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Hi. Um, I'll just give everyone until about like one minute past two minutes. I'll quickly introduce you and then you can take it away. Um, warning you in advance for me. The slides are working like I just saw that you tried to switch them. Yeah, I just tested it. Yeah. Um, people might tell you in the chats that the slides aren't working for them. So what you can do is you can stop presenting and then start presenting and it'll go straight to the slide that you were on and that usually works to reset it for everyone, but just be aware that sometimes it can lag on other people's systems. Ok. Great. Thanks. No worries. Right. Because I am wary of the time I am gonna start things off. So good evening everyone. Um, we've got a ay teaching session today on difficult communications really centered around, um, patients and how to communicate with them efficiently. We've got, uh, Zona, is that right? Ok. Presenting, um, for us today, as per usual, it's gonna be about 45 minutes of teaching followed by some sy practices which will be held by our volunteers in the breakout. Rooms. Um So please do stay for that because I think it's quite essential to uh consolidate everything that Zona has taught today in terms of um practicing it in aus scenarios. So uh don't forget to fill out the feedback form because that's super important. You'll get to receive Zona S uh powerpoint slides as soon as you've filled out the feedback form and she gets to hear the wonderful comments that you have to say about her. So uh Zona off you go and hope you guys enjoy. OK, thank you. So, hi, everyone. Thank you for joining. As Alina said, I'm Zona and I'm a student at Manchester. Um I'm currently intercalating after my fourth year. So today we're gonna be discussing difficult communication and some ethics and law topics. I know from experiences can be quite, these can be quite a daunting stations, but they actually are fairly easy to approach. Once you have the right structure in your mind, they rely less on sort of knowing hard facts like other stations. So I've actually found that easier to score higher in. So hopefully by the end of this, you'll feel a bit more comfortable tackling these kinds of stations. So we'll get started. Let me know if you have any questions at any point and if you can't see the slides, just let me know. So there's a discount code there for um gee medics. And as Elina said, this is the rough session structure we'll begin with this teaching session and then we'll go on to CCA practice. So we're gonna start off with a quick cli um don't worry if you don't know the answers, we'll go through them in detail at the end, but just to get us started. So the first question and you can just pop your answers in is which of the following documents is legally binding. So there's a in advanced statement, B advanced decision or CDNA CPR form. So you can just put a B or C in the chart. And if you're not sure, just give it a guess, I'll just give it a few more seconds, then we'll just go on. OK? I can't see any answers. So we'll just go on to the next one. So one more question, I know it's a bit more lengthy. So I'll give you a bit more time in which of the following situations. Can you break confidentiality? So there are three scenarios. The first one. A, the patient has been diagnosed with HPV, but they don't want to tell their partner with whom they have unprotected sexual intercourse. Ba patient thinks their partner who is another one of your patients known to you has an sti and wants to know if they came to see you and you're aware that the partner recently tested negative in an S ti screen or see an inpatient has become unconscious and their relatives have arrived and they didn't know that this patient was admitted, but they want to know what's happened. Ok? I'll just give it a few more seconds just in the interest of time. Ok? We'll move on. We'll go through the answer at the end. So don't worry if you didn't know. So today, these are the learning objectives that we're gonna go through. So there are three sections. First, we're gonna talk about how to deal with strong emotions and how to kind of approach these difficult communication stations, then about raising concerns about care, thinking about patient complaints and concerns. And then finally, they're gonna go through some important ethics and law definitions and some of the facts that you need to know for these stations, particularly regarding consent, capacity, confidentiality, and safeguarding. So firstly, we're gonna talk about dealing with strong emotions. So here are some signs that a patient may be angry or frustrated. Um I'm sure you're quite aware of these, but these are just some of the things that someone might help, someone might come across in a station and in real life. So with regards to how to approach the station, it's really important that you provide structure to the conversation whilst these stations are primarily about listening to the patient and making sure that they and you are on the same page and that they, you heard you do need to give a bit of structure um to make sure that you cover everything that you need to. So firstly, it's really important to have this golden minute, which you may have heard about basically a minute. We let the patient talk without interrupting. Obviously, it doesn't have to be exactly a minute. But in general, at the beginning of the station, you should make sure that you gather all the background information. This also includes ice. So ideas concerns expectations. You need to be doing this in every pretty much every single ay station. And I would always suggest getting it done fairly early because particularly at Manchester, it's included on the mark schemes. So if you don't include it, you will be marked down and it is just helpful because it really gives you a guide on where to go with the station. And at the end of this station, you'll summarize it and what they've spoken about with you and confirm an action plan throughout all this. You should be acknowledging the patient's emotions, making them feel heard. And this will really help, particularly if they're angry, it will help them be more open to discussing with you if they feel like you're listening to them. So if we start with how to begin a consultation, so as usual, you'll introduce yourself, get their name, get their date of birth. Usually sometimes if it's a relative, you're not gonna ask them if it's what their date of birth is, you'll just confirm the patient's date of birth and always ask what they'd like to be called particularly in these stations don't assume their first name because they're more likely to get offended by that. Um, but they might be fine with it but that just to ask, um, something like, and how would you like me to call you today and then check why they've come to see you. Something I like to do in every station is when you're checking, sort of why they came to see you. I think it's best not to come in with an assumption of why they're there, even if you've had the station brief, because often if you tell them, so we're here to discuss this. They might say they might not have heard that they might say, oh, that is not why I'm sitting down with you today. So I usually say it's my understanding that you've come here to, for example, discuss some concerns you have about your care or if you've wanted to speak to a member of the medical team and then end it with. Is that right? Or is that correct? How phrasing, whatever phrasing is, um, natural for you and usually wording it as a question, helps them feel a bit better about beginning the station and beginning the conversation and it helps you be on the same page. And once I've told you why they're there, always thank them for speaking with you or reassure them that you're happy to discuss this. Basically, a lot of these things help diffuse any strong emotions that might be there always start with open questions, gather the background very sensitively and so going on to the little sections if we start with ice. So beginning with ideas and understanding when, when you're gathering information, responding to cues and emotions appropriately is very important. So reflecting their emotions is a pretty good way to demonstrate that empathy saying things like that must have been quite upsetting or I see that this has been quite frustrating for you match the patient terms that they use to describe their emotions and their tone and they'll feel a lot more heard. Um nonverbal communication is key as with any station. And I often find in sort of ethics and law or difficult communication stations, it's important to have quite sensitive wording of questions more so than other stations rather than saying, why are you worried about that? I would sort of preface it with like a couple of words to make it a bit more gentle such as may I ask what's worrying you about this or can I ask? And if you say that and word it sensitively without appearing too cautious, it works quite well. And as I said before, you should provide a structure whilst also letting the conversation be very patient centered and patient l there's a balance there. And when you're also gathering ideas, it might be a good opportunity to sort of correct any misunderstandings or misinformation. For example, if there's a long wait, they might not know that emergencies are prioritized. Um One situation that I've had in a station is a patient wanted to come home after having an untreated m and what you have to do in that station was tell them that it could be fatal if they went home. And if you didn't say that then it was a safety issue. So, just making sure that you're on the same page essentially and gathering patient concerns, we've kind of covered this. But if you summarize regularly, it really shows that you're listening and it's helpful for you to do summaries. I'm sure you've been told this a lot, but it really helps you gather your thoughts, particularly if you're stuck and also on mark schemes on especially at Manchester, there's usually points for summarizing. So it's a win, win really. And when you acknowledge your concerns, I find it helpful to um when you want to gather, if there's any more concerns, I think it's important to first do a mini summary such as saying other than the long way to A&E and then show that, that they, they've been affected by it, which has been quite frustrating. And then you ask if there's anything else just to show that you've been listening and not just asking, is there anything else without kind of reflecting back at them? And then moving on to expectations. This is another good time to summarize and stimulate concerns. I would give a suggestion of their expectations and then ask if there's anything else just to kind of show that proactiveness and that empathy, for example, saying something like other than being seen quickly, is there anything else you'd like me or the medical team to do for you? And so something I think there can be a lot of confusion about in difficult communication stations or patient complaint stations is whether you can apologize or not. Um Generally saying the word sorry is not a bad thing. If you think about it in a normal real life situation, you would say sorry. It's just a very clear demonstrator of empathy and it's just a natural thing for most people to say. So you can absolutely say sorry, but you should avoid certain false reassurances. For example, if the patient is blaming a specific member, you should avoid stoking the fire in a sense and avoid assigning blame to certain members of the team. But you should acknowledge that certain things shouldn't happen. For example, incorrect medications given. And this is because any medical error is never the fault of one person. There's always multiple factors. For example, if the wrong dose of medication was given, perhaps that staff member was tired and maybe that was because there was understaffing or they hadn't had time to have a break. It's never as simple as blaming a person. So really important to avoid that. And so it's important to demonstrate that you're sorry that something has happened but, and keep it quite general, but also don't distance yourself too much from an event. Um Otherwise it will come across as in instance there. So some phrases that I think are quite helpful are things like I'm sorry that this happened. I'm sorry that you've been put in this position. I'm sorry that you've been made to feel this way important not to say things like I'm sorry that you feel that way because that's a bit of a non apology. And then finally, um and when it comes to closing these stations important to summarize again and form an action plan, um you already have gathered what the patient wants from their expectations, part of ice, but you can also give suggestions and um check that they're happy with it. You shouldn't not always expect the patient to be completely happy, particularly in ay stations. You've only been speaking to them for about eight minutes. They're never going to feel completely better about a situation. But as long as they're somewhat satisfied with the action plan, then that would be a successful station and a successful conversation. And again, always thank the patient for their time and for speaking with you and always ask if there's anything else that they'd like to discuss. So that's the structure of how to approach difficult communication stations in general. Some tips that I have, I've mentioned this already, but always ice and do it pretty early on in the station, don't be afraid of strong emotions. I think particularly anger can be quite an intimidating emotion in ay scenarios. But do keep in mind it's not real life and in the exam, they're never going to get extremely angry. They can't shout at you because it would interfere with other stations. Um And whilst you can expect that in real life, sometimes you don't have to worry about that in Aussies and just always be understanding, they're never gonna cross the line in an ay station. I doubt. So, don't be afraid of it. They're just really dig deep to find out why they're angry or why they're upset and find that worry and acknowledge it. And usually if you say the right thing, it will really make the patient open to discussing things further and pause is completely fine in these stations. More so than any other station really. Um silence can be very effective and it's a good opportunity to summarize again and again, allow the patient to talk freely without any interruptions. By the way, guys, if you have any questions at any point, just let me know, I know we're going through this quite quickly. So the next part we're going to discuss is some specific difficult communication style stations you might have. So we're going to begin with raising concerns about care. So this is the station brief, Mister Smith has been diagnosed with community acquired pneumonia and was admitted for treatment with IV antibiotics. He was prescribed coamoxiclav. Despite a known penicillin allergy, the medical team recognized this error and Mr Smith did not come to harm. His daughter is frustrated that this has happened and would like to speak to you about their options. Mr Smith has given his consent for you to share details of his condition and care. So just to pick out a few bits from this brief, importantly, this scenario is about a medical error and patient complaints. So he's been prescribed amoxiclav, which as you'll know, contains amoxicillin, but he is penicillin allergic. Thankfully, nothing's um not come to harm, it was recognized, but naturally the daughter is frustrated. Um Often these patients have a little sentence to tell you that the patient has given their consent for you to um share details or break confidentiality. It might also say that the relative has lasting power of attorney for healthcare if it doesn't say anything like that. Um Generally, you can assume it's a relative or next of kin, it's fine to discuss care with them. But you can always clarify with the patient, whether they have lasting power of attorney, specifically the healthcare and will go through lasting power of attorney later. So as normal, uh when beginning the station, we'll stick to a structured approach as we've mentioned before. So introducing yourself, gather information, make sure you and the patient or relative are on the same page and do a bit of ice as always done, we'll talk a bit about sort of advice to give and sort of what things you need to mention in these stations. So always make sure that patients are aware of their options, encourage them to speak with those directly involved in the patient's care, which is usually you in the station. And another really important thing is signposting patients or relatives to appropriate channels where they can give their complaints or receive support. So usually this will be pals in a hospital setting which stands for patient advice and liaison service. P is definitely something um to remember in any patient concern, they shouldn't always mention pals. But if it's in a GP setting, you can tell them they can speak with the practice manager. And another thing to be aware of is the process of significant event analysis. This is a bit less relevant for a CCA station, but it's still important to know and significant event analysis basically concerns making sure certain things don't happen again. So in the chat, could anyone tell me some examples of events that might be considered significant or never events? I'll just give it a few more seconds. OK. No worries. We'll go through that in the next slide. So with regards to significant events or never events, these include things that should never happen and are very avoidable. For example, um misdiagnosis, wrong dose given medication, given that someone has an allergy to so significant event analysis involves reflection on why an event occurred. And we talked about this briefly earlier. But remembering that it's never the fault of one person. There's always multiple factors, um completion of an incident report form and then an investigation to prevent it happening. Again, this is always the most important part of any kind of complaint concern. Significant event is always to do with the action plan and what we'll do to prevent this. So that's some examples of um raising concerns. We're now gonna talk about some legal definitions, these include consent, capacity, um confidentiality, and we're also gonna talk a bit about safeguarding. So we're going to talk about the following. Here is some really key um documents and definitions to be aware of for your CCS or OS. So the Mental Capacity Act and lasting power of attorney are particularly important when patients might lack capacity to make their own decisions. And then some other documents that are really important particularly in end of life or palliative care is um DNA CPR, advanced decisions to refuse treatments and advanced statements. Some helpful resources I think are GMC guidance and OOP is really good. They form out everything really nicely and it's really clear there's also some practice stations on there. So here is the station brief. So Mr Jones is an 87 year old man who has been diagnosed with late stage dementia. His daughter, Sally is his carer and would like to speak to you about his care and how decisions are made, given his fluctuating confusion. So things, some things I'd like to point out in this station brief are that um, whilst Mr Jones has late stage dementia, his confusion is fluctuating and that's something we'll really focus on with regards to how capacity can change and his daughter is his carer. So that's his next of kin. So generally you'd expect to be able to sort of break confidentiality or talk about any aspect of his care with her. So we're first going to talk about the Mental Capacity Act. So patients are assumed to have capacity unless proven otherwise. And capacity is time and decision specific. So this is really important. Someone can just have capacity or not have capacity. It has to be this person has capacity to make this decision at this specific time because as we saw previously, um with Mister Jones, his confusion is fluctuating the capacity can change over time and it should be assessed when consent is required or it should be assessed when that person has capacity. So for example, um if he tends to have less confusion in the mornings, you should speak to him then about important treatment decisions to get his opinion on his care at that time. If a patient lacks capacity, you have to act in their best interests. And importantly, just because you believe a decision is unwise, it doesn't mean that they lack capacity or it doesn't necessarily bring into question their capacity because their autonomy has to be respected. So, for example, if a patient had an M I and wanted to go home without treatments and it was quite a severe M I and you told them that it could be fatal that they could die and they still wanted to go home. If you believe them to have capacity, you can't stop them unless it all in sense in situations. For example, there's Children involved, you might have to intervene a little bit. But in general, just because something's unwise, um doesn't mean they don't have capacity. So we're gonna go on to how to assess capacity. Can anyone tell me some of the components of assessing capacity or how to tell if someone has the capacity to make a decision? You can just pop any answers in the chat, ok? I'll move on in a few seconds, ok? We'll just keep going. We'll go through this now. So there is a simple two stage test to assess capacity and someone only lacks capacity if the answer to both questions is yes. So first you have to assess if the patient has any impairment or disturbance of brain function. For example, in this um scenario, Mr Jones had late stage dementia. So that would be a yes. And then question two, you only go on to if they have an existing impairment of brain function and then you have to check if they're able to make a decision at that time. So there are four components in um making decisions. The patient has to be able to understand the information you tell them retain it for a certain amount of time we that information up or be able to use that information to make an informed choice. And finally, they have to be able to communicate that decision back to you. If they can't do any of those, they don't have capacity to make that decision at that time. And when someone lack capacity, as we said, you'll act in their best interest, um you might communicate with their relatives, you'll see if they have anyone has lasting power of attorney. Um And yeah, in general, just act in their best interest. So going on to another example station, now we're gonna talk a bit about end of life care decisions and also lasting power of attorney. So this is June, a 72 year old lady who's been diagnosed with stage four pancreatic cancer. And she'd like to know more about how she can plan her future treatments and decision making. So I actually had this as a station in third year and it was a gentleman who came in and he had um end of end stage cancer and he wants to talk about all his options and stations like this. They're not so much whilst you have to be very sensitive generally because it's only eight minutes. The patient is very receptive to hearing about everything. It's very easy to speak with them. Um And it's very doable as long as you approach it. Well, word everything quite sensitively because they've come in to speak about this, so they're ready to hear anything you have to say. So, uh DNA CPR, I'm just gonna go back a slide um in the chat. Can anyone tell me with the DNA CPR S or do not attempt cardiopulmonary resuscitation? Um Who makes that decision? Is it a patient's decision or is it the decision of the medical team? And if you're not sure you can just put a guess in? Ok. No worries. We'll just go on. So we're gonna talk a bit about DNA CPR. So this is a decision made to not start CPR in the event of cardiac arrest. So you can see an example of DNA CPR form on the left. Um This decision only applies to CPR, not other aspects of treatment. This is a really important thing to keep in mind because in these kinds of stations, a pretty common question you, you'll get asked by the relative of the patient is if I have DNA CPR form, does that mean um they're not going to treat me as much? Does that mean my care will be different? You have to reassure them that no, it only applies to CPR. Every other treatment will be done. Every other effort will be made. It's not gonna affect the quality of their care. Um Having DNA CPR doesn't mean like they're being given up on it in any sense at all with regards to who decides DNA CPR. This is another common question you might get in a station. It's important to be aware that it's a medical decision. This is not the patient's decision, but as um you should discuss these decisions with the patients. Um and the patient has to be made aware of the decision. Generally, there's um quite good agreement between the patient and the medical team on whether to have DNA CPR put in place. If a patient wants DNA CPR, um the medical team may agree and put that in place. Um But it's important to be aware, I'm not sure how many of you have been in a cardiac arrest situation, but it's a very, it's very, very intense and it can lead to quite poor outcomes. So if it's felt that DNA CPR is not going to be successful, then it's quite futile to attempt it because afterwards, um like good CPR often leads to things like um cracked ribs, then leads to ICU stays and it's um it's a, it lacks a lot of dignity as well. So this isn't a decision that's made lightly and um the medical team will weigh everything up. But it's important to be aware that DNA CPR S are not legally binding. The decision can be overridden by clinical judgment, particularly if there's an immediately reversible cause of um respiratory or cardiac arrest, like choking anaphylaxis. So that's something else you can reassure a patient about if um you're informing them about DNA CPR decision. And so next, we're going to talk about advanced decisions and advanced statements. I know there can be a bit of confusion between them. So an advanced decision is short for an advanced decision to refuse treatment. This is legally binding, important to be aware and it's signed by a patient and a witness. It enables an adult with capacity to make a decision to refuse a specific treatment in the future. Um I'm pretty sure this will also apply to under eighteens with gille competence with regards to certain treatments and it allows everyone to be aware of the patient's wishes if they become unable to make or communicate those wishes. Um It's a really handy document to have in place and patients can change their mind at any time. I think it's quite important any end of life care discussions or end of life care stations to remind the patient that they can change their mind about anything advanced decisions, advanced statements, anything at all about their care, nothing is set in stone. So even DNA CPR S are not necessarily set in stone. If a patient's condition approves the medical team might change their mind about whether um it's likely to be successful or not and um change that decision and then advanced statements conversely and not legally binding. So, advanced statements are advanced statements of patients wishes. So this can include anything. It's quite a nice document to have. Um It really allows care to be very patient centered and you can literally put anything in. There's some examples there. So things like spiritual beliefs, um place of care, food and drink preferences, um preferred treatments can be put in there. But it's important to be aware because it's not legally binding. It's more a document that is um consulted when making decisions, but it will be taken into account. And finally, another legally binding documentation is lasting power of attorney. So lasting power of attorney allows you to appoint someone to make decisions on your behalf in the event that you like to do so for yourself. There are two types. It's really important to clarify which type someone has um in an a station. They will, if they say they have lasting power of attorney, you can clarify it, but it's more than likely gonna be health and welfare. But in real, in real life, it is really important to clarify which one they have because if they don't have the health and welfare power of attorney, you might not necessarily be able to break confidentiality and speak to them about the care or have them make decisions. So with those different missions out of the way, now, we're gonna speak about confidentiality and we're just going to go a bit more quickly now. So patient confidentiality is a really important responsibility of the whole medical team. It maintains the public's trust in us as doctors. However, there is an exception and that is when um not sharing information would put the patient or others at risk of harm. So here are some specific circumstances in which confidentiality can be broken. So as we said, when there's significant harm, risk of harm to the patient or another person, Um if there's Children or vulnerable adults involved, you may be able to break confidentiality. A really important point is that you can break confidentiality when it comes to blood borne diseases like HIV or syphilis, but non blood borne diseases, particularly nonblood borne ST is like chlamydia, you cannot break confidentiality. This also applies to things like HPV. You can't break confidentiality because it's not blood borne. So in these sorts of situations, I think it's wh you can't break confidentiality. You can't emphasize to the patient that if they the risks of passing on certain diseases, for example, chlamydia can lead to pelvic inflammatory disease. Um and in severe cases can lead to things like infertility. Um but you can't break the confidentiality. You can also break confidentiality when it comes to notifiable diseases. This is things like mumps and there's a whole list of them, you can find it online and then finally D VLA and drivers. So for certain health conditions, um patients are expected to self report to the D VLA. And if they don't do so, um there's a duty on the doctors to inform the D VLA. So there's things like um certain people with epilepsy, depending on their seizures and seizure control, they might have to inform the D VLA. Um But also with confidentiality, one more thing is if you're going to break confidentiality, remember that you have to inform the patient first. Um So you can tell a patient that um, I would really encourage you to share this information. And if they don't, you can say, um, you have to tell them that you're afraid you'll have to break confidentiality and you'll have to share that with that person because, um, that's a duty placed upon you and now we're just gonna discuss briefly domestic violence. Um This is more common in fourth year acies at Manchester, but it can and has come up in third year. So this topic is one to be approached very sensitively with quite gentle open questions. Um I'm sure you can appreciate it can be very difficult to speak about these things and it's very easy for people to become quite defensive if you word questions in a certain way. So saying things like, could you tell me how things are at home or I'm worried from what you've told me that you might not be safe at home. Um There's a heart questionnaire which are quite blunt questions, but they can be very important with regards to screening for domestic violence. So it's things like asking. Does your partner ever humiliate? You, do you ever feel afraid of your partner? Have you ever been raped by your partner? And have you ever been kicked by your partner? Always risk assess in these kinds of stations. Um, check in with the patient how their wellbeing is if they've had any thoughts of harming themselves or others, if they believe they're in danger of being harmed by their partner, and if there are any Children involved, um generally, if there's Children involved, it might lead you to have to um escalate this to safeguarding leads. So some signposts, some results to signpost for patients are things like women's aid um helplines and that can be really helpful for people. So to conclude, here are some helpful links and resources. OSK stop is really handy. There's a lot of stations, a lot of info displayed in a really clear way. And of course GMC guidance, I've always really liked the NHS website for preparing for OSK stations in general, not just difficult communication. So we're gonna go through the questions again from earlier. Um Again, you can pop your answers in the chat. So hopefully you're a bit more aware of the knowledge in these questions. So the first one is which of the following documents is legally binding and the options are a in advanced statement, e advanced decision or CDNA CPR form. And so if you just pop your answer in the chat. So someone said C OK, C is a good gas. Um particularly since DNA CPR forms, you can measure quite a um well thought out decision, but the answer is actually b so if we go through all three of them advance statements um are general statements of wishes. It's not legally binding, but it's a really helpful document when it comes to being aware of a patient's preferences. It can literally include anything in advance decisions to refuse treatment are legally binding. Um You have to follow them, patient can change their mind, of course. But um they are legally binding DNA CPR forms are not legally binding partly because there are certain situations where they can be overridden. Um if a patient's condition changes or if there's a reversible cause. So the next question a bit longer was in which of the following situations, can you break confidentiality? So the first scenario is a patient with HPV who doesn't wish to tell their partner B is a patient thinks their partner has an sti and wants to know if they came to see you and you're aware that the partner tested negative. Both A and B I've had come up as a stations though. Um A was more sort of a secondary part of the station and then see an inpatient has become unconscious and their relatives want to know what's going on, but they didn't know the patient was admitted. So you just pop any ads in the group chat. Um, they are, II think things can be a bit ambiguous with these. So don't worry about getting it wrong. Just give you a best guess. So one person per a, so a is a really good, um, answer in this one. It's actually, um, c where you can break confidentiality and so we'll go through the reasons why. So if you start with a, um, HPV is not a notifiable disease specifically because it's not blood borne. So blood borne diseases like HIV, syphilis, you can break confidentiality. HPV, chlamydia, things like that. You cannot because they're not blood borne, but you can emphasize to the patient the risks. You can tell this patient that HPV can confirm an increased risk of certain cancers, um specifically cervical and anal cancer. Um But you can't break confidentiality in B again, you can't break confidentiality. Um You cannot say that the partner came in for an appointment. You can't say the reasons for the appointment even though it's negative. You can't say anything. You can only suggest that the, your patient speaks to their partner. And um if the patient has any symptoms, they can get a test and see, you can break confidentiality because um in general, in these situations, you can assume that you can tell the next of kin um details or at least a brief background of what's happened. Unless the patient has previously said they don't want anyone to know that they're there or what their condition is. So, thank you so much for joining. If anyone has any questions, I'm very happy to answer them. Um But there's a QR code there and be very grateful for your feedback. See what went well, what we can improve. Um And then we're going to breakout rooms for your cca practice. Yes. So I've just also sent everyone the feedback form on the chart. So, um, thank you very much, Zona. Yeah, let's if everybody could break out into the sessions now, um, just try to evenly spread yourselves out as, as well as you can. It's quite hard to do. I understand. Um, if you see that there's more than one or two people in the room assume that it's uh full and drop into the next one. So, um, you will be sent the slides once you've filled in the feedback forms. Uh Thank you very much and hope you guys enjoy the practice sessions.