Master the MRCPCH – Communication Skills
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Emma F: Hello and welcome to Master the MRCPCH. In this podcast, we tap into the expertise here at Great Ormond Street Hospital, giving you an overview of a topic on the RCPCH curriculum. You may be revising for an exam, or just fancy brushing up on a need-to-know topic. I'm Emma, an anaesthetic registrar and the digital learning fellow at GOSH, and today I am joined by the brilliant Dr. Kier Shiels, a consultant in general paediatrics at GOSH, textbook author and examiner for the Diploma of Child Health.
He is giving a masterclass on the communication skills station of the clinical exam, covering common scenarios that tend to come up, pitfalls to avoid, as well as some top tips for success. An essential for anyone sitting the clinical exam soon. We hope you enjoy the episode.
Thank you for joining us again today, Dr. Shiels.
Keir S: It's lovely to be here.
Emma F: So to start, what would you like people to get out of the podcast today?
Keir S: Now you see what you have asked there is a semi-closed question, inviting a very specific set of replies. And that's what I'm wanting to talk about. I'm wanting to talk about understanding how you talk to people, understanding what it is in the nature of a question and an answer that allows a clinical encounter to flow, specifically looking at situations that you may not be comfortable in or may not have done before.
Because they're gonna come up in the MRCPCH communications stations, and we all think we communicate all the time, and it's the area that I see people revising the least. And actually it's something that you still need to concentrate on.
Emma F: So firstly, do you have any general tips for dealing with difficult communication skills scenarios?
Keir S: I guess the first tip for dealing with difficult communication scenarios is to just pause and to try and make sure that the flow of your conversation is relatively slowly paced. You can come over as relatively authoritative, relatively knowledgeable, just by laying out things slowly, and it gives you thinking time, because when you absolutely rush things under tension and your voice goes really quick and everything starts blurting out, eventually you end up in chaos, and one sentence leads into another and everything ends up really unstructured. So, the first tip is to slow down, because it sounds better and it is better.
The second tip is to do more listening than talking. And this applies to all of the communication stations. Really they should all be an exercise in asking a question and listening, even the explanation and planning ones. And trying to work out where your simulated patient, or simulated parent, or simulated colleague is coming from. Learning about their situation and working out how you can help them.
And then the final thing is to underpin it all by knowledge. You are actually going to be tested in communication about either knowledge or real world process. And so try to make sure that you bring some of that in, so that you show yourself as knowing what to do, because that's being helpful. So those are the four things.
Emma F: So they are some general tips. I suppose your other advice would vary according to the actual scenario that was being tested. What are some common scenarios that come up frequently in the communication skills station?
Keir S: So sometimes in these sorts of situations I like to ask students to put on a different pair of shoes and sit briefly in a mixed metaphor - I dunno why you're sitting in shoes - but sit briefly in the chair of the question designer and the examiner. And try to work out exactly what it is that examiners want out of candidates. And the classic mantra of the MRCPCH is that it is supposed to test your ability as a registrar. And of course, the problem is that the people who are sitting the exams are not registrars.
So there will be some clinical situations, some communication stations that are not strictly speaking clinical, where you may not have actually been involved in those sorts of conversations before. And they're not curveball questions. They're not unfair questions. They are questions that are written entirely within the guidelines of the exam, but they're things that you should be prepared for so that they don't turn up as a surprise. There are some really good books that can give you practice communication stations, but everything is going to reflect real life for an on-call paediatric registrar.
So there will be stations around history. There will be stations around difficult consultations about explanation and planning, just like there are for OSCEs at medical school. But they are going to be the next level up. They're not going to be basic, "take a history" or basic, "explain what the risks are of meningitis in a febrile baby, and why you need to do a septic screen". It's going to be that next level up because you are testing knowledge that shows that you're fit to be a registrar, and so you've got to make sure as an SHO that you are prepped in these registrar-level conversations, that they're the ones that sometimes you deliberately don't have and ask your registrar to do for you.
So topics that can come in, in sort of history taking, might be taking histories, but taking histories from adolescents, or taking a safeguarding history, taking a history from an adolescent who you've got to sort of do a heads assessment on, or something very paediatric-specific. Examples of explanation and planning might be about the risks of a premature delivery, or again, explaining why you are going down a safeguarding line. You might get something that's sort of SHO/reg border-line like talking about febrile convulsions and why it's not epilepsy, and why you're not worried about meningitis. But I think it's worth just bearing in mind for all of the classic type of stations, that you're going to get something that is just that little bit more advanced than maybe you were used to at medical school.
Emma F: Are there any other ways that it's different from the medical school OSCE?
Keir S: Yes. So the other thing that you've got to bear in mind, is that there are additional sorts of stations in communication that are totally reasonable reflections of life as a registrar, but that you won't have come across in medical school. So for example there may be a more professional communication that you've got to do, which could be teaching a nurse or a pharmacist or a junior doctor about something. It might be that you've got a junior colleague in difficulty or conflict resolution.
I work with an actress and we teach communication skills for MRCPCH, and one of the situations that we've got is of an F2 doctor who's desperate to do paediatrics, and has been going around basically falsifying the notes, writing the correct diagnoses against her clerkings in hindsight, in an attempt to try and make sure that the patient's notes are a good reflection of her clinical abilities, rather than an accurate reflection of what she was thinking at the time. And you as a registrar have identified this and need to talk to her about it. Now, that's a discussion about professionalism. It's a discussion about the culture within the department, and whether she feels that she is being almost coerced into doing it by a culture of senior doctors who are not supportive, or who are being dismissive and looking down on her. There is a discussion within that about needing to raise this with her educational supervisor, but also how to use her portfolio to reflect very positively on the fact that she has got insights now into what the expected levels are for her at her level. And also a little bit of discussion about her ongoing family problems at home. Now that's a sort of little nine minute supervision really. But it comes from the sort of conversation that a registrar can have with a junior colleague that you may not have had before.
Emma F: And are there topics that are likely to come up that you would need to be hot on?
Keir S: I think in terms of topics that are likely to come up, almost anything is game, but I think the thing that you probably need to make sure that you have really got a handle on is child safeguarding, because that is another example of something where you will have done your level three safeguarding as an SHO, but you may well never have done a safeguarding medical. You may never have had a safeguarding discussion. You may never have been in the strategy meeting. Because you may have just been running around the wards doing all the ward jobs, titrating oxygen, and doing blood tests while your registrar or consultant was involved in the safeguarding and strategy stuff. That can very easily come up and it would be a reasonable question to have a child with a toddler's fracture or a child with unexplained bruising, and have to talk to their mother about safeguarding assessment needing to be done.
You can imagine that going one of two ways. Either having a mother who was very compliant and it turns more into an explanation and planning situation, or it turns into a sort of conflict resolution thing. A parent gets very uptight and defensive. So I think that safeguarding is something you really need to look into in order to understand the processes that you are going to go through and that you're going to have to explain.
Emma F: And are these clinical exams assessed any differently from communication skills stations in medical school?
Keir S: Yes they are. As a simple example, you're not going to be assessed against a long checklist of whether you have washed your hands, whether you have said hello, whether you have introduced yourself, whether you have offered them a patient information leaflet. It's not as prescriptive, and not as easily learnable as a checklist as medical school OSCEs are. Ultimately you are examined in really only two blocks. You are examined on your knowledge, and whether you have imparted the correct knowledge correctly and accurately, and you are also assessed on the manner in which you've done it, and that includes your demeanor. It includes your level of authority, it includes your ability to chunk and check, and sign post, and all of the sorts of stuff that you will have learnt in the Cambridge-Calgary model of how to perform good communication. But if I can give one example about how things are different, it really pertains to your level of knowledge and confidence, and some of the safety nets that you can't really just abuse anymore.
I think that ultimately at this level, you can't rest on the laurels anymore of just saying, "I will consult my local guideline and get back to you", or "I will consult my senior and get back to you" on matters of protocol that you should know. It's totally reasonable to say, "I'm gonna start antibiotics. I've just moved to the trust. I'm used to starting Ceftriaxone, and I'll, double check that that's the right thing with my local protocol". That's fine - you are giving some information that's within your sphere, and then you're saying you're checking it. It's not good enough to say "I don't know whether this is a safeguarding situation or not, and I need to go away and check". That level is down in the borderline and fail section unfortunately. So you've got to have a really good command of protocols and guidelines. And if you are going to fall back on the sort of safety net of asking somebody something, you've got to be clarifying something that you have definitely said, rather than just throwing in that you're going to ask because you don't know.
Emma F: Are there any pitfalls that candidates should be aware of, or mistakes that you see people commonly make?
Keir S: The pitfalls fall into a couple of different categories. There are some pitfalls that anybody can fall into, but there are also some pitfalls that people for whom English is their second language, needs to be more aware of than people for whom English is their first language. And one of the things that I would really recommend is that anybody, but particularly those for whom English is a second language, make sure that their vocabulary is broad enough and moderated enough to be jargon-free.
Now it is very easy when you work in a professional environment to talk about abdomens and culture swabs and so forth. And one of the things that I find examining as well as teaching is that people for whom English is their first language, seem very easily to be able to talk about tummies instead of abdomens, and the "stick-in-the-nose test" or something like that for a per-nasal swab or something like that "we'll put a little cotton bud in your nose", or "we'll take a snot sample". I think that one area where you do have to be careful is making sure that you don't come over knowledgeable about medicine, but looking as though you can't actually talk to a human who is in crisis or who is worried. And measuring that vocabulary down a little bit to a more human and a less scientific vocabulary is really important. And I think there are quite a few people who don't necessarily realize where the boundary is between scientific vocabulary and general vocabulary. So that's one point.
I'm not meaning to pick out people who have come from overseas here. It is a fault that everybody can make, but it is one that is disproportionately made by people for whom English is second language and it's one that I would encourage people therefore, to sort of research and look into, and ask for feedback from either the patient's parents, or from their colleagues because it's something that people will not probably be giving you feedback on, and you need that feedback and it's only by being taught and encouraged that you will actually learn. So request feedback about that in particular.
The other common pitfalls that apply to everybody is that you feel that you're on show and that the exam situation is about assessing you, and therefore you have to do the talking. And that's actually not true. It's really important to give long pauses for the actor to respond. It's really, important to make sure that the actor does most of the talking and that you then feedback based on what they've said, that you are exploring issues. And even in explanation and planning, you ask people what they are particularly worried about. You pause in the middle of a sentence when the actor's body language bristles, and you say, "Have I said something that's made you uncomfortable?" or "is there something that you want to say?" You have to make sure that you don't go into performance mode too much and just end up with a stream of consciousness.
The last thing that it is really important to do is to answer the actual question. Now when you go into a station for communication, it will say "take a history from Person X" or "explain to person X that their child has down syndrome", or explain more likely at this level that "a diagnosis of Down syndrome has been made, explain what the next steps are to this family". It won't just be a sort of breaking news station, it will be an actual "Do you know what the stages are now of admitting this child to SCBU or not, and feeding by NG tubes or not, and what blood tests to do?" and all the rest of it. I have seen so many people fail communications stations because they've been asked to explain something, and then they go in and they take a history. I've seen so many people fail because they have been asked to explore what's been going on with their colleague and have turned it into a teaching session. You can only be rewarded for answering the question, not for talking and listening. Make sure if you can take notes and take them in that you write the question in big letters at the top, and also the patient's name because I always forget that in exams, you're so rattled about trying to remember whether you test for thyroid disease or not, the fact that their child's called Derek suddenly goes out of your head and you end up talking about "your baby", because you can't even remember whether it's your son or your daughter. And just make sure that you've got some notes there that help prompt your actual fluency, not just your structure.
Emma F: And is there anything that you could do to rescue a station if, for example, you got halfway through and just thought that things weren't going very well?
Keir S: I think the honest answer to that is exactly what you would do in real life, which is actually sometimes just to take a pause, take a little breathing step, and then just summarize where we are so far, and if you feel that your patient is annoyed with you or angry with you, do apologize and take a step back, and go "Look, maybe we haven't got quite off on the right foot, and I'm sorry if I've phrased things in a way that hasn't quite worked. Let's just go over where we are so far and what we still need to discuss, because I want to make sure that this goes right". And slowing down and summarizing really is helpful, because it gets your thoughts back into some sort of logical pattern.
The other thing to bear in mind though, is that things might not feel like they're going well because they're not supposed to go well, and an example of this would be when I did the MRCPCH, one of my clinical scenarios was about a 14-year-old girl with Cystic Fibrosis, and you were telling her that she had to come into hospital. And she didn't want to come into hospital, and it was about explaining why she had to. But she was a very sad, very miserable, very depressed 14-year-old girl who wouldn't actually say very much. And she absolutely didn't want to come in. And you felt that you were fighting a losing battle.
Ultimately, looking into the mark scheme after I passed, which was a relief, the point was not actually to get the girl to say yes. The point was not to persuade her that she had to come in. You didn't win the station by her saying yes and lose the station by her saying no. It was an assessment of whether you were delivering the correct information in a manner that was appropriate for delivering things to a sad, lonely, sick teenager who didn't want to come into hospital. And so actually some people persuaded her to say yes, some people didn't persuade to say yes, but that didn't alter whether you got a top mark or a middle mark or not. So it's perfectly possible that you will have a situation for which there is no sort of direct end point, that coming to your ninth minute, you just need to summarize something and say, "I can see you need a bit more space", or "I'll be talking to your parents". There may be uncomfortable things that you have to say that you don't want to, like when you're talking about Gillick competence saying, "Well look, you can consent to treatments, but you can't actually refuse them if they're in your best interests and we can do things against your wishes, actually". Which seems unfair, and maybe it is unfair, but that's the law. And trying to find a way to phrase that in a way that is sensitive and non-coercive and non-threatening is challenging. But it's a perfectly reasonable thing for a registrar to have to say to a teenage girl who doesn't want to come into hospital.
So I guess those are my two tips. Number one - take stock, repeat, slow down and restart if necessary. But the second is, bear in mind that the end point isn't necessarily to win or lose the station. It is actually to deliver the correct information in a way that's sensitive. And if you are doing that, even if it feels uncomfortable, you are still actually achieving the marks.
Emma F: And moving on to our final questions. Are there any classic exam questions that pop up about this subject?
Keir S: Do you know what? I've done enough of these podcasts now to know what these three questions all are that you are about to ask me, and I'm going to be really naughty and I'm going to take issue with the format of the question, which is something that you should only do in A-level and you shouldn't actually do at membership level, but here we go. I think that there is no sort of "classic" topic that you should look at more than any other, but I have flagged up in previous answers the fact that you need to look at some stuff that maybe you haven't actually covered before, like safeguarding or like dealing with colleagues in distress, et cetera.
But your next question is going to be about resources, useful resources that I would recommend. And so I want to bring the answer to that question into this one, which is actually to get out or at least look at a couple of MRCPCH clinical communication guides, because there are a couple on the internet, on FOMeds, so free online medical education resources, and also produced by the Royal College. And they've got samples of their examiner's mark schemes as well. And by looking at a whole load of past questions or sample questions, you will get the idea of some of the situations that you feel that you would be comfortable with, and others that actually you might take a step back and go, "Hang on, I haven't really done a dietary history for a kid with coeliac disease before. What on earth is that? Other than what do you eat and when do you eat it? I need to look into that".
It's also worth looking and I'm maybe going over a bit of repetitive ground, at a certain podcast that a certain general paediatrician did about how to do communication with adolescents, because that may well turn up, and I've done a podcast on the HEADDSSS assessment and the mental state examination, which I think ties into this quite nicely. I've now only left you with one more question instead of two. I'm sorry.
Emma F: Yeah, you've stolen my second question. So the third question is, what are your three takeaway learning points?
Keir S: So the three takeaway learning points are, number one, clinical communication is not simple just because you've done a lot of it. There will be stuff that you have not covered before that you need to learn, and you will need to get feedback on the way that you actually currently do your communication, because it's probably not as registrar level as you necessarily think it is.
The second point is that in order to do well in the communication skills stations, you need to deliver the correct content in the correct manner. That is how you get the marks, and it's not just a checklist of washing your hands and falling into the safety nets of saying, "I will give them a leaflet in case I've forgotten anything", and "I will ask a microbiologist" in case I don't know what the correct protocol is. You've got to know your stuff and you've got to say it sensitively.
And then I guess the third thing is about knowing what your own faults are. And that comes from informative feedback that you need to get either from training or from CBDs and CEXs and that sort of stuff. And most people will generally be quite positive about people's communication styles, and you really need to turn to whoever's assessing you and say, "Look, I've got my exams coming up. I realize that you think I'm being nice, and I've asked appropriate questions, et cetera, but I really need you to hone in on some really specific feedback". And that includes particularly the use of jargon, and people need to be aware of when they're not aware that they're using jargon, as it were. If you know the word tummy and you know the word belly and you know the word abdomen, you should have an idea of which one of those is jargon. If you only really use the word abdomen in normal conversation, you probably won't realize that it's a scientific word and that you need to moderate your vocabulary. So those are my three tips.
Emma F: Thank you so much once again for coming on the show today. As ever, it's been brilliant talking to you.
Keir S: Thank you. I think it's not been the hallmark of great communication for me because I should have been listening a lot more than talking, but there you go. We've all got something to learn and reflect on.
Emma F: Thank you for listening to this episode of Master the MRCPCH. We would love to get your feedback about the episode and get your ideas for future topics that you would like to hear covered. You can find a link to our feedback page in the description for the episode, or email us at
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