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.

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

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

Why you are so important

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

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

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.

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?

The Leicester OSCE

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?

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

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

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

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?

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

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

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

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

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

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

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

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

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

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

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

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

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

Effective communication is essential to the practice of high quality medicine

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

A Comprehensive Clinical Method

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)

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

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

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

Modeling

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?”

Staffing

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

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”

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?

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.

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

Observation of learners

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

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

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)