1. Communication skills (2)
ST1 (2016)

2. videos
83c VPk k_w

3. Upcoming ESRs. Are you prepared ?
Have you done your MSFs and PSQs (if in primary care)
3 CBDs and 3 COTs/ mini- CEXs
CSR done ?
Appt with ESR organised before the end of the month ?
REMEMBER SELF RATINGS ………
Give your ES time to respond – he will love you forever !

4. Recap on communication skills 1.
We looked at consultation models.
We looked at Calgary– Cambridge framework.
ICE and PSO
Introduction to CSA
Role plays – concentrating on initiation, data gathering (empathy and rapport).

5. EXPANDED FRAMEWORK

6. Calgary- Cambridge 1. Initiating the Session
Establish initial rapport.
Greeting and introduction.
Identify the reasons for the consultation.
Listen to the opening statement without. interruption- remember the golden minute!
Confirm list and screen for further problems.
Negotiate the agenda.
“We may not have time to deal with everything today, which problem(s) would you like us to concentrate on?”

7. Calgary –Cambridge 2. Gathering information
Explore patient’s problems.
Listen attentively.
Open to closed cone of questioning.
Pick up on cues- verbal and non verbal.
Periodically summarise.
Understand the patient’s perspective.
Ideas
Concerns
Expectations
Effects on life

8. Calgary- Cambridge 3 Examination
ALWAYS ASK PERMISSION TO EXAMINE!
Remember to offer chaperones for intimate examinations.
Brief, focussed, relevant. And slick !

9. Calgary- Cambridge 4 Explanation and planning.
Providing the correct amount and type of formation
Chunks and checks
Discover how much information the patient wants to know.
Avoid jargon and medical terminology
Aiding accurate recall and understanding
Diagrams/written information
Check patients understanding
Achieving a shared understanding
Which incorporates the patient’s perspective
Planning: shared decision making

10. Calgary- Cambridge 5 Closing the session
Summarise
Contract for the next step for both patient and Dr+ safety net
Feedback – be specific and explicit.

11. CSA Marking schedule
Each case in the CSA is marked in three domains and each domain contributes to an overall score. You must aim to score as many points as possible in each domain in each case.
The pass mark varies with each exam and is peer referenced.
Possible scores:
Clear fail, Marginal fail, Marginal pass, Clear pass

12. Domain 1- data gathering and assessment skills
This means history, examination and the use of medical equipment;
Interivew should be focused and relevant to the complaint
History should be sufficient to reach a diagnosis and exclude likely serious possibilities
Physical examination should be done with courtesy and efficiency
Information from the records is obtained and made use of

13. Domain 2 – Clinical management skills
Explaining the problem/diagnosis
Offering effective and safe treatment
Using investigation, prescription and referral appropriately
Recognition of and response to urgency
Managing risk and co-morbidity
Encouraging health promotion
Arranging appropriate follow up

14. Domain 3 –Interpersonal skills
Attitude, empathy and good communication skills are all being considered
Establishing rapport
Showing sensitivity and empathy
Exploring the patient’s concerns
Listening and understanding
Using appropriate language
Negotiating options for treatment
Respecting patient autonomy

15. Look at this video.
Hand out CSA marking schedule
And scoring sheets.

16. Role play. Giving feedback.
Ask the registrar what they thought they did well
Observers says what they thought they did well.
Registrar says what they think they might do differently in future
Observers suggest possible changes.
Registrar constructs an action for improvement (essential)

17. Evidence - Explanation
Most Patients want more information than they are given (Jenkins 2001;Richard and Lussier 2003)
Doctors Overestimate time they give to explanation by 900% (waitzkin 94, Macoul 95)
Pts and Drs disagree relative value of info type
Significant Problem with retention of information given (tuckett 85;Dunn 93)
Patients prefer cause, prognosis, dx; drs prefer rx and drugs

18. Evidence – Explanation (2)
Checking Understanding - improves retention by 30% (Bertakis 77)
Categorisation, summarisation, signposting, diagrams, clarity – all increase recall (Ley 88)
Teaching and Learning Communication skills in medicine”
Kurtz, Silverman, Draper;2nd edition
Pages 14-20

19. Evidence “While I am here” is reduced Patient satisfaction increased
Complaints reduced
Litigation reduced (discount on MDU in USA)
Information retention improved
Concordance improved
Consultation shortened! (Levinson 2000)

20. The Research
➤ Patients of physicians who encourage them to participate more actively in the medical encounter and in treatment decisions enjoy more favourable outcomes both physiologically and functionally.
➤ Patients who were given the prognosis and treatment options before the diagnosis were better able to assimilate and retain information.
➤ Patients and doctors who agree on the nature of the problem and the follow-up plan achieve better patient outcomes

21. Explanation Have a go! In threes, each in turn 4-5mins each
non-medical explanation
observer noting good points – 1 min feedback

22. Good Explanation Checks it’s Wanted
Provides Correct amount and Type Information
Aids Recall and Understanding

23. Good Explanation Provides Correct amount and Type Information
Baseline Knowledge
Appropriate Language
Chunk and Check
Aids Recall and Understanding
Organises explanation logically
Signposts (there are three things…..)
Repeats for emphasis
Summarise
Check Understanding

24. Case 1 (male) Bob Smith – aged 55.
You are seeing Bob after a consultation last week in the middle of a busy surgery. Bob had a 2 month history of tiredness and vague symptoms, as well as a bit of stress.
You organised tests for ‘TATT’ and the random glucose has come back at all other results were normal.
The aim of this consultation is to practice skills of explanation when discussing the results with Mr Smith.

25. CASE 2 (female) Michelle Jones, aged 33years.
You are seeing Michelle today to discuss a recent finding of raised TSH. This is a follow- up appointment. You saw her 2 weeks ago when she presented with weight gain and tiredness. No other medical problems. No current medication.
The aim of this consultation is to practice skills of explanation when discussing the results with Mrs Jones.

26. Case 3 (male/ female) Mr/ Mrs Wilson - aged 58 years.
The practice nurse advised him/ her to see the GP, after a raised BP reading, earlier this week. BP reading was 153/92.
You check it again today and it is 155/95mmHg.
No past h/o hypertension. No other medical problems. No current drug treatment.
FH of stroke.

27. Closing the session. Role play – anybody traumatised ?? Feedback
Confidence rating scale for explanation.
Ideas for improvement

28. Hot topics GP partnerships Sepsis – is it a bit OTT ??
New GP contract.
Denigration of GPs – how to react as junior doctor ?
Private sector making profits over NHS
Private GPs – is it a good thing ??
Seven day GP access
OOH as a registrar – safe working and appropriate skills/ mentoring.