framework to work in some of the interpersonal skills that we'll talk about throughout the audio book.

So that's your first half working out the issues of the situation,

The second half is:

Chuck and check technique every time you say a couple of lines you just stop and make sure the
patient says something back

Say a couple of lines does that make sense Mrs. X? Sure doctor

A couple more lines how does that sound so far? Great doctor

A couple more lines any questions? no doctor

How does that sound?

Am I making sense to you?

Let me know if I'm going too fast?

Any questions so far?

mrs. X I can see that you're holding your arm is everything okay

mrs. X I can see this is very difficult for you I can see a really embarrassed with the situation

mr. X I can see this is really frustrating you I know the questions that I'm asking you are quite annoying at
times

mr. X how is it affecting you at work have your bosses talked about this

mr. X you mentioned work I'll come back to that in a second that's obviously quite important

Mr X I'll come back to your work in a second

mrs. X when it comes to indigestion there's a few specific questions you like to watch just to make sure
everything's okay

mr. Eckland people come with coughs there's lots of different causes just wondering we had any thoughts
as to what was going on yourself with this cough
Mr. X u r right cough can be a really clear sign of infection and it right it could be some of them we need to
look into

Mr. X is there any particular thing worrying you about this cough

Mr. X you’re absolutely right I mean coughing can be a sign of lung cancer, and it's really good that you've
come to check this out, but just so you know lung cancer is quite rare but we'll certainly make sure it is
nothing like that before going forward

Mr. X when you came in of course we're gonna try and check you over and see what's going on. Was there
anything maybe you thought that we could do for all of this today

absolutely I mean antibiotics we do use for certain types of chest infection so maybe wants to examine you
and check to over we can see if that's reasonable or not

I can see how difficult this has been for you

I can see it's been a really challenging time for you

1- angry patient scenario number one

look it may be difficult to carry on like this should we sit down and see how we can help best

Mr. X I can see this is really frustrating you at this point.

Mr. X I can clearly see that you're annoyed by the situation

Mr. X I am so sorry, I know I'm irritating you by all of these questions. we're almost finished

you're right your medication is really important it's really important that we get medication on time and
this is something that we often aim for

Mr. X how can I think about helping going forward. What can I do to try and make sure that we can resolve
the situation?

Mr. X let's see if we can move this situation on. How about I do X Y and Zed.

Mrs. X let's see if we can resolve this for you how about I talk to so-and-so in order to move the situation
forward.

look after this I promise I'll going at your medication straight away
after this discussion I'll go and get your x-ray and I'll discuss it with you

discussing it with team members talking to senior members of staff filling out a significant report form
discussing in a clinical events meeting

2- scenario 2 looks at a patient complaint

I can see that you're really frustrated about what happened it seems like it was a really challenging
situation for you

I'm sorry that you felt that they were rude to you

Mrs. X I can see this has been really frustrating for you and you're really annoyed by this but unfortunately
I can't go over details myself because I wasn't aware of what happened or wasn't witness to the situation I
need to do a little bit more looking up of things myself and then perhaps we can have a more detailed
discussion again

Mrs. X you're absolutely right you have every right to complain if you wish

“Mrs. X would it help if I discuss the situation with the colleague who was involved”

“how do you think Mrs. X I could help resolving the situation for you is there anything you think that I could
do to take the situation forward to aim that doesn't happen again”

Scenario 4: palliative care or end-of-life care

Rapport
please take your time there's no rush Mrs. X you're my main priority at this point please feel free to tell us
what's on your mind

ICE
Mrs. X I can imagine there's quite a few things going through your mind at the moment do you might tell
me what really matters to you at the moment and how do you think we can help you best at this point

EMPATHY
mrs. X I can see this must be a really difficult time both for you and for your family

mrs. X seeing family members in this situation can be a real challenge and I can see it's been really difficult
for you and for the rest of your family
OFFER SUPPORT
“would you like me to speak to your son or your daughter or your sister sometimes that can really help in
these situations

mr. X please don't feel alone in all of this there are many ways that we can support you there are many
people that can support you there are many people who are very good at understanding some of the key
things that you're going through at this point

mrs. X I know this is a difficult topic but I wonder if anyone has spoken to you about what would happen if
things dropped to progress quite quickly

5- Scenario 5 is looking at a patient who refuses a particular treatment

mr. X you're absolutely right I mean you have every right to be involved in your own treatment and no one
can force you to take any type of medication it's our job I think as doctors to go through the pros and cons
and make sure you understand that and then allow you to cover the decision yourself

I'm not here to try and change your mind or enforce something on you

mrs. X do you mind your telling me why you don't want the treatment does the medication concern you in
any way

Mr. X I can see that your job is really important to you and I can understand how you think how low sugar
levels because of a medication may cause problems for you

Mr. X I can see how you may feel against these medications given that your friend had all of those nasty
side effects I can completely see where you're coming from

Mr. X the reason that we usually give for example steroids in this situation is that if we don't treat temple
arteritis with steroids potentially you could lose your vision

Mr. X I'm not 100% sure about the rules around this medication maybe it's okay how about I look into the
rules for you maybe there are specific rules or allowances for these types of medications let's look into it in
a bit more detail
is there anyone that you know that might have a bit more knowledge about this than you perhaps one of
your bosses or do you have someone at work who looks into these kind of things

this is not something that I come across every day let me have a little bit of a look on the internet or
perhaps talk to one of my seniors about it perhaps there's a way that we can work around this

6- Scenario 6: patient wants to leave hospital against medical advice

Mr. x is there any particular reason that stopping you from staying in hospital today is there any way that I
can help with certain things that may be causing you to need to go home

Mr. X I can see how you may feel like this no one wants to be in hospital at the end of the day I know
you're close to going home everything else has been sorted out this is the last thing that you'd want to
have some chest pain and have some further tests I can see that it's a real inconvenience to you and let's
see how we can make it be as quick as possible again

Mr. X I don't want to worry you too much but the reason we want to keep you in hospital and do these
tests is that sometimes chest pain can things going on in the heart things like heart attacks and we need to
make sure that that hasn't happened

Mr. X I don't want to worry u too much but if it is things like a heart attack that potentially they can be life-
threatening and it's really important that you understand that

ok I can see that you still wish to go home you know we can't stop you like we explained but could we at
least have an alternate plan in place because I'm still worried about you

Scenario 7 involves adult safeguarding

Mrs. X do you have any concerns about going home

do you feel safe at home

you seem a little frightened when I mentioned going home tell me a little bit more about what's going on
at home yourself

everything you say is confidential in this room unless there's concerns about your safety

please take your time don't worry we're here to help you it's normal to find these kind of things difficult to
talk about
Mrs. X is something that you don't need to put up with at all stealing is a criminal offense this is something
that the police deal with all the time so please don't feel you're alone in all of this

I can see how this is going to be very difficult with it being your own son

I'm really sorry that you're going through such a challenging situation unfortunately this is much more
common than you think it may be I don't think you're alone in this situation

Scenario 8 dietary counseling

Mr. X there are many benefits that you may find through changing diet things like your cholesterol may be
reduced your weight may come down you may feal you have more energy for example

Mr. X if you continue with your diet as it is unfortunately there are a few negative implications your blood
pressure might continue to rise your cholesterol would likely go up your weight may go up as well all
increasing your risk of other things like heart attacks and strokes

I can understand it's really difficult to achieve a balanced diet with modern-day challenges you mentioned
canteens they serve unhealthy food you're absolutely right it can be difficult when all this in front of you is
unhealthy habits are really difficult to change we appreciate that but sometimes smaller but regular
changes that don't impact you so much can be easier than big changes

Mr. X one of the reasons we're talking about diet change is to reduce your risk of having another heart
attack

You mentioned your wife and your family Mr. X could your family potentially get involved with this
sometimes having family mealtime or cooking meals together can sometimes make a big difference

Mr. X is there another way that you think we can support you here sometimes talking to other people can
help in making these changes

Scenario 9 bereavement (very challenging)

I'm very sorry to hear of your loss losing someone's parent can be a very difficult time and I can see it's
been a challenging time for you

Mrs. X is really quite normal for you to feel as you do I don't need to feel guilty for feeling how you are at
the moment such a huge loss will inevitably cause pain this is something that is very normal and is in fact
part of the healing process
It may be worth going through the five stages of bereavement

1- Denial

2- Anger

3- Bargaining

4- Depression and finally

5- Acceptance

I can see that you're finding it very tough at the moment I can see she meant a great deal to you

Mrs. X is there anyone else that you think you may feel able to talk to at this point is there anyone else so
you think we could put you in touch with, would you like us to offer some support suggestions there are
many available for this type of situation

Scenario 10 the angry relative (challenging)

I can clearly see that you're angry I can clearly see why you are frustrated about what happened

Mrs. X I know it's really frustrating but I do need to check that we have permission to discuss your father's
medical records

“Your father has had a stroke is a big thing and I really can see how this is a difficult thing to take in.”

“Mrs. X seeing your mother have a complication of an operation is a very big thing and I can see that you're
frustrated about it.

“would you mind if I looked into the situation a little bit further I think some of the details needs to be
clarified as I wasn't involved in the bit that you're talking to me about

Mrs. X it's actually very important to us that we minimize harm and suffering for our patients this is the last
thing that you would want to happen to your mother

I assure you that we will look into this fully but if you wish to take this further then of course I can explain
the complaints procedure to you that's your right and I'm happy to go through things in this regard with
you

How can we take it from here how can I improve things how can I look into it in more detail

Scenario 11 is looking at a missed diagnosis

I can see why you're so angry about this it is natural to feel like this when it comes to your own child

Can I just check how your son is doing at the moment I'm really glad that he's feeling better

unfortunately I wasn't present at the time so I'm gonna unable to comment on what happened without
knowing more details anaphylaxis is a condition that can present in a number of different ways and it can
be difficult to pick up early on but yes is something that we need to treat very quickly when we pick it up

you're perfectly right to question what happened these things are taken very seriously and will be
appropriately looking into this like we do with all situations of this nature I can inform you of the complaint
procedure if you wish to know this

normally in this situation we write this up as a formal event we discuss with all members of the team and
we see how you can learn to make sure this thing doesn't happen in the future

we will keep you informed of all developments as they happen we'll keep in regular touch with the son to
make sure he's improving but please don't hesitate to contact us with any other queries or questions that
you might have going forward

Scenario 12 domestic violence

mrs. X can I just ask how your relationship is can I ask if you have any arguments when you have
arguments does he get angry and when he gets angry what does he do

mrs. X how does it make you feel when all these things happen to you what are your views on whether
these things are right or wrong

are they his or her children

has he or her ever hit the children himself

are the children ever around when this is happening

mrs. X this is actually illegal you really don't need to put up with this this is not your fault at all and you
don't need to blame yourself

we can help in any way that you think we can

have you ever considered approaching the police for example

we can contact the relevant people for you if you think this is easier
scenario 13 is looking at sexual history taking
mr. X when it comes to symptoms like these there are a few personal questions that we may need to also
throughout the consultation and might be asking you a few

mr. X I'd like to ask you a few symptoms that can present with infections down below if that's okay

Mr. X I'd like ask a few questions about your partner and your partner history if that's okay

I can see that you're a little embarrassed Mr. X to be honest we see this tightening all the time as doctors
please don't feel like that

your symptoms are actually really common and things can be easily done about them

I can see that you're really uncomfortable here would you prefer to see a male or female doctor

1- If an STI has been diagnosed or likely has treatment been talked about

2- If you're talking about treatment of an STI have you talked about the partner and need for contact
tracing and

3- if one form of STI have been diagnosed has this person had a full screen for all potential STI’s

scenario 14 is looking at consent and capacity

remember at age 16 and beyond someone is presumed competent to make decisions about their
healthcare

Below 16 you need to be assessing for Gillick competence and there are four components to think about
remember for competence:

Can this person understand the information you're giving to them

Can they retain the information you're giving to them

Can they weigh up the information you're giving to them

And they can they somehow communicate the decision to you

John can you tell me what you understand about what we discussed today

John I've mentioned quite a lot of things there could you repeat what I've talked about so why now I
haven't confused things

John are you able to tell me what's running through your mind at the moment what kind of things are you
thinking about

John are you able to tell me what you have decided

when it comes to treatment refusal however things change a little bit if a young person refuses treatment
which may lead to their death the decision can be overruled by the Court of Protection also the parents of
a young person who's refused treatment may consent for them but usually getting legal advice is better in
this situation

scenario 15 patient worried or anxious about a situation

mrs. X I can see why you may be so worried about the result of the blood test I can see why you may be so
apprehensive about having the procedure done it's perfectly normal

Jessica it's perfectly normal to worry or be anxious about this type of test just so you know we do several
of these tests every day it's quite a routine thing for us

Jessica the reason we do this is it give us lots of valuable information which will allow us to treat you as
well as possible if we can understand what's going on better then we can treat your symptoms and
hopefully your condition in a much more accurate way

it could all be nothing to worry about the result could even be normal and even if the result comes back as
positive would you not agree that it's a good thing to understand that as early as possible so we can get
the plan started and things moving as quick as we can

Scenario 16 is looking at non accidental injury Mrs. x can you take

me through what happened were little Johnnie we're just trying to put together the story as to what
happen at this point no one is blaming anyone else here it's just trying to figure out the steps of what led
to this

inconsistency with the story

delayed presentation to the hospital

and of course an injury that's not consistent with the story provided

then you may need to think about other things like the situation at home

who's at home for example what's the environment like are there other children around are there any
particular stresses going on at the moment is there a history of domestic violence in the house could it be
histories of financial stress what about habits things like smoking alcohol drugs for example

mrs. X I'm a little bit concerned the story that you mentioned doesn't seem to match up to little Johnny's
injury this type of injury doesn't usually happen with a story that you describe and our number one
concern has to be the child's welfare

mrs. X having assessed the whole situation I'm a little bit worried to be honest normally in this situation
what we tend to do is get an assessment done by someone with a lot more experience than we have I
think I'm going to have to go and get that done now

mrs. X actually that's not always true there no.1 aim is to keep children with their parents in fact they just
need to make sure what the environment is safe for that first

mum I know this is difficult but I think it'll be easier for you and the child if you're happier that's taking this
next step

Unfortunately I know it's difficult but given what's happened it's just not something I couldn't let go and I
need to take this further

Scenario 17 is looking at the psychiatric history

mr. X I would like to ask you a few questions about your thoughts and how you are feeling some of these
may apply to you some of them may not some of them may seem a little bit strange but please bear with
me they're quite normal questions in this situation

mr. X it might seem a little bit strange it's sometimes when people can feel a little bit down or a little bit
low they can hear voices of people who are not around at times is this never the case notice how this is

Mr. X sometimes when people feel quite low they can sometimes feel that life isn't worth it has that have
been the case
mrs. X to be honest these thoughts and symptoms are you having are actually quite common you're
certainly not alone in experiencing these there is lots that can be done to help your symptoms and I'm
really glad that you came to see us about them

mr. X are you aware that you are feeling like this are you aware that you're hearing these things or are you
aware that you're having these thoughts for example how do you feel about them when they happen

Mr. X sometime people feel like this feel a little bit low they can turn to things that they think may help
cope things like smoking alcohol even drugs perhaps I check into this case with yourself

mrs. X sometimes people benefit from talking through their symptoms to other people sometimes we
think about referring to a counsel and it can be very useful is that something that you think it may benefit
you

Mr. X I'm actually a little bit worried by the things that you've been telling me I would actually like you to
be seen by another colleague of mine on the same day if that's okay before you leave today

Scenario 18 is looking at the demanding patient

ACKNOWLEDGE

Mrs. X I know you really want the MRI scan I promise I'm coming onto that very shortly

mrs. X I know you're really keen on the scan I assure you that I'll get to it soon just a few more questions

ICE

Mrs. X can I ask why you'd like another MRI scan

what are the reasons behind your thinking there has anything changed since the last time we had a
discussion about this

has someone been through the pros and cons of an MRI scan with you were you aware some of the risks
associated with this
is there anything particular that you're worried about that has led you to wanting this scan

Mrs. X I appreciate that you want the scan I know that's something you want to talk about but
unfortunately for me to make any kind of decision or to sign any kind of scan form I need to get through a
few medical questions first I hope that's okay
mrs. X you're right when it comes to a cough we can do an x-ray this is a really good test to do but actually
sometimes we have things like CT scans we can show us a lot more someone who presents with a cough
maybe that's gonna be more beneficial so let me ask you a few questions first and figure out which is the
best investigation for you potentially there's something even better than an x-ray

mrs. X it actually now makes complete sense I can see why you want an MRI scan headaches are not nice
and brain tumors are things that people worry about so I can completely understand where you're coming
from with this request

mrs. X I'm really very sorry but I really don't think a scan is gonna benefit you in this situation at present
there are a lot of side effects of things like MRI scans radiation for example and our job is to weigh up pros
vs. cons and I don't want to do anything that potentially could lead to harm

now you mentioned that you worried about a brain tumor I'm really pleased to say from talking to you and
examining you nothing worries me about a brain tumor here and I can explain those in a bit more detail
and maybe some other steps that we can do that can try and take the situation forward there's a few
things that you've mentioned in your story that I think we can look at to try and deal with these headaches

Mr. x I really don't think that it's something that's gonna benefit you but look I know you're really keen for
this so let me get a bit of advice let me speak to my radiology colleague run through the story with them
and just see what they suggest it may be what their opinion on this

Scenario 19 a patient presents with possible depression

mr. X we actually see depression very frequently it could be considered a normal medical condition and
often people don't realize that they are depressed it oppressed for many years and cope with it themselves
I'm really glad you came looking for help we can often learn to cope with things when we don't have to and
I'm really glad that you came here so that we can support you

Mrs. X you’ve actually done nothing wrong to cause this depression often we have no control over whether
it comes or not

is there anyone who can turn to and home on a particular day what about at work mrs. X what do you do
there have you got anyone that you can talk to there for example

mr. X sometimes when people feel a little bit down or a little bit low they can start to feel that life isn't
worth living this has ever been the case
mrs. X there are several ways that we can help here when you from self-help talking therapies medications
let's find how best we can help you through this let's aim to get you back to how you used to be

Mr. X sometimes we can pinpoint why depression happens often we can't either way it can be treated

Mrs. X have you thought about anything that you can look forward to for example a holiday coming up

scenario 20 exercise counseling

mr. X benefits of you exercising may include reducing your risk of cancer heart disease and things like
diabetes

mrs. X unfortunately if we don't need to change your exercise plan you're increasing your risk of things like
cancer heart disease and even diabetes

mrs. X I can understand how it's a challenge to fit exercise into your normal day it's not easy to change
habits and I really appreciate that

mrs. x actually mentioned that you work 14 hours a day and you have a long commute to work I can
understand how it's quite difficult to fit in exercise time or gym time in that how about we think about
parking maybe a mile away from work and walking the rest of the way that way you get your exercise in
but it also doesn't disrupt your busy day

mr. X you mentioned that you work on the 15th floor I know you take a lift most days but maybe on some
occasions if you have time maybe go up to say the 13th floor and then walk a couple of flights each time
that way again you get your exercise but it's not interrupting with your busy day

mrs. X how about using a fitness tracker and set some daily targets often when we have things that we're
aiming for we find it more fun and enjoyable to reach and achieve those targets rather than trying to just
be more healthy

scenario 21 alcohol
mr. X how do you feel about your alcohol intake are you aware of any guidance about alcohol are you
aware of some of the effects that excess alcohol can have on our body for example
mrs. X drinking alcohol is actually a very common activity we're certainly not here to judge you we're just
here to guide you on its potential effect on health of course you make decisions about your lifestyle and
habits absolutely I think it's important however that we went through a couple of possible harmful effects
and then you can make their decisions in a much better manner

mr. X current guidance is to drink no more than 14 units of alcohol per week both for men and for women
and remember you should also have two to three alcohol three days per week

mr. X it may seem a bit of a funny question but is there actually a particular reason that you drink alcohol
could it be due to increased stress levels could it be due to boredom could it be simply due to habit could it
be peer pressure the people around are all drinking so therefore they do maybe is to help cope with
anxiety or depression maybe is used to deal with some chronic pain that they may be having

mr. X do you think you'd be able to reduce your alcohol intake at all how can we best help you I think it's
important that you consider reducing your alcohol for certain health band there are several health
implications of drinking too much alcohol and I'd like to go through some of them at this point

Scenario 22 is dealing with uncertainty

mrs. X I'll be honest with you I'm not hundred percent sure about what's going on here I think I can rule out
a few serious things I think I can rule out a few worrying causes but I'm not hundreds unsure about the
complete diagnosis we've got a bit of information here maybe if I have a bit of time I'll look things up get a
bit more information have a chat with one of my seniors and maybe get back to you with a more firm
answer

mr. X to be honest it'd be wrong of me to give you an incomplete answer or incomplete information at this
stage do you mind if I just go away and look this up in a bit more detail and come back to you with some
firm answers

Mrs. X I can see that waiting and not having answers is a real difficulty at present I know it's a challenge I'm
gonna try and do whatever I can to try to speed things up and get those answers for you I just don't want
to give you any incorrect information at the point

scenario 23 is the blase patient or the patient who just

does not want to be in front of you at this point
mr. X I can see that you really don't seem to want to be here discussing your diabetes today for example I
can appreciate there are many other things that you'd rather be doing than talking about your blood
pressure with me

so mr. X why do you think your diabetes is uncontrolled

mr. x you don't seem to be too concerned about a lot of things that we've told you about smoking in the
past is there anything that worries you about your smoking

mrs. X I know you really don't want to be here but now that you are here is there anything that you think
we could do to take this situation further

mr. X I know that you mentioned you were worried about your kidneys why don't we try and change him
so we can see what we can do to make sure we save those going forward let's have a look at things like
your weight or exercise to help try and save your kidneys long term because I know that's a big worry of
yours

mr. x I've got to be honest if we don't look at your diabetes and start focusing on some of the things in your
lifestyle who may end up losing your kidneys so that's something that we definitely don't want to do so
maybe let's try and make a plan to make sure this doesn't happen

Scenario 24 weight counseling

mr. X are you aware of the risks that increased weight can lead to when it comes to our health you
mentioned your diabetes are you aware how weight can impact with your diabetes control

mr. X the BMI is a measure of height against weight unfortunately yours does come into what we call the
obese category and this does come with some risks

Scenario 25 we'll look at the embarrassed patient

Mrs. X there really is no rush please do take your time I can see this is quite difficult for you to talk about

Mr. X I really can't see this is a challenge for you and I know it's the last thing that you want to be doing at
this point but I'm here to help you so please do feel free to let me know what's on your mind

Mr. X I just want to thank you for coming to the hospital to discuss this I know it can't have been easy I can
see it's been on your mind for a long time
mr. X what you're talking about is something really common you're certainly the first person to have this
we see this on a regular basis

Mrs. X please don't worry everything you say here today will be confidential

everything you say today is going to be confidential

Mr. X by far most things you tell me today are going to be confidential

Mr. X everything you say today is going to be confidential unless there's any risks to you or to others

how does that sound Mr. X

how is that sounding am I making sense to you let me know if I'm going too fast

Mr. X migraines a really common cause of headaches or gosh I can see why you're really worried and I can
see why thinking about a tumor might cause a lot of stress

Mr. X a bit of an odd question but sometimes things like smoking or alcohol can make indigestion worse
can ask give you do any of those

Mrs. X I can really see how this has been difficult for you

may be better than

I can understand how you feel