Teaching clinical communication: a mainstream activity or just a minority sport? Jonathan Silverman Professional Communication – the Research-Practice Interface University of York 2008 Thank you so much Juliet and Sarah. I’m delighted to be talking to about the teaching of communication. A fantastic strength of this meeting is that the 2 worlds of research and teaching about communication come together. I’m speaking from and about the world of teaching – but teaching and research in communication are entirely inter-dependent – teachers are reliant on the researchers to know what and how to teach, but without the translation of research into mainstream teaching, patients will not benefit by any changes in clinicians’ skills And just some acknowledgements before I start. There are many people who have contributed to the thoughts I’m going to express – so thank you particularly to Suzanne Kurtz, Julie Draper; I’d also like to thank my team in Cambridge, some of whom are here today. And I ‘d also like to acknowledge our students and ex-students, who as you will see have kindly allowed us to see their video clips As you’ve heard, I come from Cambridge – a University that traditionally changes very slowly

Plan Why does clinical communication often appear to be a minority sport in medical education? How to overcome this: integrate, don’t separate Five specific areas of integration The progression to maturity in communication curricula However, before I start there are two premises to this talk which I wish to mention. I don’t think I need to convince you of either of them, they are indeed why you are here at this conference. And so I am not going to spend a lot of time but skip through fairly fast just to set the scene And I have deliberately not included the research evidence here on the sides but I have created a more comprehensive PowerPoint which I will make available for people to peruse

Effective clinical communication High quality healthcare Premise 1 Medical education cannot ignore the central importance of Effective clinical communication High quality healthcare to

Clinical competence - the ability to integrate: Premise 1 Clinical competence - the ability to integrate: knowledge communication physical examination problem-solving I want to see two things about the central importance of communication to high-quality healthcare, First I want to talk about clinical competence Talk about good knowledge/clinical reasoning and poor communication and the reverse and Doctor Ellis

All slides with a white background are additional slides to the original presentation. These slides provide selected research evidence that augment the concepts presented

Are there problems in communication between doctors and patients? reasons for the patient's attendance gathering information explanation and planning adherence to plans medico-legal lack of empathy and understanding

Kurtz, Silverman and Draper (2005; 2nd Ed) Teaching and Learning Communication Skills in Medicine Radcliffe Medical Press Silverman, Kurtz and Draper (2005; 2nd Ed) Skills for Communicating with Patients Radcliffe Medical Press

Discovering the reasons for the patient’s attendance 54% of patients’ complaints and 45% of their concerns are not elicited (Stewart et al 1979) in 50% of visits, the patient and the doctor do not agree on the nature of the main presenting problem (Starfield et al 1981) only a minority of health professionals identify more than 60% of their patients' main concerns (Maguire et al 1996) consultations with problem outcomes are frequently characterised by unvoiced patient agenda items (Barry et al 2000) doctors frequently interrupt patients so soon after they begin their opening statement that patients fail to disclose significant concerns (Beckman and Frankel 1984, Marvel et al 1999 ) doctors often interrupt patients after the initial concern, apparently assuming that the first complaint is the chief one, yet the order in which patients present their problems is not related to their clinical importance (Beckman and Frankel 1984)

Gathering information doctors often pursue a “doctor-centred”, closed approach to information gathering that discourages patients from telling their story or voicing their concerns (Byrne and Long 1976) both a “high control style” and premature focus on medical problems can lead to an over-narrow approach to hypothesis generation and to inaccurate consultations (Platt and McMath 1979) oncologists preferentially listen for and respond to certain disease cues over others – while pain amenable to specialist cancer treatment is recognised, other pains are not acknowledged or are dismissed (Rogers and Todd 2000) doctors rarely ask their patients to volunteer their ideas and in fact, doctors often evade their patients’ ideas and inhibit their expression. Yet if discordance between doctors’ and patients’ ideas and beliefs about the illness remains unrecognised, poor understanding, adherence, satisfaction and outcome are likely to ensue (Tuckett et al 1985) doctors only respond positively to patient cues in 38% of cases in surgery and 21% in primary care (Levinson 2000)

Explanation and planning in general, physicians give sparse information to their patients, with most patients wanting their doctors to provide more information than they do (Waitzkin 1984, Pinder 1990, Beisecker and Beisecker 1990, Jenkins et al 2001, Richard and Lussier 2003) doctors overestimate the time they devote to explanation and planning in the consultation by up to 900% (Waitzkin 1984, Makoul et al 1995) patients and doctors disagree over the relative importance of imparting different types of medical information; patients place the highest value on information about prognosis, diagnosis and causation of their condition while doctors overestimate their patient’s desire for information concerning treatment and drug therapy (Kindelan and Kent 1987) doctors consistently use jargon that patients do not understand (Svarstad 1974, Hadlow and Pitts 1991) there are significant problems with patients’ recall and understand of the information that doctors impart (Tuckett et al 1985, Dunn et al (1993) only the minority of patients achieve their preferred level of control in decision making in cancer treatment (Degner et al 1997)

Patient adherence patients do not comply or adhere to the plans that doctors make: on average 50% do not take their medicine at all or take it incorrectly (Meichenbaum and Turk 1987, Butler et al 1996) non-compliance is enormously expensive. The cost of wasted funds spent on prescription medications used inappropriately or not used in Canada amounts to 5 billion a year, based on an annual expenditure of 10.3 billion and data indicating that 50% of prescription medications are not used as prescribed. Estimates of the further costs of non-adherence (including extra visits to physicians, laboratory tests, additional medications, hospital and nursing home admissions, lost productivity and premature death) were CAN$ 7-9 billion in Canada (Coambs et al 1995) and US$billion plus in the US (Berg et al 1993)

Medico-legal issues breakdown in communication between patients and physicians is a critical factor leading to malpractice litigation (Levinson 1994). Lawyers identified physicians’ communication and attitudes as the primary reason for patients pursuing a malpractice suit in 70% of cases (Avery 1986). Beckman et al (1994) showed that the following four communication problems were present in over 70% of malpractice depositions: deserting the patient, devaluing patients’ views, delivering information poorly and failing to understand patients’ perspectives. Patients of obstetricians with a high frequency of malpractice claims are more likely to complain of feeling rushed and ignored and receiving inadequate explanation, even by their patients who do not sue. (Hickson et al 1994) in several states of the USA, malpractice insurance companies award premium discounts of 3 to 10% annually to their insured physicians who attend a communication skills workshop (Carroll 1996)

Lack of empathy and understanding numerous reports of patient dissatisfaction with the doctor-patient relationship appear in the media. Many articles comment on doctors’ lack of understanding of the patient as a person with individual concerns and wishes there are significant problems in medical education in the development of relationship building skills: it is not correct to assume that doctors either have the ability to communicate empathically with their patients or that they will acquire this ability during their medical training (Sanson-Fisher and Poole 1978, Suchman and Williamson 2003)

Premise 1 Research into clinical communication More effective interviews: accuracy efficiency supportiveness Enhanced patient and health professional satisfaction Improved health outcomes for patients And this is what we know and what this conference is all about Don’t talk to We have the research evidence for improved health outcomes for patients by the application of specific communication skills in practice Summary of research evidence on-line

process of the interview Research evidence to validate the use of specific communication skills: process of the interview satisfaction recall and understanding adherence outcome: decreased patient concern symptom resolution physiological outcome

Process of the interview the longer the doctor waits before interrupting at the beginning of the interview, the more likely she is to discover the full spread of issues that the patient wants to discuss and the less likely will it be that new complaints arise at the end of the interview (Beckman and Frankel 1984, Joos et al 1996, Marvel et al 1999, Langewitz et al 2002) the use of open rather than closed questions and the use of attentive listening leads to greater disclosure of patients’ significant concerns (Cox 1989, Maguire et al 1996, Wissow et al 1994) asking “what worries you about this problem” is not as effective a question as “what concerns you about this problem” in discovering unrecognised concerns (Bass and Cohen 1982) the more questions patients are allowed to ask of the doctor, the more information they obtain (Tuckett et al 1985) picking up and responding to patient cues shortens rather than lengthens visits (Levinson et al 2000)

Patient satisfaction greater “patient centredness” in the interview leads to greater patient satisfaction (Stewart 1984, Arborelius and Bromberg 1992, Kinnersley et al 1999, Little et al 2001) discovering and acknowledging patients’ expectations improves patient satisfaction (Korsch et al 1968, Eisenthal and Lazare 1976, Eisenthal et al 1990, Bell et al 2001) physician non-verbal communication (eye-contact, posture, nods, distance, communication of emotion though face and voice) is positively related to patient satisfaction (DiMatteo et al 1986, Weinberger et al 1981, Larsen and Smith 1981, Griffith et al 2003) patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors (Hall et al 1988) information giving, expression of affect, relationship building, empathy and higher patient centeredness lead to increased patient satisfaction. (Williams S, Weinman et al 1998) in cancer patients, satisfaction with the consultation and the amount of information and emotional support received are all significantly greater in those who reported a shared role in decision making (Gattellari et al 2001)

Patient recall and understanding asking patients to repeat in their own words what they understand of the information they have just been given increases their retention of that information by 30% (Bertakis 1977) there is decreased understanding of information given if the patient’s and doctor’s explanatory frameworks are at odds and if this is not discovered and addressed during the interview (Tuckett et al 1985) patient recall is increased by categorisation, signposting, summarising, repetition, clarity and use of diagrams (Ley 1988) the provision of audio or video tapes of the actual interview and writing to patients after their consultation increase patient satisfaction, recall, understanding and patient activity (Tattersall et al 1997, McConnell et al 1999, Sowden et al 2001, Scott et al 2001)

Adherence patients who are viewed as partners, informed of treatment rationales and helped in understanding their disease are more adherent to plans made (Schulman 1979) doctors can increase adherence to treatment regimens by explicitly asking patients about knowledge, beliefs, concerns and attitudes to their own illness (Inui et al 1976, Maiman et al 1988) discovering patients’ expectations leads to greater patient adherence to plans made whether or not those expectations are met by the doctor (Eisenthal and Lazare 1976, Eisenthal et al 1990) consultations using a structured exploration of patients' beliefs about their illness and medication and specifically addressing understanding, acceptance, level of personal control and motivation leads to improved clinical control or medication use even three months after the intervention ceased (Dowell et al 2002)

Outcome Symptom resolution resolution of symptoms of chronic headache is more related to the patient’s feeling that they were able to discuss their headache and problems fully at the initial visit with their doctor than to diagnosis, investigation, prescription or referral (The Headache Study Group 1986) training doctors in problem-defining and emotion-handling skills not only leads to improvements in the detection of psychosocial problems but also to a reduction in patient’s emotional distress up to six months later (Roter et al 1995) in the management of sore throat, satisfaction with the consultation and how well the doctor deals with patient concerns predicts the duration of illness (Little et al 1997) patient-centred communication is associated with better recovery from discomfort and concern, better emotional health two months later and fewer diagnostic tests and referrals (Stewart et al 2000)

Outcome Physiological outcome giving the patient the opportunity to discuss their health concerns rather than simply answer closed questions leads to better control of hypertension (Orth et al 1987) decreased need for analgesia after myocardial infarction is related to information giving and discussion with the patient (Mumford et al 1982) providing an atmosphere in which the patient can be involved in choices if they are available leads to less anxiety and depression after breast cancer surgery (Fallowfield et al 1990) patients who are coached in asking questions of and negotiating with their doctor not only obtain more information but actually achieve better BP control in hypertension and improved blood sugar control in diabetes (Kaplan et al 1989, Rost et al 1991)

Premise 2 Communication skills can be taught and learnt And we know which methods work My second premise is that we know we can teach communication skills and we know which methods work There is absolutely no point knowing that there are problems in communication and potential solutions unless this can be taught and learned and indeed retained. If it’s all a matter of personality, and not amenable to change, we might as well not bother! Overwhelming evidence for positive effect of communication training More research than any other kind of teaching in medicine – because it’s the new kid on the block Retention Although as we see this is one of the most difficult areas in curriculum design

Premise 2 Aspergren K (1999) Teaching and Learning Communication Skills in Medicine: a review with quality grading of articles Medical Teacher 21 (6) Smith S, Hanson J, Tewksbury L et al (2007) Teaching Patient Communication Skills to Medical Students: a review of randomised controlled trials Evaluation and the Health Professions 30 (1)

Aspergren K (1999) Teaching and Learning Communication Skills in Medicine: a review with quality grading of articles Medical Teacher 21 (6) Overwhelming evidence for positive effect of communication training Medical students, residents, junior doctors, senior doctors Specialists and general practice equally

Rutter and Maguire (1976) showed in a controlled trial that medical students who underwent a training programme in history-taking skills reported almost three times as much relevant and accurate information Confirmed by Irwin and Bamber (1984) and Evans et al (1989). Evans et al (1991) showed that medical students who learned key interviewing skills were diagnostically more efficient in interviewing medical and surgical patients and yet took no more time

Langewitz et al. (1998) demonstrated that specific patient-centred communication skills can be taught to residents in internal medicine over a 6-month period. Smith et al. (1998) showed that a one month intensive training course in interviewing and related psycho-social topics for primary care residents improved their knowledge about, attitudes toward and skills in interviewing, with both real and simulated patients. Humphris and Kaney (2001) demonstrated an improvement in communication skills in medical students over 17 months of their undergraduate teaching following a comprehensive and on-going communication skills course. Fallowfield et al. (2002) showed that senior clinicians working in cancer medicine have many difficulties when communicating with patients, with patients’ relatives and with professional colleagues. In a randomised controlled trial of 160 oncologists from 34 UK cancer centres, an intensive 3-day training course produced significant subjective and objective changes in key communication skills three months later Yedidia et al. (2003) evaluated the effects of a communications curriculum instituted at 3 US medical schools. The curriculum significantly improved third-year students' overall communications competence as well as their skills in relationship building, organization and time management, patient assessment, negotiation and shared decision making-tasks.

Stillman et al (1977) demonstrated that trained students maintained their post-training superiority over their non-trained peers at follow up a year later Maguire et al (1986) followed up their original students five years after their training. They found that both groups had improved but those given communication skills training had maintained their superiority in key skills such as using open questions, clarification, picking up verbal cues and coverage of psychosocial issues. These effects were found in interviews with patients with both psychiatric and physical illnesses Bowman FM et al (1992) showed that the improvement in interviewing skills of established general practitioners following an interview training course was maintained over a two year follow-up period Oh et al (2001) showed that trained medicine residents use of patient-centred interviewing skills significantly improved after an intensive course and these improvements were maintained for 2 years.

Which methods of learning work Maguire et al 1978 randomised medical students into four training conditions and discovered the following key steps: • the provision of detailed written guidelines of the areas to cover and the skills to use • the opportunity to practice interviewing under controlled conditions • observation by both self and facilitator • the provision of feedback by an experienced facilitator with the aid of audio or video tape Evans et al 1989 compared: • a series of 5 one hour lectures covering the background to communication training and the verbal, non-verbal and listening skills that were helpful in the medical interview. Students were given comprehensive hand-outs, including relevant theory and research. • 3 two hour workshops, after the lectures, using experiential methods such as role play, discussion, videotaping with real and simulated patients and feedback

Premise 2 The need for experiential learning active small group or 1:1 learning observation of learners video or audio recording and review well-intentioned feedback rehearsal Experiential teaching is required to change behaviour Don’t read this

Plan Why does clinical communication often appear to be a minority sport in medical education? 8 minutes So now to the first point of my presentation Yet despite this, why does clinical communication teaching still so often appear to be a peripheral element rather than a mainstream activity in medical education?

1 Do learners think it is an add-on? Do real clinicians model this? Why clinical communication often appears to be a minority sport Do learners think it is an add-on? Do real clinicians model this? Does bedside teaching back it up? Who doesn’t teach it? Is there a planned curriculum? When doesn’t it occur? Do the teachers understand the research? Is it rigorously assessed? Have teachers been trained?

1 Why clinical communication often appears to be a minority sport Do learners think it is an add-on? Do real clinicians model this? Does bedside teaching back it up? Is clinical communication integrated into all clinical challenges students learn? Who doesn’t teach it? Is there a planned curriculum? When doesn’t it occur? Do the teachers understand the research? Is it rigorously assessed? Have teachers been trained?

Summary point 1 Learners still often perceive clinical communication teaching as an optional extra, not central to their learning

Plan Why does clinical communication often appear to be a minority sport in medical education? How to overcome this: integrate, don’t separate So my central argument is for the absolute need for integration of communication with the rest of the curriculum to become mainstream

What do we know about curriculum design? How to overcome this: integrate, don’t separate 2 What do we know about curriculum design? Without training, medical students’ communication skills deteriorate as the curriculum progresses (Helfer 1970) Without reinforcement, learning from one-off courses deteriorates over time (Engler et al 1981, Craig 1992) Residents graduating from schools with more comprehensive sustained communication courses have better interpersonal skills (Kauss et al 1980) At the very least, a curriculum with more sustained communication training in yrs 1-3 led to less deterioration in yr 4 (Hook & Pfeiffer 2007) Integrated longitudinal programmes achieve more effective sustained increase in skills (van Dalen et al 2002) What does the research about curriculum design tell us about the need for integration?

How to overcome this: integrate, don’t separate 2 So how does this research translate into designing a communication curriculum? A curriculum rather than a course Many of the problems of past approaches to communication skills teaching stem from the tendency to structure communication training into a single self-contained course, frequently offered near the beginning of the overall teaching programme. Commonly, this course concludes with a single assessment of what students have learned in isolation from the rest of the medical curriculum. Yet to achieve a significant and lasting impact on learners’ communication skills, we need more than a one-off course. Learners’ communication needs change and develop as they progress though training. Our teaching interventions therefore need to be appropriately timed. Learners’ needs change in tandem with their increasing levels of intellectual and clinical sophistication and different clinical contexts.

How to overcome this: integrate, don’t separate 2 So how does this research translate into designing a communication curriculum? A curriculum rather than a course A helical rather than linear curriculum - review and reinforcement Just as a one-off module is not enough, neither are sequential modules that do not allow the learner to revisit areas previously covered. Communication skills learning must be reiterated throughout learners’ clinical training or else as we’ve seen it will diminish. There are two reasons for this. First, any initial emphasis on communication skills appears to be swamped as students struggle to come to grips with medical problem-solving: preoccupation with the disease process and closed questioning needs to be repeatedly counterbalanced by communication skills training Second, poor role modelling from clinicians in practice may counter the effect of formal communication training programmes. The curriculum needs to provide opportunities for learners to review, refine and build on existing skills while at the same time adding in new skills and increasing complexity

How to overcome this: integrate, don’t separate 2 So how does this research translate into designing a communication curriculum? A curriculum rather than a course A helical rather than linear curriculum - review and reinforcement Integrated not separated from the rest of the medical curriculum Without integrating communication back into the larger medical curriculum communication will be perceived as a separate entity divorced from “real medicine”. An inessential frill rather than a basic clinical skill relevant to all encounters with patients. Furthermore, if we want communication to be seen as a bone fide subject applicable to all disciplines, then it must be taught not only in primary care or psychiatry but also in other specialty areas and with the active help of doctors from a wide range of disciplines.

Summary point 2 If clinical communication is not integrated throughout the curriculum, it will always be perceived as an inessential frill

Plan So why does clinical communication often appear to be a minority sport in medical education? How to overcome this: integrate, don’t separate Five specific areas of integration 16 minutes I now want to explore five examples where integration can occur

Integration with history taking skills Five specific areas of integration 4 Integration with history taking skills Integration with practical skills Integration with specialty teaching Integration with the hidden curriculum The crucial role of assessment in integration

 3a integration with history taking skills Communication skills teaching model versus Traditional medical history model Common problem that students perceive there are two models for interviewing. Leicester OSCE And it stems from a lack of integration. Commonly 2 separate courses being taught by two separate groups of people, two tribes each concentrating on a different thing and not coming together

Communication model (process) Integration with history taking skills 3a Communication model (process) Initiating the session Gathering information Building relationship Structuring the interview Explanation and planning Closing the session Communication models provide a framework and list of skills which detail the means through which doctors conduct the medical interview This is commonly referred to as the process of the medical interview – i.e. how we do things. Taught in communication modules by communication experts including doctors from general practice and psychiatry

Traditional Medical History Model (content) Chief complaint Integration with history taking skills 3a Traditional Medical History Model (content) Chief complaint  History of the present complaint  Past medical history  Family history  Personal and social history  Drug and allergy history  Systematic enquiry This is the content of the medical interview, in effect the information we need to obtain

Integration with history taking skills 3a Confusion between process and content: GP/psychiatry/psychology v real doctors The issue of how learner’s are observed (if they are) 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 Commonly taught in history taking courses by a separate group of doctors, including specialist physicians and surgeons - doctors in white coats who can know nothing about communication but everything about medicine Whereas communication is commonly taught by communication faculty, and the doctors involved are normally general practitioners or psychiatrists – doctors in woolly jumpers who clearly know nothing about medicine And the problem is that students are rarely observed on the wards taking histories and so are only observed presenting histories and only get rewards for the content of their presentations and so somehow get the idea that is how to take the history as well What happens at bedsides is often a test of knowledge Students don’t get the message that the difference is between how to obtain the history and how to repackage it to tell a story and remain confused between content and process

Another confusion between process and content Integration with history taking skills 3a Another confusion between process and content Communication skills teachers have introduced their own new content And there is another problem. When they do present their histories there is an element of the content that we have provided as communication skills teachers which does not get validated in ward presentations We as communication teachers have introduced a new content. A large part of this conference has been about patient-centred medicine

content to be discovered in gathering information: 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 This is the additional content which we definitely need to obtain

content to be discovered in gathering information: the patient’s perspective (illness experience) ideas and beliefs concerns and feelings expectations effects on life Yet this is the new content of the patient’s perspective

content to be discovered in gathering information: 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 Yet when students present all of this as we encourage and teach, they often get knocked down because this is not perceived as being essential information for clinical reasoning

Integration with history taking skills So what’s the solution?

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

Integration with history taking skills Effective communication is essential to the practice of high quality medicine

Integration with history taking skills Effective clinical method is essential to the practice of high quality medicine One course taught by one group of teachers including specialist physicians and surgeons teaching both content and process together and not artificially separated And hidden in this is my concern about the use of the word communication at all which I think has the tendency to sideline this and not make it central. I much prefer talking about the medical interview as a whole or clinical method which includes both content and process

THE CALGARY- CAMBRIDGE GUIDES TO THE MEDICAL INTERVIEW Integration with history taking skills 3a THE CALGARY- CAMBRIDGE GUIDES TO THE MEDICAL INTERVIEW Kurtz, Silverman, Benson and Draper (2003) Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides Academic Medicine;78(8):802-809 And that is why we ourselves produce the Calgary-Cambridge guides to the medical interview

Initiating the session preparation establishing initial rapport identifying the reasons for the consultation Gathering information Providing structure Building the relationship exploration of the patient’s problems to discover the:  biomedical perspective  the patient’s perspective  background information - context making organisation overt attending to flow using appropriate non-verbal behaviour developing rapport involving the patient Physical examination Explanation and planning providing the correct type and amount of information aiding accurate recall and understanding achieving a shared understanding: incorporating the patient’s illness framework planning: shared decision making Closing the session ensuring appropriate point of closure forward planning

Five specific areas of integration 3 Integration with history taking skills Integration with practical skills Increasingly, students practice practical clinical skills initially with disembodied plastic dummies and you often see them talking to these isolated arms while attempting to take blood! And it looks ridiculous

Kneebone R, Kidd J, Nestel D, Asvall S, Paraskeva P and Darzi A (2002) Integration with practical skills 3b Kneebone R, Kidd J, Nestel D, Asvall S, Paraskeva P and Darzi A (2002) An innovative model for teaching and learning clinical procedures Medical Education 36: 628-34 We have in our curriculum taken the very innovative work of Roger Kneebone, Jane Kidd and Deborah Nestel and turned it into a module for all students Students practice their technical skills in tandem with their communication skills – talking to patients, doing a procedure, obtaining consent, coping with the stress while maintaining a sterile field And this can be taught with active clinicians in the field

Photos from the original paper

Need to show that communication applicable to and taught in all: Five specific areas of integration Integration with history taking skills Integration with practical skills Integration with specialty teaching This is perhaps the most important area that I want to get across about integration We have seen how commonly communication skills teaching peters out after the first couple of years and does not enter the clinical years when students are engaging most with real patients and need to really hone their communication skills in a variety of different clinical contexts. I want to talk about how integration into the clinical years is both doable and essential Need to show that communication applicable to and taught in all: disciplines contexts

University of Cambridge Integration with specialty teaching 3c University of Cambridge clinical rotations

Integration with specialty teaching 3c Stage 2 Obstetrics and gynaecology Paediatrics Psychiatry Major adult diseases/Infection-GU/oncology Elderly, neurosciences, rheumatology and orthopaedics In our curriculum in Cambridge, in the penultimate year, students rotate through five major blocks as you can see We have been able to establish integrated communication skills teaching in all of these blocks without any difficulty whatsoever We approached the attachment director for each block and asked them what communication area they would like to provide for their students and what content area they would like teaching on in return which they did not feel they covered adequately so far - use obstetrics and gynaecology as an example Everybody came up with something immediately and willingly and gave us at least half a day of curriculum time

Integration with specialty teaching 3c Stage 2 Obstetrics and gynaecology Dealing with diversity Paediatrics Interviewing children and parents Student selected difficulties Psychiatry Psychiatric interviewing Assessing suicidal risk and depression following an overdose Interviewing the patient with delusions and hallucinations Major adult diseases/Infection-GU/oncology The sexual history Practical clinical skills/communication course Elderly, neurosciences, rheumatology and orthopaedics The explanation and planning course (three sessions) So you have already seen the women’s health module, the practical clinical skills/communication module Let’s look at the explanation and planning course Rachel Sagar – with almost 2 years to go The group has taken a history from a simulated patient, worked together with a senior neurologist around clinical reasoning, researched the diagnosis and returned a week later to give the explanation to the patient with the results of her tests

Five specific areas of integration Integration with history taking skills Integration with practical skills Integration with specialty teaching Integration with the hidden curriculum Perhaps the most difficult area

Integration with the hidden curriculum 3c Formal communication skills teaching Informal communication skills teaching Modelling Not so much can you teach it but will they do it in the climate they are in Informal teaching is not always congruent, does not mention the communication challenge, only the content Not surprising, communication skills teaching is often the blind leading the blind will sometimes worse the blind leading the partially sighted - there were whole generations of doctors like me who received no communication skills training and yet are now teaching it!

Five specific areas of integration Integration with history taking skills Integration with practical skills Integration with specialty teaching Integration with the hidden curriculum The crucial role of assessment in integration 35 minutes

Assessment essential for driving the communication curriculum forward The crucial role of assessment in integration 3e Assessment essential for driving the communication curriculum forward Assessment acts a tool for integration Assessment essential for driving the communication curriculum forward: it changes everything – and especially for the students – it is not assessed it is not important Assessment is a tool for integration – enabling faculty to work together to test clinical method, devise stations, and be involved in the assessment, spreading the word through the medical community

Simulated Clinical Encounter Examination (SCEE) The crucial role of assessment in integration 3e Simulated Clinical Encounter Examination (SCEE) Very high-stakes examination Finals examination

Description of the SCEE The crucial role of assessment in integration 3e Description of the SCEE OSCE-style examination 12 stations 4 stations of history taking and clinical reasoning 4 stations of explanation and planning 4 stations of other inter-personal skills Simulated patients and examiners 2 hours 40 mins face-to-face testing time 4

What does the SCEE test? 3e The crucial role of assessment in integration 3e What does the SCEE test? Process skills of doctor-patient communication Integrated with content and clinical reasoning Tests clinical competence in the medical interview

Involve all disciplines and all contexts Summary point 3 Pay constant attention to the many opportunities for integration throughout the medical school curriculum Involve all disciplines and all contexts So my summary about integration is

Plan So why does clinical communication often appear to be a minority sport in medical education? How to overcome this: integrate, don’t separate Five specific areas of integration The progression to maturity in communication curricula This is in effect a summary of all that I have said so far. We need to look at where we are in the development of our current curricula and think of where we want to go next Do this by getting them to reflect on where they are now

Increasing maturity The 20 year approach: invest in faculty development involve faculty in teaching and assessment involve senior students and junior doctors back into the programme Fully integrated into assessment Increasing number of communication domains covered Integrated helically and with clinical teaching throughout curriculum Multiple stand-alone courses throughout all years Multiple stand-alone courses in early years Maturing communication skills curricula Increased maturity leads to integration rather than stand alone Many of you have already made enormous upward strides in your curriculum but others are just starting Make the above the important issue Part of the issue is people coming through and it may take 20 years to get there Students getting into the profession, trying to involve senior students and junior doctors post qualification back into the programme Single stand-alone course in early years The progression to maturity in communication curricula

Conclusion Integrate Collaborate Persevere