HOW TO TREAT 23 judgment and management. On the other hand, if the doctor keeps aloof from the child so as not to become distressed by the child’ s anguish, he or she may lose the sensitivity required of a child’ s physician.” 24
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HOW TO TREAT 23 judgment and management. On the other hand, if the doctor keeps aloof from the child so as not to become distressed by the child’ s anguish, he or she may lose the sensitivity required of a child’ s physician.” 24
Therapeutic consultations
Dr Winnicott’ s therapeutic consultations encompass a non-directive interview approach; that is, asking open-ended questions, offering general direction, but allowing the patient / parent to guide the process. 3 This is especially helpful during the first consultation, as the patient / parent tends not to be‘ defended’. The clinician listens and observes, clarifying and restating problems, and establishing a therapeutic relationship. There is often a wealth of information obtained during that first interview that may well include emotionally charged revelations. These revelations tend to become less frequent beyond the second or third interviews as the patients / parents become more defended. Further progress may only occur if one deals with the issues of transference and countertransference addressed if the patient becomes involved in ongoing psychotherapy with an appropriately trained clinician. 3, 25
PATHWAYS IN TRAINING AND PERSONAL DEVELOPMENT
ATTENTION to and education about communication skills are offered throughout one’ s undergraduate and postgraduate training. To that may be added other options often initiated by the clinicians themselves.
Colleges
Each college has core components with respect to acquiring the knowledge and developing the skills in communicating with patients. 11, 26 For example, in paediatrics, apart from specific lectures on childhood development, there may be a term in child psychiatry together with a further term in community paediatrics. That may be extended if the paediatrician, during their three-year advanced training component, elects to continue working as a community and / or behavioural paediatrician.
The RACGP curriculum and syllabus includes Domain 1: Communication Skills and the Patient-Doctor Relationship; this is addressed throughout its training program and explored within the context of the clinical scenario under review. 27 The aim throughout is to allow the trainee to acquire those skills under the guidance of their supervisor.
Associate Professor James Brown and Dr Anna Sallos of the RACGP have kindly provided information about the communication skills in the RACGP’ s GP registrar education program( see box 4).
Balint-type groups
These groups, led by a psychiatrist or psychologist and attended by likeminded clinicians, whether a group of GPs or paediatricians, are often very helpful and educational. 28 They provide a forum to discuss difficult patients( see figure 5) and how best to manage them. Experiences are shared and participants receive the support of their peers, with further elucidation of the psychological basis of the problem by the group
Box 4. RACGP’ s GP registrar education program.
Overview Communication skills are one of the important core topics addressed in all national registrar educational programs delivered by the RACGP. Communication skills are a key feature in all regional and local educational programs, and registrars are involved in educational interactive activities to practise these skills in simulated clinical scenarios involving patients of all age groups and demographics, including Aboriginal and Torres Strait Islander patients and those living in a rural community.
How communication skills education is included within an educational program is decided on locally, depending on the registrars’ learning needs and contextual considerations, particularly the communities they are working with.
GP registrars spend the majority of their training time in clinical placements, and this is where most of their learning occurs, and therefore the out-ofpractice registrar education program serves as an adjunct to complement their in-practice and self-directed learning. Important resources available to all GP registrars are:
• The RACGP curriculum and syllabus, which provide outcomes specific to end-of-training competencies in communication and consultation skills and
• Workplace-based assessments, where registrars receive focused individualised feedback on how they are meeting competencies in communication and consultation skills under a wide variety of clinical contexts.
Summary of how communication skills are addressed in the RACGP GP training program
When is education and training on communication skills addressed?
RACGP out-of-practice GP registrar education program
In-practice supervisor educational sessions and workplace-based assessments by supervisor and other independent GP assessors
Resources and self-directed learning
leader. 29 The insights so gained may extend to the care of all patients, including those with straight forward organic illnesses.
Supervision
Psychiatrists regularly supervise their trainees in the latter’ s ongoing management of one or more patients. 30 That is very seldom undertaken in other disciplines, where apprentice learning is generally the norm. Such ongoing supervision and the insights gained— if carried out, for example, within a paediatric setting— is often invaluable for the paediatrician in their dealings with the many day-to-day
23, 31 problems encountered.
This also applies to the subspecialists who often manage more serious illnesses that may evoke a
How is education and training on communication skills addressed?
Communication skills are addressed in all GP registrar education programs nationally and are an essential core area with nationally consistent learning outcomes( see below). Registrars attend workshops where communication skills are practised and assessed in peer-led small group learning sessions, simulated roleplays and case-based discussions. Regional education programs address communication and consultation skills in multiple contexts according to registrars’ learning needs, community health needs, as well as addressing culturally diverse and vulnerable population groups( eg, Aboriginal and Torres Strait Islander patients, people living in rural and / or remote communities and patients with a disability).
Observation of GP registrars during their consultations occurs throughout all GP term placements, both by the GP registrars’ supervisors and other visiting independent GPs with a focus on education. Multiple aspects of communication and consultation skills are observed, formatively assessed, and evaluated with the aim to support a GP registrar’ s improvement until the end of their training program. Multiple communication and consultation competencies are assessed that include but are not limited to the following:— establishing rapport— understanding and negotiating the doctor / patient’ s agenda— working in partnership with patients and their families to meet agreed management outcomes.
The RACGP curriculum and syllabus support all GP registrars in developing and refining their communication and consultation skills in multiple clinical contexts. This important resource provides multiple practice case examples for registrars to work through, suggestions for individual and small group activities, and recommendations for in-practice learning activities for multiple clinical contexts, and has a focus for each on the competencies needed for an appropriate consultation through effective communication strategies.
RACGP out-of-practice registrar education program’ s learning outcomes for communication skills Example of
Communication and consultation skills for complex clinical consultations, difficult conversations, breaking bad news and managing uncertainty.
Communication skills when consulting patients from diverse backgrounds inclusive of vulnerable population groups
Learning outcomes
At the end of this session, GP registrars will be able to: 1. Communicate effectively in challenging situations. 2. Communicate effectively and safely via electronic media. 3. Use appropriate resources to communicate effectively where there is disability, impairment or language barriers. 4. Communicate in a way that is respectful and responsive to the sociocultural context and beliefs of the patient.
At the end of this session, GP registrars will be able to: 1. Communicate in a way that is respectful and responsive to the sociocultural context and beliefs of the patient. 2. Incorporate sociocultural elements to tailor health education to the local context. 3. Consider the patient’ s level of health literacy, acknowledging that this factor can influence a patient’ s experience of illness and health behaviours. 4. Conduct a consultation that is aware and appropriate to the needs of the patient. 5. Listen to and acknowledge the illness experience from the patient’ s perspective.
There are more learning outcomes that address communication skills, and these include those related to:
• Aboriginal and Torres Strait Islander cultural and health training
• Patients living in rural and remote settings
• Motivational interviewing skills
• Abuse and violence
• Mental health
• Bullying, harassment and racism
• The business of general practice, including medico-legal considerations
• Professionalism— managing patient privacy, consent and confidentiality.
profound psychological burden. In addition, ongoing supervision helps the clinicians in sorting out their own feelings, as well as learning how best to deal with more stressful situations. Being supported while acquiring those skills may help reduce the likelihood of burnout or leaving clinical practice altogether. 8
Psychotherapy under appropriate supervision
The GP performing ongoing psychotherapy for their patients, under appropriate supervision( see figure 6), may add to the experience of the clinician and it may be rewarding, as the insights and understanding so gained may extend to the management of patients in general. 23, 33 Others have gained from the experience of training in family or group therapy as an adjunct to their ongoing clinical practice.
Personal therapy
Personal therapy, almost routine amongst psychiatrists who wish to undertake psychotherapy, has been found to be invaluable by an increasing number of clinicians working within general or specialist practice. 32 Such therapy helps in the understanding of issues particularly meaningful to the clinician, whether in a positive or negative way, and that may further influence the care of their patients. 33 This understanding allows for a more meaningful interaction with patients. 34
CASE STUDIES
JANICE, aged three months, was referred acutely following a focal right-sided seizure. She had previously been seen by a dermatologist who had diagnosed a capillary haemangioma( see figure 7). This lesion involved Janice’ s left forehead. Having been earlier reassured by the dermatologist that she was otherwise“ perfect”, and that the lesion was of little concern and readily hidden by applying appropriate make-up( therapeutic laser treatment was yet to be developed), the parents were surprised and distressed to learn that that the minor affliction could have significant short- and longterm implications. The parents were further unaware that the vascular abnormality might also involve the underlying brain tissue.
Janice was diagnosed with Sturge-Weber syndrome that involved the ophthalmic division of