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Hello, good evening everyone. Welcome back to four sessions of Mind the Bleed pla two most this evening. And thank you for those who's re our sessions and welcome to those whose attending the first ever sessions. Um Just a quick introduction. My name is Dennis. I'm one of currently one of the fy ones who is working in Ports of Queen Alexandra Hospital having passed plat recently in about a year and a half ago. Um I was quite lucky um to have passed every station. So hence this um validates a little bit more while I'm running this session rather than anyone else. Um With me tonight, I've got Rosa here. Who is the I MG lead for um Mind the Bleed. Would you like to introduce yourself or just? Hi guys. Um I'm uh one of the AC CS S uh in emergency medicine uh at Norfolk Orange Hospital and I'm just gonna be helping Dennis today being a facilitator and disclaimer. I am I am a GMC examiner, so I cannot actually give any specific teachings for the pla exam. I'm just gonna be a patient um and just to, to facilitate for dentist tonight. Ok. Thank you for that. And I'll be discussing about communications tonight as per our introduction earlier, um I will be running through the most commonly seen stations tonight um in, during pla two and the stations that people would normally struggle with such as angry patients, breaking bad news and um counseling. But for counseling, it will be a bit tricky, but I will run through all, all the important bits and Bobs um later for communications, essentially, it's sounds simple, but it's difficult for us I MG especially because it's not something that we do in our own when we were in our training because in the UK um in most of the western country, for example, we do focus on patient centered care. So hence the reason why we need to be more and the junior doctors or any doctors need to be more empathetic, more patient centered um approach like um you need to get them involved in your um clinical plans or your management. Um For, for example, in other countries where we just tell the patients what to do what we're gonna do and then end of the station and end of the counseling and that will be all. So I'm gonna start with angry patients because it, it is quite these kind of stations. It's very difficult. A lot of people do struggle with that. And if you go to an academy where they would just teach you, I'm sorry, I'm sorry, this is what God is, what you want to be. And you just, you, you don't know what to say because eight minutes feel very long if you are with somebody who's angry, who's upset, so you will end up not knowing any, don't know what to say. And then you will be shocked and you would just, there will be lone pauses or awkward silences during the stations where you've got an angry simulator just looking at you staring at you like what are you gonna do? And it's more relevant after you've passed PLA two and starting your job as a junior doctors working in the UK because it is um what you will be facing every day. For example, my current job, you will have angry patients shouting abusing at you. So you just need to know the best way to calm them down and to get your points across to them. So I'm gonna start with these very simple slides, but I will run you guys through every single points. I'm not saying that you have to follow each and every single things here like you invite them, you listen to them, you sign post. It's just a general approach. You need to come up with your own sentences, your own ways of talking, talking to them. But in the pla exam, most importantly, it's, I would say it's building a rapport with the patients. So because it's just a stimulator, they would eventually calm down. They will give you a really difficult life like they won't be abusing you too much. They will know when to stop. So which is a good thing. But the examiners will be looking for your voice, your tone and your body language. I think it's one of the very subtle sign that you can score for your interpersonal skill in terms of interpersonal skill. It's not just about what you say to the patients, but how you reacted during that stations and how you actually talk to the patients. Are you getting a good rapport with the patients? If you are building good rapport with the stimulators, they would actually give you a little bit more informations that um you're expecting them to. So that would be a good thing because you're making them more comfortable and they will start talking. So that's the point that I was trying to make. So in terms of the stations when you go in, um I'm sorry for those who attended the station before, I would always stress the importance of go in save the times in the beginning. So memorize your name, your name and a GMC number, go in, go approach the examiner. Tell them your name. For example, my name is Denny still my GMC number, blah, blah, blah, blah, blah. And then you sit down, start talking about don't waste too much time in the beginning, introducing yourself to the examiner, just ignore them, they are not there. So after you sit down, I would say smile would be a good point to start the stations because it make yourself more relaxed as well. So, um for in terms of voice, because you are seeing anyone who's angry, so you feel agitated yourself, it's not just plate exam. It's like in any case, any, any real life scenarios, if anyone who's angry at you and you get agitated and you start getting louder and louder, it's not gonna help the case. So you need to p present yourself in a calm tone in a calm manner. I know it's easier said than done in a advanced situations. But if you start to be more calm and they will start, they will abuse you less because the simulators in the practical exams are really good. They are spec especially hired by the GMC to abuse you in that station. So they will be loud. They will be like straight to your straight like in your face asking you what to do, but obviously they won't abuse you. So you just need to be calm if they are standing out, invite them to sit down with a calm tone and smile at them and then you will start the stations with inviting. So this invite is essentially as telling them. Um Hi, my name is Dennis. I'm one of the junior doctors in this working in this department and I have been asked by the nurse to come and talk to you or you can say something. I understand that you want to speak to a doctors. So before that, can I confirm your name and age? So that's a, that's an introduction done and you move on in any communication stations. Be it breaking bad news? Be it angry patient? Be it counseling Medicare errors? It's important to listen because communication stations doesn't test you a single bits of clinic issue. It's just about how you communicate with the patients. So listening will be key because once you interrupt them, I know it's a bit stressful. You want to finish the stations. But in the communication station, it will be slightly different because you know the cases is gonna be short, it's gonna be addressing concerns. So in your proms, you will be looking at addressing concerns and the prom is normally longer where they will give you a full scenario. So utilize the one minute 30 seconds when reading outside the stations, remember every single sentence of that prompt. And if once you finish reading, I will strongly advise you to read again. So that in your mind, you can start formulating this different sentence that that you're gonna say. So in your bank, in your brain, you should have a bank of what empathetic sentences that you can use, what approaches you can use so that you can use them without having to memorize the script. So it's just a bank of sentences that you can actually say in different cases or different scenarios. So utilize that one minute, 30 seconds, read through the scenarios. They will tell you patient is upset because Candela has not been changed or in breaking bad news, there will be like patients had a meter after an accident had a fall or there's a bleed on the ct brain. Speak to the family. So I'm gonna go back to invite here again. So if you are speaking to a family member and it will tell you the pro in your prompt, speak to Missus Smith. So you, you can actually go in. Um Hi, my name is Dennis, one of the junior doctors here. Um Is it Mister Smith? So just to confirm, um how are you related to Mister, for example, Andrew Smith, can I or you can say something like can I confirm um Andrew Smith's uh can I confirm your husband's name or age? It's some a simple introduction like this. So carry on you sy post them. What you're gonna say, you're gonna say, oh, I've been asked to come and talk to you um in this angry patients, like I've been asked to come and talk to you and so patients will start getting a bit agitated now. So you can always have, is it a is it all right if I ask you a few questions to get some history or so I can get a better understanding of what's happened. These are really good sentences to get what you want from the patients and the more they started talking they were act as a stimulator. I mean, not in a real life scenario in the pla world. Once the patients start talking, once you get more, a bit more of the history, they will actually be calmer so you can actually listen to them what they want to tell you. So there are cases like the candy that has not been changed. Um The candle has not been changed or you there will be like um my baby is covered in pool and vomits. I'm sure those who was having exam sooner would have realized would have already gone through the cases like this. So get the full, not the full history but get enough history. They are already on the scenario. So you can actually know so acknowledge validate explanation, these things can come together something like so it would from this point onwards, after the history, it will be testing your interpersonal skill at this point like how you actually communicate with the patients. Something you can say something easy. Like I can see how frustrating it is or you can always address the elephants in the room. I can see how upset you are, but please give me a few minutes. Um I will find out a little bit more about what's happened so that I can help you better or in terms of validating the emotions you can say. Um I can I can understand how frustrating right? Having, rather than saying, I'm sorry that this, you can say I'm sorry, but not all the time. There's a few things that you can say. I can see how frustrating it is. Um I'm sorry that this happened to you, but I'm now here to help you. Should we sort this out together? So the patients are actually ok, fine. This person is actually coming with the solutions to my problem. So they will be calmer. They will actually tell you what's happened or then you explain to them. So I would do a quick summarize here at the, I mean, not the full summarize just so based on what you tell me. Um um so your can has not been changed for the past half an hour. You've not received the antibiotics. Now, um I'm gonna for and II can see that you're a bit upset. But should we get this sorted? Now if the patient or you can just ask something easy? Like are you in pain? How are you feeling? Because patient will still be in the hospital means they're coming with something or they are not? Well, so you can always ask or say something like are you in pain? How are you feeling now? I mean, this can come at any point but it would be better if it comes at the, in the beginning of the stages. So, um how are you feeling now? Are you feeling OK. OK. Or you can always uh for the solutions, you don't actually have to come with a quick fix. So you can just come with um try to force them off, which will make extra patients a bit more agitated or angrier. So in terms of explanations, you can always say I'm gonna use the cases like um patients can let been changed. I love that stage. I love that case because I got that urine exam and my patients was not very kind. So the candle has not been changed. She's due for the antibiotics now. So rather than having her going on and on and on about, she's been know in the emergency department, um the doctors are supposed to be here two hours, just say right. I know, I understand. So I would do a quick fix here like I can see that you're a bit f you're very frustrated. But what I can do for now is I will change your cannula. We can give you the antibiotics as soon as possible and then you stop and once it gets sorted, once it's sorted, I will look at in, into this problem a, a little bit more. I will have to speak to my colleagues. I will speak to the nurses to find out a little bit more what's happened so that we can always sort them out later or you can get a sieve of if the patients you're not happy. Say I want to complain. So you can signpost them to the pals. Patient advisor relies on service where they can make a complaint, they will look into it or in the cases like medical errors, something that something wrong that's happened. And they are very angry this so you can get the incident report in. So you can say some, it's just the solutions that you're providing them. So you can always say something like um for, we will definitely look into this Mister Smith. But um once we get you sorted, um we can uh I will look into, I will speak to a few people and we can write something. We can, I will file an incident report so that the senior management can look into this and prevent it from happening in the future. It's rather unfortunate that this happened to you but um in we will try to prevent it to ha prevent it from happening in the future and you reassure them. Uh for example, angry patients, you can reassure them. I will sort this out for you. I mean the issues at the moment. So you sort them out and then at the end of stations, you summarize them like, ok, Mister Smith, um your cannula hasn't, your Cannula was supposed to be changed in an hour ago. But unfortunately, you've not, it's not, it's not happened. But what I'm gonna do now is I will get the new can put it in for you and we'll get the antibiotics for you as soon as possible. And in that case, I remember there was, uh, she said something like she has to be at work. So summarize those point as well. What you've, what you've answered, what you've talked to her and always, always listen to them and address the concern. These are the two things I want you to do in the stations only that. So remember listening and addressing concerns because at the end of the stations, once you've addressed all the problems that they have, they will be quite happy. They will be like, oh, thank you very much, doctor. You're actually the first one who's actually listened to me or you're the actually the first one who's actually care about me. So you know that you've done that stations, well, you're good enough to pass. All right. So the next one, if you've got any questions at any point, please do pop in the chat box below and I will answer them as I go. All right. And the next one will be quite a difficult one, I will say breaking bad news. So in the UK, most of the junior doctors or any doctors, we use something called spikes, so spikes, um a protocol where you, if you follow them, you will actually be an, you have an empathetic approach to breaking the bad news to their patients. So in breaking bad news stations, um normally in plap, um there would be like um uh stations like um postoperative bleeding, intracerebral bleed, um stroke stations uh where uh you have to speak to the family. Um The father is having a stroke, um breast cancer or breaking any, any news about uh Magne C essentially and a terminal dementia about a and with a concerning daughter. So spike would actually be relevant in all the stations I would say in the prep world. Again, the settings will be always idea because you will be in a closed room, you will be quite close to the patients in the room. But if the patient is standing up, always invite them to sit down and on the table itself, sometimes you will notice some water there, you will notice some tissue papers depending on the station, but you can always offer them if there's, if you can see water there, you can always offer them first. Can I get you something to drink? Even though it's an even though it's not actually that or we can always say, can I get you something to drink and you start this? I would just do a quick um overview run of the stations go in. Um You will need to make eye contact with the patients um be open and relax and when you sit down and open your arms like this with your legs open as well and when they are talking, not to acknowledge their problems and build that reporting. So I will start the stations with. I will go and tell them G my GMC number and sit down and I will. So in the breaking bad news station, you know, from the prom that it's gonna be breaking bad news. I won't be smiling at them. You will get yourself into big trouble so your face should be neutral. Just say, um, good afternoon. Um, is it Mister Smith? Um, my name is Dennis, one of the junior doctors here coming to talk to you about Mister Andrew Smith. Can I confirm how is the relation with him or you can say something like um can I know how you are related to Mister Andrew Smith? So, um is it all right? Is it all right if I have a chat with you about your husband, for example, I mean, you don't have to follow my sentence, always come up with your own sentence because you will come across a scripted exam which is not gonna go well. So with your own sentence, say, um you can say start invitation from the patients, let's move on to the next one will be invitations from patients who give informations will be, you can always say something like check their understanding of how much they know because in cases like stroke patients will actually the family will send the father in, in an ambulance or the patients that on the phone is I've been told that my father had a stroke. So you can always invite them. I would always, I would normally say just to catch yourself up to speed. Mr Smith. Um, can I just check, um, what you've been told so far or what is your understanding so far about Mr Smith, for example, so they will start telling you. So it will be a quick history taking something you can remember quite easily will be before, during, after. That's what I want to know. That's all before. Um, before coming to the hospital, my husband was not, well, and he had a fall or things like that. And then, um, you can say something, Chuck and check. One thing will be chuck and check as well. Um, will be something like, uh, my husband was, had a fall at home and we come in, we can reassure them. Um, I've called the ambulance to get my husband to the hospital so well done for getting your, your husband to the hospital. Um, then you check, uh, then you carry on with the stations. So you carry on with the stations by, um, asking them, uh, what was he like before the fall? Was he normally fitting well or any symptoms that you noticed the before part during, if it's a fit or a seizure, they will be like, what did you notice at the time? But normally in cases like these patients will actually tell you so you can skip all that part. So if the patient has given you quite a comprehensive answers to what uh to your understanding, I would just carry on. So once they have told you what happened, you can always explore um the emotions like um you can always get the, if once you've got the knowledge, you can always explore them uh explore the emotion and sympathize, um say something like I'm sorry that's happened or that must be quite daunting, that must come as a shock to you. Anyone would feel worried in your situ in this situation. So it's things like this that you say, it's quite simple, things like this that you say to make patient uh feel more comfortable. And when you go back in terms of um knowledge, I would say something, do a warning shots first, which should be important. Like um unfortunately, we don't have very good news for you and then you do pauses and then you carry on with explaining and um um and just say, unfortunately, I don't have very good news for you and then you pause and then you carry on just something like um your heart. Uh We did a CT scan of the heart, your, on your husband's and we found out there's, there's a bleed in um the BR on the CT uh A, a bleed in the brain on the CT scan. And then your pa patient will be a bit shocked and they will actually, they are such great actors and actresses where they would actually start crying, which I was surprised during the exam itself, but these patients will actually start crying. So pause us again. There will be lots of pauses and listening in the stations. So pause again, get them the emo they will start crying. So there will be some tissue or you can always say I know this is very difficult. I know this is shocking for you. Um Take your time, I'm here if you need me. So give them the tissues that's done because um b in breaking bad news, it will be for you. It probably is just another day at work but in real life, not just back to work, it will be a single worst day of their life. So we just need to be empathetic because put ourselves in the shoes when that happened to you, how will you, how you want the person across to you deliver that news to you? So that's what I always tell myself when I'm breaking bad news to the stations in an acute setting or when you ring them um to tell them that husband, their family is not. Well, so who you want to be breaking that bad news to you when that actually happened? So when you have that thoughts in mind, you would apply it the same way during the plateau exam. So it's the point where these six points will come out. But I'm not saying that you should follow them rigidly um follow every point rigidly to a point where you're memorizing the stations, I would say, go in, know what you want to say, but say your own way. So at the end of the stations, you can always summarize it. Um like Mr Smith, another thing I will find easy to know to uh building rep in terms of building report. I think the, the I will find it quite easy to just keep saying the name Mrs Smith because you're acknowledging them, you are actually engaging them in your conversations because in the breaking bad news stations, there will be a bit lost. What I'm gonna do now. Doctors, oh, he's my, he's my life. I mean, yes. So just say Mr Smith, we are here if you need me. So provide loads and loads of support for the patients themselves. And one great that I find um I was, I was working with one of the really good registrars and the one thing that I find after breaking bad news, he say something. So if you can say that during exam, I'm sure it's gonna be different to any other candidates and it would actually impress the examiners because even the consultants was impressed. So if for example, if your cases of breaking bad news is something like cancer or terminal of some common diseases, you can always say when you were looking after the person who is really unwell, we tend to forget ourselves. So um it's always good to know that you, it's always, it's always good to know uh to take care of yourself as well. So they sent sentences like this. It would actually get you a really good interpersonal skill score because you are engaging them in your conversation and you care about not just your patients but the family member that will be the holistic part of the consultations, which I think is brilliant. I, that, that was the only time that I actually seen a registrar that did that. But I think I'm, I'm actually using that in my day to day life now because you need them to take care of themselves before they can take care of their loved ones. But again, set it in your own sentence. I'm not asking you to copy and paste this sentence in your exam. So the most important bit about breaking bad news, I would say lots of pauses. Don't worry about awkward silence. There's no awkward silence in breaking bad news. They need time. So once they make eye contact with you, say what's next or they would say what's next doctor. So only then you carry on if not, don't ever interrupt them. Second, important things is to Chuck and check when you are explaining anything at all. Always do Chuck and check. Do I make sense or one or two sentences later you can ask, do I make, do I make sense so far? Does it make sense? What I've explained so far. Any questions at all before I carry on Mr Smith. So, Chuck and Chat would be a good way to get you to think what you want to say next to give you a little bit more times. And in the same way, showing the examiner that you are an empathetic doctors in a sense. And the third things, the most important ones again, summarize. So Mister Smith, unfortunately, um your husband came in with an intra uh with a bleed in the brain and this um we um you can give them the solution as well that we've refer him to palliative care to keep him more comfortable. But this will be a more um shorter, a more summarized version of it. I want you to have a look into it because of the time that we've got and I will discuss a little, little bit further in our stations later. All right. Any questions so far? So, yeah, I'm using it now. So carry on. So the next up will be counseling where a lot of people struggle with. To be honest, I struggle with that as well because counseling is not a blanket rule of what's gonna come out counseling. They have got loads of different stations. Like there are different parts where you actually have to have the informations for. You need to know what you want to say. It's not just um taking history, having pain Socrates, other symptoms or the para family history, social history, nothing as simple as that. But it will be some things more specific to the stations. I have summarized a number of that actually, more than that, but I've summarized a few sentence, a few stations that actually it's quite high. You, they come out quite often during the exam, but I'm not saying that it will come out in your exam because they're the UK MLA and we don't know what would happen so far. But it would be quite similar to the plateau exam as far as I've heard. So for counseling, um I'm just gonna run through them the eight weeks vaccinations. Um It will be a a worried mother coming in asking questions if the babies need to be vaccinated. But the good news is you don't have to memorize what vaccinations you have to give to the patients at what age because they will give you a list of um the current nice guidelines or NHS guidelines about what vaccinations will patients receive at eight weeks, six month, one year old. So you can actually refer to that one. But that stations in all counseling stations, I would say if you could address every single concerns that the patients have, then you're looking quite well, you're looking very well to pass that exam because essentially you just go in and answer questions that you would do in your doctor's life in your own country as well. So patients will come in with questions and you answer them. Um One of the few things that I would actually say that's important, it's um the thing that I struggle myself with is seizures. Um the first attack or first fit clinic because you will see that quite a lot. They will come out in a different sort of approaches or sort of different things, but essentially they are the same thing about what you would do. Uh What is about what you would see in seizures or what you would advise patients after they are discharged from the hospital. Like for example, you need to tell them to avoid taking the bath or avoid locking the door and um will be try to avoid um dangerous or high risk activity like rock climbing. I wa I want you all to actually look into every stations and remember not the script, some academies will give you the whole script. I don't want you to look, I don't want you to memorize those things. I only want you to look at the last bit of it where it's tell you what is the importance advice you give to the patients. But if you are unsure, you can always type in Google and for example, Parkinson's and then type in Google, Parkinson and HS and they will have an patients information leaflet and you can read into that and tell the patients that rather than having to memorize everything. So coming back to the first clinic seizures that I've mentioned take a quick history in counseling stations. Always take a 23 minutes history maximum because I want you to spend your time addressing concerns. I know you want to get the points for history taking as well. But when the patients ask you questions, you will need to have a two way communications as well. So you can actually take history at the time. So they have got a list of questions to ask, um, the candidates actually. So if they can actually go through every single question, if you could go through them with, go through the question with them, you're nearly there. Ok. Um, let's have a look for the, um, diarrhea one year old child for va with vaccinations like uh more towards uh pediatrics cases. Um, there will be an anxious mother. So that will be a bit tricky because you need to calm them down and at the same time, go through the point with them. But at the end of the day, what they were expecting from, you would be how to be a safe doctors. So always remember your red flags or your warning signs that um if you feel unwell do come back or for things that you're not sure you can always tell them. Um, if they actually ask you questions where you don't know the answers to. Oh, that's a really good questions. But do you mind if I just have a chat with my consultants or uh do you mind if I just have a look, quick, look into the guidelines so that I can advise you better on what to do in these scenarios. So it doesn't have to be uh you don't have, they're not expecting you to know everything but you need to sign, post them to what you know and how to be a safe doctors essentially. Ok. And the rest of the counseling, I mean, communication stations, I mean, these are the one that would come out during an exam as well. Abuse, safeguarding. Um what I would say is important in these cases, like it will be confidentiality and try to push it a little bit more because patients sometimes will be like you, it will never confuse you patients that I'm all right doctor. So I'm all right. But if you look at the age, if they are under 18, they are 12 years old, 11 years old with the bruises in your prob I would say push a little bit more with something like I can reassure you. Um Andy that our conversation today will remain confidential. You are in a safe space, but I'm here to help you say something like this because patients, I mean, um as the patient as the stimulator, they will be like try to resist this. So they won't tell you straight away. But if you push it a little bit with one additional sentence, they will tell you actually doctors, I have been abused or uh someone had did this to me. So you will get the history and you will have a little bit more idea of what state that station is about. So always a quick history and then try to see the subtle sign, patients expressions or patients tone and things like that. And the colleague scenario, I'm sure some of you have come across um during your practice or whatsoever where there will be like patients um uh your colleagues, they come in late try to speak to your colleagues or your colleagues. Um They'll write the short summary for example, and you have to speak to them or you have to speak to a juniors about that. So that would be a bit tricky but it's that how you would speak to uh colleagues in the professional setting. Uh But with respect, you're not telling them off but you're finding out what happened or you can say something like I can see that you're struggling. Is there any help that you need or anything that I can help you with? It's about building a rapport and get your interpersonal skill points. And the next one will be ethnic scenarios, refusing treatments change or self discharge. These are also like any counseling stations or communication stations where you just have to do your own. Um you know, being empathetic, get a quick history and uh for refusing treatment, it will be good. I mean self discharge or refusing treatment, you would need to do a quick capaci capacity assessment. So you need to check if they have capacity to refuse the treatments. For example, do you know what you have? You explain it to them first? Uh Do you know um explain it to them? What is the consequences and ask them to communicate that back to you and ask them, do you know what the cons do you know what will happen if you don't take these treatments or do you know what will happen if you go home? But try to persuade them as well before you actually let, ok, you've got capacity as you've got capacity, I'm gonna send you away but try to persuade them in terms of um speak to them first. Take a history, sometimes patients refusing treatment for a reason. So always, always ask why, why and why do you, why do you feel that way? Why do you not want to get treated or why do you want to get home so eagerly, is there anything at home or try to sort the problem out? So, so they will help you in the exam and the next one will be medical errors. So the approach to medical errors will be quite similar to angry patients because no one will be happy if they know that um they have been involved in a malpractice or something wrong that's happened to their treatment. So it will be a bit like angry patients, but it's fine if you say sorry and, and meet the mistakes, you won't get in trouble. You won't have to be about the most that this happened. But you just have to be honest with them. Look, Mr Mr Anderson, um, this happened unfortunately that, um, this has been missed during your last admissions but try to give them a solution what you, what would happen or you could give them uh we will do incident report to prevent it from happening or tell, it's not something that's commonly happening in the NHS, but sometimes mistakes do happen. So it will be things like it will be things around um reassuring them, giving them a solutions, check and check, summarize and that's your communication stations done. Um The only way to score well during the exam I would say is to practice because as most Im Gs English would not be our first language. So you will struggle with coming out a new sentences or um if there's, if they change the way of talking to you, you struggle a little bit about what should I say next. So what would actually help is to keep practicing the cases and get your part study partner to give you an honest feedback. I mean, it doesn't help if they tell you you're excellent during your practice, but you perform poorly during exam. But as your study partners, I would strongly advise you to give all this feedback, it's so much easier, uh so much easier in the communication stations because have you addressed all my concerns? Do I feel that you're empathetic enough? Do you feel like I do? I feel like as a doctors, this person in front of me has actually improved my conditions or improve how I feel that will be all. So this is what NHS is expecting of a junior doctors anyway. So I want you all to be a safe doctors and keep practicing and try to speak English more because if you're not in the countries and if it's not your first language, you don't speak it enough and you would struggle with coming up a sent, coming up with a sentence. OK? So any questions about um communications before we move on to, before we move on to the stations? OK. I see there's no questions in the chart group. So we will start for those who's not attended this mo before I will have this app on my phone and it will be at eight minute stations with a minute and 30 seconds sec uh a minute, 30 seconds to read the prompt. I want you to read the prompt for a minute, 30 seconds. If you are done, read again and try to formulate what you want to ask or what you want to say in the stations. I think from the chat box, we have got two volunteers. So a third volunteers will be really great. And I think it's important to, it's important um to practice in front of, especially with a lot of people and with us giving you as a feedback because it first it will build your confidence. Like you can go into the exam, tell yourself, just hype yourself up, motivate yourself. I have no, I've done it in front of so many people and how difficult can, how difficult can it be? I'm just speaking to a person with another examiner listening. So you just have to calm yourself down, hype yourself up and that will be old and you will prac you will actually perform like how you normally practice. Ok. So who want to be our first volunteers? Is it Patricia there? Yeah, it's Patricia. Excellent. Hello, Patrick. Thank you. So, ok. I'm just gonna get this ready. And are you ready? Can you listen to us? Can can you hear us? Ok. Yeah. Can you hear me? Yeah. Yeah. Yes. So Rosa here will be our patients so speak to her and ignore me like I'm not here. Ok. There we go. Begin. Enter the room. Uh I'm Patricia. My E MZ number is 699431. Hello. Hi. Hello, I'm Patricia. I'm one of the unit doctors working in this department. Uh May I confirm your name please? Um I'm Sarah. Um D Darren Smith is uh his wife. Ok. Uh and uh is it ok if I quickly confirm uh, is your husband? Right? If I'm understand correctly. Yes. Yes. My husband and if I can confirm, uh, your husband's name and age, please. Um D Darren Smith. Ok. Very well. He's, he's doing, is he ok? Uh, so Susan, I'm here to talk about, um, about your husband's condition and, um, is it ok if I ask you a few questions before I proceed with this? Yeah. Yeah, sure. Just, um, yeah, let me know. It's just, uh, so I can be in a better position. Uh, I would like to, um, have an idea what happened, how he came here to the hospital. Well, we were just watching TV. Really? And, and then he just collapsed. II don't know what happened. Ok. Um, did he, uh, well, according to my notes, I have that he collapsed at home. Is this correct? Yes. Yeah. Yeah. Was it all of a sudden or was he? Yeah, we, we were watching, we were watching TV and, and, and, and he just, he just fell? Ok. Um, um, first of all, I'm really sorry that you have to experience, uh, this situation. Uh, but, um, but he did very well to, uh, uh, from my notes, I can read that you call an ambulance. So you did very well and come back and come to us straight away. Um, and, um, do you know if your husband had any, uh, like any medical conditions or anything in particular? Uh, well, he um, he, he took tablets for, for, for high BP. Yeah. Ok. Was it for a long time? Uh, yeah, I think so for 20 years. Ok. Very well. So, um, so Susan, uh, your husband is here with us. Uh, we have provided him with, uh, medical attention. He's been here. He's been looked after. Um, and I would like to discuss, uh, the condition of your husband with you. Uh, but, uh, this is, um, a very sensitive, uh, a sensitive, uh, topic. So, uh, would you like to have someone with you? I don't really have anyone. My daughters are in Australia. Ok. Um, ok. And, um, very well. So, um, uh, so what we have done, uh, so far, so your husband came to us? Um, and at the moment, um, he is, um, well, he is not awake but he's breathing independently. Ok. That's, that's good. Right. Mm. Um, but, um, we have done, um, uh, I can see where you're coming from. Uh, we have done a few investigations in him. We did a scan and I'm afraid to say that the results, uh, didn't come back as we had expected. Ok. What, what, what does that mean? What do you mean? Um, well, I'm afraid to say that, uh, the CT scan is showing, um, massive bleeding in, in the, in the brain. I'm, I'm really sorry, but there is something you can do about it. Uh, so we have done, um, but we have, uh, he's receiving, uh, medical attention. He has been assessed by, uh, the surgical neurosurgical team. And, um, well, unfortunately they have said that, uh, probably a, an operation would not, uh, be beneficial, uh, for your husband. Right. Well, well, then what, what will you do? Um, so what we're gonna do now, uh, so your husband is gonna, uh, go to, um, so he's gonna, um, stay for the moment with us. Uh and he's gonna start receiving um something that we call a symptomatic uh symptom control uh treatment. I'm sorry. II don't understand what control. Mhm. Sorry. So, um, so what we're gonna do is we're gonna look after you, your husband and uh we are gonna provide him uh with uh medication that will help him to be uh free of pain uh that he will be comfortable and uh we're gonna look after his um his um vital signs. Um, and we're gonna look after about his hygiene and make sure that he's uh uh well cared. So you're saying he's not gonna wake up, there's no chance of him waking up. Um Well, I'm, I'm afraid, um, and I'm really uh uh I know that this is a very shocking uh news and uh this is a very difficult um situation for you but uh I'm afraid that uh the surgeons um have uh predict, well, have said that uh your husband condition might be um terminal. What about uh intensive care, people, people go to intensive care and, and they get better, don't they? Um, so what the, what do you mean with intensive care or you're looking for? They sometimes get in car accident and they put tubes and machines and things and they get better. Ok. And, oh, I can see, uh, where you're coming from. Uh, but I'm not worried that, uh, for your husband, uh, if we, uh, if he gets, uh, in intensive care, it might cause, uh, cause him more, uh, distressed and it wouldn't be as unofficial as if we look after him in the wards. And also, uh, because of this, uh, brain in the brain, uh, sorry, bleeding in the brain that he had, uh, it will be very difficult to predict, uh, from another one happening again. Right? Um, so how long does he have? Um, well, um, uh, I know that this is very frustrating, uh, but I'm afraid that I can, I can't give you a number, uh, or anything, uh, or about this is beyond my expertise. Uh, but, uh, definitely something I can talk to the specialist and come back to you. You know, my, my daughters are in Australia. Do, do you think I should call them, move on to the next session? Ok. I couldn't hear part. Uh, it's really hard. Sorry. Sorry. II was really horrible. I'm sorry. But I just, I don't understand. It's really, really hard. I was trying to make it smooth but, uh it's challenging, uh I would say kudos to result. So, for being such an outstanding patient actress. Uh, yeah, exactly. We have to set it to. Yeah. Um, but how do you find, I know you find it a bit difficult. But did you, did you feel like you actually get your point across? Do you feel like you get a report with your patients? Um, well, it's difficult. Uh, I don't know, I try my best. Uh but I think it's difficult. It's very difficult. Uh I know this is an exam but uh I can't help to start to think that that could be something in real life. And uh it's, it's difficult to build a rapport. Obviously, you're trying your best, you try to be as empathetic as possible. Uh And so mindful about the words and how to say it. And then I think I do struggle to get the order of the things of how am I gonna disclose one thing at a time. Uh I think maybe I started too soon. Um with this closing, the bad news, I think you did very well. Um I like your tone and I like the speed of, of the consultations because you actually listen to them. Uh You actually address what the question is, but just a few more things that I would say to further improve your station. I'm not saying that you will fail your station, but II think you've got all the points there, but it's just about s make it more systematic of what you want to say. So, I would normally for myself or a good, how you're gonna do, how you're gonna be more systematic, especially when you're nervous, you need to come up with uh what you actually want to say, you can always start with, um, how much do you know about your husband's condition? So, you know, you can, you are both on the same page now and then you carry on. Unfortunately, I don't have very good news or unfortunately, this is not what we are hoping for. And then you do a pause so it's layer by layer, you give a few warning shots first. Mhm And then um just say, I don't, unfortunately, I don't think I have very good in you. So do a pause. I mean, take your time there. It doesn't matter how, how long it will take. So patient, what do you mean? Doctor just say? Um, so we have done some scan that explain to them slowly with patient friendly terminology. We have done some scan and we found out there's a be uh there's a massive bleed in the brain and I think what you've done well is that you say, you know, a few uh so uh the surgeons, we had this, had the discussion with the surgeons. I don't think that's what that we can do an operation and you need explain you get, you've got all the points you've asked all the questions. So, um, no, so that from that part, I've got no problem at all. All right. But it's just been a bit more systematic and sometimes you see the patients is very disturbed or very visibly distressed. Um You can always say something like, um, do you, would you like more time? I can see how upsetting this is for you. Would you like more time before I carry on? So, um it's the worst things that ever happened to them, period. So just know that it's gonna be difficult for them. Would you like more time and I'll be here if you need me. So if they say are, you know, I sometimes patients will ask, are you actually giving up on my husband? You can say we are not give, it's a few things that you can say is that we are not giving up, we never give up, but it's sometimes it's better for the patients to be more comfortable rather than being in pain or we, we need to preserve the dignities. So it's things like this that can actually make you a better doctors in terms of breaking bad news. So another thing would be um the name always listen to the name and I think uh I think Raza say she is Sarah. There is me. Y oh my God, it's true. Yeah. So in any stations listen, listen to the name. All right. But otherwise I think you did very well. You've got the interpersonal skill poison. You've addressed the problems and you tell them, uh, you tell them what they, what you want, you tell them what you actually wanted to tell them in a sense. All right. So get practicing. Just get practicing. I think you would do well, but just be more systematic next time. All right. Thank you. Who's the next stations? Uh It is VV VVI. Sorry, I don't know if I said that right. Um, but I'll invite them to stay. Ok. Hello. Hello. Good evening. Are you ready? Yeah. Can, can you hear me clearly and see me clearly? Yes. Yes, great. Thank you. So there was a problem last time and I couldn't join so. Ok, I remember that. Yeah, things are fine now. Yeah, perfect. Ok, let's crack on time starts now. Forget. Oh, can I begin now? No, if you finish reading a problem, read again. Ok. Sorry. Enter the room. That's the. Hi, my GMC number is 1234567. Um Hello, I'm doctor. I am Missus Daniella White's uh son. No, I'm Missus Daniella Terson. Yeah, I will, I will have some. Yeah. Yes. Could you please, uh could you please confirm her age for me? She's 67 right? Um Could you please tell me your name as well? How may I address you today? Uh Peter. Hello, Peter. I see that you've come to talk about your mom. How is she doing today? Well, I'm, I'm very upset doctor. I, um, I, II, she was diagnosed with cancer, apparently, lung cancer. They said, um, but I brought her in, you know, and they said it was a chest infection. So II II don't understand. Yeah. Yeah, I see that. Uh, you know, I see that but I understand it could be, you know, it could, you might be annoyed with all that. Uh, I completely understand that how you might feel. Um, before I talk through this, can I just ask a couple of questions, you know, if just to see if nothing has changed, uh, from what, from what, uh, she has experienced before? Is that ok with you? Yeah. Yeah, sure. I'm so sorry. Yeah. Um, so you said that you were upset and all, but how is she right now? I mean, she came with complaints of breathlessness and all. How is she today? Well, she's getting worse, obviously she's still having worsening breathlessness. Oh, I mean, how is she being managed now then for that sort, breathlessness, they've given her some medication from the hospital but, you know, they said if she was diagnosed early they could have, um, they could have done a surgical intervention which they can't do now. Oh, ok. Um, can I just ask, uh, when was, when did this happen? You know, when was the first appointment that she booked for? I mean, coming into the hospital with that sort of breathlessness. Well, she saw the GP about a month ago and, um, he said she, she had a cough with, with, with some phlegm and he said it's, it's an infection. So he gave her some antibiotics and she didn't get better. She just kept getting worse and worse and, you know, they didn't do anything, they just did bloods, they didn't do an X ray or nothing. Is it ok. Did she have fever then? No, you mentioned that they gave her antibiotics because she had that cough and phlegm. You know, usually that is what, uh, that is the first thing which doctors think when they have cough and phlegm, maybe that might have been, but we can dwell into more of her symptoms and understand what is, what is actually going on and where, you know, from where this all has come. Is that ok? Yeah, just go into more details of her. So, uh, well, she has, you know, there were a couple of questions about her. I hope, you know everything about her. Do you stay with her first of all? Yes, I live with my mother. Yeah. Ok. Good. Um, I mean, um, do you, uh, is there anybody else other than you staying with her? No. So it's just you, you take care of her. Good, good to know. Good to know. So, do you work as well? I mean, it's on and off? That you see her. Well, yes, I will. Um, I see her in, in the evenings. Ok. Good. So, then how is she managing? She's managing in the meantime, with, by herself, with the medication and you'll come back, you'll check her medications and stuff. Right. Yeah, she's, she's not forgetting them. She's, her brain is fine. Um, good. Good to know. Mhm. That's, that's nice. She's taking care of her own medications and all She's doing it all right. Uh, so have you noticed any weight loss with her? No, she, she, no, she looked the same. Ok. Um, then was there anything else with the cough and the breathlessness that you've noticed? Not that I can think of? Ok. Um, you mentioned that they ran a couple of blood tests and all, uh, they did a chest X ray as well. Have they told you anything, like, what was going on with the test? I mean, did you, did they discuss the reports with you or your mom? No. No. Um, but the, the first, the, the x-ray was only done the second time when I brought her in because she was not doing any better the first time. They, they didn't even do that. Ok. Um, they didn't do that. You mean, I mean, after the blood test they ran a chest X ray. Is it, am I correct? They, they ran, they did the chest X ray on the second visit. No, like on this visit? Not on the previous visit. And you were told that she had an infection after the chest X ray. Is it? No, no, no, no. She had an infection on the first visit a month ago. All right. Sorry, sorry to get that going. And, you know, I had to repeat. Um, um, so is she still on antibiotics? No, they didn't work. Ok. Um, I understand that. So how is her diet and all going on? I mean, is she eating well? And how was it with her? Is she feeling tired lately? Have you noticed anything, any changes in her? Other than being breathless is getting worse? I mean, the, the breathlessness is making her tired because she can't go very far now. But I need to, I don't think I've noticed anything else. Nothing fever or nothing. Her diet is ok. She sleeps good. Yeah. Mm. Ok. Um, do you have any idea about, uh, the things that she, I'm sorry, this could be personal? But, uh, can I just check because some things can affect the situation? Some, uh, you know, having some habits can affect medical conditions? So, just so to ask, does she smoke or drink? No, no, she doesn't. Ok. Ok. That's good. Um, has she had any previous medical condi conditions that, you know, she had to be admitted or she had to use the medications for a long time? Was there anything of that sort? She's a healthy woman. She never had anything wrong with it before. She's never been to the hospital. That's why I don't understand how it could have been so advanced and no one found out. Oh, dear. Yeah, that, that could be, you know, that's the thing they, they might have mentioned. But, ok, um, was there any other allergies for you? Didn't? I mean, by me, I mean, that they could have thought because she's quite healthy, they thought, uh, the cough and phlegm could be an infection. But now I can tell you what has, what has actually happened to her with the x-ray and stuff, we can talk into that just before, you know, just give me a couple of few minutes before I go on to. What's actually happening? Is that ok? Just a couple of questions. Bear with me, please. Ok. Uh, is there any family history of cancer or any other medical problems with high BP or high blood sugars? We've got, yeah, high blood sugars in the family, but she didn't have it. Good, good to know she was healthy fit and well, um, so, uh, what are your ideas about this? I mean, what do you think that, uh, since you have told that if she does something was diagnosed early, they, it, you said that she could get better, but what are your ideas? What do you think that your mom is having? Well, well, I'm not happy with the way the GP handled everything relating to my mother and then, and then I want to complain. Ok. Um, II can see that, uh, you're frustrated and annoyed but, uh, you know, I can make you, I mean, we can talk through this in some time but I mean, uh, sometimes things get wrong. No, I can, uh, take you there but, uh, we can do things, uh, about the complaint, putting that aside. What are you actually concerned about her health? You know, what are your ideas that she might have? And what are you expecting out of today's consultations? The complaint. I've, I've already been told she's got lung cancer and, and there's nothing we can do about it. I, um, time is already up. I didn't go to the management. That's fine. Don't worry. I can see you're a bit nervous. I was very scared actually. So it's very normal and then if you go in and that patients in, uh, the patient is not happy. I mean, there will be some of the patient will be worse than us now. So it will throw you off, I would say, but the problem is you've spent too much time trying to get to the diagnosis. So what I would like what I like about, um, your case is that you asked how the patients is doing at the moment, which I think is good. So you are, you're making sure that you got two, you've got the history, you've got all the background but I think that's too much of a background. You could have saved your time not asking who's taking care of the mother. How is she taking the medications and stuff like that? Those are not important. Take a focused history. Two minutes for history max enough. That's it. So you could just ask something like what brought your mother into the GP initially. So once they tell you all that done, so you want to address her frustration and address her concerns. Like how can it be missed if there's an elephant in the room? Since there's a medical errors that happened, we don't have to get defensive, but we just have to address it. You can say something, you don't have to avoid it because it happened. It's been missed. So there's a fact that patients with the family would know. So even if we avoid it, it's not, it's not your fault, it's not my fault. It's been missed. It's happened. So you could easily explain it as um since initially because you've got the background. Now my mother a a meet her with cough with phlegm and treated with antibiotics and the chest X ray. You can always say normally patients when patients come in with symptoms like this, it tends to be infection. But unfortunately, in your mom's case, it's been missed, you can always address it. I can see how frustrating it is. If so you say sorry or you want to address the su the frustration that up only if you mean it. So if the patient starts to get a bit angry, agitated at this point, I can see how frustrating that is, but I'm here to help you. You can give a solution. Now, in the middle of it, I'm here to help you and we can look into what's happened. Mhm So this case has got a mixture of medical errors and angry patients. You don't know what happened to the GP. So you can tell them, you can literally tell them. Unfortunately, I don't know what's happened. What did the GP say? But I can find out for you. So there's that she, because the patient, the family was angry that she was not investigated further. She was formal with just antibiotics and the second time, I mean, you second time she brought her mom in, she just had a chest X ray. So you can address that. I don't know what's happened then, but I can find out for you. And the second thing I would say is important would be really, really important is to say and the patients say I want to complain. This is what I'm here for. Let the patients complain. Mm You were following her off at some point like let's leave that aside first and we'll talk a little bit more about what's happening. But that, that's the only thing she wants to do, let her do it. So I will side post you to our pals and we can look into it and just what they want, what they demand you give it to them. But, but how do we say when, sorry, sorry to cut you down. When um when doctor, as I said that as a patient now, I want to complain, how do we react to that? You know? Um how do we say? Yeah, so it's perfectly reasonable to want to, to want to file a complaint because this has happened. We can't avoid it from, we can't uh so we can say um it's perfectly reasonable to want to file the complaint. So uh there is a good department in these hospitals called, there's a service in the department in our hospital called Patients Advisory Liaison Service house where I can give you the contact details for you to contact them and file a complaint. In the meantime, you can say in the meantime, we will do our investigation here while you go through that process to look into why this happened and how we could prevent it from happening in the future. OK. So once you address that he will be so the patient, the family will be quite will will be will calm down a little bit like, ok, this doctor is giving me a solution. Mhm. So we we can't, first there's a few things like we can't be defensive when things when errors has occurred because it's not our fault. Sometimes it's the system or in the medical, in the medical world. Normally you get miss patient with especially lung cancer, a meter with breathlessness, heavy antibodies. It's quite normal. So we can actually tell the patients that. Yeah. Yeah. Ok. Yeah. But I think if you spend a little less time to take background history, you've got more time to actually talk to the patients having a two way conversation in a communication station that will help you pass the exam. Yeah. Yeah, got it. All right. Thank you so much. Thank you so much for a week. Yeah, no problem. I mean it's, it's nerve, I understand. It's nerve wracking but just keep, you'll be fine. Yeah. Yeah, thank you. No problem. Bye bye. So who's gonna be, is it a Met's gonna be our other patients? Yeah, it's um close. Oh, my day you are around. I've invited you to the stage there. We are. Ok. Hi. Hello. Hello. Hello. How are you? Yeah. All right. Are you ready? All right. So I am excellent. Let's do this begin. Yes. Enter the room. Yes. Hi. My name is doctor which is GMC number 880337. Ok. Hello. Good morning. My name is doctor and I am one of the doctors in the clinic. Uh May I confirm your name please? Ashley Brown. Ok, can I call you? Yeah. Ok. Happy to meet you, Ashley. And could you thank you. Could you please tell me your age. I'm, uh, 55. Ok, nice to meet you, Ashley. I understand that you have been admitted here in our hospital for the past four days. Is that right? Yeah. Yeah. Ok. And how is the things going on with you? Yeah, things are going well, I'm about to be discharged. Ok. That's good news. Yeah. Um, yeah, how your COVID go up? Yeah, everything's fine. Really? I'm ready to go home now. Uh, that's great news. Uh, I'm happy that you will be discharged but before that I want to have a short talk with you to make sure that we are on the same page here. Is that ok. Sure. Yeah. Ok. So, uh, uh, Ashley, could you tell me why this happened for the first time? How, how you have been admitted to the hospital? What happened? Well, I had this chest tightness, um, you know, it was bothering me for a day or so and, and I came to the hospital, they told me I had a heart attack. Um, oh my God. But, but it, it's, it's fine. They gave me medications and, and now they said that I was, I was good to go. Ok. Ok. I think the good news is that you are well now. Yeah. Ok. I understand. And this is the first time you have been admitted to the hospital. Yeah, I've never been here before. Mhm. I see. And, uh, do you, uh, have any medical problems before? To be fair. I've never really been to the doctors. How do I? That? Well, I feel fine. I don't wanna bother you people. You're busy. We are busy taking care of you. Of course. That's true. Ok. And, uh, you don't take any kind of any medication? No. Mhm. No, that's good. And you don't have any allergies? No. Ok. That's good. And, uh, do you have any, uh, problems run in your family? Like your condition? Uh, well, I think my father also had a heart attack in his fifties. Um, I'm sorry about that. Yeah, but that one killed him. So, you know, I'm still there. My sincere apologies for that. Thanks. Ok. And, uh, a bit about your, uh, your social life. Uh, uh, do you, uh, do exercise? I don't really have time. Hm. And why is that? I'm a bus driver so I drive sort of long hours. Um, and the, there's not really, you're sitting all day in. I see. I see. Yeah. Um, yeah, fair enough. I understand that you don't have time for that and of course we can't, uh, have a short talk about that and we, we seek what we can do for this. Um, what about your diet? Well, I suppose it's the same, isn't it? Um, yeah, I stop at mcdonald's a lot of the time on my breaks. Uh, don't really have time to make food. I see. Any vegetables. You don't take any vegetables. There's do you know what, there's lettuce and mcdonald's burger? Ok. That's count. Ok. And, uh, do you, by any chance do you smoke? Yes. Is that bad? Um, uh, I think it's bad. Right? Um, ok, let me see. How much do you smoke? About 10 a day? It's not that much for how long? 40 years? Oh, I see. This long. Yeah. Uh, ok. Uh, we'll talk about this and try to cut this down. Is that ok? Ok. Ok. And, uh, I think I had it. Uh, ok. So Sarah, uh, from you tell me, and I see my note, uh, your notes that you had a heart attack, as you say. Mm. And we have managed your condition and you are now better and safe. Yes. Mhm. Ok. Uh, there is, uh, something we should talk about it, uh, to make sure that you don't have this again. Hm. I think we, there are some change, uh, change that need to make in your life to make sure you are unhealthy, unfit and well. Right. Yeah. Ok. So we have, uh, a lot of things here. We have the medication which is new for you that a whole bag of medications. I don't know what they are and I don't know what they do. I see it's overwhelming and there is a number of medication but it is all for you and will benefit you and help you. And most important that you take it in, in the time and don't, uh, stop taking your medication. Mhm. Ok. Do you, uh, do you have any concern? WW, what is it for? Uh, ok. We have aspirin for your heart to protect your heart, uh, to maintain your heart rate and the, and the lowest thing we can to, uh, to protect it. Ok. Uh, simvastatin to lower the li lipid profile, lipid, uh, count in your blood also to protect your heart. Clodine. The lipid count is that like, like that? It's a fast in the blood. There's not in there. I, what we call it. Yes. Like what happened? Hello, Carol Car. No, there's still time. You've got two minutes. Carry on. You've got two minutes. So, ok, you have club? Ok. Ok. That's the same as to protect your heart. Clear. Oh, Elizabeth. Can you hear me? Yup. Ok. Ok. So we need to discuss also the lifestyle, which, I mean, the smoking and exercise and eating habits. I know it is difficult to take it all in one. But we will, we will, I will try my best, uh, to try to break it down and make it easy for you. Uh, which w which one do you want to start with? Uh, the, the smoking? Ok. The smoking. Yeah. Excellent. I think that we need to cut down the smoking. I know it is difficult for the first time and we are here to support you and help you. Uh, do you have any idea how we can help you to stop smoking? Well, I have seen some people with like, you know, gums and patches and different things to, to try and stop. I, I've never tried but I mean, II, suppose II should know, ok, for sure, we can try it. And also I can add that there is a water group and smoking cessation clinic which will help you a lot in that. And we take it step by step. We can decrease the count to make it no smoking, smoking free for you. Ok. Yeah, that's good. And, ok, what about the diet now? How we can do, I don't know how to cook, you know. Um, but I can, I can get salads, I can get more salads and move on to the next session. I know at times out. What do you think? What do you think me? You asked me? Ok. This is my first patient. I did not see this patient before I start to preparing. Yeah. Do I? Sorry, you were cutting off, have any approach for this? Hello? Can you hear us now? I do. No, I don't. We can't hear you very well. Can you hear me? Ok? I think you're back on. Ok. Here is ok. Ok. Ok. Right. Um, because, because of time I'm just gonna tell you, I'm just gonna give you the feedback. Um, if you can hear me? Ok. Ok. I can hear. So I think you I think you did very well. You've built that report as an examiner even though you don't, you don't, even if, even though you don't finish the station, I still feel like you deserve to be on a really high school because you build that report, you make the patients feel comfortable. You tell them what you want to ask what they are. They will be expecting from you, like from taking history. You smoke. We was, I like how you say we will, we will, we will look into that later. Uh Is that reprimanding the patients without actually making her feel uncomfortable? So I think that's a really good thing in your interpersonal skill that you should keep it on. Thank you. And you did explain everything else. So I kind of like how your approach to this station is. But um in terms of your history taking, you did quite a good one, but I feel like there's a few more sense you've say you've wasted a little bit of time in the beginning. Like if you wanna have it done perfectly, I would save a bit more time in the beginning in the introduction, bits and Bobs and get into it. But you did very well in general in terms of building report, in terms of your interpersonal skill, in terms of your communications. But if you could finish the S stations off and summarize them, saying that um look, you've admitted in the hospital four days ago we've given you all these medications and I've given you some, oh, he's gone. Uh, I've given you some advice on your ha lifestyle. Um, any questions so far. But I think otherwise I don't have any problem with. I, I'm very happy with how you've done the stations. Um, so, yeah, well done. Thank you. Thank you. Thank you. That if you could just make it shorter, I mean, just concise it and finish off the stations, it will be perfect, but I don't see the reason why you, why you can't pass the station there too. But I still you get, you're gonna get a good score in there. All right, I think that's coming to the end of our sessions. Thank you very much for everyone who's attended and just a quick summary in the communication stations. A few things, listen to the patients, make it a two way conversations, build, report, do check and check and you will be fine, just keep practicing them and it will be grateful if you can leave us the some feedbacks of what we want to do in the future session and how, how else we could actually deliver the session better? All right, have a good evening everyone. And uh for those who have an exam sooner than our next session, I wish you the best of luck and thank you again for attending. Goodnight everyone. Thank you everyone. Thanks Dennis. Bye bye.