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Assessing Communication as a Clinical Competency Why Bother? Suzanne Kurtz, PhD College of Veterinary Medicine Washington State University Washington State.

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Presentation on theme: "Assessing Communication as a Clinical Competency Why Bother? Suzanne Kurtz, PhD College of Veterinary Medicine Washington State University Washington State."— Presentation transcript:

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

3 AARRGGHH!!!

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

6 Evidence Base Human Medicine Evidence Base Human Medicine Enhancing communication leads to: More effective consultations More effective consultations Accuracy Accuracy Efficiency Efficiency Supportiveness Supportiveness Better relationships (partnership) Better relationships (partnership) Better coordination of care Better coordination of care Kurtz, Silverman, Draper, 2005

7 Evidence Base: Improved Clinical Outcomes in human medicine Enhancing communication leads to better outcomes: Enhancing communication leads to better outcomes: understanding & recall understanding & recall symptom relief symptom relief physiological outcomes physiological outcomes adherence adherence patient safety patient safety patient satisfaction patient satisfaction doctor satisfaction doctor satisfaction costs costs complaints and malpractice litigation complaints and malpractice litigation

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

9 Evidence Base Veterinary Medicine Compliance range is between 23-65% Compliance range is between 23-65% Problems cited: Problems cited: Not enough informationNot enough information Relationship not establishedRelationship not established Client opinion not consideredClient opinion not considered No follow up regarding patient well beingNo 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: 50-82% of complaints to CVO related to communication problems: Client was misinformed Client was misinformed Consent was not obtained Consent was not obtained Client felt disrespected Client felt disrespected Client felt like opinion did not matter Client felt like opinion did not matter Procedure was not explained Procedure was not explained College of Veterinarians of Ontario (2005)

11 What are we assessing? Clinical competence Knowledge base Knowledge base Physical examination skills Physical examination skills Medical problem solving, diagnostic skills Medical problem solving, diagnostic skills Communication 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 dont Communication is a personality trait, either you have it or you dont Communication is a series of learned skills Communication is a series of learned skills Not a personality trait Not a personality trait Anyone can learn who wants to 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 Overwhelming evidence for positive effect of communication skills training Only 1 of 81 studies didnt report positive effects Only 1 of 81 studies didnt report positive effects Med students, residents, junior drs, senior drs all improved Med students, residents, junior drs, senior drs all improved Specialists as likely to benefit as primary care drs Specialists as likely to benefit as primary care drs Aspegren, 1999 Aspegren, 1999

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

15 Common (mis)perceptions Experience is a good teacher of communication skills Experience is a good teacher of communication skills Experience alone tends to be a limited teacher Experience alone tends to be a limited teacher of communication skills It is a great reinforcer of habit - just doesnt discern well between good and bad habits It is a great reinforcer of habit - just doesnt discern well between good and bad habits

16 Our perception may be flawed What gets us into trouble is not what we dont know. Its what we know for sure that just aint so. Mark Twain

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) Doctors 5 years out of medical school still strong in information gathering (taught) but weak in explanation and planning skills (experience only) discovering pts views/expectations 70% no attempt discovering pts views/expectations 70% no attempt negotiation 90% no attempt negotiation 90% no attempt encouraging questions 70% no attempt encouraging questions 70% no attempt repetition of advice 63% no attempt repetition of advice 63% no attempt checking understanding 89% no attempt checking understanding 89% no attempt categorizing information 90% no attempt categorizing information 90% no attempt Maguire et al 1986 Maguire et al 1986

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

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

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

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

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

24 CALGARY-CAMBRIDGE GUIDES FRAMEWORK FOR THE MEDICAL CONSULTATION Initiating the Session Gathering Information Physical Examination Explanation/Planning Closing the Session Providing Structure Building the Relationship Kurtz, Silverman, Draper (2005)

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

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

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

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

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

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

32 What forms can assessments take? Competence – can you do it? Competence – can you do it? OSCE using standardized simulated clients OSCE using standardized simulated clients Stand alone communication stationsStand alone communication stations Communication stations integrated with PE, medical problem solving,Communication stations integrated with PE, medical problem solving, Real interviews: Real interviews: Series of live interviews with examiner presentSeries of live interviews with examiner present Series of self-selected videotapes/DVDs submitted for expert assessmentSeries of self-selected videotapes/DVDs submitted for expert assessment Web-based OSCE (physicians link to simulated patient whom they interview online) 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? Performance – do you (choose to) do it in practice? Videotapes/DVDs submitted with assessors randomly choosing tapes to be assessed Videotapes/DVDs submitted with assessors randomly choosing tapes to be assessed Undercover simulated clients Undercover simulated clients Real clients assessments Real clients assessments Client and clinician do immediate assessment of same individual interview Client and clinician do immediate assessment of same individual interview Colleagues assessments Colleagues assessments Results – what happens to pts, clients, drs? Results – what happens to pts, clients, drs? Self assessment/report Self assessment/report Chart audits Chart audits Follow up studies re compliance, outcomes of care, etc. Follow up studies re compliance, outcomes of care, etc.

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

35 Formats for Feedback quantitative______________________ __ _qualitative evaluative feedback_________ descriptive feedback number scores, good/bad heres what I see global_____________________ _________ __detailed

36 Two types of assessment Formative Formative Summative Summative

37 What does it take to learn clinical communication skills, change? Knowledge doesnt translate directly into performance Knowledge doesnt translate directly into performance Essentials needed to learn skills, change: Essentials needed to learn skills, change: Systematic delineation & definition of skills Systematic delineation & definition of skills Observation of learners communicating (video) Observation of learners communicating (video) Well-intentioned, detailed, descriptive feedback Well-intentioned, detailed, descriptive feedback Practice and repeated rehearsal of skills Practice and repeated rehearsal of skills Planned reiteration and deepening of skills Planned reiteration and deepening of skills Small group or one-on-one format Small group or one-on-one format

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

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

40 What makes for effective feedback? 1st Principles of Effective Communication Ensures interaction not just transmission Ensures interaction not just transmission Reduces unnecessary uncertainty Reduces unnecessary uncertainty Requires planning, thinking in terms of outcomes Requires planning, thinking in terms of outcomes Demonstrates dynamism (engagement, flexibility, responsiveness) Demonstrates dynamism (engagement, flexibility, responsiveness) Follows helical vs linear model 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 Shot-Put Approach the well-conceived, well-delivered message is all that matters the well-conceived, well-delivered message is all that matters emphasis on telling, interaction/feedback not in picture emphasis on telling, interaction/feedback not in picture Frisbee Approach Frisbee Approach 2 central concepts 2 central concepts confirmation = to recognize, acknowledge or endorse anotherconfirmation = to recognize, acknowledge or endorse another mutually understood common groundmutually understood common ground emphasis on interaction, feedback, relationship emphasis on interaction, feedback, relationship A Barbour 2000

43 Example of an Integrated OSCE University of Calgary Day of exam 1 Interview with SC - videotaped examiner scores content checklist examiner scores content checklist SC completes written feedback form (after interview) 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) Pairs of students meet with expert examiner to assess communication process skills (Calgary-Cambridge Guides) 1 View students 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 Communication is core clinical skill Skills are appropriate focus for teaching and assessment Skills are appropriate focus for teaching and assessment Build on whats already available (research, teaching and assessment models in human and vet medicine) Build on whats already available (research, teaching and assessment models in human and vet medicine) Include educational impact in design of assessment Include educational impact in design of assessment Train faculty and learners to participate in feedback process to enhance communication learning Train faculty and learners to participate in feedback process to enhance communication learning Integrate communication with other clinical skills teaching and assessment Integrate communication with other clinical skills teaching and assessment


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