Scenario 1

Question 1

Overview/Introduction

Answer 1

Divide into before (preparation), during conversation and after.
Aim is to understand the patient and why their view is at odds with the teams.
o Understand patients care/management plan. Whether this has been appropriate or not.
o Understand source of patient’s grievances. May be a genuine failure of care that needs escalating.
o Then try to achieve a consensus. Come to a collaborative plan than bridges the gap, if a patient has capacity and disagrees with their treatment they are unlikely to comply.

Question 2

• Before – Preparing

Answer 2

o Described as complex – important to gather as much information as possible. Bio/Psycho/Social and 5Ps formulation of issues.
Regarding:
* Diagnoses
* Treatment history/past psychiatric history.
* Psychological formulation -consider patients relationship with care, reflection of trauma, transference and personality? What about teams dynamics?
* Social history
* What has worked well or poorly in the past.
From:
* Case notes/letters
* Discussion with MDT colleagues
* Contacting other services e.g. (GP/CCO/Social Services/Third sector organisations)
o A good understanding will give me confidence going in and also reassure the patient I have taken the time to learn about them.

Practicalities

o Consider risk assessment and setting of interview
o Consider barriers to communication e.g. language, intellectual impairment, hearing or vision impairment
o Could ask family member, trusted staff member or IMCA to join (but mindful of confidentiality/GDPR)
o Could ask another team member to join to support me e.g. psychology/OT to provide another perspective and chaperone.
o Make sure interview is in a quiet place where won’t be disturbed with sufficient time.

Question 3

During conversation

Answer 3

o Introduce myself, explain who I am and that I will try to be impartial and want to understand their concerns.
o Solicit patients perspective and concerns.
* Understanding of their diagnosis and current treatment?
* Unmet needs or desired treatments?
o Communication skills:
 Open questioning and body language
 Active listening
 Reflecting and summarising
 Eye contact
o Keep tone empathetic, non-judgemental and responsive.
o Validate their distress is acknowledged – may be genuine failings have occurred.
o Summarise their concerns
o Next steps:
 Explain desire to take back to MDT to discuss
 Don’t make promises you can’t fulfil RE: plan.
 Offer to schedule another appointment to follow-up, could invite family too.
 Signpost to other sources of support/information
 If they wish to formally complain direct to PALS

Question 4

After

Answer 4

o Clear and accurate documentation
o Discuss with supervisor/MDT/seniors in the first instance. Explain patient’s concerns.
o Could take to a complex case meeting/grand round/Balint for further perspectives
o Consult guidelines e.g. NICE/BAP/Maudsley
o Second opinions/Specialist teams
o Reflect

Question 5

Q1 - How would you respond to the patient and give an example of what you might say?

Answer 5

Hello my name is Dr. Wellby and I’ve recently taken over your care. I understand you’ve been unhappy with your care and I’m sorry to hear that. I’d really like to understand your concerns so that we can work together to try to find some solutions to this, would that be okay?

Question 6

Q2 - How could good communication skills help?

Answer 6

o Communication skills:
* Active listening
* Open body language and questioning
* Empathic tone
* Eye contact
* Reflecting and summarising

Benefits

o Helps to gather information from patient
o Build rapport and trust - allows for collaborative care plan later.
o Make them feel understood, feelings validated. Neutralises anger.
o Help to communicate ideas to patient e.g. about diagnosis or treatment options

Question 7

Q3 - What challenges might this patient present with and how would you respond?

Answer 7

o As acknowledged the case is complex. Can be understood through Biopsychosocial and 5 Ps formulation.
 Bio – treatment resistance, medication side effects, compliance, physical health, breastfeeding/pregnancy, substance misuse.
 Psycho – trauma, transferance reactions, lack of insight, negative history with services
 Social – stigma, family input, social isolation, poverty, cultural issues, homelessness, domestic abuse.
o May be that patient has preconcieved treatment ideas or agenda at odds with ours.
o Patient may elicit strong transference reactions in professionals, worth thinking about. Note that team feel she is ‘complex’.
o Patient may be challenging in consultations. May be splitting.

Response
o MDT support important to share understanding of presentation, solicit different perspectives, share risk
o Could consider a multi-agency professional meeting.
o May benefit from discussion at complex case forum/grand rounds/Balint
o Formulate thoroughly
o Reflect on difficulties/feelings

Question 8

Q4 - What kind of support might you need?

Answer 8

o Discuss with supervisor/MDT/seniors in the first instance.
o Complex case discussion/grand rounds/Balint.
o Reflective practice with team.
o Consult guidelines e.g. NICE/BAP/Maudsley.
o Local resources/third sector organisations.
o Second opinion/specialist advice.

Question 9

Q5 - After working with the patient for 2 months, you receive a complaint. What would you do?

Answer 9

o Understand the complaint.
o See if need for duty of candour or letter of apology
o If legal issue then contact trust legal support team and indemnity provider.
o Engage in complaint investigation process. Learn from this.
o Understand if complaint personal or systemic.
o If systemic consider audit or QI project to address
o If personal seek further feedback from colleagues/supervisor to improve
o Consider may need to transfer to a different team/clinician
o Seek personal support from supervision/reflective practice/Balint
o Reflect on in portfolio
o Look after own mental wellbeing if stressed
* Legal
o Do they want to make a formal complaint or happy dealing with informally?

Question 10

Q7 - The family disagrees with the patient, how would you proceed?

Answer 10

o If patient has capacity and not under section/CTO ultimately their choice on treatment.
o Ideally would all be agreed though - carers support important as part of triangle of care.
o Offer family separate appointment to discuss concerns.
o Offer family the team/OOH contacts so they can share concerns.
o Offer family further support e.g. carers groups, family therapy or carers assessment - may be lack of support is main issue.

Question 11

Q6 - The consultant tells you this is the best treatment plan and the patient disagrees, what would you do?

Answer 11

o Try to understand what the patient disagrees with. Understand their wishes.
o If appropriate offer psychoeducation to help patient understand rationale for treatment.
o Try to find compromises e.g. alternative formulations/similar treatments e.g. antipsychotics/depot
o If no success review other alternative options with team/consultant
o Consider seeking a second opinion if appropriate