Communication skills, therapeutic relationships, patient-centred and trauma-aware consultation

Overview

• Effective communication in obstetrics and gynaecology is a clinical skill with direct patient safety implications, not a soft adjunct to technical practice.
• The RANZCOG Fellowship exam tests whether candidates can demonstrate, under examination conditions, the same communication behaviours expected in complex clinical encounters: breaking bad news, managing conflict, obtaining valid consent under time pressure, supporting bereaved parents, and working safely across cultural and linguistic difference.

The regulatory and standards architecture underpinning this domain includes:

• Australian Charter of Healthcare Rights (ACSQHC, 2nd edition): seven rights including access, safety, respect, partnership, information, privacy, and the right to give feedback or make a complaint.
• NSQHS Standard 2 - Partnering with Consumers: requires health service organisations to involve consumers in planning, delivery, and evaluation of care; mandates consumer engagement in governance and shared decision-making at the individual care level.
• NSQHS Standard 6 - Communicating for Safety: addresses clinical communication at clinical handover, patient identification, and documentation; directly relevant to theatre handover, escalation, and open disclosure.
• Calgary-Cambridge Consultation Model: a structured framework for the medical consultation covering initiating the session, gathering information, physical examination, explanation and planning, and closing the session, with a continuous thread of building the relationship and structuring the consultation.
• SPIKES Protocol: a six-step framework for delivering bad news: Setting, Perception, Invitation, Knowledge, Emotions (Empathy), and Strategy/Summary.
• RANZCOG Open Disclosure Policy and consent guidance: aligns with the Australian Open Disclosure Framework (ACSQHC).
• Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2016-2026 (Australian Government): sets out principles for culturally safe, responsive, and respectful care.
• AHPRA Good Medical Practice: professional obligations regarding communication, consent, and cultural safety.

Key Concepts

1. Patient-Centred Communication and Autonomy

Patient-centred communication requires the clinician to elicit not only the biomedical history but also the patient's ideas, concerns, expectations, and the effect of the problem on their life (the ICE-E framework, embedded within Calgary-Cambridge). In O&G this is particularly important because:

• Reproductive decisions carry profound personal, cultural, and religious weight.
• Patients may present with prior trauma, including obstetric trauma, sexual assault, or pregnancy loss.
• Power differentials are heightened in labour ward and theatre environments.
• Autonomy requires that patients receive information in a form they can understand, have time to deliberate, and are free from coercion.
• Under the Montgomery v Lanarkshire principle (adopted in Australian law through cases including Rogers v Whitaker and subsequent case law), clinicians must disclose material risks: those a reasonable patient in that person's circumstances would want to know, not merely those a reasonable doctor would disclose.
• RANZCOG consent guidance explicitly references this standard.

2. Non-Verbal Communication

Non-verbal behaviours account for a substantial proportion of the emotional content of a consultation. Key behaviours include:

• Proxemics: sitting at the same level as the patient, not standing over a bed-bound patient.
• Eye contact: culturally variable; sustained eye contact signals engagement in most Anglo-Australian contexts but may be experienced as confrontational in some Aboriginal and Torres Strait Islander, East Asian, or Middle Eastern cultural contexts.
• Paralanguage: pace, tone, and silence. Silence after delivering bad news is therapeutic and should not be filled reflexively.
• Open body posture: uncrossed arms, slight forward lean, facing the patient.
• Mirroring: subtle alignment of posture and pace that signals attunement.
• Recognising the patient's non-verbal cues is equally important: a patient who is nodding but has a fixed, flat affect may not be processing information.
• A patient who crosses their arms and looks away during a consent discussion may be signalling distress or disagreement that has not been verbalised.

3. Managing Strong Emotions and Disagreement

• Strong emotions, whether the patient's or the clinician's, impair information processing and decision-making.
• The NURSE mnemonic (Name, Understand, Respect, Support, Explore) provides a structured approach to responding to emotion before returning to information-giving.

Disagreement between patient and clinician most commonly arises around: refusal of recommended treatment (e.g. refusal of caesarean section), requests for interventions the clinician considers inappropriate (e.g. elective caesarean without clinical indication), and second-opinion requests. The appropriate response is:

1. Acknowledge the disagreement without defensiveness.
2. Explore the patient's underlying concern (often an unmet information need or a values conflict, not a clinical disagreement).
3. Provide information clearly and without coercion.
4. Document the discussion and the patient's decision.
5. If the patient has capacity and refuses recommended treatment, respect that refusal and document it. Involve senior colleagues and, where appropriate, the hospital ethics committee or legal counsel.

• A patient who requests a second opinion has a right to do so under the Australian Charter of Healthcare Rights.
• The appropriate response is to facilitate this, not to obstruct it.

4. Optimising the Physical Environment

NSQHS Standard 2 and the Australian Charter of Healthcare Rights (right to privacy) require that clinical environments support dignity and confidentiality. Practical considerations in O&G:

• Conduct sensitive discussions (e.g. termination of pregnancy, sexual assault, domestic violence screening) in a private room, not in a shared bay or corridor.
• Ensure an interpreter is present for patients with limited English proficiency; do not use family members as interpreters for sensitive consultations (risk of non-disclosure, coercion, and breach of confidentiality). Use the Translating and Interpreting Service (TIS National) or a credentialled hospital interpreter.
• In remote and rural settings, telephone or video interpreter services may be the only option; document the interpreter's identification number.
• For patients with disability, ensure physical accessibility and consider communication aids.
• In the emergency setting (e.g. consent for emergency caesarean), the environment cannot always be optimised, but the clinician should still introduce themselves, use the patient's name, make eye contact, and position themselves at the patient's level where possible.

5. Shared Decision-Making and Tailoring to Individual Needs

Shared decision-making (SDM) is mandated by NSQHS Standard 2 and is the operational expression of patient autonomy. It requires:

• Presenting options (including the option of no treatment or watchful waiting).
• Explaining the benefits, risks, and uncertainties of each option in plain language.
• Eliciting the patient's values and preferences.
• Reaching a decision collaboratively.
• Decision aids (written, visual, or digital) support SDM.
• RANZCOG produces patient information leaflets for common O&G conditions and procedures; these should be offered but not substituted for a conversation.
• Tailoring SDM requires recognising that patients differ in their preferred role in decision-making.
• Some patients prefer a more directive approach ("just tell me what to do, doctor"); others want to lead the decision.
• The clinician's role is to assess the patient's preference and adapt accordingly, while ensuring the patient has the information needed to exercise their right to choose.

6. Trauma-Aware Consultation Techniques for Sexual Assault Survivors

Sexual assault survivors presenting to O&G services (e.g. for forensic examination, emergency contraception, termination of pregnancy, or antenatal care following assault) require trauma-informed care. Core principles:

• Safety: establish physical and emotional safety before proceeding with any examination.
• Trustworthiness and transparency: explain every step before it occurs; obtain explicit consent for each component of the examination.
• Choice and control: offer choices wherever possible (e.g. which clinician performs the examination, whether a support person is present, the order of examination steps).
• Collaboration: position the patient as an expert in their own experience.
• Empowerment: affirm the patient's strength and agency.

Practical techniques:

• Use a calm, unhurried manner and avoid clinical jargon.
• Do not ask "why" questions (e.g. "why didn't you report it earlier?") which can be experienced as blame.
• Avoid re-traumatisation by limiting the number of times the patient must recount the assault; coordinate with forensic nursing and social work to minimise repetition.
• In New South Wales, Victoria, Queensland, and other jurisdictions, Sexual Assault Services have specific clinical pathways; be familiar with your state or territory protocol.
• Mandatory reporting obligations vary by jurisdiction and the age of the patient; see the table in Clinical Application.

7. Bereavement Counselling

• Bereavement in O&G encompasses perinatal loss (miscarriage, termination for fetal anomaly, intrauterine death, neonatal death), gynaecological cancer diagnosis, and loss of fertility.
• The Kubler-Ross model (denial, anger, bargaining, depression, acceptance) remains a useful framework but grief is not linear; patients may move between stages or not experience all of them.

Key principles for bereavement counselling in O&G:

• Use the baby's name if the parents have chosen one.
• Avoid euphemisms ("we lost the baby", "it wasn't meant to be") which minimise grief.
• Acknowledge the reality and significance of the loss directly: "Your baby has died."
• Offer parents the opportunity to see and hold their baby; do not make this decision for them.
• Provide written information about practical steps (registration of stillbirth, funeral arrangements, support organisations such as SANDS Australia).
• Arrange follow-up: a bereavement review appointment at 6 weeks is standard practice in most Australian tertiary centres.
• Screen for complicated grief and refer to psychology or psychiatry where indicated.
• Involve the midwifery bereavement team, social work, and pastoral care as appropriate.
• Document all conversations, decisions, and referrals.

Clinical Application

Worked Example 1: Consent for Emergency Caesarean Section

• A 28-year-old primigravida at 39 weeks presents with a category 1 fetal heart rate abnormality.
• The decision-to-delivery interval target is 30 minutes.
• The registrar must obtain valid consent under time pressure.
• Calgary-Cambridge application: Initiate the session by introducing yourself and using the patient's name.
• Gather information briefly: confirm the patient's understanding of the situation.
• Explain the indication, the procedure, the key risks (haemorrhage, infection, injury to adjacent structures, anaesthetic risks, risks of not proceeding), and the alternative (continued monitoring with likely deterioration).
• Elicit concerns.
• Obtain verbal consent and document it.
• If the patient lacks capacity (e.g. unconscious), proceed under the doctrine of necessity and document.
• Key pitfall: Rushing through a consent checklist without checking understanding.
• Ask: "Can you tell me back what I've just explained?" or "What questions do you have?"

Worked Example 2: Breaking Bad News - Intrauterine Death

• A 34-year-old woman at 36 weeks presents with reduced fetal movements.
• Ultrasound confirms intrauterine death.

SPIKES application:

• Setting: private room, support person present if available, sit down, turn off pager if possible.
• Perception: "What have you been told so far? What were you expecting when you came in today?"
• Invitation: "I have the results of the scan. Are you ready for me to share what I found?"
• Knowledge: "I'm very sorry to tell you that your baby has died." Pause. Do not immediately continue.
• Emotions: Allow silence. Use NURSE. "I can only imagine how devastating this is."
• Strategy/Summary: Explain next steps (induction of labour vs expectant management), offer time, provide written information, arrange follow-up.

Worked Example 3: Open Disclosure After Surgical Complication

• A patient undergoes laparoscopic hysterectomy and sustains an unrecognised ureteric injury identified on day 2 post-operatively.
• Open disclosure is required.

Governance pathway:

• The Australian Open Disclosure Framework (ACSQHC) requires an apology that includes an expression of regret, an explanation of what happened, and a description of what will be done to prevent recurrence.
• An apology under open disclosure is not an admission of liability under most Australian state and territory legislation (check jurisdiction-specific provisions).

Worked Example 4: Working with Aboriginal Health Workers in Remote Antenatal Outreach

• A registrar is conducting antenatal outreach in a remote community.
• The Aboriginal Health Worker (AHW) is a key cultural broker.
• Brief the AHW before the clinic: explain the clinical agenda and ask about any community context that may affect the consultation.
• During the consultation, address the patient directly, not the AHW.
• Allow the AHW to facilitate cultural interpretation, not just language interpretation.
• Respect the patient's right to have a family member or community member present.
• Be aware that direct questioning may be culturally uncomfortable; use open-ended, indirect approaches.
• The Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2016-2026 emphasises that cultural safety is determined by the patient, not the clinician.

Worked Example 5: Mandatory Reporting - Suspected Child Abuse in Antenatal Clinic

• A 16-year-old presents for antenatal care.
• She discloses that her 25-year-old partner is the father.
• She appears fearful and has unexplained bruising.

• The registrar must report regardless of the patient's wishes.
• Explain to the patient that you are required by law to make a report, that this is to protect her and her baby, and that you will support her through the process.
• Document the disclosure, the clinical findings, and the report made.

Pitfalls

1. Using jargon during bad news delivery: Terms such as "intrauterine demise", "non-viable", or "fetal compromise" are not plain language. Use "your baby has died" or "your baby is in danger."

2. Filling silence: After delivering bad news, silence is therapeutic. Resist the impulse to fill it with information or reassurance. The patient needs time to process.

3. Conflating interpreter and advocate roles: A professional interpreter conveys meaning; they do not advocate, advise, or filter. Family members used as interpreters may omit, distort, or add information, particularly in sensitive consultations.

4. Assuming capacity: Capacity is decision-specific and time-specific. A patient in active labour with severe pain may have fluctuating capacity. Assess capacity explicitly and document it.

5. Documenting consent as a form rather than a process: A signed consent form is evidence that a conversation occurred, not a substitute for it. The medical record should document the specific risks discussed, the patient's questions, and their expressed understanding.

6. Neglecting the physical environment in emergencies: Even in a category 1 caesarean, taking 10 seconds to introduce yourself, sit briefly, and make eye contact significantly improves patient experience and trust without materially affecting the decision-to-delivery interval.

7. Responding to second-opinion requests defensively: A defensive response ("I've been doing this for 10 years") erodes trust and may constitute a barrier to the patient's right under the Australian Charter of Healthcare Rights. The appropriate response is to facilitate the request.

8. Applying a single cultural framework to all patients from a given background: Cultural safety requires individualised assessment. Not all Aboriginal and Torres Strait Islander patients share the same cultural practices; not all patients from non-English-speaking backgrounds require the same communication adaptations.

9. Failing to screen for domestic violence in the context of bereavement or sexual assault: Perinatal loss and sexual assault are associated with increased risk of intimate partner violence. Routine screening using a validated tool (e.g. SAFE questions or the Composite Abuse Scale) should be part of the consultation.

10. Omitting follow-up planning in bereavement consultations: A single conversation at the time of diagnosis is insufficient. Bereavement support requires a structured follow-up plan, documented in the medical record and communicated to the GP.

Examiner Expectations (Structured Oral)

The Structured Oral examiner is assessing whether the candidate demonstrates the behaviours of a safe, senior O&G clinician, not whether they can recite a framework. The following are specific behaviours that attract marks in this domain:

• Naming the framework and applying it correctly: Candidates who say "I would use the SPIKES protocol" and then demonstrate it step by step score higher than those who describe a generic empathic approach. Similarly, referencing NSQHS Standard 2 in the context of shared decision-making signals specialist-level knowledge.
• Demonstrating the NURSE response in role-play stations: When the examiner (playing a distressed patient) expresses strong emotion, the candidate should pause, name the emotion, and respond empathically before continuing with information-giving. Candidates who continue delivering information over expressed distress will lose marks.
• Identifying capacity issues explicitly: In any scenario involving refusal of treatment or a patient in extremis, the candidate should explicitly state: "I would assess this patient's capacity to make this decision" and describe the four components of capacity (understanding, retaining, weighing, communicating).
• Citing the Australian Charter of Healthcare Rights by name: This signals awareness of the regulatory framework within which Australian clinicians practise.
• Demonstrating cultural safety, not cultural competence: Cultural competence implies a fixed body of knowledge about a group; cultural safety requires the clinician to reflect on their own assumptions and to be guided by the patient's experience. Examiners will probe this distinction.
• Articulating the open disclosure process correctly: Candidates should know that open disclosure requires an apology (expression of regret), an explanation, and a commitment to improvement, and that this is not an admission of liability in most Australian jurisdictions.
• Knowing mandatory reporting thresholds and processes: In any scenario involving a minor, domestic violence, or suspected abuse, the candidate should identify the mandatory reporting obligation, name the relevant legislation for their jurisdiction, and describe the process including documentation.
• Describing the bereavement follow-up pathway: Candidates should mention the 6-week bereavement review, referral to SANDS or equivalent, GP communication, and screening for complicated grief. Stopping at the initial consultation is insufficient.
• Avoiding paternalism in role-play: Phrases such as "I think you should" or "the best thing for you is" without eliciting the patient's values will attract examiner comment. The candidate should demonstrate SDM by presenting options and asking what matters most to the patient.
• Demonstrating awareness of interpreter services: In any scenario involving a patient with limited English proficiency, the candidate should proactively mention TIS National or a credentialled hospital interpreter and explain why a family member is not appropriate for sensitive consultations.