Presentation on theme: "Jonathan Silverman Aarhus 2012"— Presentation transcript:
1Strategies for implementing clinical communication training in every day practice - how to do it? Jonathan SilvermanAarhus2012One 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.
2Bringing the Hidden Curriculum out of hiding: Strategies for bridging the gap in teaching and learning about communication EACH St Andrews
3Teaching Communication Skills in the Context of Clinical Care Marcy Rosenbaum, PhDDr. Harold A. Myers Distinguished ProfessorAssociate Professor of Family MedicineOffice of Consultation and Research in Medical Education
5Introduction/reflection Formal teaching of communication skills occurs in undergraduate and intern levelDuring their clinical work as doctors, their experiences can contradict and not reinforce the communication skills they have been previously taught
6Introduction/reflection In pairs, discuss what experiences learners may have with the “hidden curriculum” and their impact on development and retention of effective communication
7Problems of ‘in the moment’ teaching: achieving satisfactory re-rehearsalobtaining constructive feedback from patients unused to this method of workingdiscussing sensitive issues in front of the patientthe availability of time in the ‘real’ world for both professionals and patientsthe multiplicity of tasks – including patient care itself – that require attentionthe wide range of possible teaching agendas, including issues concerning clinical reasoning, physical examination, investigations, treatment alternatives, etc.
8Are 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 yearsStandard of history takingMention MRCSPaces – observed stationsPostgraduates – assumed to knowNurses and doctors need to knowWho teaches you howTie into Mark and FrancesThe cardsProcess v contentSo how do you?What are the skillsTapes?
10Have 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 yearsStandard of history takingMention MRCSPaces – observed stationsPostgraduates – assumed to knowNurses and doctors need to knowWho teaches you howTie into Mark and FrancesThe cardsProcess v contentSo how do you?What are the skillsTapes?
11Three elements of gathering clinical information How you communicateProcessOpenDirectiveBiomedicalPatient’s perspectiveWhat you discuss,record and presentContentClinical reasoningFeelingsWhat you think and feelPerceptionLets just explore information gathering and just think what you are doing – three things simultaneously
12Three elements of gathering clinical information How you communicateProcessOpenPatient’s perspectiveWhat you discuss,record and presentContentThis would be particularly grieving given our concept of a CCM: integration of content and process.Overemphasis of:Open QEmpathySummarisingScreeningPt’s perspectivegives communication a bad nameFeelingsWhat you think and feelPerception
13Three elements of gathering clinical information How you communicateProcessDirectiveBiomedicalWhat you discuss,record and presentContentIt isn’t this either – the overemphasis on directive questions by themselves does not lead to good biomedical content or clinical reasoning abilityIn fact in the GKT Finals OSCE, they did not do clinical reasoning eitherAs if it is one all the other and they will do whichever one will please youClinical reasoningWhat you think and feelPerception
14Dilemmas in history taking teaching The students are being taught a different approach to what we practice on the wardsThey don’t seem to know what questions to askThey seem to concentrate on patient’s ideas, concerns and expectationsOf the clinicians, how many of you have noticed that students ideas of history taking seem different to your own?
15Communication skills teaching model Traditional medical history model Communication skills teaching modelversusTraditional medical history model
16Confusion over Process Content The confusion over process we have covered – learners choose the content guide for their process guideLet’s look now at content. This where it gets trickyYou’d think content is pretty clear - we know what information we need and that is all in the traditional medical historyLets look at the information gathering part of the history
17Communication model (process) Initiating the sessionGathering informationBuilding relationshipStructuring the interviewExplanation and planningClosing the sessionIn the red cornerCommunication 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
18Chief 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
19Confusion between process and content (1): How to obtain information v. how to present infoHow to obtain information v. how to write down infoEquating problem solving with patient care at the bedside – observation of snippetsThe issue of how learner’s are observed (if they are)GP/psychiatry/psychology v real doctorsWhat happens at bedsides is often a test of knowledge
20Gathering Information process skills for exploration of the patient’s problemspatient’s narrativequestion style: open to closed coneattentive listeningfacilitative responsepicking up cuesclarificationtime-framinginternal summaryappropriate use of languageadditional skills for understanding patient’s perspective
21Chief 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
22Confusion between process and content (2): Communication skills teachers have introduced their own new content
23content to be discovered: the bio-medical perspective(disease)sequence of eventssymptom analysisrelevant systems reviewbackground information - contextpast medical historydrug and allergy historyfamily historypersonal and social historyreview of systems
24content to be discovered: the patient’s perspective(illness experience)ideas and beliefsconcerns and feelingsexpectationseffects on life
25content to be discovered: the bio-medical perspective the patient’s perspective(disease) (illness)sequence of events ideas and beliefssymptom analysis concernsrelevant functional enquiry expectationseffects on lifefeelingsbackground information - contextpast medical historydrug and allergy historyfamily historypersonal and social historyreview of systems
26Are communication skills and traditional history taking mutually incompatible? So what’s the solution
27Effective history taking is essential to the practice of high quality medicine
28Effective communication is essential to the practice of high quality medicine
29Effective clinical method is essential to the practice of high quality medicine
31A Comprehensive Clinical Method The explicit integration of traditional clinical method with effective communication skillsto 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) andillness(the individual patient’s unique experience of sickness)
32Why integrate communication training into everyday practice Reinforce and validate content and skills emphasized in previous educationAddress more advanced communication skills and issuesAddress interviewing challenges identified by learners
33How Doctors Learn in Clinical Years observing senior doctorsfeedback on presentationsconducting 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 matchDoing their own interviews – not observed and message they get is to limit the information and have time constraintsPresenting – message they get is doctors don’t want to know so don’t ask that stuff33
34Opportunities to teach communication in the context of clinical care Modeling for learnersStaffing: Responses to learner presentationsObservation of learner interactions with patients and feedback
36Modeling communication: Strategies for maximizing learning Outpatient or Inpatient - Especially useful with advanced tasks1) 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 modelingHave a plan, consider the skills you use3) Debriefing after observation is key“What did you notice (analyze skills used), what do you have questions about, what would you use in future?”
38Cues 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 withDiscuss what skills you could recommend for the learner to use
39Cues 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”
40Cues 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?
41Initiating the session: Listens attentively to the patient’s opening statement, without interrupting or directing patient’s responseChecks 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 accountGathering informationAsks 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.
42StaffingAdditional strategies for assess and address learner communication needsPriming before patient encounters if need for certain process skills can be anticipatedAsking learner how the interaction went with the patientAsking learner what they were trying to accomplish with patient and did they feel they achieved itProblem solve with learner about skills that could be helpful
44Observation of learners Though it takes more time, can give clearer picture of communication strengths and challengesObservation can be done in brief forays – at the beginning of patient encounter or during explanation phase after staffing
45Observation of learner Example of resident with mother of asthmatic adolescent patientOn observation sheet, write down what you see, including specific phrases, questions and responses – both effective and less effective
46Observation sheet asked appropriate specifics Content(CC, pmh)Effective behaviors that you seeBehaviors you don’t’ see or that could benefit from changeGreeting(8:50 am)CCPMH9:05introduced selfgood eye contact asked appropriate specifics("Can you describe that?")open-ended questionsgood paraphrasing("what I hear you saying…")Didn't mention student statusInterrupted too quickly("daughter…how severe pain")no follow-up(can't afford to be sick)