1. Strategies for implementing clinical communication training in every day practice - how to do it?
Jonathan Silverman
Aarhus
2012
One of the concrete challenges in the Danish setting is that we send all interns on obligatory communication courses, but when they return to the wards and general practice, very few of their senior colleagues have this training and thus neither knowledge about nor focus on the importance of communication. And thus the skills learned at the intern courses (or pre-graduately for that matter) rarely become integrated in clinical practice.

2. Bringing the Hidden Curriculum out of hiding: Strategies for bridging the gap in teaching and learning about communication EACH St Andrews

3. Teaching Communication Skills in the Context of Clinical Care
Marcy Rosenbaum, PhD
Dr. Harold A. Myers Distinguished Professor
Associate Professor of Family Medicine
Office of Consultation and Research in Medical Education

4. Why you are so important

5. Introduction/reflection
Formal teaching of communication skills occurs in undergraduate and intern level
During their clinical work as doctors, their experiences can contradict and not reinforce the communication skills they have been previously taught

6. Introduction/reflection
In pairs, discuss what experiences learners may have with the “hidden curriculum” and their impact on development and retention of effective communication

7. Problems of ‘in the moment’ teaching:
achieving satisfactory re-rehearsal
obtaining constructive feedback from patients unused to this method of working
discussing sensitive issues in front of the patient
the availability of time in the ‘real’ world for both professionals and patients
the multiplicity of tasks – including patient care itself – that require attention
the wide range of possible teaching agendas, including issues concerning clinical reasoning, physical examination, investigations, treatment alternatives, etc.

8. Are communication skills and traditional history taking mutually incompatible?
Why history taking – surely we all know how to do that – my experience with oncology SHOs and prep for the foundation years
Standard of history taking
Mention MRCS
Paces – observed stations
Postgraduates – assumed to know
Nurses and doctors need to know
Who teaches you how
Tie into Mark and Frances
The cards
Process v content
So how do you?
What are the skills
Tapes?

9. The Leicester OSCE

10. Have you seen this problem?
Are communication skills and traditional history taking mutually incompatible?
Have you seen this problem?
Why history taking – surely we all know how to do that – my experience with oncology SHOs and prep for the foundation years
Standard of history taking
Mention MRCS
Paces – observed stations
Postgraduates – assumed to know
Nurses and doctors need to know
Who teaches you how
Tie into Mark and Frances
The cards
Process v content
So how do you?
What are the skills
Tapes?

11. Three elements of gathering clinical information
How you communicate
Process
Open
Directive
Biomedical
Patient’s perspective
What you discuss,
record and present
Content
Clinical reasoning
Feelings
What you think and feel
Perception
Lets just explore information gathering and just think what you are doing – three things simultaneously

12. Three elements of gathering clinical information
How you communicate
Process
Open
Patient’s perspective
What you discuss,
record and present
Content
This would be particularly grieving given our concept of a CCM: integration of content and process.
Overemphasis of:
Open Q
Empathy
Summarising
Screening
Pt’s perspective
gives communication a bad name
Feelings
What you think and feel
Perception

13. Three elements of gathering clinical information
How you communicate
Process
Directive
Biomedical
What you discuss,
record and present
Content
It isn’t this either – the overemphasis on directive questions by themselves does not lead to good biomedical content or clinical reasoning ability
In fact in the GKT Finals OSCE, they did not do clinical reasoning either
As if it is one all the other and they will do whichever one will please you
Clinical reasoning
What you think and feel
Perception

14. Dilemmas in history taking teaching
The students are being taught a different approach to what we practice on the wards
They don’t seem to know what questions to ask
They seem to concentrate on patient’s ideas, concerns and expectations
Of the clinicians, how many of you have noticed that students ideas of history taking seem different to your own?

15. Communication skills teaching model Traditional medical history model
Communication skills teaching model
versus
Traditional medical history model

16. Confusion over Process Content
The confusion over process we have covered – learners choose the content guide for their process guide
Let’s look now at content. This where it gets tricky
You’d think content is pretty clear - we know what information we need and that is all in the traditional medical history
Lets look at the information gathering part of the history

17. Communication model (process)
Initiating the session
Gathering information
Building relationship
Structuring the interview
Explanation and planning
Closing the session
In the red corner
Communication models provide a framework and list of skills which detail the means through which doctors conduct the medical interview, obtain the required information described in the traditional medical history and then discuss their findings with patients. This is commonly referred to as the process of the medical interview – i.e. how we do things. Examples of communication process skills might include the physician's nonverbal behaviour, the use of open or closed questions, the skills used to ensure accurate understanding or the ways in which the interview is structured, how to build a relationship.
Comms skills: how you do things (process skills), was traditioanlly taught as a separate one-off course, taught by a whole tribe of woolly jumpered people, GPs, psychologists and psychiatrists – communicate but know nothing

18. Chief complaint Traditional Medical History Model (content)
 History of the present complaint
 Past medical history
 Family history
 Personal and social history
 Drug and allergy history
 Systematic enquiry

19. Confusion between process and content (1):
How to obtain information v. how to present info
How to obtain information v. how to write down info
Equating problem solving with patient care at the bedside – observation of snippets
The issue of how learner’s are observed (if they are)
GP/psychiatry/psychology v real doctors
What happens at bedsides is often a test of knowledge

20. Gathering Information
process skills for exploration of the patient’s problems
patient’s narrative
question style: open to closed cone
attentive listening
facilitative response
picking up cues
clarification
time-framing
internal summary
appropriate use of language
additional skills for understanding patient’s perspective

21. Chief complaint Traditional Medical History Model (content)
 History of the present complaint
 Past medical history
 Family history
 Personal and social history
 Drug and allergy history
 Systematic enquiry

22. Confusion between process and content (2):
Communication skills teachers have introduced their own new content

23. content to be discovered:
the bio-medical perspective
(disease)
sequence of events
symptom analysis
relevant systems review
background information - context
past medical history
drug and allergy history
family history
personal and social history
review of systems

24. content to be discovered:
the patient’s perspective
(illness experience)
ideas and beliefs
concerns and feelings
expectations
effects on life

25. content to be discovered:
the bio-medical perspective the patient’s perspective
(disease) (illness)
sequence of events ideas and beliefs
symptom analysis concerns
relevant functional enquiry expectations
effects on life
feelings
background information - context
past medical history
drug and allergy history
family history
personal and social history
review of systems

26. Are communication skills and traditional history taking mutually incompatible?
So what’s the solution

27. Effective history taking is essential to the practice of high quality medicine

28. Effective communication is essential to the practice of high quality medicine

29. Effective clinical method is essential to the practice of high quality medicine

30. A Comprehensive Clinical Method

31. A Comprehensive Clinical Method
The explicit integration of traditional clinical method with effective communication skills
to enable doctor and patient, in partnership, rationally to explore, diagnose and manage both:
disease
(the bio-medical cause of sickness in terms of underlying pathophysiology) and
illness
(the individual patient’s unique experience of sickness)

32. Why integrate communication training into everyday practice
Reinforce and validate content and skills emphasized in previous education
Address more advanced communication skills and issues
Address interviewing challenges identified by learners

33. How Doctors Learn in Clinical Years
observing senior doctors
feedback on presentations
conducting interviews themselves
(Observation and feedback rarely occurs)
When we asked students how they learned they identified these main ways of learning about communication skills. It is worth looking at each one of these ways of learning and the impact it may have on their communication skills and their perceptions of how much what they learned in the classroom matches what they see in the clinic.
Observation – what is modeled doesn’t match
Doing their own interviews – not observed and message they get is to limit the information and have time constraints
Presenting – message they get is doctors don’t want to know so don’t ask that stuff 33

34. Opportunities to teach communication in the context of clinical care
Modeling for learners
Staffing: Responses to learner presentations
Observation of learner interactions with patients and feedback

35. Modeling

36. Modeling communication: Strategies for maximizing learning
Outpatient or Inpatient - Especially useful with advanced tasks
1) Prime learner before observation
“Please pay attention to the way I…..”
“What aspects of the clinical encounter do you have questions about?”
2) Conscious awareness of communication choices while modeling
Have a plan, consider the skills you use
3) Debriefing after observation is key
“What did you notice (analyze skills used), what do you have questions about, what would you use in future?”

37. Staffing

38. Cues in Staffing In small groups,
Based on the learner’s presentation cue, “diagnose” what the communication issue(s) might be that the learner is struggling with
Discuss what skills you could recommend for the learner to use

39. Cues in staffing
“This patient had so many problems I had a hard time sorting it out and it took a long time”
“The patient seemed kind of upset but I’m not sure why”
“He is a very difficult historian”
“I explained to her that she needs to take the medication regularly which she has not been doing”

40. Cues in staffing
“This patient had so many problems I had a hard time sorting it out and it took a long time”
What communication issues does learner have?
What skills could address them?

41. Initiating the session:
Listens attentively to the patient’s opening statement, without interrupting or directing patient’s response
Checks and screens for further problems (e.g. “so that’s headaches and tiredness, what other problems have you noticed?” or “is there anything else you’d like to discuss today as well?”)
Negotiates agenda taking both patient’s and physician’s needs into account
Gathering information
Asks about patient ideas, concerns, and expectations (ICE)
Periodically summarises to verify own understanding of what the patient has said; invites patient to correct interpretation or provide further information.

42. Staffing
Additional strategies for assess and address learner communication needs
Priming before patient encounters if need for certain process skills can be anticipated
Asking learner how the interaction went with the patient
Asking learner what they were trying to accomplish with patient and did they feel they achieved it
Problem solve with learner about skills that could be helpful

43. Observation of learners

44. Observation of learners
Though it takes more time, can give clearer picture of communication strengths and challenges
Observation can be done in brief forays – at the beginning of patient encounter or during explanation phase after staffing

45. Observation of learner
Example of resident with mother of asthmatic adolescent patient
On observation sheet, write down what you see, including specific phrases, questions and responses – both effective and less effective

46. Observation sheet asked appropriate specifics
Content
(CC, pmh)
Effective behaviors that you see
Behaviors you don’t’ see or that could benefit from change
Greeting
(8:50 am) CC
PMH
9:05
introduced self
good eye contact
 asked appropriate specifics
("Can you describe that?")
open-ended questions
good paraphrasing
("what I hear you saying…")
Didn't mention student status
Interrupted too quickly
("daughter…how severe pain")
no follow-up
(can't afford to be sick)