1. Try not to come in groups of more than two students.
2. Make sure your name badge is visible to the patients.
3. Introduce yourself – name, role, stage of training – patients feel more relaxed with you when you do this and will be more open and are less likely to find your presence distracting.
4. Find a member of staff to ask whether I am okay with seeing you without you present – that way I will feel more able to say no – this builds trust.
5. Ask consent - to be present, to read my notes, to take my history.
6. If patients say no, make it clear that is okay.
7. Tell them what you would like to do/how you will be involved, e.g., watch, ask questions, take a history.
8. Include the patient and carer in all discussions that you are present for.
9. Never talk about patients in the third person when they are in the room.
10. The more engaged you are, the more you will get out of the experience – if you take an interest in us, we will take an interest in you. You can show this with your body language and by asking me questions.
11. Please remember I’m a human being; you are more likely to remember things about my clinical condition.
12. Be aware that patients may not always feel able to speak freely in front of their carers or family.
13. Say thank you – this is respectful and acknowledges the patient’s contribution to your education.

So long as the patient consents to you reading their notes, it is helpful to have an understanding of their history before seeing them and learning to read and process patient’s notes is an important part of your training. Do however be aware of the possibility of forming negative judgements and of unconscious bias based on what you have read in the notes. 

Psychiatric notes can be lengthy! Ask a member of staff to show you how to read the notes effectively by focusing on key assessments including clinic letters, admission notes and risk assessments.

Consider whether the patient you are seeing has any access needs and take this into account when planning where to see them. Some needs may be apparent, but some can be less so, for example needing a calm and quiet, less stimulating environment. 

Best practice would be to ask where a patient would feel most comfortable to talk.

Absolutely! Taking a history in a patients first language is always preferrable as much subtle but important information is lost in translation. If you are able to do this, you will be making a significant contribution to the care of our patients.

Many patients will be aware that you are still learning – especially if you introduce yourself clearly! Some patients may even be able to help you find better ways of asking questions and many patients are also concerned not to upset you. 

For patients who are more unwell, it can be helpful to acknowledge that you may upset them and ensure they know that they can stop the interview at any time if it becomes too overwhelming. 

Also, it is helpful to be aware that some patients may prefer different ways of communicating such as texting. Patients who are neurodivergent may be very uncomfortable with eye contact so it can help to ask patients how they prefer to communicate and if there is anything you can do to make your conversation more comfortable when you introduce yourself at the beginning. Cultural differences may also affect this. 

Finally, you may want to check with patients what information they have about medical education and why you are asking to see them. If they haven’t seen the Patient information about clinical education, offer to share this with them.

If a patient becomes distressed, check whether they want to continue and if not ask what you can do to help and let a member of staff know that they are upset.

Students often feel uncomfortable asking questions about suicidality, but patients are often relieved to be invited to talk about these feelings in a non-judgemental way. 

It can be helpful to start by acknowledging that when people feel very low, they often have these thoughts. For example, you might say, ‘Often when people feel down, they have thoughts that they don’t want to be alive anymore. Have you had any thoughts like this?’ If the patient has had these thoughts, you could then follow up with an invitation to talk, such as ‘Can you tell me a bit about that?’. 

Some patients may be able to help you with these questions by sharing their experiences of being asked these questions and talking to you about which ways were more helpful or supportive. 

For more suggestions about how to ask difficult questions, see Practical Guides in Psychiatry: The Psychiatric Interview by Daniel J.Carlat.

It is important to ask about delusional beliefs as it will help to keep the patient, their family, the public and members of staff safe. Often patients will not volunteer this information, but if you know a little about things they have said in the past, you are more likely to be able to support them in talking about their fears or beliefs. 

While it is important to understand what patients are thinking, it is not a good idea to pursue these thoughts beyond what is necessary to keep them safe as this can reinforce the beliefs. You may need to test out how firmly these beliefs are held but try to maintain a neutral stance as delusional beliefs do not respond to reassurance or evidence to the contrary. You can, however, reassure them that the team is there to keep them safe and look after their health.

Always be polite and respectful. Think about your body language and degree of eye contact. Be aware that people who are agitated may require more personal space and may experience sustained eye contact as aggression. 

Talk calmly and explain that you want to help. If you feel out of your depth, explain to the patient that you are going to get more support. Always ask a member of staff for advice or assistance.

Patients are assumed to have capacity unless there is reason to suspect otherwise. The team you are placed with can help you think about whether this is likely to be an issue depending on which patient you are planning to talk to. 

The GMC does not stipulate whether, as a student, you can take a history from a patient who lacks capacity. 

In line with GMC advice on disclosure of clinical information, we suggest that if possible, it is better to talk to patients who have capacity to consent.

If there is a reason to suspect that the patient might lack mental capacity to consent to participate in medical education, speak to your supervisor and they will need to assess the patient’s mental capacity and make a best interest decision with regards to the patient’s participation. This decision and the reasoning behind it should be documented in the patient’s notes. 

The best interest decision will take into account a number of factors, including: 

1. if the patient is happy to talk to you
2. any risk of harm/distress being caused to the patient
3. any benefits to the patient
4. previously expressed views and wishes of the patient either in the notes or from talking to carers, relatives, friends or a legally appointed representative

The Mental Capacity Act applies to those over the age of 16 years living in England and Wales. 

A person can lack capacity to make a particular decision because of an impairment of, or a disturbance in the functions of, the mind or brain (diagnostic test), which can include a psychiatric illness, dementia, substance misuse or a learning disability. It is not necessary for the person to have a particular formal diagnosis for the diagnostic test to be met. 

However, not all patients with these disorders will lack capacity and some patients will have capacity to make relatively simple decisions but not to make more complex decisions.

If you do have concerns about a patient’s capacity to consent to taking part in medical education the mental capacity act stipulates that the following functional test should be applied to assess whether the person is able to make a decision for themselves. They need to be able to do all of the following:

• To understand the information relevant to the decision
• To retain the information
• To use or weigh that information as part of the process of making the decision
• To communicate their decision (whether by talking, using sign language or any other means) 

The capacity decision is specific therefore it is essential you always review the person’s mental capacity with regard to the particular decision. 

It is essential that you are able to demonstrate how the disturbance in function of mind or brain leads to the person failing to do one of the four tasks in the functional test above. The fact that someone has a formal diagnosis and makes an unwise decision does not automatically mean they will lack mental capacity. 

The lack of mental capacity can be temporary, and if so, it would be appropriate to come back to see the patient once they have regained capacity.

The decision to take part in medical education is a relatively benign decision with limited if any risk of harm to the patient. This reduces the complexity of the decision and means that most patients would have the capacity to make this decision.

Every effort should be made to support patients in making their own decisions, including but not limited to using hearing loops, ensuring a patient has their glasses or hearing aid, holding the conversation at the best time of time or in the best environment for them, having a relative or friend present to support them. 

In discussing the issue of taking part in medical education, it is worth considering whether there might be any benefit to the patient of taking part. When we were putting together this information about medical education, our People Participation Team members provided some insights into this:

Some patients find that talking to students can lead to different ways of thinking and can bring a different perspective. Different ideas can feed into and possibly improve their care. 

Some patients may feel more able to open up to students about difficult experiences that they have had within the healthcare system as students can be seen as somewhat outside the system. Sometimes the interaction between a student and a patient is different because they tend to come from a younger generation and so may be more aware and engaged with issues around diversity, neurodiversity, gender and intersectionality. 

If you would like more information about the Mental Capacity Act 2005, please follow this link: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/348440/OPG603-Health-care-workers-MCA-decisions.pdf 

As you know, patient notes and information shared with health professionals is confidential. This means that the information is shared with the team looking after a patient, but not beyond that without their consent. 

Occasionally patients share information which suggests there is a risk to them or another individual and in these instances the team may be legally required to share this with other services (for example the police or social services) or individuals. Usually, this will be discussed with the patient before the information is shared. Any information shared outside the team would be limited to that necessary to ensure the patients’ and other people’s safety. 

As a medical student, you must follow the same policies around confidentiality: you will not share information outside of the team looking after the patient; any record you keep must not contain information that would make the patient identifiable; any paper notes made must be disposed of in the confidential waste. These are called the Caldicott principles. If you would like to know more about this, you can follow this link: https://www.gov.uk/government/publications/the-caldicott-principles