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Um So I'm Claris. I just graduated from Imperial. Um And I'm going over the Professional Practice Station today. Um And basically, I think there's a lot of apprehension and uncertainty about the station because you don't really know what's coming up. Um So hopefully I can give you some tips. Um There is a ment code, the questions are very relaxed. I'm not going to show any of the answers. It's literally just because you are more likely to retain something if you actually put an answer in. Um So please just put something in, but I'm not showing any of the answers. Um Oh, you're frozen. Yeah, and there's also like, II think it's better now. Ok. Um Yeah, just let me know when it freezes or whatever. Um So this is what we're going through, I'll go through the structure of the station. Um And we'll go through how to tackle most the most common scenarios and then just general trip tips for the station. So this isn't my learning objectives. This is taken from the actual Sophia or something like that and it just looks very complicated, but when you actually read them, it kind of tells you what they are expecting for the station and gives you a be about and then how to do the specific scenarios including DNAC CPR, how to break bad news and communicating with colleagues and family. So, um I don't know if you had like your revision lectures yet, but I remember very clearly. They said this station is a blessing. It's the only one where you don't have to revise. And I just thought it was a complete lie when I did my mock. Like I remember being like, ok, you actually do need to know some things. Um So yeah, don't take it lightly. It's quite a difficult station, I would say. Um the actual structure of the station starts with about 3 to 4 minutes of role play with the actor and it's usually where you information gather and see what the actual station is about. Then you have three minutes of discussion with the examiner where you'll come out of the role play and then they will ask you questions. The question they'll always ask is what are the issues in this case? And we'll go over what that means and then they'll ask you questions like, how would you manage this? What would you do with this patient and what maybe sometimes what are the ethical? So you're, you're frozen again. Principles. I don't know if it's OK. Anyone give me a thumbs up. Yeah, it's like back now. OK, fine. Um OK. Sorry. So this is the structure of the station via the domains that they mark you on for the actual cases. And as you can see, the first domain is always that information gathering, which you do in the first four minutes and then you do formation of clinical issues. That's when they ask you what are the issues management. And then domain four is just your overall approach. So this will be the type of scenario that will be on the door. Um And this is the amount of information they'll give you. So this is an 85 year old lady admitted for community acquired pneumonia. After discussion, the team have decided DNA CPR is appropriate, have a discussion with their daughter um about resuscitation and treatment plans. So the first question uh will be, what information would you want to get from the patient here? Um So yeah, just I'll give you like 30 seconds, just submit anything again, I'm not gonna share the answers. So just try your best and put anything in. Um, the information that I would want to gather from the station is why she was admitted, first of all. And then what the daughter understands about what has happened so far. Um So yes, we know that they had a community acquired pneumonia. But what happened where they brought in by ambulance? When did the symptoms start that kind of thing? Then what does the daughter actually know about the treatment we've done? And how likely it is that the treatment is going to work. And then if we're doing DNA CPR discussion, we need to know what the daughter actually knows about CPR before we continue with that discussion. And we also need to know her daughter's name because that's such a big part of this. Remember that the patient or the actor is marking you as well on your behavior. So just something simple, like knowing their name and saying their name to them can make a big difference. Cool. So then we'll move on to the next question. Uh which is what they'll ask you in the exam, which is what are the potential issues that can arise in a scenario. So this isn't specific to um the last scenario. This is just any issue that could come up. OK. Good. So um these are the potential issues that you might be able to say one is confidentiality. That's quite an obvious one. Patient safety is one that I probably said in every single station that I did. Um Just because it's, you can mold the situation to say it's an issue of patient safety. Uh an issue of autonomy, dignity, especially when we're talking about CPR um the duty of candor, communication, professionalism and trust. There are obviously other issues that you could talk about, but these are the main ones that will probably come up in the stations themselves. Um Cool. So we're going to move on to breaking bad news and how to do that before I carry on. Does anyone have any questions at all? Um I can't see the chart so unmute if needed, how is it um an issue of patient safety in, in this scenario? So in this scenario, so sorry, this question wasn't about this scenario, but even in this scenario, patient safety is all about, you could really mold the question. So it's a community acquired pneumonia. If I don't put in this DNA CPR, then there is an issue of patient safety because you haven't thought about the treatment that they are going to get. And I think in this one, it's not this one. Probably I wouldn't say patient safety. But I'm just trying to say like you could bullshit a issue basically. But that specific scenario, I wouldn't say patient safety. I'd say this is more a communication um and a autonomy. You could even talk about confidentiality because you need to make sure you've got consent of the daughter. No, not the daughter of Mrs Wallstrom herself. Does that make sense? Yeah, thank you. OK. Cool. Any other questions? OK, cool. So let's go through breaking bad news. So the number one most famous structure is spikes. I personally actually never used spikes. But um I think when you're learning how to do it, it's maybe a good idea. Um So you start with the setting, which is basically where are you telling this patient the bad news, make sure it's a private room. Um The layout is good, you're facing each other and it's not really relevant in the exam. This is just more general stuff. But what is relevant for the exam is asking if they want someone else to be there throughout medical school? Someone early on told me, always ask if they want someone there. And every single time I got feedback, everyone said we really like that. You asked if they want someone else. So I would put that in right at the beginning before I tell you the result. Would you like someone to be here? Um It's really easy and it just makes the patient feel much better perceptions. So this is when you information gather and ask them, what do they think has happened and you sort of correct them or you agree with them, you would just be like, yeah, OK, you're right. This is what happened. Your, your mother came in for a community acquired pneumonia. She has been given antibiotics, blah, blah, blah. And you do the sequence. You can also use this opportunity to go through investigations like the chest X ray showed this or the CT head showed this etc then you invite them, which means basically you ask if they are OK for you to give the bad news. So say, OK, so I you're frozen. Have some news. Hello? Am I still sorry guys? I don't know what's going on with the internet. Um Yeah, we can hear you maybe just go from invitation uh in. Ok, fine, I'll go from invitation. So um yeah, so invitation. I was basically saying this is less of an invitation, more of a, you're warning them and asking them if they're happy to go through the results. Um And then you tell them if it's bad news, these aren't the results that we were hoping for so that they know you're about to go into a bad news conversation, um, knowledge. So as soon as you say, these aren't the results we are hoping for. You kind of set them up to, to think the worst. So you need to be straight up. So if they have cancer, you need to say straight away, the scans show that you have cancer, there's no point beating around the bush. As soon as you tell someone, their bad results, you've already put that in their mind and they don't like you to waffle around. So be straightforward. Don't use jargon. Um, and once you give them the bad news, give a big pause to give them time. You have to be comfortable in the silence for breaking bad news. Um, don't explain too much because like if you imagine you got given life-changing news, you wouldn't want them to suddenly bombard you with information. Let them sit for like what 10 seconds, which it feels like ages, but it makes a difference. Let them sit and then say, would you like me to explain this further? Again, it's very much giving the patient the control over the conversation, um emotions and empathy. So I think the most fake statement you can use is I'm sorry to hear that like, ok, sometimes people actually mean it, but when I've heard it from certain people, it just sounds so fake. You can even say it in a slightly different way like, oh you know, I'm really sorry, I have to deliver this news. I'm sorry that this is such a horrible situation, but I think that that snap of I'm sorry to hear that is just so overused and it's really obvious when you've just put that in for your empathy points. So I would avoid it. Other things that you can say is I can see this is a really huge shock or I know this is a really huge shock for you and I'm sorry that I have to deliver it. Just things like that, like just actually be empathetic, don't just put in an empathetic statement and then strategy and summary. So by now you should have had a million pauses because you are letting them digest the information and you are always checking to make sure they are OK to continue, make sure you are checking their understanding halfway. I would say once you, once you sort of explained what it is, you're talking about, you can say like, does that make sense? Do you want me to explain something again and then make sure you're always asking if they have any questions and sign post to whatever is going to happen next. This is the plan for the future. Um So yes spikes and then the tissue thing. So this is when medical students or anyone pretends to take out a fake tissue when they are crying, I probably wouldn't do that. I feel like it really removes you from the situation. Like if someone is crying, I know it's so tempting to pretend to give them a tissue, but I just feel like it takes you out of it and you don't really feel empathetic for them. Um So I wouldn't do it. That's my personal preference. Um Another thing is don't lie to them, don't make up information. I remember once it was AD N CPR station and I made up a percentage of successful cases and like just don't do that. It's not worth it. This is what I would say. Instead, I just say I don't have information. I don't want to give you a rough estimate without having the evidence and I know it's really frustrating, but just reassure them that everyone is there for them. Um And then for scenarios involving palliative care, it's always a good thing to reassure them that they are not being abandoned by the team because I think when you tell them, we are not going to give you specific treatment, they think that you are completely leaving them alone. So it's really good to say like we are still going to look after you. We'll still look after your symptoms. We'll still make sure you haven't got pain. We are just not treating the actual thing. Um Cool. So that's breaking bad news. Does anyone have any questions about that? Cool. Ok. So this is now about DNA CPR and TE discussions te being treatment escalation plans. Um So this is just a quick overview of what you do. You obviously introduce yourself and then you do that information gathering again, which is what do you understand about the So you're frozen again, itch I unfreeze if yeah, you're back, maybe just go from the beginning in front of me. OK. Um So sorry for the T discussion. Um Introduce yourself, find out what they know about the clinical situation, clarify and recap that. So that's agreeing or disagreeing. And then you say while you're here, there's a conversation I wanted to, wanted to have about their care or your care. And this is when you start talking about chest compressions or CPR. So first of all, you ask them what they know about CPR, then you explain fully what CPR is and then you check for understanding and questions and then you ask them if they agree with your plan. So um I won't fully go through this. I can at the end if someone wants me to, but you'll get the slides. This is just what I used to say for DNA CPR um discussions. The main thing is making sure they understand that difference between reality and TV. Because on TV, obviously they like wake up. But that's so that doesn't happen. So I think also a lot of people jump to the fracturing of ribs, which is really important. But remember they also get hypoxic brain injuries. So it's important to explain that. And I think the number one most important thing is actually about dignity and death and that a lot of people feel that they don't get that dignity when they are being surrounded by a bunch of people, their clothes have been ripped off, needles are being shoved into them. It's just not a nice way to go. So I think that's one of the most important points to take from it and then just tell them that we've reviewed your case and we feel like it wouldn't be successful and then see what they feel about it. Cool. So, oh, I forgot to take the animation off, never mind. Um So as part of at e discussion, you're not only talking about DN, you're not only talking about CPR sorry, there are a bunch of other interventions that you could do and can be discussed as to whether they want it or not. So, hemofiltration, inotropes, intubation and invasive monitoring. These are the more invasive ones and even things like N ABGS IV fluids and IV antibiotics. These are things that people might not want either. Usually, if someone has multi, lots of comorbidities, we usually just say this is their ce of care, niv abgs and fluids. Um, cool. Then this is the form that you do in my hospital at the moment. It's electronic but some people do paper forms. Remember that the F one cannot fill out this form. A senior has to do this. So don't get tricked into filling it out. I think there are, I did something once where they, the nurse is supposed to ask you to fill out the form and you are not allowed to do that basically. And you fail if you, if you fill it out. So just remember, you don't fill it out. That's literally it. Cool. Any questions about DNA CPR and tap? OK. Cool. So the next one is communicating with a colleague. Um I think usually it's to do with confronting them. Um or just, yeah, it's usually confrontation, having some sort of discussion about something that's gone wrong. Um The introduction is really tricky because you're in the scenario, you usually already know them. So it's kind of hard to get that introduction in. But I would just say like, oh, hey, how are you? And then they will usually start the conversation for you, find out what their perspective is, whatever it says on the door, just ignore it and let them say what they want to say, and then usually you disagree. You're a little bit frozen again. Three on my bike. Yeah, you're back. Ok, cool. Um, yeah, sorry. So I was just saying about tell them that you're understanding. So just say like, ok, I think this, that it's, it might be seen as inappropriate if you do this. Um, what do you think? Do you agree with me? Um, the main feedback that lots of people got from the station is that they were too confrontational. If you don't agree with them, you still can't go in and be like this is wrong. This is so inappropriate. You shouldn't be doing that like that, you will get marked down for doing something like that no matter how wrong the thing they did is don't be confrontational about it. And then basically the main point of this is to see whether you will ask a senior for help and then somehow telling your colleague, look, I'm going to tell the senior if you don't do it yourself. So I would always offer first, let's tell them together. Um Maybe we can talk to them for advice. Would you like help in escalating it? If they say no, that's fine. Don't argue with them. Just say, look like I might have to tell someone because I'm quite worried about the situation and if they kick off, they kick off, like don't respond to it. I think this is the only situation this station is the only one where you can really feel like this is fake, like you're not going to have any consequences from them being angry at you. That's what they are supposed to do. Um Cool. Any questions about colleague discussions? Ok. So um the next question uh well, the next section is about the Capacity Act and mental capacity. So I'll give you 30 seconds to answer a mentee. What the principles of the mental Capacity Act are? Ok? Cool. So there are five principles of the Mental Capacity Act. Um The first one is presuming that everyone has capacity unless you can prove they don't. The second one is making sure you support them to make a decision. So if you need to give them AIDS, you need to um help them communicate more and then that's what you need to do. Then the third one is they are allowed to make unwise decisions. So even if they say I don't want any medications, even though I know they're going to help me, that doesn't mean they don't have capacity. Number four, anything that you do uh on behalf of a patient needs to be done in their best interest. And number five, it has to be the most least restrictive option. Um So you don't want to take away their rights basically and do something very restrictive. Um The next one is about how we actually assess capacity, which you could be asked to do during this. You, yeah, you're back, I'm back. Ok. I mean, I wasn't saying anything anyway. Ok, cool. I hope I'm still here. Um, so these are the four questions or four bits of capacity assessment? Number one, do they understand information about the decision? Number two? Can they retain that information and remember it? Three? Can they use what you've told them to weigh up the risks and benefits? Number four, can they actually communicate the decision to others? So if someone is in a coma, they don't fit number four and they probably don't fit any of the other ones either because you actually can't assess it. And during a capacity assessment, you're basically going to be asking them. OK. So I want to, for example, a chest X ray, I want to refer you for a chest X ray. Um Do you know why I'm doing this? They tell you I'm having a chest X ray because I have a cough and you think I've got a chest infection. And then you say, OK, what are the advantages and disadvantages of sending you for the scan? And then they can tell you. So advantage is you'll diagnose me and treat me the disadvantages is radiation. And then the fact that they've said that to you and then you say, OK, so would you like the chest X ray or not? Then they say yes or no and that is communicating the decision to you. Um That is a capacity assessment in itself. It's, it doesn't take very long. I think the thing that's long is the information gathering before that you do. Um And then what if they don't have capacity? So what are the steps that we can take? And this is like an easy question they can ask you in the station. So ADT ACP I don't know if anyone knows what I'll just say. So this is the advanced decision to refuse treatment or an advanced care plan. These are both things that need to be done with a team and you basically say, OK, if it comes to the point where I can't make a decision for myself, I don't want intubation, I don't want IV fluids. Um And that is put in place. There's also something called A, I can't remember what it is. I think these are legally blind binding and there's one version where it's not legally binding. So I think it's like an opinion or something like that. Anyway, UCP is an urgent care plan. If you go on like or something, sometimes you can see a banner, a red banner that says UCP in place. Um This is basically an ACP but only for urgent scenarios. So if someone is unconscious, if they need to be put in recess, this is the UCP. I would say ACP is more for like everyday treatment. And if they are an inpatient LPA is your lasting power of attorney, that's when someone has nominated another person to make the decisions on their behalf. And that has to be done when they still have capacity. IMCA going back to psych is your independent mental capacity advocate. Um This is someone where you don't have a lasting power of attorney and you don't have friends or family that can influence the decision. So they are an independent party that will help advocate for the patient and their rights and then court of Protection, which is where if there is a disagreement between the medical team and everyone else, it will go to the Court of protection. Um This is just to say that capacity is time and decision specific. So don't get trapped in the trick where they say this patient didn't have capacity before. So we are going to assume they don't. Now that's not true. Um Over time capacity can change. And if they have capacity to make a decision about IV antibiotics, it doesn't mean they have the capacity to make a decision about having surgery, you have to assess every single decision separately. Um Cool any questions about capacity assessment. OK. Um The next question is about the next section which is dealing with a mistake that has been made. So which duty of the GMC will this involve? Good? OK. So I don't have the answer. So the duty would be the duty of candor, which is all about honesty and owning up to your mistakes and things. So this is just like a structure slide of how you would deal with the mistake. And an example would be you gave an antibiotic to someone when they were actually allergic to it. So again, in every single situation, we are understanding what they know about the situation. Why is that patient in? What did they come in for or with and what's happened until now, then explain the situation and you're frozen. So it's working now on my back. Ok. All right. Yeah. Um Fine. So is that ok? Ok. Um Right. Sorry. Going back to the situation. Um So make sure you explain what the mistake was and how that's going to impact their care. So both, both the short term and long term effects don't justify it. Don't say I was really tired. I'm so sorry. I could just literally say this was the mistake. I'm sorry that it happened and it shouldn't have happened. So for example, you explained the situation at the bottom here, you were admitted with shortness of breath and a chesty cough on X ray. We could see you had a chest infection and therefore we treated you with IV antibiotics. However, we understand you were allergic to penicillin and a mistake was made and we gave you a penicillin antibiotic. That's it. Don't say I sorry, like I've misread the label. Sorry, I didn't see the message on the thing. Just say, I'm sorry, you were given the wrong antibiotics. This is when you big apologize. Just say, I'm sorry it happened, it shouldn't have happened. Then you go on to say the next steps. This is how you're going to rectify the mistake now and then what you're going to do to prevent the, I'm going to investigate why it happened. I'm going to tell the seniors that this has happened and I'll, I'll put in a DATEX or incident report. Um, then you need to talk about interventions to prevent this mistake. These are things like I'm going to make sure that the system always puts a notification to say that you have an antibiotic allergy. You could even put a sign by their bedside or you can have a meeting in the morning with everyone involved in their care to say, look, this person has the allergy, don't give them this antibiotic and it's just explaining what you are going to do. Basically make sure you ice. It's very important to ice, see what they're worried about, see what they if they want anything else from you. Um And I would apologize again at the end and say, look, I'm really sorry. Um But hopefully, you know, we can rectify the situation now. Um They're usually quite angry around this apology, but once you explain in detail what you're going to do about it, they calm down um any questions about this scenario? OK, cool. And then I think this is the last bit which is communicating with family members angry family members. Um It's quite short. Um What principles are important in communicating with family members. I'll give you like 10 seconds to put something through. Ok. So these are the principles of talking to an angry patient or relative or family member, etc. Um Make sure you're clear about what has happened. Be concise with it. Don't give over explanation because it's complicated and it makes it seem like you're waffling, be honest. Don't lie quite obviously and make sure it's tailored to what that person wants to know, which is why ice is very important. Um They might not want to know specific clinical details, shared decision making. I always like to say, you know, this is a decision we are going to make together and then it makes them feel like they are involved in everything. Um If you have any support and resources to mind, it's always nice to say that because it's kind of like an intervention you're giving them and always, always, always check their understanding midway and at the end. So um these are just like tips um for communicating with angry people. Um Don't invalidate their reason for anger, don't say um there's no reason to be this angry about this. Um I want you to like which is what this little bubble is about. Like stop you're frozen and at on my back. Yeah. Yeah. OK. Fine. Yeah. So what I was saying is if someone told me that my mum was given an antibiotic, she was allergic to, I would be very angry. And so remember in that scenario you're not, oh you're frozen again. Just facing, we can hear you now. Ok. Fine. Um Sorry. Yeah, I'm saying like just don't fight back with them. It's the same as the colleague discussion. Just keep very calm um empathize with them again. I don't like the statement. I understand how you feel because most of the time you don't understand how they feel. If you've told someone that their loved one has died, I don't OK. Actually lots of people relate, but you know what I mean? It's like, usually don't really know their whole situation. So I think it's nicer to say something like it's completely understandable why you feel that way. So you are not saying you understand their situation, but you are saying that you know why they feel angry. Um And then you can, what I always like to say, you know, is very difficult when all these things are going on all at once and it must have been so stressful for you. Um So you're basically validating their feelings. Um So I also think it's nice to thank them for sharing their feelings with you and you know, thank you for bringing this up to me. It's really important that we know, allow them to explain everything that they are angry about and try not to interrupt them again. Don't be afraid to apologize you're not going to get a consequence, Erin for it. It's an exam. Hello? Yeah, we can hear you. Ok, fine. Sorry. Um fine. How, which is the patient Advisory Liaison service? I think that's like a nice one to fit in. I'm so sorry. We can't hear you. Let me now. Yeah. Ok. Fine. Um let me know if you can see the slides. We're almost done. Anyway, can you see the slide? Yeah, we can see the slides, we can see the slides, it slides, sharing. Mhm. Yeah. Oh, ok. Um fine. I don't know why I can't hear you. Um cool. I'll just keep going if you can't hear me. That's fine. Um Just let me know. Yeah. And then so the things that you would tell the examiner is pals or refer them to pals and then debrief always think about your own well being and say that hello? Hey guys, I'm so sorry. I don't know what just happened. Like boots me out. Um Don't worry. Let me try and share again. Can you see the slide? Yeah, we can. Ok. Good. Fine. Um I don't know what you last heard. I'll just say it one more time in case. Um So when the examiner asks you for your plan, you would say pals and debrief. Debrief being looking after your own well being, I think that's like something I'd like to hear you say as well. Um Debrief with a senior with a fellow colleague, anything like that? Cool. So this is the list of the potential stations that um I got um managing a self discharging patient. This will be things about the Mental Capacity Act and the Mental Health Act maybe um language and communication barriers. So talking with a patient who doesn't speak the same language as you or um a mistake has been made because they couldn't communicate in your in English um E OL care. I'm not too sure what that was. Yeah. Sorry. And then patient refusing treatment again, that's Capacity Act, lifestyle advice. Sorry, I should say advice with ac in a disengaged patient um being asked to work outside of your competency, competency is a very good one because you're basically arguing with a colleague and it's something that can come up when you're doing your on call shifts as well. Again, capacity assessment, dealing with mistakes, social media use is a, is a popular one because they're trying to be modern with it. Um So maybe a colleague who has inappropriate social media use confidentiality, inappropriate relationships um working respectfully with other people and managing strongness of like anger and stuff. Um So when I said like you need to kind of know things you can't not revise. Basically, the GMC has a list of rules. So rules about social media use rules about relationships that they do actually expect you to know. It's too long for you to go through by yourself. Maybe I would say if you have a group of friends, you could each pick a section, learn it and then make notes on it. I mean, at the end of the day it's very minor. It's kind of common sense. Some of the stuff like, don't post patient pictures on social media. But there is little nuances that maybe you need to know. Um, it came up in one of my exams, I would tell you but then it might come up in your mock or something. I don't want to spoil it and stuff. Um OK, so these are just the general tips. The introduction is so, so, so important. Um Make sure you try to remember their name and keep repeating their name throughout the thing. So they feel like you're actually listening to them. Um again, ask if they want someone else to be there. I can't emphasize this enough. Every single feedback I got was thank you for asking that question. Um Don't be confrontational, avoid generic empathy statements like I'm sorry to hear that. Um Always do your midway check for understanding and questions and then do an end check for understanding and questions as well. So you get a lot of marks just for saying? Does that all make sense? Do you have any questions at this point? Um Cool. So that's it. I hope that wasn't too fast and I'm really sorry about the internet issues. Um Please fill in the feedback form because this was the um I think the first professional Practice me lecture. So it would be helpful to know what the, what needs to be changed for the next few. Um Does anyone have any questions that they want to ask at this point? Um You can unmute or put it in the chart? Um Cool. So if there are no questions, I mean, I can stay for like another couple of minutes if you want to stay behind and ask a question um by yourself. Um Please please fill in the feedback because you know, it all counts to our portfolios. Um So it would be very, very useful for me and for med ed as well. Um But yeah, I hope that final year goes. Um Well, if anyone had questions about foundation ranking, um I am in London and I was very lucky with my rank. I didn't go through a FP or anything like that, but I heard that's random for you guys too. Um So yeah, any questions about anything, it doesn't have to be about this particular topic.