Section 2

INTRODUCTION TO SECTION 2 STRUCTURE AND CONTENT Section 2 has 36 questions and you will have 45 minutes in which to complete them. That is 75 seconds per question. Questions are generally based on excerpts of interactions, literary texts and personal reflections describing or relating to interpersonal situations. Passages can involve interactions between health professionals and patients, friends, relatives and other general situations. They ask you to identify the option that best describes or explains a person’s behaviour, thoughts or feelings. In the past, Section 2 included 'scenario' questions. This placed you in a situation and asked you to choose the most appropriate response or action. Such questions no longer form part of UMAT. Note that you do not need to have detailed knowledge of medico-legal issues like confidentiality and informed consent, or knowledge of the specifics of medicine. Such issues will be taught during the university course; what ACER hopes to test is your empathy and your ability to understand people. You do, however, need a firm understanding of what constitutes compassionate, ethical and respectful behaviour. This guide covers such qualities.

SCORING In the past, ACER stated that in Section 2, 'there is no correct answer; each response attracts a different level of credit. Only one response attracts no credit’ (2000 UMAT booklet). This meant that responses were ranked in order of appropriateness. However, information from ACER in the following years suggested that ‘grading’ in order of appropriateness no longer occurs (at least for the majority of questions), and there is one correct answer.

WHAT DOES IT TEST? ACER describes Section 2 as ‘Understanding People’. According to the UMAT booklet, it assesses the ‘ability identify, understand and, where necessary, infer the thoughts, feelings, behaviour and / or intentions of the people represented in the situations’. For health practitioners to effectively understand patients and treat them in a compassionate manner, they need certain qualities. These qualities include empathy, integrity, compassion, respect, communication skills and humility. Section 2 of the UMAT aims to test these qualities.

HOW IS THIS RELEVANT TO BEING A DOCTOR? ‘If we treat diseases we might succeed or we might fail. If we treat people we will always succeed’ – Patch Adams, MD The idea of treating people and not diseases is the key to compassion, empathy and forming patient-doctor relationships. Increasingly, patients, health professionals and the community are recognising that to effectively treat people, doctors need a high level of personal interaction skills and ability. Good communication and empathetic interaction with others is a vital characteristic of a health professional. It is just as important as the traditional pillars of the basic sciences, anatomy and clinical skills. Indeed many

progressive medical schools have communication and interaction skills as one of the major themes in their courses. Increasingly, we are recognising that the ability of a health professional to empathise and develop rapport with a patient dramatically influences health outcomes. Effective interaction skills helps build an effective relationship between health professionals and patients, creating an atmosphere of trust in which the patient feels comfortable to discuss matters, raise issues, ask questions and in the end, restore themselves to health.

THE HIPPOCRATIC OATH Hippocrates, an ancient Greek physician known as the ‘father of medicine’, formulated an oath that guides health professionals in their ethical conduct. It effectively captures the mentality of a compassionate and effective health professional. Below is a modern version of the oath, which was written in 1964 by Louis Lasagna. I swear to fulfil, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of over-treatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug. I will not be ashamed to say ‘I know not,’ nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. Exercise: Reflection on the Hippocratic Oath Think about the ways in which the Hippocratic oath is relevant to the skills that section 2 is testing. Here are some excerpts to take special note of: ‘I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.’

‘I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.’ ‘I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.’

THE PHILOSOPHY BEHIND PSYCHOLOGICAL TESTING PERSONAL QUALITIES Psychological psychometric testing such as section 2 of the UMAT focuses on assessing personal attributes. Various studies into the selection of students for medical courses have been undertaken, and these provide valuable information about what is considered a 'desirable' quality. The following table summarises some of the qualities considered relevant to selection of applicants to the health science profession. Beneath the table, you will find a more detailed explanation of some of the terms. Personal characteristics that are generally considered desirable Empathy and interpersonal sensitivity1

Personal characteristics that are generally considered undesirable Unwillingness and inability to empathise with others

Compassionate

Tough-minded, insensitive

Ethically sensitive, having a positive attitude towards ethical issues

Doubtful ethical orientation, likely to engage in ethically inappropriate behaviour

Emotionally stable, resilient, calm

Easily stressed, predisposed to anger, panic and temper, easily upset, defensive

Trustworthy and honest, trusting of others

Untrustworthy others

and

dishonest,

suspicious

of

Open and accepting

Prejudicial and judgemental

Possessing humility and modesty

Arrogant, aloof, dominant, power-seeking, selfcentred

Sociable, involved, warm and easygoing, enthusiastic, relaxed

Unsociable, detached, cool, reserved, tense, isolated, indifferent

Understanding

Condescending, patronising

Stable and reliable

Unpredictable and unreliable

Willing to obey rules when required, compliant

Hostile towards manipulative

authority,

aggressive,

Self-disciplined and deliberate

Impulsive, undisciplined, brash

Conscientious

Expedient, self-sufficient

High degree of emotional intelligence2 (eg. self-aware)

Low degree of emotional intelligence2

Communitarian3, group-oriented

Libertarian3

4

Low-Mach

High-Mach4

1

Interpersonal sensitivity

Interpersonal sensitivity involves having an awareness of the needs and feelings of others and using this awareness effectively in interactions and decision-making. This concept is discussed in more detail in the ‘Empathy’ section of this guide. 2

Emotional intelligence

Emotional Intelligence (EQ) is a concept that involves a wide range of qualities such as self-awareness, emotional resilience, motivation, sensitivity towards others, persuasiveness, decisiveness and conscientiousness. 3

Libertarian vs. communitarian

Those with a communitarian outlook value laws and norms and obey them, even if this is detrimental to their own well-being. Libertarians, on the other hand, value the individual freedom to act in their own best interests, with low regard for social norms.

Libertarians focus more on individual rights and welfare, with less concern for the group. In contrast, communitarians are more concerned with groups and society and place less emphasis on the consequences of various actions for individuals.

4

Low-Mach / High-Mach

Interactions between people can be rated high or low on a scale of human behaviour called ‘Machiavellianism’. This scale is based on the writings of Nicolo Machiavelli, a controversial political philosopher during the Renaissance in Italy. The scale measures the willingness of people to place the interests of others above their own. High-Machs are generally self-interested and are easily able to resist social pressure. They are also inclined to cheat and break rules if necessary. On the other hand, low-Machs more closely follow rules and conventions, are more trusting and cooperative and need to be coaxed into breaking rules. Politics and business tend to attract high-Machs, while low-Machs are generally found in teaching and medicine.

PRESENTING YOURSELF POSITIVELY Many of you will lack at least some of the characteristics listed in the ‘desirable’ column of the table, and may attempt to present yourself in a more positive light in the UMAT. If you are planning on doing this, be careful. Modern psychological tests often include ‘lie-scales’. They are essentially trick questions to determine whether someone is attempting to fool the tester by pretending to have qualities that they do not possess. Following are some words of advice. Be consistent Many psychological tests cover the same ground twice to catch those who attempt to present themselves differently to what they are. It is important to be consistent in the way you present yourself and try not to contradict yourself. Believe that you have the desirable quality(s) If you have a certain quality, it is much easier to convey this during a test. If you do not, it is may be helpful to make yourself believe that you do. See the desirable quality(s) in others The fundamental basis underlying all psychological testing is that individuals with undesirable qualities will view behaviours and situations differently to those with desirable qualities. For example, research has revealed that people most likely to steal are those who have a cynical philosophy of life. People who believe that ‘everyone steals occasionally’ or ‘it’s human nature to steal’ or ‘nobody is truly honest’ are those most likely to engage in theft. Psychologists have found that a single question can tell a lot about a person: ‘Do you believe that people are basically honest?’ Consider the questions carefully

Most people find it is much easier to finish section 2 than it is to finish section 1. However, time constraints are nonetheless imposed in section 2. A possible reason for this is that test-makers believe that by forcing you to think fast, you are more likely to expose your ‘real’ personality. Time management can thus be very important in section 2. Try self-improvement Of course, it is much better for both the UMAT and your future career if you actually develop these desirable qualities. While you are ‘born with’ many, and many are ingrained during your childhood years, this does not mean you can’t change. In fact, you should have a commitment to continuous improvement in all aspects of your life, including personality traits. Following are some strategies to help this process: •

Do work experience in a healthcare setting. This will develop your empathy skills. It will also help you gain a better idea of what a health professional does and be useful in your interview.

•

Become interested in people and expose yourself to as many people as you can. Interacting with people from a wide variety of backgrounds will improve your ability to relate to people and allow you to better understand other people’s situation. For example, as a doctor you are more likely to be successful in relating to a smoker and helping them quit if you know someone who has had difficulty doing this.

•

Interact with people who have desirable personality traits. The people you surround yourself with influence you greatly, even if you do not notice this consciously. Their qualities tend to ‘rub off’ on you.

MINDSET OF THE PATIENT AND DOCTOR THE PATIENT’S POINT OF VIEW Even before arriving to see a health professional, patients will be experiencing a myriad of emotions, and will have certain preconceptions about their illness and the health science profession. It is important to understand where patients are coming from, as this will impact on the manner in which you treat them. Every patient is different and reacts very differently to illness, so it is not possible to make generalisations. However, the following may be helpful in understanding where patients are coming from. •

Most people who are unwell or think they are unwell go to a doctor for advice, help or reassurance. They may be feeling uncertain or fearful about their illness. Some patients may appear to overplay their illness; others may find it difficult to acknowledge that they are ill.

•

Patients arrive in a consultation feeling a variety of emotions – anxiety, fear, anger, mistrust, inadequacy, apathy. They are often at their sickest and most vulnerable and therefore may act in an apparently irrational or irritable way. It is important to be understanding of these feelings when conducting a consultation.

•

Patients come with a variety of expectations. Some seem overly dependent, unwilling to accept any responsibility for their own health, and may place seemingly unrealistic demands on the health professional. Others may be very critical and untrusting.

UNDERSTANDING PEOPLE Following is discussion of the elements that constitute effective personal skills and empathy. Although the focus is on the patient-doctor interaction, the information applies to all interpersonal situations, whether it be with family, friends, co-workers or strangers. These concepts are discussed separately to aid learning, but should not be considered in isolation – they all interrelate.

EMPATHY, EMPATHY, EMPATHY! What is empathy? Empathy is the ability to identify, appreciate, understand and accept another person’s thoughts, feelings, behaviour and motives. Basically, it is being able to put yourself in another person’s ‘shoes’, and understand their emotional situation. Comments that show empathy are common in everyday conversations: ‘that must have felt so exhilarating!’, ‘that’s awful!’, ‘I bet you just wanted to hit him!’, ‘great!’. These very different comments all share a similar message: ‘I know how you feel. I would feel similarly in that situation, so I view your feelings as appropriate.’ These comments do not mean that the speaker is experiencing the same feelings, but rather indicate that s/he recognises and understands them, and acknowledges that if placed in the same situation, would have similar feelings. It validates the person’s feelings, rather than being aloof to them or rejecting them (eg. as ‘weak’). How do you empathise with people? It is difficult to empathise with people who are experiencing something that you have not experienced yourself. For example, if you have never broken your leg, it might be difficult to understand what someone with a broken leg would be experiencing. However, this is not to say that it cannot be done. For example, you could empathise with the pain that the person is experiencing because you will have experienced some kind of pain before. In addition, you may be able to understand their feelings at being incapacitated, for example, if you have ever had an illness that left you ‘out of action’. In the UMAT, your ability to draw from your experiences and relate them to the scenario is crucial in empathising with characters. You may also find it useful in the UMAT to imagine that the person in the passage / scenario is someone you care about. This may help you empathise with the person. However, it is important to realise that

Everyone reacts differently to illness or adversity

That’s why it is inappropriate, presumptuous and unhelpful to say ‘I know exactly how you feel’. We are all unique individuals, with a diversity of life experience that will impact on the way we view and respond to certain situations. Sympathy vs. Empathy – the difference Sympathy is a true sharing of another’s painful emotions (literally, it means ‘suffering together’). In general, empathy is more appropriate than sympathy. If as a health professional you were to ‘suffer together’ with every patient, you would soon feel overwhelmed and therefore be of little use to your patients. This is because you would be feeling the full force of their emotions, and would not be in a position to actively understand, legitimise and act on their feelings.

Sympathy can also result in the opposite effect, creating a power imbalance. When a a person communicates his / her pity of another person, the first person is placed in a superior position. You might feel ‘sorry’ for a person, but an empathetic person needs to do more – you need to understand their situation and act accordingly.

Exercise: The Patient Mindset This exercise will help you get into the mindset of the patient, which is what you are often required to do in Section 2. This is not an airy-fairy exercise, but one designed to get you thinking in the same way you should in the UMAT. Please do not ‘skip over’ the exercises in this guide, but invest a few minutes on them. Spend about five minutes reflecting on a time when you, a family member or a friend was ill. Think about how the person felt, how they were treated within the medical system and how the illness affected their lives and the lives of those around them. Think in terms of emotions, and the effect on financial situation, social situation and relationships. Literally imagine yourself in their position. Jot down a few notes that you can refer to later.

Exercise: Reactions to Illness and Adversity Talk to people who are ill or who have experienced adversity in the past. You don’t need to go out to a hospital and talk to patients (although this would be worthwhile), but simply make an effort to seek out such people and take an interest in their lives. These may be your neighbours, people you meet in community service activities (such as work at a nursing home), family friends, family members, friends, co-workers, your boss, your teachers… When you open your mind to their stories, it will give you a greater insight into adversity and how people deal with it. Keep in mind that while you cannot be exposed to every sort of experience that patients are likely to have, one experience is sometimes enough to gain an insight into the impact that adversity has on people's lives. Exercise: Literature The next time you watch a film or read a book in which the thoughts, feelings and behaviour of a person are examined in-depth, actively consider the concept of empathy. Some films we recommend are Patch Adams, The Doctor and I am Sam.

COMMUNICATION SKILLS Why is good communication so important? Communication is an integral part of all human relationships and is the cornerstone of the patient-doctor relationship. Effective communication generates trust and enables people to be treated effectively and compassionately. From the doctor’s perspective, effective communication skills help elicit the patient’s story. This aids accurate diagnosis and improves patient adherence to treatment. From the patient’s perspective, a doctor who conveys concern and a willingness to listen in a non-judgemental manner can allow them to share their concerns and anxieties, which can be therapeutic in itself. Exercise: Communication Many of you will have had an experience with a health professional or other service-provider who had poor communication skills. Think back to this experience and ask yourself – why were they such a poor

communicator? Did they not listen effectively? Did they fail to understand what you were feeling and convey this to you? Did they fail to address your concerns? Consider how this experience made you feel and how it impacted on your willingness to share information with the person. Communication is about listening It is often said that listening is the most important aspect of communication and talking the least important. Remember that listening is not hearing – it is far more complex. It is an active, not passive process. It involves identifying major concerns, understanding those concerns and thinking about the best way to respond to them. Let’s take an example to illustrate: Doctor:

So how have you been Henry?

Henry:

OK I suppose, doctor. It’s just that these headaches are starting to worry me.

Doctor (1):

On a scale of 1 to 10, how painful would you say these headaches are Henry?

Doctor (2):

That’s understandable Henry. What is it about them that is worrying you?

Here, Doctor (1) has not listened to Henry. Henry has mentioned that his headaches are ‘starting to worry [him]’. He has not said anything about pain at all and yet the doctor leaps to this conclusion. A good communicator Responds to what the person is actually saying, rather than what they assume the person is saying In contrast, Doctor (2) shows far superior listening skills. Doctor (2) displays empathy (‘That’s understandable Henry’), identifies Henry’s main complaint (the ‘worrying’ nature of the headaches) and invites Henry to talk more about it (‘What is it about them that is worrying you?’). As you can see, the ability of a person to listen effectively can steer the interaction in a completely different direction and ultimately have a positive effect on wellbeing and health outcomes.

Reasons to communicate well To elicit information The patient knows more about themselves and their illness than the doctor – they are the most valuable source of information about their illness. In order to elicit this knowledge, the doctor needs to have effective communication skills. Here is an example: Doctor: Is the pain blunt or throbbing? Hazel: Um…throbbing. I think. Compare with this: Doctor: Hazel, can you tell me a bit more about the pain you’re feeling? Hazel: Well, it comes whenever I go for a walk, and it comes in sharp bursts, really unexpectedly… (continues)

The second doctor is able to gain a much greater insight into Hazel’s pain and her experience of it than the first. This will enable him / her to not only make an appropriate diagnosis, but provide treatment that is catered to Hazel’s individual needs. Without good communication, the result could easily be a wrong diagnosis or unnecessary, painful and expensive tests.

The therapeutic nature of listening Talking in itself can be beneficial to people. If you’ve ever chatted to a friend about a personal problem, you’ll have experienced the power of communication. ‘Offloading’ emotions and having them acknowledged, legitimised and listened to in a non-judgemental manner can be a significant source of relief.

Open-ended questions Open questions are crucial in order to a) determine what is wrong; b) find out what the person’s priorities are and c) allow you to explore more difficult / complex issues that would not otherwise be raised. Open questions allow the person to answer in a manner that they deem appropriate and not in a ‘yes’ / ‘no’ or limited fashion. An example of an open question is: What seems to be bothering you? In answering this question, the person can focus on what they feel is important and can describe their thoughts and feelings in their own language using their own experience. This not only provides more information, it can also make the person feel that they are being listened to. Further examples of open questioning include: ‘how has this affected you?’, ‘how have you coped?’ and ‘how did you feel about that?’ In contrast, closed questions direct the person to respond in a particular way and thus closes the discussion to other possibilities. For example: How many hours of sleep do you get a night? In this case, the person is directed to answer the question in a purely factual manner. A much more open question would be: How would you describe your sleeping patterns? This would allow the person to talk about a range of matters in relation to their sleeping, not only the number of hours of sleep they get a night. Open questions also allow the interaction to be directed in the way the person wants. For example: Closed questioning: Doctor: How can I help you? Patient:

I’ve been getting this dry cough recently.

Doctor: Are you having difficulty breathing? Patient:

No.

Doctor: What about pain? Patient:

A little bit, I guess, but not much.

Open questioning: Doctor:

How can I help you?

Patient:

I’ve been getting this dry cough recently

Doctor: Tell me a bit more about the dry cough – describe it for me. Patient:

Well I’ve been getting it for the last year or so and it seems to get worse in winter and when I have a smoke.

As you can see, the interaction can move in very different directions. The first example also demonstrates how closed questioning can give the impression of an interrogation rather than interaction, and give the person little room for description, explanation or qualification. In general, the more open the question, the more revealing the answer. Reflective listening and ‘verbal encouragers’ People can be encouraged to talk more by using the techniques of reflective listening and ‘verbal encouragers’. Reflective listening is useful to demonstrate that you are listening to a person by rephrasing something they have said to you and extending it. It is not good enough to simply repeat what the person has said. However, if you digest their main points and present it back to them with further information, it shows that you are listening actively. This is likely to encourage people to talk more. ‘Verbal encouragers’ are phrases such as ‘go on’, ‘I’m listening’ and ‘Please continue’ that encourage the person to keep talking.

HUMILITY What is humility? Humility involves having a modest or low opinion of your own importance. It is the opposite of being cocky or arrogant. Why is it so important? It involves: •

Realising that as a health professional, you will be placed in a position of incredible power and responsibility. You are likely to be interacting with patients who are at their most vulnerable, and may have involvement in issues determining life / death and quality of life. This enormous responsibility must be approached with humility.

•

Realising that you (or anyone else) does not know everything there is to know about anything, including a person or a social issue.

•

Realising that health professionals are merely advisors to patients.

•

Realising that individually, doctors, dentists, physiotherapists and pharmacists form only one part of the healthcare team. They need to cooperate with each other and other allied health workers such as nurses and complementary health practitioners to ensure optimal healthcare for patients.

HONESTY AND TRUST Why is honesty and trust so important? Honesty forms the basis of any relationship because it promotes trust and an atmosphere of openness. This is true between friends, family andhealth professionals. Even at the best of times, it is often difficult for people to consult others for help and to share their problems. Imagine how difficult it would be if people did not trust their health professional or friend to be honest. Trust is important because it facilitates effective communication. If people feel secure that sensitive and personal information will remain confidential, they are more likely to share their concerns. The knowledge that a patient can trust their health professional or friend to act in their best interests may in itself aid recovery. It also encourages patients to respond to the advice of the health professional, which may involve treatment, lifestyle changes, complying with recalls or returning to the doctor if there are complications with the condition.

RESPONSIVENESS What is responsiveness? Responsiveness involves being sensitive to the needs of a person and responding to them. This will often involve picking up on subtle cues communicated by the person. Why is responsiveness so important? People may not always feel comfortable talking about issues such as adversity, pain or death, and may communicate in an indirect fashion. It is vital to pick up on such hidden meanings and cues and respond to them. By doing this, you send the message that you are willing to talk further about the matter, which in turn is likely to encourage the person to open up. The following example shows the importance of responsiveness: Doctor:

(about vaginal discharge) Does it have an unpleasant odour?

Patient:

Yes it does (looks away, dropping her voice)

Doctor:

What colour is it?

Patient:

Well, it’s difficult to describe, darkish I suppose.

Doctor:

But is it white? Yellow? Green? Brown?

Patient:

It could be any of those colours at different times.

Doctor:

(frustrated) You can’t tell me what colour it is, then?

Compare with this scenario:

Doctor:

Does it have an unpleasant odour?

Patient:

Yes, it does (looks away, dropping her voice)

Doctor:

You feel self-conscious about it? Do you think other people would be aware of it?

Patient:

Doctor: Patient:

Well… yes… my husband certainly. When it was bad last year, he made remarks about it. I just avoid letting him come near me now. And has anyone, apart from your husband, said anything? Well, not actually. But I’m always afraid that other people notice. I don’t go out much socially nowadays. I don’t feel comfortable with others.

In this case, responsiveness by the doctor has helped uncover serious issues in the patient’s life. Responsiveness is also vital if a person appears anxious, upset or angry. Such emotions must be identified and addressed immediately. This may involve comments such as ‘You seem angry’ or ‘It’s understandable that you are upset’. If such emotions are not identified and addressed, they can hinder the interaction. This concept is demonstrated in the scenario above.

COMPASSION Being a health professional means putting yourself in a position of awesome responsibility. You will be privy to people’s most intimate fears, beliefs, personal details and emotions. Compassion is crucial if health professionals are to assume this position of responsibility. You must really care about your patients, care about their concerns and have a desire to help them back to health.

RESPECT What is respect? Respect encompasses the overall attitude of a person to others. It is not limited to ‘being nice’ but also includes issues such as humility and understanding. Having ‘respect’ for someone does not necessarily mean you have to like them. Respect involves the understanding and acceptance of another person’s situation, behaviour and beliefs. It involves recognising where another person is coming from and why they are acting in a particular manner. Attitudes towards people Your attitude towards particular people should never be clouded by their personal characteristics, beliefs, culture or personality. As a health professional, it is your obligation to treat everyone with the same high degree of respect and clinical care. This can be difficult. For example: Doctor: Patient: just

Have you been taking the medication I prescribed last time? Nah

–

couldn’t be stuffed. You doctors are trying to fob us off with drugs and all that.

all

the

same

anyway

–

In this situation, it might be easy for the doctor to get exasperated or even angry. The doctor may have invested considerable time and energy diagnosing the patient’s illness, identifying treatment and then explaining the importance of the treatment only to be ‘slapped in the face’ by the patient’s attitude. However, a part of being a health professional is maintaining respect for patients, whatever their situation. Instead of getting angry or exasperated, an effective health professional would try to find out why the patient feels this way, attempt to address underlying concerns and determine the kind of treatment the patient would accept. Respecting people It is important to realise that everyone has something to give – every individual has his or her own talents and qualities to offer. It may be helpful to identify and acknowledge these traits, for example, that a patient has coped well with their illness. This will not only help you respect a person, it will also convey to the person your respect for them. This helps reinforce the relationship.

THE QUESTIONS

WHAT SHOULD I EXPECT?

Questions are generally based on a passage or extended interaction. The stimulus may be drawn from a variety of sources – interactions, personal reflections, interviews and literature - and is generally quite lengthy. People involved in the passages may be family, friends, health professionals, patients or other individuals. You will be asked to consider the stimuli from a number of perspectives (eg. the friend, the sister, the patient). Puestions are usually organised into units, with one passage being relevant to more than one question (often 4 or 5). In these questions, you will be asked to choose the option that best describes or explains a person’s behaviour, thoughts or feelings. Essentially, this will require you to empathise with a person.

APPROACH TO ANSWERING SECTION 2 QUESTIONS

Gain an initial impression

It is important to have an initial understanding of the text and question before launching in. Again, resist the natural tendency to read the question from top to bottom. Start by briefly considering the question stem(s). Previewing the question stem in this manner will help you focus your empathy and understanding. For example, in an interaction between a grandmother and granddaughter, the emphasis of the questions may be on the grandmother's thoughts, feelings and behaviour. You can then read with a focus on this perspective. Before reading the passage, it is important to read any other information provided. Often questions will have an introductory note (often in italics) that describes the background of the stimulus. It is important to read this carefully, as it provides a context, 'sets the scene' and may offer helpful clues. For example, this part of the question may tell you where the extract was taken from, what the setting is (time and place) and what the context is (eg. conversation at a family dinner).

Read the passage carefully and actively It is important to underline and carefully consider key words in the stimulus that provide clues as to what a person is thinking or feeling. Remember that the passage (not your own experiences) is always the primary source of information you have about a person and the way they react to particular situations. Sometimes the thoughts and feelings of the characters will be obvious - 'The way he spoke infuriated me.' Sometimes it will be less so - 'I clenched my fist.' Sometimes it will be subtle, and require you to place yourself in the character's position - 'I had put my heart and soul into that painting. I watched him slowly rip it to shreds.'

It is vital that you read with an emphasis on empathising with characters. To help you do this, it may be helpful to place yourself in their position, or imagine them as someone you care about. But remember that people react differently, and you should not assume that just because you would react in a particular way, others will too. It is important to acknowledge the complexity of a person. At any one time, a person is likely to be experiencing a range of emotions and be influenced by a variety of life experiences. You should be alert to this and willing to identify several emotions and feelings. Try not to approach a question with preconceived ideas. For example, despite stereotypes, not all people with disabilities are ‘depressed’, ‘suffering’ or feel they are ‘victims’. It is also important not to be overly judgemental towards characters, and to try to appreciate where they are coming from. Avoid making unwarranted assumptions about characters.

Be particularly alert to aspects of the passage that may form the basis of a question. Often this involves things such as: - Complexity in the text eg. "The polished metal doors of the lift show a fantastically deformed reflection of my face and body.' - Any symbols or imagery eg. 'The clock kept ticking.' - Any change in a characters' thoughts or feelings - Any conflict between characters

Reflect! At this stage you are probably eager to start answering those questions. But hold off that urge for one more moment. It is often very helpful if you spend a few moments reflecting on the text. What does reflecting mean? It means thinking about the text to gain a deeper understanding of the situation and the characters involved. Ask yourself: - What are the key issues? - What are the key conflicts? - What are the key aspects of the interpersonal situation? - What are the thoughts / feelings / behaviours / motives of each character? How do these change? Why?

Answer the question(s) Now you have reached the question. Start by carefully re-reading the question stem, paying careful attention to what it is asking you to do. In section 2 there is a wide range of instructions, and each of these will require you to view the situation and respond in a different way. Read each option carefully, and use the process of elimination to choose the best possible answer. If you are stuck between two words, think about the contexts in which you would use each word. This will often help you decide which one fits best, or is most appropriate.

If you are finding a question difficult, it is often helpful to mark what you think the answer is, and

come

back

later. This is because when you read something the second time, you often view it from a different perspective, or pick up on something that you had missed before. It may be the key to the question.

TYPES OF QUESTION

You will be asked to answer a number of different questions. We cannot discuss every single question you are likely to come across, as this will depend on the particular scenario. Please consult our practice exams and solutions for a better idea of the types of question you are likely to be confronted with. However, some common questions will be discussed. These include: · · ·

Identifying what a person may be feeling Identifying the reasons behind a particular action or behaviour Considering the response of a health professional

Identifying what a person may be feeling In order to answer these questions accurately, you need a good grasp of some common emotion words. ACER assumes that you know the meaning of such words. You most likely have a solid understanding of words such as angry, happy, scared and sad, however, more complex words are often used. While you probably have some idea of what they mean, the following exercise will help you gain a deeper understanding.

Exercise: Emotion words Following are some of the more complex emotion words that have appeared in the UMAT and / or are likely to appear. There is also some room at the end for you to include more words. Use the table below to record the definition of such words and give an example of their use. The first word is done for you. Note: If you would like to print this table, a printable version can be found in the document entitled "Table of Emotion Words" under Section 2.

Word Guilty Embarrassed Concerned

Frustrated Ashamed Annoyed Comforted

Definition

Example

Feeling blame or responsibility for wrongdoing

I feel guilty about visiting her so rarely

Disappointed Lonely Rejected Fearful Grateful Patronised Humiliated Shocked Isolated Reassured Uncertain Hostile Depressed Anxious Relieved Satisfied Resigned Resentful Disgusted Confronted Jealous Pathetic

Let’s take a look at an example. The following passage is an extract from the personal reflections of Mary. I looked after mum for almost four years. She has progressive dementia. She got progressively worse, and by the end she couldn’t even dress herself properly. She needed almost total care. I found myself taking time off work and I spent less time with Robert (Mary’s husband) and the kids. It was really difficult for me to make the decision to put mum in a nursing home. I used to visit her often, but now I can’t. I feel like I should be caring for mum at home. What word would best describe how Mary is feeling? A) Frustrated B) Lonely C) Guilty D) Concerned Solution: Start by briefly previewing the question stem. Here we are being asked about Mary (not her husband, or kids) and we are being asked about feelings (not thoughts or behaviour). The italicised portion tells us that it is from the 'personal reflections' of Mary. Now read the passage actively, paying attention to key words. We are told that she found herself spending less time with her family, and that it was "really difficult" for her to make the decision to place her mother in the nursing home. She "can't" vist her often, and feels she should be caring for her mother at home. So, what `s q„e main conflict here? Mary's obligation to her mother, and `er difficulty reconciling it with work and family commitments. What is likely to be the dominant emotion Mary is feeling? Probably guilt. Now, lets look at the question. There is no sense of anger or frustration in the piece (option A). Yes, Mary is missing her mother, but this does not make her lonely (option B). Option C is a good match. Mary is likely to be feeling a more intense emotion than mere 'concern' (option D). Let's look at another example.

Henrietta is a twenty two year old woman with a rare genetic disease. She is transferred to a large teaching hospital for treatment. After being there for two weeks, her parents have noticed that she is becoming increasingly withdrawn. On questioning, Henrietta says: 'I can't stand the rounds. Twice a day they come here, a big group of them - the surgeon, nurses and about a hundred medical students. Then the surgeon asks the students to examine me, and off they go, prodding and poking me one by one. It's like I'm some weird freak specimen'. Which of the following best describes what Henrietta feels when she is examined by the medical students? A) Shame B) Anger C) Humiliation D) Embarrassment Solution: Again, start with the question stem. We are being asked to find Henrietta's emotions, but importantly, her emotions "when she is examined by the medical students." This should be our focus. Now, let's read the passage actively. She is 22, has a "rare genetic disease" and is being treated in a "large teaching hospital." She is becoming "withdrawn", so the emotions she feels must be intense. Henrietta says she "can't stand" the

rounds, and uses exaggeration "about a hundred medical students", "weird freak specimen". Now reflect. Henrietta seems to be feeling a mixture of anger and embarrassment. How would you feel in this situation? Shame (option A) and embarrassment (option D) are part of the picture, and so is anger (option B). Only humiliation (option C) captures both these emotions, and is therefore the best answer. Identifying the reasons behind a particular action or behaviour Questions in section 2 may focus either directly or indirectly on a character's motives, or the reasons behind their behaviour. This can be inferred from their thoughts, actions, or words. Keep in mind that there may be a number of factors motivating people’s behaviour. Let's look at an example. Nurse: Mr Hantley, you can't leave the hospital now. Your condition isn't stable and you need to rest before it's safe for you to go home. Mr Hantley: I can't stand this place any longer. Its whiteness, its monotony, its coldness and emptiness. I need to go home. And anyway, I feel fine. I don't feel light-headed anymore and my legs and arms are working fine. I don't see why I can't leave this horrible place! It is possible to tell that Mr Hantley: A) Does not understand why it is not safe for him to go home B) Has little concern for his own wellbeing C) Does not have a good understanding of his own condition D) Is unable to appreciate the positive aspects of the hospital Let's start by previewing the question stem. It doesn't give us much specific information, so let's move to the text, in this case an interaction between nurse and patient. There is a key conflict here - the nurse believes Mr Hantley cannot leave the hospital, and Mr Hantley believes he can ("I feel fine... my legs and arms are working fine.") Further, he expresses a marked dislike for the hospital environment - "I can't stand this place... its whiteness, its monotony, its coldness and emptiness" and describes it as a "horrible place." Let's consider the options now. Option A could be true - Mr Hantley believes it is safe for him to go home, and does not seem to appreciate what the nurse is telling him. This does not mean that he does not value his wellbeing (option B) this is an unfair assumption. Option C is true, but is a subset of A, which is a more complete answer. Mr Hantley certainly highlights the negative aspects of the hospital in his appeal to the nurse, but this does not mean he is unable to appreciate any good things about the hospital environment (option D). Considering the response of a health professional In this type of question you may be required to describe the function and / or consider the appropriateness of a comment(s) or action(s) by a health professional. Following are some guidelines as to what constitutes empathetic and appropriate responses by health professionals (and indeed other people). Responses should:

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Show evidence of listening to the person. What is the person really communicating? Be perceptive – pick up on cues and read between the lines

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Show respect for people's beliefs, culture, attitudes and choices (including a decision to refuse treatment)

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Encourage the person to talk and share their concerns

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Demonstrate empathy and reassurance

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Address the person's concerns

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Be responsive. They should not ignore a verbal hint or expression of emotion

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Empower people. Responses should acknowledge the person's resourcefulness and expertise, and involve them in all stages of decision-making

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Acknowledge and legitimise a person's feelings, so they feel more comfortable sharing their concerns. This involves being responsive and demonstrating empathy

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Respect the person's individuality - i.e., take account of the individual needs and circumstances of each person in determining the most appropriate course of action

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Not make unwarranted assumptions about people eg. if a patient is reluctant to take certain medication, responses should attempt to find out what their concerns are and address them. Assumptions should not be made about the cause of their reluctance (eg. side-effects), as this may be ineffective in addressing their concerns

•

Inform patients about their illness and the various options available to deal with it

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Convey a wish to support people through their time of adversity

•

Be diplomatic and non-judgemental at all times

In judging appropriateness, it can be helpful to think about the possible consequences of the remark or action. Ask yourself what might eventuate (eg. would there be further argument, would the situation be resolved, would there be further discussion).

Let's consider an example: 1. Doctor: 2. Mr Yi:

3. Doctor:

How can I help you, Mr Yi? I have come to discuss with you the less than satisfactory results I have been experiencing. I do not think you have got it right. What do you think is wrong?

4. Mr Yi:

I have done some reading on the internet. I found some really good sites and I’ve reached some conclusions. I agree that the gallbladder condition is unlikely, but I’m not sure that my ulcer has gone. The pain I feel fits with what I have read and I can understand how such a condition could develop. The current medication I am on does not treat an ulcer.

5. Doctor:

So, you’re concerned that if we missed the ulcer on the first test and have not made the correct diagnosis, you would be taking the wrong medication and might get worse?

The doctor’s primary aim in the consultation is to A) Discover what the patient is feeling B) Show the patient that she knows what is wrong with him C) Discover what the patient believes is wrong with him D) Diagnose the patient’s illness Answer: C

Solution: This scenario demonstrates how informed some patients can be. The doctor’s comments suggest that she is attempting to discover what the patient’s concerns are, i.e. what he believes is wrong with him (option C). The doctor is not attempting to diagnose the patient (option D), rather determine what the patient believes is his diagnosis. There is little indication that she is attempting to discover what the patient is feeling (option A) and she does not show a desire to show the patient that she knows what is wrong with him (option B).

Comment 5 (by the doctor) is A) Inappropriate, since it repeats what the patient has said B) Inappropriate, since the doctor should be focussing on diagnosing the patient C) Appropriate, because it empathises with the patient D) Appropriate, because it checks that the doctor has understood Answer: D Solution: Comment 5 is an attempt by the doctor to display reflective listening. She does this in order to ensure she has understood what the patient has said, and also demonstrate to the patient that she is listening to his concerns. The doctor actively re-states what the patient has said; she does not merely ‘repeat’ it – furthermore, this is appropriate rather than inappropriate (option A). Option B is untrue. Option C correctly identifies the comment as appropriate, but empathy is not the primary function of the statement – checking understanding is (option D).

SUMMARY OF STRATEGIES

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Preview, and pay careful attention to, the question stem

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Carefully read any other information, such as an italicised introductory note

•

Read the passage actively, underlining key words

•

Read with an emphasis on empathy

•

Avoid being judgemental or making unwarranted assumptions

•

Be alert to parts of the text that could form the basis of a question

•

Reflect!

•

If you are having difficulty, come back to the question later

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EXERCISES

Exercise: Emotion words Word

Definition

Example

Guilty

Feeling blame or responsibility for wrongdoing

I feel guilty about visiting her so rarely

Embarrassed Concerned Frustrated Ashamed Annoyed Comforted Disappointed Lonely Rejected Fearful Grateful Patronised Humiliated Shocked Isolated Reassured Uncertain Hostile Depressed Anxious Relieved Satisfied Resigned Resentful

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Disgusted Confronted Jealous Pathetic

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