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Assessing Communication as a Clinical Competency Why Bother?

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1 Assessing Communication as a Clinical Competency Why Bother?
Suzanne Kurtz, PhD College of Veterinary Medicine Washington State University March 14, 2008 Washington DC

2 ACKNOWLEDGEMENTS Kurtz S, Silverman J, Draper J (2005)
Teaching and Learning Communication Skills in Medicine, 2nd Ed. Radcliffe Publ: Oxford & San Francisco Silverman J, Kurtz S, Draper J (2005) Skills for Communicating with Patients, 2nd Ed. Radcliffe Publ: Oxford & San Francisco Riccardi V & Kurtz (1983) Communication and Counselling in Health Care. Charles C Thomas, Springfield, Illinois Cindy Adams, PhD, University of Calgary



5 Who’s Endorsing Communication in Veterinary Medicine?
National Commission on Vet Econ Initiatives American Animal Hospital Association American & State Vet Med Associations American College of Veterinary Internal Medicine Veterinary Colleges - Canada, UK, USA, etc. Intl Conf on Communication in Vet Med National Board of Vet Med Examiners Vet Industry Partners

6 Evidence Base Human Medicine
Enhancing communication leads to: More effective consultations Accuracy Efficiency Supportiveness Better relationships (partnership) Better coordination of care Kurtz, Silverman, Draper, 2005 All this and no side effects for patients - If this were a drug we’d all be lining up to use it

7 Evidence Base: Improved Clinical Outcomes in human medicine
Enhancing communication leads to better outcomes:  understanding & recall  symptom relief  physiological outcomes  adherence  patient safety  patient satisfaction  doctor satisfaction  costs  complaints and malpractice litigation And what does the evidence say - what is the benefit we get from going to the trouble to use these skills?

8 Evidence Base Veterinary Medicine
PEW National Veterinary Education Program (1988) AVMA Market Study (1999) “Veterinarians are strong in scientific, technical and medical skills and lacking in communication and management skills necessary for success in practice.” Brakke Management and Behavior Study (2000) Identified three business practices to increase practice income (employee longevity, employee satisfaction, and client satisfaction) Personnel Decision Study (2003) Identified non-technical competencies for career success (business acumen, work life balance, effective communication, and leadership skills) AVMA-Pfizer Business Practices Study (2005) Identified client relationships as a pillar of financial success

9 Evidence Base Veterinary Medicine
Compliance range is between 23-65% Problems cited: Not enough information Relationship not established Client opinion not considered No follow up regarding patient well being Adams V (2002), AAHA (2004)

10 Evidence Base Veterinary Medicine
50-82% of complaints to CVO related to communication problems: Client was misinformed Consent was not obtained Client felt disrespected Client felt like opinion did not matter Procedure was not explained College of Veterinarians of Ontario (2005)

11 What are we assessing? Clinical competence
Knowledge base Physical examination skills Medical problem solving, diagnostic skills Communication skills Communication is a core clinical skill with considerable science behind it

12 Common (mis)perceptions
Communication is a personality trait, either you have it or you don’t Communication is a series of learned skills Not a personality trait Anyone can learn who wants to

13 Results of Lit Review (human medicine) 81 high to medium quality articles included
Overwhelming evidence for positive effect of communication skills training Only 1 of 81 studies didn’t report positive effects Med students, residents, junior drs, senior drs all improved Specialists as likely to benefit as primary care drs Aspegren, 1999

14 Evidence: Veterinary Medicine
Significant improvement in veterinary students’ communication skills with increasing levels of training (p<.0001) No significant difference between no training and intermediate training Clients’ recall highest in student group with highest level of communication training Latham CE, Morris A Veterinary Record (2007)

15 Common (mis)perceptions
Experience is a good teacher of communication skills Experience alone tends to be a limited teacher of communication skills It is a great reinforcer of habit - just doesn’t discern well between good and bad habits

16 Our perception may be flawed
What gets us into trouble is not what we don’t know. It’s what we know for sure that just ain’t so. Mark Twain We Students are sure that experience is all they’ll need. Double indemnity: so are faculty. The go-to group here is practicing clinicians.

17 Taught skill retention vs development with experience alone
Doctors 5 years out of medical school still strong in information gathering (taught) but weak in explanation and planning skills (experience only) discovering pt’s views/expectations 70% no attempt negotiation % no attempt encouraging questions % no attempt repetition of advice % no attempt checking understanding % no attempt categorizing information % no attempt Maguire et al 1986 5 years out of medical school drs. were still strong in the information gathering skills they had been taught, but very weak in the explanation and planning skills that had been left to be learned by experience.

18 Evidence-based Rationale Veterinary Medicine
Data gathering Primarily closed questions No open-ended questions in 25% of interviews Empathy Empathy statements in only 7% of appointments Shaw, Adams, Bonnett, Roter 2003, 2004

19 What are we assessing? Behavior = what we do anyway vs
Professional competence = awareness & attention intentionality ability to reflect on & articulate with precision and it’s evidence based Goal = to enhance communication in practice to a professional level of competence

20 What are we assessing? Skills* Attitudes, beliefs, values
Capacities (eg, compassion, integrity, flexibility, mindfulness) In what circumstances? Difficult situations (complex case, breaking bad news, death and dying, medical error, adverse outcomes) Everyday run-of-the-mill consultations, client education, prevention

21 Types of Communication Skills
Content skills what you say, info you gather & give Perceptual skills - what you think, clinical reasoning - what you feel attitudes, biases, intentions, assumptions Process skills - how you question, respond, explain, plan - how you structure talk - how you relate to patients - nonverbal skills/behaviour

22 Do we know what skills are worth assessing?
Many models available: Calgary-Cambridge Guides Patient-Centered Model Macy Model SEGUE Framework Bayer-Fetzer Essential Elements MAAS-Global

23 Numerous approaches to assessing communication are out there
Boon H and Stewart M (1998) Patient-physician communication assessment instruments 1986 to 1996 in review. Patient Education and Counseling. 35: Cushing A (2002) Assessment of non-cognitive factors. In: GR Norman, CPM van der Vleuten and KJ Newble (eds) International Handbook of Research in Medical Education. Kluwer Academic Publishers, Dordrecht. MacLeod H (2004) Physician performance assessment and communication skills assessment. Unpublished review of the literature from 1990 to Task Force on Physician Communication Skills Assessment and Enhancement in Canada, Medical Council of Canada, Ottawa, Ontario Kurtz S, Silverman J, Draper J (2005) Assessing learners’ communication skills. In Teaching and Learning Communication Skills in Medicine (2nd ed). Radcliffe Publishing: Oxford & San Francisco

Initiating the Session Gathering Information Providing Structure Building the Relationship Physical Examination Many models have been developed to delineate the communication process skills - the point is that models work in communication skills teaching. An example is the C-C Guides, which are built around a framework that corresponds directly to the way we structure a consultation in real life. [HANDOUT of pocket version] - it provides a summary of the literature on the skills worth teaching and a structured way to frame personal learning as well as teaching and learning of others, feedback, and curriculum development. Explanation/Planning Closing the Session Kurtz, Silverman, Draper (2005)

25 Calgary-Cambridge Guides Communication Process Skills
56 process skills organized around framework (plus Options in Expl & Pl section = 15 more process & content skills:) Backbone of communication teaching and learning Cross-disciplinary & cross-cultural application SEE HANDOUT

26 Same process skills for an array of communication issues
Conflicted or difficult situations Gender issues Cultural issues Generational differences Ethical dilemmas Performance reviews

27 Flexibility Is Key C-C Guides offer evidence-based guidance with considerable latitude for personal style Tailor your approach to fit client’s preferences and perspectives

28 Advantages of Guides Accessible summary of research evidence
Comprehensive delineation of skills Memory aid to keep skills in mind, organized Framework for systematic skill development Basis for comprehensive feedback & evaluation Core content for training faculty, creating consistency Common foundation for programs at all levels – basis for coherent, helical curricula from undergrad through CE Same skills pertain to effective teaching or communication with colleagues


30 What are we assessing? Miller 1990 Knowledge – do you know it?
Competence – can you do it? Performance – do you (choose to) do it in practice? Results – what happens to pts, to drs? Miller 1990

31 What forms can assessments take?
Knowledge – do you know it? MCQ, essay/short answer, oral, Objective Structured Video Exam…

32 What forms can assessments take?
Competence – can you do it? OSCE using standardized simulated clients Stand alone communication stations Communication stations integrated with PE, medical problem solving, Real interviews: Series of live interviews with examiner present Series of self-selected videotapes/DVDs submitted for expert assessment Web-based OSCE (physicians link to simulated patient whom they interview online)

33 What form can assessments take?
Performance – do you (choose to) do it in practice? Videotapes/DVDs submitted with assessors randomly choosing tapes to be assessed Undercover simulated clients Real clients’ assessments Client and clinician do immediate assessment of same individual interview Colleagues’ assessments Results – what happens to pts, clients, drs? Self assessment/report Chart audits Follow up studies re compliance, outcomes of care, etc.

34 Objectives of Assessment
Motivation Drives what gets learned and taught Legitimizes importance of a subject Encourages acceptance by otherwise skeptial students and faculty Progress check, certification that is valid and reliable Educational impact

35 Formats for Feedback quantitative______________________ __ _qualitative evaluative feedback_________ descriptive feedback number scores, good/bad “here’s what I see” global_____________________ _________ __detailed

36 Two types of assessment
Formative Summative

37 What does it take to learn clinical communication skills, change?
Knowledge doesn’t translate directly into performance Essentials needed to learn skills, change: Systematic delineation & definition of skills Observation of learners communicating (video) Well-intentioned, detailed, descriptive feedback Practice and repeated rehearsal of skills Planned reiteration and deepening of skills Small group or one-on-one format

38 Teaching and learning communication skills is different
Closely bound to self concept No one starts from scratch No achievement ceiling More complex than simpler procedural skills

39 Stages in skills learning/change not a linear progression
Consciously skilled Awkward Fully assimilated Beginning Awareness Wackman et al 1976

40 What makes for effective feedback?
1st Principles of Effective Communication Ensures interaction not just transmission Reduces unnecessary uncertainty Requires planning, thinking in terms of outcomes Demonstrates dynamism (engagement, flexibility, responsiveness) Follows helical vs linear model Same principles apply to effective teaching

41 What makes for effective feedback?
Agenda-Lead Outcome-Based Analysis (ALOBA)

42 Approaches to communication
Shot-Put Approach the well-conceived, well-delivered message is all that matters emphasis on telling, interaction/feedback not in picture Frisbee Approach 2 central concepts confirmation = to recognize, acknowledge or endorse another mutually understood common ground emphasis on interaction, feedback, relationship Broadly speaking there are basically 2 approaches to defining ‘effective communication’ A Barbour 2000

43 Example of an Integrated OSCE University of Calgary
Day of exam 1 Interview with SC - videotaped examiner scores content checklist SC completes written feedback form (after interview) 2 Student thought time 3 Presentation of case to examiner with problem list, hypotheses, & ideas for PE 4 Performance of selected PE related to interview (PE unrelated to interview tested at other stations) 5 PE results given to student - student gives ideas re investigations 6 Investigation results given to student - student gives ideas re differential diagnosis

44 Integrated OSCE conti Within 12 days of exam:
Pairs of students meet with expert examiner to assess communication process skills (Calgary-Cambridge Guides) 1 View student’s videotaped interview, stopping tape periodically 2 Self, peer, and expert assessment (yes, yes but, no) 3 Compare results (not about reaching consensus) 4 Mini-tutorial re problem skills, strengths, next steps 5 Compare process skills with content checklist, hypotheses and differential, SC feedback Individually tailored remedial for unsatisfactory students; retake of exam (x2 possible)

45 Concluding thoughts Communication is core clinical skill
Skills are appropriate focus for teaching and assessment Build on what’s already available (research, teaching and assessment models in human and vet medicine) Include educational impact in design of assessment Train faculty and learners to participate in feedback process to enhance communication learning Integrate communication with other clinical skills teaching and assessment

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