Assessing Communication as a Clinical Competency Why Bother?

1. Assessing Communication as a Clinical CompetencyWhy Bother? Suzanne Kurtz, PhD College of Veterinary Medicine 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!!!

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

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

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

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

9. Evidence BaseVeterinary Medicine • Compliance range is between 23-65% • Problems cited: • Not enough information • Relationship not established • Client opinion not considered • No follow up regarding patient well being Adams V (2002), AAHA (2004)

10. Evidence BaseVeterinary Medicine • 50-82% of complaints to CVO related to communication problems: • Client was misinformed • Consent was not obtained • Client felt disrespected • Client felt like opinion did not matter • Procedure was not explained College of Veterinarians of Ontario (2005)

11. What are we assessing?Clinical competence • Knowledge base • Physical examination skills • Medical problem solving, diagnostic 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 don’t • Communication is a series of learned skills • Not a personality trait • 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 • Only 1 of 81 studies didn’t report positive effects • Med students, residents, junior drs, senior drs all improved • Specialists as likely to benefit as primary care drs Aspegren, 1999

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

15. Common (mis)perceptions • Experience is a good teacher of communication skills • Experience alone tends to be a limited teacher of communication skills • It is a great reinforcer of habit - just doesn’t discern well between good and bad habits

16. Our perception may be flawed What gets us into trouble is not what we don’t know. It’s what we know for sure that just ain’t 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) • discovering pt’s views/expectations 70% no attempt • negotiation 90% no attempt • encouraging questions 70% no attempt • repetition of advice 63% no attempt • checking understanding 89% no attempt • categorizing information 90% no attempt Maguire et al 1986

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

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

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

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

22. Do we know what skills are worth assessing? Many models available: • Calgary-Cambridge Guides • Patient-Centered Model • Macy Model • SEGUE Framework • Bayer-Fetzer Essential Elements • 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: 161-76. • 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 2003. 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 & SanFrancisco

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

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

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

27. Advantages of Guides • Accessible summary of research evidence • Comprehensive delineation of skills • Memory aid to keep skills in mind, organized • Framework for systematic skill development • Basis for comprehensive feedback & evaluation • Core content for training faculty, creating consistency • 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

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

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

31. What forms can assessments take? • Competence – can you do it? • OSCE using standardized simulated clients • Stand alone communication stations • Communication stations integrated with PE, medical problem solving, • Real interviews: • Series of live interviews with examiner present • Series of self-selected videotapes/DVDs submitted for expert assessment • Web-based OSCE (physicians link to simulated patient whom they interview online)

32. What form can assessments take? • Performance – do you (choose to) do it in practice? • Videotapes/DVDs submitted with assessors randomly choosing tapes to be assessed • Undercover simulated clients • Real clients’ assessments • Client and clinician do immediate assessment of same individual interview • Colleagues’ assessments • Results – what happens to pts, clients, drs? • Self assessment/report • Chart audits • Follow up studies re compliance, outcomes of care, etc.

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

34. Formats for Feedback quantitative______________________ __ _qualitative evaluative feedback_________ descriptive feedback number scores, good/bad “here’s what I see” global_____________________ _________ __detailed

35. Two types of assessment • Formative • Summative

36. What does it take to learn clinical communication skills, change? • Knowledge doesn’t translate directly into performance • Essentials needed to learn skills, change: • Systematic delineation & definition of skills • Observation of learners communicating (video) • Well-intentioned, detailed, descriptive feedback • Practice and repeated rehearsal of skills • Planned reiteration and deepening of skills Small group or one-on-one format

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

38. Stages in skills learning/changenot a linear progression Consciously skilled Awkward Fully assimilated Beginning Awareness Wackman et al 1976

39. What makes for effective feedback? 1st Principles of Effective Communication • Ensures interaction not just transmission • Reduces unnecessary uncertainty • Requires planning, thinking in terms of outcomes • Demonstrates dynamism (engagement, flexibility, responsiveness) • Follows helical vs linear model Same principles apply to effective teaching

40. What makes for effective feedback? Agenda-Lead Outcome-Based Analysis (ALOBA)

41. Approaches to communication • Shot-Put Approach • the well-conceived, well-delivered message is all that matters • emphasis on telling, interaction/feedback not in picture • Frisbee Approach • 2 central concepts • confirmation = to recognize, acknowledge or endorse another • mutually understood common ground • emphasis on interaction, feedback, relationship A Barbour 2000

42. Example of an Integrated OSCEUniversity of Calgary Day of exam 1 Interview with SC - videotaped • examiner scores content checklist • 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

43. Integrated OSCE conti Within 12 days of exam: • Pairs of students meet with expert examiner to assess communication process skills (Calgary-Cambridge Guides) 1 View student’s 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)

44. Concluding thoughts • Communication is core clinical skill • Skills are appropriate focus for teaching and assessment • Build on what’s already available (research, teaching and assessment models in human and vet medicine) • Include educational impact in design of assessment • Train faculty and learners to participate in feedback process to enhance communication learning • Integrate communication with other clinical skills teaching and assessment