doctor, I would like to ask for a favour. You have been very nice so far! Is it possible if you could change my notes?”
    
    • “Oh right… Can you clarify what you mean by changing your notes?” 
      
  • → “Doctor, I need something to end my mother’s suffering.”
    • “I’m sorry to hear that your mother’s been suffering. I’d like to ask you some questions to get a better understanding of her situation and see what we can do to help.“
  • → “Hello! How are you? How is my mum’s CT scan result?” 
    • “Hi Mr James, I’m good how are you?... Before we can discuss your mother’s condition, I’m required to first check a few details. Please bear with me a moment.”
  • → “Hello Doctor, please don’t tell my father/mother yet that he/she has got cancer.”
    • “I’m sorry to hear about your father’s/mother’s diagnosis. I’d like to ask you some questions to get a better understanding of their situation and see what we can do to help.“
      

3) Focused History: Start with Open Q’s 

• Start by exploring reasons for the request or concern from their point of view. For example,
  • “Can you take me through what happened in the accident?” 
  • “Can you take me through your reasons for needing a sick note?” 
  • “Can you take me through your reasons for why you feel you need antibiotics?”
  • “Is there any particular reason why you would like me to change your notes?”
  • “Can you explain what’s worrying you about your daughter?”
  • “What do you know so far about your mother’s condition?”
  • “What are your reasons for not wanting your father/mother to know about the diagnosis?"
  • “What makes you feel that she’ll not be able to cope at home?”
  • “What makes you feel that your mother is suffering at the moment?” 
  • “Can you take me through your reasons for wanting a boy?”

4) Focused History: Empathy Break 1 (EVE) 

• Demonstrate active listening by exploring their emotions accurately with an empathetic response, making sure to demonstrate relevance in your response by avoiding the use of stock phrases. For example:
  • Explore – “I can see that you’re clearly in need of some help now that your husband isn’t here to help with looking after the children.”
  • Validate – “I’m really glad you’ve come in today to discuss this issue with me as it’s very important that childcare arrangements are in place in advance to ensure your children’s safety. ”
  • Empathise – “It’s clearly a challenging situation you find yourself in and we’re here to help you get to a solution.”
  • Finish on a Positive Note – “I’d like to ask you a few further questions to give me a bit more of a background about your circumstances to see what I can suggest to best help you with this…”

5) Focused History: Finish with Closed Q’s 

• Select relevant questions from: 

Px – Inx – Dx – Tx – Now

PMAF – Psychosocial – ICE - Ex

• As a general rule in PLAB 2, if a task tells you to address their concerns, then you probably should ask ICE! 
• Demanding patients like this usually have lots of misguided ideas, big concerns & unfeasible expectations that need to be picked up in your data gathering and addressed in your management, so definitely do not miss ICE in these cases!
• For example:

Management

6) Empathy Break 2 (EVE) 

• Thank you very much Miss Jones for answering all of my questions. I know it’s a lot of questions / some of those questions were quite intrusive so thank you for bearing with me.
• EVE protocol
  • Explore – I can see that you are anxious to resolve this issue / to find out about your daughter or mother / for your father or mother not to find out about the diagnosis.
  • Validate – I think it’s natural to want the best for our loved ones / to want to find out what’s going on with our loved ones / to want to find an effective solution.
  • Empathise – And I do empathise with the situation you find yourself in at the moment. 

7) Say No Politely (Decline the Request, Give Reasons, Apologise)

• A) Decline the Request - However, unfortunately I won’t be able to…
  • …Issue a sick note / prescribe antibiotics / change notes or show you your notes now / disclose or withhold information without their permission / arrange an assisted death or sex-selective abortion. 
• B) Give Reasons - The reason being that…

• C) Apologise - I’m really sorry.

8) Offer Solutions to the Problem (Can I suggest?... What I can do...")

• "However, there may be some other things to consider which I think you may find helpful in this situation...Can I suggest?... What I can do..."

9) Apologise Again + Check Expectations

• Once again, I’m really sorry about not being able to meet your request today.
• I hope that the reasons I’ve given are satisfactory and that you find the alternative measures I have suggested helpful. 
• Was there anything else I can help you with today? 
  
  

Lesson Summary

• Scope
  • Request for a Sick Note
  • Request for Antibiotics
  • Request to Change Notes
  • Request to Receive Information about Relative
  • Request to Withhold Information from Relative
  • Request for Nursing Home Discharge for Relative
  • Request for Assisted Death for Relative
  • Request for Sex-Selective Abortion
• Data gathering
  • 1) GRIPS Type 2
  • 2) Acknowledge Request + Transition into History
  • 3) Focused History: Start with Open Q's
  • 4) Focused History: Empathy Break 1 (EVE)
    • Explore - Validate - Empathise
  • 5) Focused History: Finish with Closed Q's
    • Select from Px - Inx - Dx - Tx - Now - PMAF - Psychosocial - ICE - Ex.
• Management
  • 6) Empathy Break 2 (EVE)
    • Explore - Validate - Empathise
  • 7) Say No Sensitively
    • i) Decline the Request
    • ii) Give Reasons
    • iii) Apologise
  • 8) Offer Solutions to the Problem
    • i) "Can I suggest..."
    • ii) "What I can do..."
  • 9) Apologise Again + Check Expectations