ST EMLYN’S · MLA REVISION GUIDE
Communication
01 / CHAPTER 4
Communication with a clear purpose
Good communication starts with understanding the other person’s account and the decision that needs to be made. A conversation about consent, an explanation of uncertainty and a referral require different information, but all depend on listening, clear language and an agreed next step. Notice the person’s response as well as their words. Give them time to speak, allow silence after difficult news and check that your explanation has answered their concern.
Read the role assigned in an assessment. On placement, introduce yourself as a medical student and agree with the supervising clinician which part of a conversation you will undertake. You can gather information, explain a plan you understand, identify a problem and contribute to a discussion; you should not independently announce an unconfirmed diagnosis, promise a treatment or take responsibility for decisions beyond your role. A newly qualified doctor also needs support for unfamiliar or high-stakes discussions.
Arrange privacy and appropriate communication support. Ask whom the patient wants involved and what may be shared. A relative’s concern can be heard without disclosing confidential information. Use a professional interpreter where needed rather than assuming a family member can interpret a sensitive discussion accurately. The example phrases below are illustrations to adapt, not compulsory scripts.
02 / CHAPTER 4
Complaints and upset patients or relatives
An upset person may be describing untreated pain, a missed diagnosis, a frightening delay or a breakdown in trust. First establish whether the patient needs immediate clinical attention. Arrange a quieter conversation if safe, check the facts available and ask an appropriate member of the team to support you. A student should help obtain the right response, not promise to investigate the organisation independently.
- Introduce yourself and establish the concern. Confirm who you are speaking with and their relationship to the patient. Ask what happened and what matters most now.
- Listen and summarise. Let the person finish where possible, then check your understanding. Avoid arguing over details before you understand the problem.
- Acknowledge and apologise appropriately. If an error is known, acknowledge it directly. If the facts are unclear, express concern and explain what you will clarify without speculation or blame.
- Address care now. Obtain assessment, pain relief or review of results through the responsible team as needed. Check the patient’s permission before sharing information with relatives.
- Agree the follow-up. Identify who will respond, how they can be contacted and when an update can reasonably be expected. Document the concern and actions accurately.
“I’m sorry this has been so upsetting. I would like to understand what has happened and make sure your immediate concerns are addressed. I’m a medical student, so I will involve the clinician responsible for your care in deciding the next steps.”
An apology such as “I’m sorry you feel that way” can sound dismissive. Be specific about the experience or known error. Do not guarantee that an incident will never recur, that a particular investigation will be commissioned or that you will personally be available throughout the admission.
The complaints route
For NHS care in England, PALS can help with immediate concerns and explain the formal complaints process. A formal complaint should be acknowledged, with an offer to discuss its handling, within three working days; the likely response period should be agreed. There is no universal 30-day response promise. Other UK nations have their own routes. Help the person find the appropriate local service rather than requiring them to resolve the problem alone. NHS England explains complaints and escalation.
Patient safety incident response
In England, the Patient Safety Incident Response Framework replaced the Serious Incident Framework. Immediate safety action, reporting and compassionate involvement of affected people remain central, but the old SIRI threshold and fixed investigation timetable should not be recited as current rules. Report concerns through the local system with your supervisor and help preserve an accurate account. The organisation determines the appropriate learning response; a safety report does not replace a response to a complaint. NHS England: PSIRF.
Candour
The professional duty of candour requires openness when care goes wrong and causes, or could cause, harm or distress: explain the known facts, apologise and arrange appropriate support and an explanation of consequences. Tell your supervisor promptly if you discover a possible error. Do not conceal it or speculate beyond what is known. Organisational statutory duties are separate and differ across UK jurisdictions. GMC: professional duty of candour.
Rehearsal scenarios
Practise a missed-fracture conversation and a parent’s request for a CT scan after a child’s head injury. In the first, identify the immediate care needed and what is actually known about the earlier assessment. In the second, explore the fear behind the request and explain that imaging decisions depend on the clinical assessment and current guidance, including benefits and harms. Neither scenario is solved by apologising and ending the conversation.
03 / CHAPTER 4
Disagreement, explanations and uncertainty
Disagreement is easier to address when you identify the reason for it. A patient may be frightened, may have received conflicting advice or may value an outcome differently from you. Establish the clinical facts, hear the concern and explain your reasoning without becoming defensive. If the situation becomes threatening, prioritise safety and obtain help; continuing a private discussion at any cost is not required.
“I can see why you want something done today. Could you tell me what worries you most? Then I can explain what the assessment suggests, what the options can achieve and what we would do if things change.”
Explain the likely benefit and potential harm of an intervention, reasonable alternatives and what remains uncertain. Use small amounts of information, then check understanding. Acknowledge when another clinician’s review is needed. Offer a second opinion through the appropriate route where disagreement remains; do not present it as a threat or a way to dismiss the person.
Common scenarios to practise
- A request for antibiotics: explore what the patient expects treatment to achieve. Explain the clinical assessment and the proposed plan, including symptom relief, follow-up and deterioration advice. Do not claim antibiotics never help a broad symptom such as cough.
- A tick bite and a request for antibiotics: obtain the exposure and symptom history, examine as appropriate and consult the current relevant guidance. A communication exercise still requires correct clinical reasoning.
- Refusal of tetanus prevention: explore the concern, explain the indication and options using the actual wound and immunisation history, and support an informed decision. Do not equate refusal with lack of capacity.
- Driving advice: check the condition-specific requirements, licence group and responsible licensing authority. Explain the advice and document it; do not invent a universal driving restriction. DVLA guidance for medical professionals is the starting point for Great Britain.
Close by summarising the concern, the agreed plan and specific safety-net advice. Ask the person to describe the plan in their own words so you can identify an unclear explanation, rather than testing whether they have remembered a script. If no agreement is reached, record the discussion and arrange appropriate review.
04 / CHAPTER 4
Referrals and safe handover
A useful referral makes the clinical question clear. Before calling, assess the patient as far as you safely can, review the relevant observations and results, and agree the referral with your supervisor when working as a student. If the patient is deteriorating, call for urgent help immediately and state that urgency; gathering a polished presentation must not delay care.
“Hello, I’m Sam, a medical student working with Dr Patel on the ward. I’m calling about a patient who needs urgent review. May I confirm your name and role? Dr Patel has asked me to give you the assessment and is available to discuss the plan.”
| SBAR | Make it useful |
|---|---|
| Situation | Give the patient’s identity and location, the immediate problem and urgency. |
| Background | Include the relevant admission reason, comorbidities and treatment; avoid reading the entire record. |
| Assessment | State the current observations, examination, results and your interpretation. Say what remains uncertain. |
| Recommendation or request | Ask a clear question: urgent bedside review, advice on investigation or agreement about continuing care. Clarify who will do what and by when. |
Listen to the receiving clinician’s questions. If you do not know an answer, say so and obtain it. Acknowledge workload without apologising for seeking necessary care. Do not order an unnecessary scan simply to secure acceptance of a referral. If a request is declined and you remain concerned, explain the specific risk, obtain the responsible clinician’s help and agree an alternative safe plan. An unresolved disagreement should not leave the patient without clinical responsibility.
“I’m concerned because their observations are worsening despite the initial treatment. I do not think waiting without review is safe. I will ask the doctor supervising me to speak with you now while the team continues the assessment.”
Read back important advice, confirm the expected review time and the plan if the patient deteriorates. Document names, time, advice, outstanding tasks and responsibility for results. At a shift handover, prioritise unstable patients and time-critical work; distinguish completed actions from proposals. Ask the receiving colleague to clarify any ambiguity.
Rehearsal scenarios
Practise handing over an older person with new confusion and reduced mobility, and referring a patient whose appropriate admitting team is uncertain. Explain the acute assessment and safe interim plan rather than labelling the problem a “social admission”.
05 / CHAPTER 4
Explaining a new diagnosis or difficult result
Prepare by confirming what the results actually establish, what remains uncertain and the immediate plan. Agree who should lead the conversation and arrange suitable support and privacy. A student can practise or contribute with supervision; responsibility for communicating a serious new diagnosis needs to be explicit. Do not turn off an urgent contact device without arranging appropriate cover.
- Establish understanding and preference. Ask what the patient has been told, what they understand and whether they would like someone with them.
- Give a clear introduction to the news. If it is unexpected or serious, a brief warning helps the person prepare. Use plain language and distinguish a suspected diagnosis from a confirmed one.
- Pause and respond. Allow the person to react. Silence is useful; counting slowly can help you avoid interrupting, but do not mechanically time someone’s distress.
- Explain the next step. Give information in manageable pieces. Address the immediate treatment, further tests and who will provide continuing care.
- Check understanding and support. Explore the effect on the person’s life, questions and practical concerns. Provide suitable written information and a clear contact route.
“The tests have shown something that we need to discuss carefully. They suggest [finding]. We still need [assessment] to understand it fully. I can explain what we know now and what the team will do next.”
Avoid blanket reassurance such as “This is easily managed” before you know the diagnosis, severity and individual circumstances. Equally, do not overwhelm the person with every possible complication in the first minute. Check what they want to know now and agree how further information will be provided. Invite a description of their understanding: “To check I have explained it clearly, what do you understand about the next steps?”
Rehearsal scenarios
Practise these examples: a new diagnosis of anaphylaxis, type 1 diabetes, atrial fibrillation or malignancy. Each requires its own clinical explanation and follow-up. For anaphylaxis, explain the reaction and prevention plan agreed by the treating team; for diabetes, recognise the practical and emotional implications of treatment; for atrial fibrillation, separate the rhythm explanation from individual treatment decisions; for suspected malignancy, communicate uncertainty accurately. With children and young people, involve parents or carers appropriately while respecting the young person’s understanding, confidentiality and safeguarding needs.
06 / CHAPTER 4
A patient’s death and support for relatives
This conversation requires preparation and support. Establish that death has been confirmed, review the sequence of events and agree who will lead. On placement, a student should not be sent alone to notify relatives of a death. In an assessment, demonstrate the communication skills appropriate to the assigned role and describe the support needed in practice.
Confirm who the relatives are, what they already know and whether they want someone else present. Use the patient’s name and clear language. A short explanation of the events can help, but do not bury the news in a long technical account.
“I am very sorry. I have some very sad news. [Name] has died.”
Pause, allow a response and acknowledge the loss. Answer questions honestly, distinguish known facts from matters that need clarification and avoid euphemisms that may be misunderstood. A patient who is alive but expected to die requires a separate conversation about prognosis and uncertainty; do not use a confirmed-death script for that situation.
Offer appropriate contact with family, friends, faith or other support, and explain the opportunity to see the person where possible. Prepare relatives gently for what they may see. Arrange bereavement information and continuity with a named team member, without promising personal availability you cannot provide. Sudden or unexpected child deaths require the local multi-agency pathway as well as compassionate family support.
Donation and further support
If organ donation may be possible, involve the responsible senior team and specialist nurse so any approach is properly planned. Do not insert an unprepared donation question into the first notification of death. Retain the original resources for NICE organ donation guidance and RCPath/RCPCH guidance on sudden unexpected death in infancy and childhood, used alongside current local arrangements. Practise both adult and paediatric scenarios with a tutor who can give feedback on language, pacing and support.
07 / CHAPTER 4
Consent as a conversation
Consent means helping a person make a voluntary, informed decision about a specific intervention. Explain the purpose, expected benefit, material risks, reasonable alternatives and the consequences of declining or delaying it. Ask what matters to the patient and respond to questions. Start from the presumption of adult capacity; concerns about capacity require assessment for this decision at this time. GMC principles of decision making and consent provide the professional framework.
Be honest about your role and the supervision involved. A patient can decline student participation without losing access to care. Explain only a procedure you understand sufficiently to answer relevant questions, and obtain help when you cannot. A signed form records part of the process; it does not replace the discussion. Consent can be withdrawn and should be checked as the procedure proceeds.
Example: intravenous cannulation
“The team recommends a cannula so we can give treatment into a vein. It is a small plastic tube placed using a needle; the needle is then removed. It can be uncomfortable and may cause bruising or bleeding, and there is a risk of infection or fluid leaking outside the vein. We will check it and remove it when it is no longer needed. I’m a student and would do this with [agreed supervision]. Would you like me to explain the alternatives or anything else before deciding?”
Tailor that explanation to the actual indication and patient. Ask about allergies, previous difficulties and preferences, and avoid calling a procedure risk-free. Check understanding and willingness to proceed before preparing equipment. Further technique, aftercare and supervision requirements are in Chapter 9: Procedures.
08 / CHAPTER 4
Concerns about colleagues
If you have concerns about a colleague, recognise the possible safety problem, describe what you have observed and obtain appropriate help. If a colleague appears impaired while caring for patients, address the immediate risk through the responsible clinician or nurse rather than investigating alone or promising secrecy. A concern about bullying, repeated unsafe practice or a distressed learner may also need educational or organisational support.
“I’m concerned about what I have just observed and whether the patient is safe. I need to involve the clinician responsible so we can address it.”
Separate observation from assumption, keep a factual record and use the placement and medical-school routes for raising concerns. Continue escalating through an appropriate route if a serious concern is not addressed. A student is not responsible for disciplining a colleague or organising the department’s staffing. GMC professional standards set out the duties around patient safety and raising concerns.