There are many dos and don’ts when delivering bad news. Breaking news over the phone is totally unacceptable, as are comments such as ‘Nothing can be done’. Professionals should avoid using unnecessary medical jargon, or being judgemental and must be careful not to allude to an exact time frame when discussing prognosis. Given the highly sensitive nature of this task, it is comforting to know guidelines exist. SPIKES (Setting, Perception, Invitation, Knowledge, Empathy and Strategy) is a communication framework for breaking bad news used in healthcare settings in the UK. The six stages of the framework guide the medical professional through the maze to ensure bad news is delivered as effectively as possible and in accordance with NHS protocol.

Firstly, finding a setting that offers privacy is essential, as are managing constraints and possible interruptions so that adequate time can be devoted to delivering the news. Open questions such as, ‘What have you been told about your medical situation so far?’ enable doctors to determine the patient’s perception of their condition with the general premise being - ask, don’t tell. Recurrence of cancer suggests the patient may already possess a certain understanding of their situation, but equally this may not be the case.  The so-called ‘warning shot’ then prepares the listener for the news they are about to hear, e.g. ‘We’ve found a problem and I want to spend some time talking with you about it.’ Next, the question: How much detail would you like me to go into?  invites the patient to indicate the level of detail they wish to receive about their condition. Patients may not be able to assimilate all the information at once, so learners need to interpret responses such as: I can’t really handle knowing all the ins and outs, accept the patient’s right not to know, if indeed this is the case, and then gauge their further interaction accordingly. Aside from avoiding use of terminology and excessive bluntness, (this can and does happen) knowledge about the condition and prognosis should be delivered in manageable chunks and clarification offered periodically throughout the consultation.

Reactions to bad news – denial, sadness, disbelief and anger - differ from patient to patient and are expressed through a variety of emotions, from silence to crying and even nervous laughter. It is important to recognise and address these emotions, validating them with statements like: A lot of people would feel angry right now, and verbalising empathy: I know that this isn’t what you wanted to hear. I wish the news were better. The old adage, it’s not what you say, it’s how you say it, naturally extends to the delivery of bad news and learners therefore should also develop their voice management skills. Patients are far more likely to forgive the odd grammar mistake than an expression of empathy devoid of the appropriate intonation pattern and therefore lacking in warmth and compassion. The final stage of the process is to summarise the salient points of the consultation and check for any misunderstandings before offering a strategy for the future.

                                                                                                                                                                                                          
Part  2 will appear in October 2015

Changes in policy guidelines mean that both non-EU and EU-trained doctors are now required to obtain IELTS 7.5 to register for the GMC (UK’s medical accreditation board). However, given the nature of the IELTS, one might wonder to what extent this enhanced score actually ensures overseas doctors are fit to practice in a UK hospital. The obvious lack of medical content is only one aspect where this exam falls short.

Four areas in particular pose problems for new NHS recruits. Greeting trainees at a medical English course recently with the expression, ‘Hey-up me duck!’ I was not entirely surprised by the sea of blank faces. Understanding and responding appropriately to the language of the patient is essential in establishing and developing rapport. Unlike most other areas of ESP, preparing overseas doctors to work in the NHS involves teaching the entire range of lexical components, from medical terminology and sub-technical vocabulary to colloquialisms and euphemisms.  Knowing that a deceased relative is ‘pushing up daisies’ as opposed to ‘smelling the radishes from below’ (as in Germany), may avoid unnecessary tension at an already emotional time.

Intonation is another cause for concern. Research carried out by King’s College London found that ‘rhythm and intonation of speech’ had a negative impact on the information and attitudes conveyed by international medical graduates (2014). Devoid of the appropriate intonation and tone, expressions of empathy might not be demonstrated to full effect to those already feeling distressed and vulnerable. While asking about her father’s treatment recently, my mother’s perception of the doctor’s response was that although he demonstrated an accurate level of English, his delivery was ‘adversarial and dismissive’. Patients and relatives are far more likely to forgive the odd grammar mistake than an intonation pattern that lacks warmth and compassion.

Medical recruiters and healthcare professionals all highlight the need to gain a working knowledge of NHS culture before hitting the wards. This includes an appreciation of the patient’s role in decisions made on their care and treatment, as well as the need for obtaining patient consent regardless of intervention, be that routine physical examination or organ donation. It also involves understanding the multi-disciplinary nature of the NHS and the working relationships with other healthcare professionals which may differ greatly from the doctors’ own experience.

Lastly, introducing the use of frameworks to enhance effective communication with patients and colleagues is another area where medical English trainers can help prepare new doctors. The SPIKES model for breaking bad news is used systematically across the NHS. Trainees can develop language to Set the scene, determine the patient’s Perception of their situation, deliver the preferred amount of Information and Knowledge, while providing Empathy and finally laying out a Strategy for the future. Communication frameworks such as this not only ensure NHS policy is adhered to, they also offer guidance from a language perspective.

While not all of these areas are directly related to language per se, they all impact significantly on the level of communicative competency required to comply with the standards of good practice set out by the GMC. The fact that none of them can be tested by the IELTS does seem to invalidate this exam as a successful means of benchmarking proficiency in a context so dependent on effective communication. 

Greeting my trainees at the Queens Medical Centre in Nottingham with the local colloquialism – ‘Hey-up me duck!’ – I was not entirely surprised by the sea of blank faces. However, as a Nottingham lass myself, I felt duty bound to ensure that each and every one of these new NHS recruits were at least able to respond with a ‘Hi, how are you?’ by the end of the session.

Awareness of patient language (colloquial language, common expressions for medical conditions, etc.) is just one aspect of the new English for Medical Professionals (EMP) course piloted recently as part of a joint partnership with Remediem, specialists in the recruitment of overseas doctors for the NHS. The aim of EMP is to prepare qualified overseas doctors to function effectively in an English-speaking environment. Although highly skilled with a minimum of IELTS 7.5, of this group of Bangladeshi, Egyptian, Nigerian and Turkish doctors, fewer than half had followed medical communications courses in their own language; a situation that is not uncommon.  Aside from an understanding of the local culture, other areas critical for effective doctor-patient communication include pronunciation (particularly word stress) and intonation, as well as an appreciation of the professional culture of the NHS which may differ significantly from their own experience. This 2-day pilot course would feature an introduction to the NHS and the development of key skills in English, such as breaking bad news and participating in handovers.

The true test of a doctor’s communication skills has to be the delivery of bad news; a complex task often carried out several times a week. If delivered poorly, the experience remains with the patient long after the initial shock of the news itself. This is further compounded if the doctor needs to do so in a language that is not his own. Beginning from the premise that ‘Bad news is any information, which adversely and seriously affects an individual’s view of his or her future’ (Baile et al, 2000), Day 2 focused on use of the SPIKES communication model for breaking bad news adapted for the medical English classroom. Trainees spent the morning developing language to Set the scene, determine the patient’s Perception of their situation, deliver the preferred amount of Information, and Knowledge, while providing Empathy and finally laying out a Strategy for the future. The morning ended with a series of role-plays enabling the trainees to put their enhanced skills into practice. 

While sharing a platform with the Medical Director of the QMC was a major coup during the pilot course, the icing on the cake was by far this quote from one of the trainees: ‘This is an excellent course, filling a void with regards to the introduction of overseas doctors to the NHS. The course has the potential to expand, develop and become a staple in trusts across the UK.’ Indeed, it is hoped the pilot will result in the adoption of EMP as part of the induction programme for all overseas doctors recruited to work in the Nottingham University Hospitals Trust.

In the meantime Nottingham’s popular greeting, Hey-up me Doc … sorry … duck, has since been made famous by the likes of Dolly Parton and Angelina Jolie. If you don’t believe me, google it! 

Whether it be the rise in medical tourism, the hiring of overseas healthcare professionals, the teaching of medicine through English, or the demands of continued professional development, the need for medical English trainers has never been greater. 

As the trend continues, YOU may well be considering transitioning into this specialized area of ELT.

Introduction to Teaching English for Medical  Purposes
31st August - 4th September 2015
Trainers: Virginia Allum, Ros Wright, Marie McCullagh
Venue: InterCity Hotel, Ulm, Germany

Registration deadline for both courses: 30th April 2015

Contact: Paul East
The Pyramid Group
Tel: ++49 731 397 6976
paul@thepyramidgroup.biz
http://thepyramidgroup.biz/teacher-training/

There's still time to submit your paper for the ...
2nd English for Healthcare Conference                                                  
Bern, Switzerland. October 24 & 25, 2015 
Confirmed speakers include: 

• Kieran Donaghy of award-winning FilmEnglish                 
  
• Sheila Thorn ( Real Lives Real Listening)
  
• Ros Wright ( Good Practice; English for Nurses) 
  
• Virginia Allum ( English for Nursing)
  

Click here for the Call for Papers

You've got til 28 Feb 2015.
 
Looking forward to reading your proposal!

European Association of Language Teachers for Healthcare
If you are not already a member of EALTHY, the European Association of Language Teachers for Healthcare, you may want to consider it for 2015. 

Membership includes reduced entrance to workshops and seminars as well as special offers on materials in the field and of course networking opportunities. 

24-25 October 2015 will see the 2nd English for Healthcare Conference taking place in Bern, Switzerland. If you are interested in submitting a proposal, you have until 28 Feb 2015 to do so. You'll find information about the association at http://www.ealthy.com/

Looking forward to meeting lots of new members very soon!