Student Reports on Finals: Communication Skills

Student Reports on Finals: Communication Skills

Written by students for students
Students attending the ADC revision courses are asked each year to give feedback
on their experiences in the clinical part of their exams and for comments about the
courses. This helps keep the courses up to date and as relevant as possible and also
helps to give subsequent cohorts of students a flavour of whats expected. Please
note that any answers suggested by students have not been checked for accuracy.
By providing real exam scenarios, our hope is that students will be able to gauge the
range of questions which most often appear in clinical exams and that this will help
guide them to practise their clinical skills in the areas most relevant both to their
exams and to their roles as junior doctors.
Students from the following Universities have contributed to these reports:
Aberdeen, Birmingham, Bristol, BSMS, Cardiff, Cambridge, Cork, Dundee,
Edinburgh, Glasgow, HYMS, Imperial, Keele, Leicester, Limerick, Liverpool,
Manchester, Newcastle, Nottingham, NUIG, QMUL, RCSI, SGUL, Sheffield,
Southampton, Swansea, Trinity College, UEA, UCL, UCD, Warwick
Patient confidentiality: new GMC guidance 2013
New guidance from the GMC was issued in 2013 and recommended extreme caution
when using patient related information on the internet. As a result, where patient
details have been provided in student reports, these have been carefully
anonymised. Furthermore, the cases have been organised by clinical subject area
rather than by medical school which provides further anonymisation of data.
Health warning: Reports can be misleading
Writing down what happened in the exam can be quite cathartic- a particularly useful
way of off-loading all the stress- and so may not always give a balanced account, as
people tend to emphasise the bits they found tricky.
Student report: Take all the cases that people write about here with a pinch of salt.
They seem like nightmares when you read them but in the actual exam you just deal
with it and get on with it. I looked at the past questions before my exams and freaked
myself out. Just look at these things to get an idea about stuff to include in your
revision. I advise AGAINST looking at these things the day before your exam.
Health warning: Remember the standard thats expected
Student report: In terms of the clinical exams I thought Id done ok but really didnt
feel Id done enough to do any more than pass. It turned out that I got As. I think the
lesson is dont get caught up in the Finals circus. They want safe junior doctors who
can examine patients and elicit signs, not their next registrar.
Health warning: Trust your own judgement
Student report: My biggest advice is not to listen to students who went before you or
to let people freak you out. You always know more than you think you do and will be
amazed with what comes out!
If you find these reports helpful, please email your own experiences of the clinical
exams: support@askdoctorclarke.com

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Student Reports on Finals: Communication Skills

Report: explain type 2 diabetes to a man with learning difficulty
Communication station. A patient with a severe learning disability in my case (the
degree of disability seemed to hugely vary with some people having patients with
mild disability). The patient was with his carer and the scenario was to explain that he
had type 2 diabetes and to devise a management plan. The examiner was not so
bothered about the medical features more assessing our communication, clarity and
safety netting I think.
Report 2: This was a real patient with Downs syndrome and we had to explain to the
patient that they had diabetes and explain changes to their diet. Then offer literature
and ask whether they prefer to read/look at picutres etc. and ask if they can come
back with someone else who lives with them/cares for them etc. I suggesting
changing some of her food items with a banana and the patient asked me if he ate
lots of bananas would it turn her into a monkey. To which I answered that If there
was one thing in this whole osce that I was sure of, it was that she wouldn't turn into
a monkey! The examiner had no other questions.
Report: breaking bad news about breast cancer recurrence
No-one was sure exactly what they wanted us to do as the instructions were a bit
vague. but at the same time had too much info on one A4 page! The scenario
basically was a woman who had previously had breast cancer (she thought she had
been given the all clear) and had come back with hypercalcaemia and the scans
showed bony mets. A consultant couldn't come to see her until Monday so we had to
tell her the cancer had come back and it looked like it had spread to her bones.
I don't think they expected us to know a lot about the different types of chemotherapy
etc. they just wanted us to break the bad news and then explain that it was unlikely to
be curable so we were going to try and manage her symptoms (she was constipated,
had a headache) and have a go at managing her pain.
The examiner told me that what she was on at the moment (which I think was
co-codamol) wasn't enough and what would I go on to prescribe and how I would
prescribe it. I said I would give her oramorph as a regular and 1/6th PRN of total
dose for breakthrough pain. She seemed reasonably happy with that!
Report: explain bronchoscopy
Some people had to take a history, some consented a pt for a procedure (ex.
bronchoscopy)
Report: explain urinary catheter insertion
Comms style station explaining the insertion of a urinary catheter to a patient. Was
told the patient had acute pancreatitis but they certainly didnt look ill, which was a bit
confusing. You didnt actually have to put in the catheter, you just had to describe the
procedure of putting in a catheter and then prescribe fluids Ive heard the amount of
fluids people prescribed vary massively, so I have no idea what the right answer was.
Report: breaking bad news - elective cholecystectomy cancelled
Cancelled because of hypertension. I treated this as breaking bad news rather than
just info giving and it worked - the guy didn't argue at all. He totally accepted what I
said and there was no anger (as others reported)

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Student Reports on Finals: Communication Skills

Report: give information about a panic attack
Information giving: this man was diagnosed with a panic attack in A & E last night. He
has come to his GP practice today to discuss this with you. You had to explain what
causes a panic attack and how he can deal with the symptoms when they arise.
Report: give information about schizophrenia
Infomation giving: this lady's 21 year old son has recently been diagnosed with
schizophrenia. Explain to her what schizophrenia is and respond to her questions
appropriately (including questions about symptoms, treatment, prognosis etc).
Report: give information about chronic fatigue syndrome
Information giving: this lady's 52 year old husband has recently been diagnosed with
chronic fatigue syndrome. Explain to her what this condition is and respond to her
questions appropriately (including questions about symptoms, cause, management &
prognosis).
Report: give information about vaccinations
Offer post natal immunisations to a first time mum when she is about to leave
hospital. She is tired and frustrated and you must discuss BCG as the father is from a
high risk country. The patient was difficult to talk to as they were exhausted and
wanted to know why her child for the BCG. Wanted to know about the schedule for
the first year and side effects e.g. pain, bruising, fever and rarely anaphylaxis also
scar in the case of BCG. They were looking for you to offer patient the choice with
benefits and risks. Give her time to think with leaflets and GP review but emphasize
the need to vaccinate as soon as possible. In the end she said she wanted to discuss
it with her husband and would take the written information.
Report: breaking bad news about bowel cancer recurrence
Breaking bad news- Old man just had right hemi for bowel Ca but was lymph nodes
positive and now needs chemo as it improves 5 year survival. The consultant
explained on the ward round but the patient was confused and now wants
clarification. So offer if he wants anyone with him he will say no, ask what he
understands, his concerns and what he expects. Ask him to interrupt if he needs to.
Break the news with a warning shot just before. Give space and silence. Ask if he
wants a break he will say no. Show empathy and ask how he feels. Offer chemo,
explain it has side effects but they are temporary but can increase his survival.
Explain you cannot say if he will be of the ones who benefit from chemo but this will
give him the best chance. Offer leaflets, future appointments and bowel Ca nurse will
be in touch. Keep checking if he understands and if he would like clarification.
Summarise and thank him.
NB Chemo will increase survival from 50% normally to 60% with chemo.
Asked questions around chemo side effects there are short term effects and long
term but this was confirming his thoughts rather than explaining.
Report: explore reasons for poor diabetic control
GP Management: Woman with poorly-controlled type 2 diabetes. You need to find
out why. It's to do with her diet (she eats lot of cakes!) rather than start her on
gliclazide (in addition to the metformin she's already on). Ask about her monitoring,
drug list and offer dietitician appointment. Follow-up in 1 month. Alright station.

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Student Reports on Finals: Communication Skills

Report: explain TB treatment
Discharging on TB Medication: Asian single women from Pakistan now living in UK
has haemoptysis, fever, night sweats, weight loss. You've got to discuss the TB
regimen and ask about any recent contacts with ill persons, prophylaxis for children
and insist on need to adhere to regimen strictly. She will have plenty of questions for
you so don't worry! They're all straightforward - read the TB medications article on
Patient.co.uk.
Report: explain laparoscopic cholecystectomy
Anxious lawyer with plenty of concerns about upcoming operation under general
anaesthesia. Answer them - 'will i wake up during the operation?', 'i don't want to be
in pain!', 'i read on the internet that the anaesthetic is really dangerous....is it', 'what
happens after the operation?', 'when can I go back to work?'. She wanted to know
how she had to prepare, the risks of general anaesthesia, and she mentioned that
she had had a bad operation in the past and had felt very sick and wanted to be
reassured that this wouldnt happen again. Mentioned leaflet. The best way to
succeed is to adopt a patient-centered approach in this station. Forget your agenda
and just address their concerns. Easy.
Report: breaking bad news of genital herpes
He took it quite badly. Wanted to know how he got it, whether he had to tell people
he had had sex with, what treatments were available.
Report: breaking bad news about stroke
Breaking Bad News: You've been asked to see the wife of your elderly patient who's
just had a stroke. You are urgently transferring him to a thrombolysis centre. His wife
has been waiting a long time and doesn't know what's happened. Update her on the
situation, break the news about the stroke and address her concerns: 'how will I get
to the hospital?'. 'what do I tell my sons?', 'is he going to die?'. Empathy is key in this
station. I found that just talking to her like a normal adult helped in this station than as
a doctor.
Report: cross cultural communication
Cross-cultural communication: This patient has come in with a dog bite but is
refusing antibiotics and tetanus jab. He is a Christian scientist who believes in God's
Power of Healing. This is all fair enough however he could die from a systemic
infection. After ICE-ing him, you find out that it's his wife who's a stronger believer
than him and it is her that he's most worried about. If you remind him about patient
confidentiality, he obliges and decides to take the medications. Easy!
Report: lifestyle advice and osteoporosis
Woman with osteoporosis, had to address lifestyle changes and management
options.
Report: advise colleague who is stressed
Communication skill Fellow Dr had been getting late to work recently. Found out
that his wife had been getting post natal depression and was very stressed at home.
Just had to tell him to speak to his educational supervisor or clinical supervisor, that I
wouldnt tell anyone about this because he was worried about other F1s knowing,
and that he should contact us if he is going to be running late, and to speak to a
counsellor if things get too much.

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Student Reports on Finals: Communication Skills

Report: advice about starting insulin
Discharge explanation - T2 DM starting on insulin. Awesome actor, who sat me
down, gave me her discharge summary, stated that she had a list of questions. She
went through the list of questions one by one and I answered all of them. Very
straight forward, not much exploration required.
Report: procedure explanation - TURP under spinal
There are huge amounts of information that could be delivered about the operation
and the anaesthetic. I knew from my practice that it would be impossible to get
through everything, so I thoroughly ICE'd them first, then addressed their concerns
one by one. Apart from that, I asked about his current meds, and he gave me a
piece of paper. I told him to stop the aspirin and clopidogrel.
Report: breaking bad news - Tazocin rash
A very convincing actor. I took a while to settle in to this station, as it turned out there
was no bad news to break - she already knew everything that had happened, and
just wanted to complain. I apologised profusely, stating 'she was absolutely right',
and that this case highlighted areas that we as doctors can improve on. We
formulated a plan of action at the end. She started angry, but seemed calm by the
end, so I felt it had gone alright.
Report: breaking bad news - pregnancy test negative
37y/o lady coming into GP for pregnancy test. She is TRYING to get pregnant. 2
previous home pregnancy tests were negative. You have to inform her that the test is
indeed negative. The difficult thing was that after discussing the result and offering
counseling and all that she wanted to know what the cause was. I said that I wasnt
sure and that Id have to take a full history and probably speak to the husband as
well. I didnt want to go into a gynae hx at a BBN station so I said that I was happy to
discuss her hx fully at another time but for now we wanted to ensure that she felt
supported and if she wanted us to discuss the result with her husband wed be happy
to do that.
Report: hypertension medication and lifestyle
HTN middle age Asian gentlemen whos a CEO of some big company undergoing a
merger. You are given a laminated sheet that says that he came in last week with
raised blood pressure and also complained of LBP a month ago. His blood pressure
today is 160/90. You dont need to take a full history but ask about drugs b/c hes
taking NSAIDs for the LBP. I stopped his NSAIDs, offered paracetamol, and said that
we would recheck his BP in a weeks time. If it was still raised then we would
consider increasing his enalapril. Also went through lifestyle mods-Exercise (doesnt
exercise), Doesnt smoke, Drinks moderately, Very stressed, Diet (offered to refer
him to the dietician). Leaflet and F/U plans.
Report: perioperative explanation
Hip. She wanted to know what she had to do prior to the op and anything with
regards to discharge. Do the typical pre, peri, post op discussion. Always check back
on her as she actually had a lot more questions then she let on initially. Was worried
that they would get the wrong hip (say they dbl check before and mark with a black
marker), how long would it take to go back to work. Also mention the importance of
OT and PT discussion pre and post op. With regards to pain management, I have
used the same spiel for every periop explanation. Say that there are a number of
ways to manage pain that includes oral, iv, and a line into your back (epidural). With
regards to the best pain regimen, that is something for the pt and the anaesthetist to
decide. Btn the 2 of you, you will decide on the most appropriate regimen.

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Student Reports on Finals: Communication Skills

Do Not get bogged down with explaining how an epidural or PCA works. Just say
that there a whole range of options and that the anaesthetist will discuss it and
together they will make a decision. Say your spiel, check the pt is happy, and move
on. Didnt actually finish this station. Pt kept coming up with new questions
throughout but everyone had the same experience so I guess thats what she was
told to do.
Report: cross cultural communcation
Vignette says father wants to talk to you following a fall his son had. Son is stable, no
LOC, no n/v, and doctors feel that he is fit to be discharged. Inside, the man is
American and says that where he used to live theyd do a brain scan. Took a quick
hx and it was pretty obvious that the son didnt sustain a severe HI. Explained that
due to the lack of red flag symptoms and no abnormality on exam, son was unlikely
to sustain a HI and that a CT would expose son to risk of high radiation especially at
the age of 8. Explained that if the son did begin to become drowsy then to bring him
back immediately to be assessed. Father was happy with explanation. Then he
asked if he could pay for a scan. I told him that this was the NHS A&E so everything
was free. Told him that there were private places that he could pay for a scan, but
even then it would be under the doctors discretion whether to undertake the CT and
due to the childs age and the lack of worrying signs, it would unlikely that the doctor
would agree. Said I would give him a leaflet that gave him info on what to look out for
during the next 24 hours as signs of possible HI. Father agreed and everyone was
happy happy happy.
Report: family history of cancer
Pt with strong fx of cancer assess risk and talk to pt. Had to get detailed hx of all fx
members and what ages they had Ca and which type. Assess risk of pt developing
ca ie he was a smoker, poor diet lack in fibre, decrease exercise etc. Red flag
symptoms asked. I told pt I could send him to smoking cessation, dietician review
and also do some tests: bloods, FOB and a colonoscopy and briefly explained these.
Ex stopped me and started bombarding me with ? Said did I really think this pt
needed all this to which I adamantly replied yes he did!! He's high risk. She made me
go through all his fhx again and I got muddled up and said one of his relatives had
ovarian Ca when they didnt...then asked me which gene I was thinking about..I didn't
know.
Report: angry relative
Had to read a page of notes got the impression her Dad was in hospital and had a
NG placed due to him aspirating and he hadn't been fed yet, due to miscommunication. Tried to be calm but got the impression she really didn't like me! She
was angry also as the nurses had been talking about her Dad in a nasty way.
Reassured her that this shouldn't have happened and we are looking after her Dad
and I understood how frustrating it can be when a loved one is in hospital and you
can't do anything. Suggested a meeting held with her, and the consultant in charge
and ward sister to come to the bottom of this. Still didn't seem satisfied!
Report: angry relative
Talk to man who wanted to see his brother having chemo because he heard he had
cancer but they haven't spoken in years and your patient has refused to let his
brother know anything -handling angry man station.

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Student Reports on Finals: Communication Skills

Report: explain haematemesis investigations and management
Focussed history. I explained common causes (mallory weiss, liver, oesephageal
varices, ulcers and some more severe cause) and that the causes can range from
common things to slightly more severe things. I told him that I would like to
do perform a thorough abdo exam, take some bloods and do a camera test and then
I would like to make him an appointment and come back when we have more info so
that we can discuss.
Report: handover
Handover- the person who was handing over made no effort to leave as they
normally do in previous year but was really helpful. Used the SBAR format breaking it
down further into I CHEWD IT SIRP
Identifiers- patient name, hops no. and ward
Complaint- presenting complaint
History
Examination- obs and whether they're stable, positive findings on examination
Working diagnosis
Drugs/Allergies
Investigations carried out so far
Tasks to be done for the patient
SenIor Review- med reg/surg reg
Plan
Simple enough, just practise writing out a system on the page before the OSCE so
you can walk in and start asked the right questions.
Report: handover
2 pts to hand over one with sickle cell crisis? Severely swollen leg, and one with
suspected chest infection. Writing down a lot on this station so cant remember much
else!
Report: haematemesis
Take history and explain that the patient will have to stay in.
An angry accountant who had a massive episode of vomiting blood. I found out he
was a bit of a drinker and he had been taken NSAIDs for the past year. Explained he
would have to stay in hospital. Cue bizarre fit of anger. I said that we were concerned
about the vomiting of blood as Im sure that he was. He agreed but stayed angry.
Asked him why he was angry. I didnt really get an answer. Something about him
being an accountant?? Asked what would happen next. I said a senior would come
but likely he needed a camera test. Cue another bizarre fit of rage. Did well on this
station so it cant have been too bad.
Report: handover
Trying to get information out of a useless F1. He was friendly enough (despite trying
to leave at the start something about him having children) but desperately
frustrating. I cant remember the first patient. The second patient was referred up
from clinic by a consultant. The F1 wasnt sure who the consultant was or what clinic
it was. Just knew that the consultant had ordered every investigation under the sun.
He didnt know why he had ordered them but took great pride in listing them all off. I
interrupted him by saying Id speak with the referring consultant myself.

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Student Reports on Finals: Communication Skills

Report: SBAR station
You had 6 minutes to review a brief sumary of a post op patients notes, work out the
patients early warning score and get ready for an SBAR station next. This involves
calling your senior and going through the motion of situation, background,
assessment and review of the patient. The patient had an EWS of 9 however their
post op scar showed no signs of infection. The senior at the other end of the phone
said he had a theatre slot ready for an operation and couldnt come straight away.
However you had to stress that you were very concerned about the patient and
needed help as soon as possible. I was asked what i thought the medical causes of
sepsis could be.
Report: multiple explanations
We had a communication skills osce:
1- teaching asthma technique to a patient who kept getting it wrong
2- explaining a post mortem request to a relative of a patient who recently died
3- taking a diarrhoea hx - pretty simple then differentials and possible investigations.
4- taking a loss of consciousness hx - again easy to take but didn't really fit an
obvious diagnosis. Asked to give differentials and list of investigations needed.
5- diabetes short review of patient control of sugars. Asked about my opinion on his
control and why. Also how to reduce pre lunch hypos which the patient had.
Your course was brilliant. Thanks so much for everything
Report: communication skills x6
I had the communication skills OSCE next. For each we had 5 minutes to read any
information given before starting the station.
First was a loss of consciousness history. Cannot remember the details of the
history, but had to present back and give our diagnosis and differentials and discuss
further investigation.
Next was a chronic diarrhoea history. Patient had IBD. Again, present back,
diagnosis and differentials and further investigation.
Third station was diabetic review history. Just had to talk through all the different
areas of the patients diabetes as he was a new patient to the practice and there were
no available notes. Things such as onset, type, symptoms, control, was he seeing
relevant specialists at hospital etc. Questions were around how would you monitor
his diabetic control - HbA1c.
Fourth station was a young woman who had been admitted with acute asthma and
you now had to review her before discharge. We needed to take a history regarding
her control, previous attacks and admissions and triggers. Also check inhaler
technique, there were two placebo inhalers available. Also offer peak flow.
Fifth station was discussing the need for an autopsy with a recently deceased
patients niece. All of the information was provided both during the 5 mins prep and in
the station, although hard to read once started. Station was about your ability to talk
with the patient as opposed to your knowledge of autopsies.

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Student Reports on Finals: Communication Skills

Important to express sympathy and give patient time. She led the station with many
questions to ask, and the main aim just seemed to be empathy.
Final station was SBAR. Had 5 minutes to read through all the information - many
sheets under each other so make sure you read them all and make notes. Then,
move into separate cubicle with all the information repeated. Again though, hard to
refer to it once speaking to med reg. Then call the med reg on the phone and go
through SBAR. Med reg then asked questions about what else you wanted to do and
what you though was going on. He was reluctant to come quickly, and myself and my
friends found we had to keep repeating how urgent we thought it was before he
agreed to come immediately.
Report: breaking bad news about stroke
The son of a patient has come to a&e as his father has had a haemorrhaging stroke
that the neurosurgeons will not operate on. He is not expected to survive. The patient
may be agitated or angry when you enter the station. You have to explain the
situation using the principles of breaking bad news and then talk about DNAR orders
such as who makes the decision, what this means regarding treatment, why hospitals
are allowed to withdraw treatment and that the patients son is unwilling to agree to a
DNAR order. I also asked whether the patient had an existing advance directive.
I explained all this and had a preliminary discussion regarding DNAR. All students
had the actor ask "So can doctors sign a DNAR without the familyd consent' - we
had to say yes and explain.
Report: explain nasogastric tube
Explain NG tube to a patient with autism who has already been assessed as having
capacity.
Report: explain about heart failure treatment
A man in heart failure clinic - asked to speak to him about adding carvediol to his
current medications. We were given % of death in 1 year, then % of death if they
were on carvediol. Needed to explain to him these numbers, ask any concerns and
why he may not want to add a new medication.
Report: explain hypercalcaemia
Asked to explain blood results to a lady with abdo pains, vomiting - had
hypercalcaemia and mild hyperkalaemia. Tell her a few possible causes. Every
patient asked "could it be cancer?" Then write up appropriate fluids for the next 24
hours.
Report: explain TB treatment
Resp History (Primary Tuberculosis) - Q. Describe the treatment to the patient, and
explain contact tracing
Report: cystic fibrosis counselling
Had a mother of a 6-month old whose new-born cousin had just been diagnosed with
cystic fibrosis. Mum was concerned her child might develop CF and wanted to know
what it was, how people got it, and if she could be tested to see if she was a carrier.
There was paper and a pen in the station so I drew out how CF was inherited, talked
about point mutation (given there was no family history of anyone else having CF),
and offered mum and dad a mouthwash test.

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Student Reports on Finals: Communication Skills

Report: breaking bad news lung cancer plus pneumonia
We had to speak to the wife of an elderly gentleman who had pneumonia on top of a
primary lung cancer. He had been admitted a week before and had deteriorated
during the day. We had to break the bad news that he was dying and had only hours
to days to live. We were asked questions by the wife about whether we were going to
give IV antibiotics and other medication he was on now that he couldnt swallow and
if we were going to give him fluids to keep him hydrated.
Report: asthma counselling
We had a middle-aged gentleman who had come to the asthma clinic for a routine
check-up. He was a traveling salesman and his asthma was poorly controlled. He
used his blue inhaler 3-4 times a day and refused to use his brown inhaler as he
didnt think it made any difference and he was worried about the side effects
(particularly osteoporosis). He didnt use the spacer because he found he couldnt
taste the drug so didnt think it was going into his lungs. We had to explain why the
steroids were important, how the spacer worked and why it was better to use it, and
why he should monitor his peak flow.
Report: angry relative
Angry / Upset family member due to drug error
Report: integrated care
Just know your ethics & law and key parts of epidemiology. The sations I had were:
1. Discussing end of life care options with patient The patient had end-stage COPD
and was in hospital with another exacerbation. I thought the instructions for this
station were a bit vague and so I'm not really sure what they wanted. I talked about
DNAR, advanced decisions and advanced statements. The patient already seemed
to understand her prognosis so there wasn't much breaking bad news involved.
Other people talked about hospices which I forgot. I think the main thing to do was
find out the patients concerns and what they wanted and explain the options
available to them.
2. Patient brings systematic review of Aspirin - interpret paper, explain & determine if
patient needs to be on aspirin. A patient had come along with a research paper
abstract and questions about odds ratios and confidence intervals. You had 2
minutes to read the abstract and then 9 minutes to explain the data to the patient and
what it meant for him. Mine was about taking warfarin after a PE, I think other people
had aspirin after a stroke.
3. Speaking with a patient, discussing why they want to leave against medical advice
& suggesting options to stay.
4. A woman was about to be discharged and wanted her medications explained to
her. Her new medication was epo injections for chronic renal failure, so I had to
explain the diagnosis and why she needed epo.

Other had: angry relative, father had just had an ischaemic stroke post-op and the
relative was angry that his warfarin had been stopped for the operation. Had to
explain why things had happened, that we were balancing risks of bleeding vs
clotting, what a stroke was and then I went on to talk about stroke recovery. As
always, the main thing with comms skills is to explore their concerns etc.
Thank you for your revision courses and material - really helped with clinicals!

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Student Reports on Finals: Communication Skills

Report: explain one of the following
I then had to explain to the patient about steroid use which didnt go wonderfully but
we spoke about the side effects for a while, the patient was quite happy with it since
she had been on them for years!
I had to explain an arthroscopy to him.
Explained to the patient about urodynamics which fortunately I'd seen so I think that
went fine.
I just had to explain secondary prevention to a patient who had had a myocardial
infarct
My communication task was to explain how his pulmonary oedema was going to be
managed and then explain warfarin therapy.
My communication task was to explain a steroid injection to the patient.
My communication task was to explain what precautions will have to be taken after a
splenectomy.
Then I had to explain to the patient what T1DM is, its management and health care
professionals who would be involved
I had to explain cystoscopy to the patient.
I was then asked to explain what stroke is to the patient and its implication for the
future.
I was then asked to convince the schizophrenic patient to take his medication.
Then had to explain to the patient about methotrexate therapy. I started by asking her
'so tell me what you already know about methotrexate' to which she replied 'you're
supposed to tell me aren't you!' - she clearly knows the game well, but when I had a
mind blank she helped me out by asking good questions to jog my memory!
Explain to the patient the use of an ambulatory ECG
Pretend this polycythaemic patient is going to have venesection for the first time.
Explain the process
You've told us smoking causes IUGR, please counsel this patient on stopping
smoking. This was the first time the patient talked at me about what she was doing to
stop smoking. I just spoke to her about the different methods and what she preferred.
I also went over the risks again with her. (According to the person after me, she was
well bored the next time she had this explained).
Explain your investigations and the use of steroids to the patient
I again forgot to mention Patch testing. I started to talk about the different levels for
steroids and how we could move on to orals. I was asked then by the examiner what
are the side effects of steroids and if you are worried about getting Cushing's from
topical creams? I said no cos only a very small amount is systemically absorbed (I
think that's right - they didn't look too convinced!) They asked me about other Orals. I
was reluctant to say immunosuppressants but found out later that would have been
right

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Student Reports on Finals: Communication Skills

Please imagine she's never taken methotrexate and explain about this medication
and how to take it.
Please explain to this patient a colonoscopy
Please explain a nerve conduction study to the patient
"Please talk to the patient about having a CT
The patient started panicking about it, saying she was claustrophobic and didn't want
it. I was supposed to pick up that she was talking about a "tunnel", and not a "donut",
i.e. and MRI and not a CT. I got this fairly late and ran out of time. However I did say
to the patient before this "I can see that you are distressed, how about I explain the
process, and the reasons why we would like to do one, and then we can explore, and
hopefully alleviate any of your fears and anxieties". Hopefully that would have been
enough.
Had to explain warfarin to the patient.
Had to explain what symptoms to look out for with DKA and what to do.
Please explain to the patient what she should do if she has a hypoglycaemic event.
Please explain caesarean section the patient.
My communication skill was to explain to the patient about steroids and the side
effects of steroids.
My communication was to try to convince the man to continue to take his antipsychotic medication. I told him there were lots of other therapies we could try which
might give him fewer side effects, so we could try a few until we found one that suited
him best. Then I explained that he should come to tell us if he is having any side
effects he doesnt like so we can potentially change again, rather than stop taking
them by himself. He said he would be happy to do this so I think that went ok...
My communications was to explain blood sugar monitoring. This was tough as I
asked her what she did (she already did it all properly) and I asked her what she did
if she noticed they were low/high (she did the right things) so I didnt find I had a lot to
say.
Had to explain diagnosis and management of post natal depression, focussing on
SSRIs.
Had to explain advantages/risks of VBAC.
Explanation to the patient was on venesection for polycythaemia. I explained the little
I knew, what she had told me in the history and then I asked her to summarise what
she understood, she proceeded to explain exactly what happens. Great lady! don't
try to predict the cases, but do go over what came up before. Some of them will
come up again. But don't panic, just try your best and this was all they wanted. And
be super nice to your patients. They love it! The revision courses were really useful
and really well presented. There were many, somewhat fundamental, principles of
medicine that I had convinced myself I understood that actually until I was in your
lecture I don't think I really had - so thank you!

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Student Reports on Finals: Communication Skills

3 explanation and planning stations
1. Trying to persuade a pregnant lady to stop smoking
2. Elderly man having hypos, turns out he can't see to do his insulin!
3. Explain the procedure of colonoscopy to a young lady
3 challenging scenarios
1. Trying to persuade an 18 year old man who was not v communicative to have a
lumbar puncture
2. Explain to a man that his wife is in her last few days of life (she had been ill for
sometime so this is not a surprise to him) See below for details
3. Pre op assessment
Example of challenging situation
Mr Jones wife has had lung cancer for 1 year and has been in and out of hospital 2
times with pneumonia. She has been admitted for another episode of pneumonia
and is now terminal. She is expected to die within the next few hours to days.
Please speak to Mr Jones, inform him of Mrs Jones prognosis and answer any
questions he may have.
Important to assess starting point (he knows everything)
Mr Jones asks: How long does she have? Shes making a rattle noise when shes
breathing, will she choke to death? Can she hear me?
The important bit in this station is the delivery of the news: warning shot and then
allowing for shut-down. Then answering the questions avoiding getting yourself in a
hole or using jargon/insensitive language. The examiner looked pleased when I
asked if he would like me to help him tell any of his relatives. He said his sons lived
down in London and they were coming up tomorrow, I said it would probably be best
for them to come up today. And you should leave him with details of how to get back
to you if he needs anything else, I said he could get the nurses to bleep me. There is
an extensive mark scheme with all of this in from the Breaking Bad News or Death
and Dying sessions. Its good to go through all of the possible questions they could
throw at you but this actor was really lovely, probably exhausted from having to cry
10 times that morning!
Example 2
Teenage boy, ? meningitis. Has had CT and now needs LP. You are handed this
information over from a colleague and told to go and get his consent for an LP.
Issues: Because the CT head is normal he thinks its fine and he can go. Its useful
to assess his starting point what do you know about why we did the CT head? And
maybe not refer to it as normal but shows its safe to go ahead with LP.
Hes stressed about his finals exams, they are this week and if he doesnt go to them
hell have to resit the year. He also wants to go outside for a fag. He hates needles
and has been told its a huge needle.
This station is mainly about explaining the procedure to him and answering any
questions he has. He kept complaining about the bright lights etc. At the end he
agreed and asked when the procedure would take place. I said in about 10 minutes,
he replied so Ive got time to go outside and have a fag then? I said you are very,
very sick.and its very sunny outside. The examiner found this hilarious.

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Student Reports on Finals: Communication Skills

Report: three challenging communication stations
(12 minute stations plus 4 minutes to read a few paragraphs outlining the scenario
beforehand):
1. Breaking bad news telling a man that he was to have no further chemotherapy
for his lung cancer because it wasnt working and explaining that he will not be cured
of the condition. Had various questions about end of life issues, e.g. how long have I
got doctor?, can I arrange not to be brought back to hospital if I become ill at home,
Doesnt want to die in hospital, doesnt want lots of tubes and wire connected to him.
Wonders about what help is available at home. Wonders about DNAR order.
2. A patient due to be discharged home but wont leave until he sees a specialist
about his long-standing leg ulcers (currently being treated by his GP and district
nurse). The notes said take a social history, and deal with any concerns he has. The
station opens with the actor telling you Im supposed to go home today, but Im not
going to. He tells you about his ulcers that no one cares about. I took the approach
of calming him down, asking about his ulcers, but also checking if there was another
reason why he didnt want to go home (i.e. social issues). Made a management plan
with him about what to do with his ulcers.
3. A station in which you are given notes, charts, etc. of a patient you have been
asked to see whilst on call. A previously well man with worsening pneumonia and
sepsis (temperatures spikes, pulse increasing, blood pressure falling, O2 saturation
falling). Asked to ring the ITU registrar, present the patient and explain why this
patient should have an ITU bed. Also asked how you will manage the patient until the
ITU registrar can get there. I ITU registrar is deliberately a bit intimidating and cross.
All about using SBAR. People had very different experiences with this. I had a reg
who told me things like I dont know why we are even talking, hes 88 for goodness
sake, I should hang up on you we have no beds. The ITU reg on the phone also
told me what is this CURB-65 you are talking about; Ive never heard of that! Other
people had a very different experience and immediately got oh, he sounds very sick,
Ill move people out of ITU to get him in for you. Im not sure that how mean the
person on the end of the phone was affected your marks too much, I think it was
more about process skills.
Report: breaking bad news
Explaining to a lady that her husband had had a severe stroke and needed to be
transferred to stroke unit in another hospital. Lots of people didn't ask what she
already knew and apparently she was 'very upset'. She was worried about transport
to the other hospital. The actress was really nice and this was a good station as long
as you were sensitive.
I just wanted to email to say thank you SO MUCH for your course - I came in
February just as I was starting to get into the finals revision and found it such a useful
two days; both for revising and highlighting areas where more practice was needed.

Report: explaining knee replacement

Man due to have surgery next week for OA of knee. Was having spinal anaesthetic.
Wanted to know everything pre/ peri and post op. Absolutely fine!
Report: cross cultural
Church going lady had had unprotected sex with man not her husband, worried about
pregnancy and STIs. Found this station quite hard, wasn't sure what the marks were
for.

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Student Reports on Finals: Communication Skills

Report: explain cataract surgery

This has never come up before and is also a specialty topic so it was a shrug, guess
and try to look confident station. I said a lot of "I suspect such and such, but I will
confirm this with a senior and let you know". I also spent a lot of time reassuring her
about her concerns and going over the things that are the same for every operation
such as pre-op assessment.
Report: communication skills
Lesbian partner wants her girlfriend moved to a side room because the other patients
are being abusive. I explained siderooms were full, apologised, asked what else
would help and agreed to speak to my team, the bed manager and make it clear to
the other patients that they cannot be discriminatory. Discussed preventing it
happening again in future.
Report: delayed discharge
Communication- break the news that occuational health have been delayed and
elderly lady cant be discharged. She want a precise deadline which you can't give,
but can promise you will act right way and let her know. Also worried about her
daughter getting time off high-powered job and she beamed when I offered to write a
letter to her boss explaining the situation.
Report: breaking bad news: positive pregnancy test
Vignette says that the patient has missed a period, took a home pregnancy test,
which was positive, but wanted to be sure so had a blood test done. The results of
blood test confirm that the patient is pregnant, please tell her. Patient has 3 kids, who
are all grown up and at university. Wants to know her options regarding the
pregnancy and options regarding termination.
Report: inter-professional communication
Vignette says that a patient has complained to you that they had to wait a long time
for their pain relief and that when they received it, they felt the nurse was rough with
them. It also says that you find the nurse to be professional and nice. Quite an easy
station, nurse did not get upset, admitted she may have been rough with patient as
they are short staffed and she has had a long day with no break. Willing to apologize
to patient and tell head sister what has happened.
Report: asthma medication advice
Asthma, guy is not taking his brown inhaler as previously had oral thrush. Advised to
wash out his mouth and he was happy with this. Also patient is a smoker. Did not
want to go over inhaler technique
Report: cross cultural
Vietnamese man who's dad had a laparotomy and found to have metastatic cancer
currently in ITU and his son wants to have a discussion with you. Listen to the son's
ideas and concerns. Basically he wants to know if he can get monks to come into the
hospital to pray for his dad. Explain that too many visitors are not allowed in ITU (he
wanted to get 10-12 monks). Offer the hospital monks can come and pray and you
will find out more about it. He was agreeable to this idea. He then goes on to say he
would not like anyone to touch the body for 8 hours post death to allow the spirit to
leave. Said I understood his concerns and religious beliefs and explained that we
would need to confirm death. He wanted to know more about what this entailed and
was agreable after this explanation and then told him the body would then need to be
moved to the mortuary. I offered getting a monk from the hospital to come and have
a chat with him about his concerns.

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Student Reports on Finals: Communication Skills

Report: cross cultural
Diabetic Ramadan + chest infection. Complicated as had chest infection and had
hypos the previous week. Struggled to get across that he shouldnt fast and spent too
much time talking about if he did fast, how he could do it. Even said that a severe
hypo could be fatal and he still didnt get it until at the end I just said that he
shouldnt do it. Not too sure how this one went.
Report: cross cultural
Young man who dies and requires a coroners post mortem. He and his family are
Jewish and the dad kicks off about the rules of Judaism and burial and 'declines' the
autopsy. You must tell him he cannot take his son home in as nice a way as possible
and then explain that you will try and get things done as quickly as possible but make
no promises. Offer to contact the Rabbi, or offer him a phone to do so and offer to put
the rabbi in contact with the coroner. Reassure that the post mortem will respect his
son's body. Explain the importance of having a post mortem in young people in
whom cause of death is not known as it may be something genetic. He will shout a
bit but is not ridiculously over the top.
Report: cross cultural
Jehovahs witness father of 22yo daughter in car accident with pelvic fracture and
organ damage, going for a CT and to theatre. Be sympathetic and understanding
this must be really hard for you, and I understand this is only making it harder etc,
Said we will try and avoid having to do a transfusion, but lay down the law that if she
needs it to save her life then we will give her blood; he cant refuse treatment on
someone elses behalf. Very reasonable actor, though asked about police and what
we were doing to catch the other driver which I steered away from. Offered him and
wife could talk to seniors/chaplain later. I explained that she may die without
transfusion, explain there is no way a cell saver can be used in this case. Need to
ask about whether she has it in a legal document that she refuses blood or that she
has made him her power of attorney.
Report: breaking bad news- diagnosis of multiple sclerosis
Telling a patient, who works as a roofer, that he has MS. Again, Id practised this
loads of times but it still fell to pot. He wanted to know what the disease was, whether
it will be passed onto his kids and what to do about work.
Report: breaking bad news- abnormal barium enema
A woman has had a barium enema with a polyp seen- highly suspicious of a
malignancy. Break the news and explain need for a colonoscopy.
Report: breaking bad news- chronic renal failure
Patient with lethargy and tiredness. Results demonstrated increased creatinine and
small kidneys on USS. Patient was being very difficult. kept asking what does that
mean and what would happen. Told him I will refer him to nephrologist--kidney
doctors---told him regarding haemodialysis, peritoneal dialysis and still kept asking
me what is going to happen .Then he enquired regarding his job and whether his son
will be affected. Explained that in order for us to find that out we would have to do
other tests, to make sure it is not something genetic. I must say he did not like the
answer and was agitated regarding further tests.
Report: breaking bad news- need for amputation
Breaking bad news - amputation (BKA) for infected ulcer + ?osteomyelitis

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