Safe and Effective Clinical Communication (SECC)

1. Safe and Effective Clinical Communication (SECC) A skills training course for International Medical Graduates (IMGs) Duncan Cross, Ann Smalldridge, Michael Sykes and Maeve Keaney (UK) reache@manchester.ac.uk

2. Background • Reache North West -Refugee and Asylum Seekers Centre for Healthcare Professionals Education established 2003 • Based at Salford Royal Foundation NHS Trust, England • Funded by NHS NorthWest • Work regionally and nationally to provide education, training and support

3. Our Results Refugee Healthcare Professionals returned to their Professional Roles in the National Health Service (NHS) Remediation for International Medical Graduates (IMGs) in post graduate medical training

4. Context in the UK • The General Medical Council (2011) reported 239,084 registered doctors • Of the total number of doctors 33% (78,898) identify themselves as having trained overseas • Increasing awareness of language, communication difficulties and limited induction with IMGs • IMGs are over-represented in complaint referrals to GMC GMC 2011 – Freedom of Information Request http://www.gmc-uk.org/publications/concerns_about_a_doctor_publications.asp#AnnualStatistics

5. Why we created the course Observations from 9 years work with IMGs Feedback from Consultant supervisors (Clinical Attachments, Clinical Apprenticeship Scheme and Employment) 1Slowther et al (2009). Non UK qualified doctors and Good Medical Practice. Report for the General Medical Council. University of Warwick. 2Illing J et al (2009). The Experiences of UK, EU and Non-EU Medical Graduates making the transition to the UK Workplace. ESRC RES-153-25-0097. 3Pilotto S et al (2007). Issues for clinicians training international medical graduates: a systematic review. Medical Journal of Australia; 187:225-228.

6. Supporting Evidence • UK - Warwick Report1, Illing et al2 • International - e.g. Pilotto et al3 • IMGs have problems with: • question formation • colloquial language • appropriate word choice (to express empathy or give explanations to patients) 1Slowther et al (2009). Non UK qualified doctors and Good Medical Practice. Report for the General Medical Council. University of Warwick. 2Illing J et al (2009). The Experiences of UK, EU and Non-EU Medical Graduates making the transition to the UK Workplace. ESRC RES-153-25-0097. 3Pilotto S et al (2007). Issues for clinicians training international medical graduates: a systematic review. Medical Journal of Australia; 187:225-228.

7. Aim • To learn Safe and Effective Clinical Communication skills

8. Methods • Deconstructing language skills • Consolidating clinical and linguistic skills • Using skills SAFELY in simulated clinical practice • 3 P model of teaching (Prepare, Practice, Produce)

9. Deconstructing Language • Communication scenario is analysed for its linguistic composition • Broken down into tasks and then linguistic elements of productive (writing, speaking) and receptive skills (reading, listening) • Individual tasks practised/taught in a non-clinical context to ensure understanding

10. Multi-Disciplinary Approach • Linguists • Doctors • Nurses • Experienced simulated patients

11. Safe and Effective Clinical Communication Skills • Prepare and Practice • Day 1 -History Taking • Day 2 - Summarisation • Day 3 - Handover Model - SBAR (Situation, Background, Assessment and Recommendation) and Telephone skills • Day 4 - Team working • Produce • Day 5 - Ward Round • Course needs to run over a short period of time (2-3 weeks) Haig KM, Sutton S, Whittington J. 2006. SBAR: A shared mental model for improving communication between clinicians. JtComm J Qual Patient Saf 32(3):167–175.

12. History Taking • Prepare • Discussion of what makes a good history in UK (Ideas, Concerns and Expectations (ICE), Patient Centred) • Active listening exercise • Demonstrations of good history taking in stages • Importance of good history- patient safety/complaints/medico-legal • Practice • Multiple opportunities to practice with actors and clinicians to gain appropriate feedback • Issues: • Jargon • Pace • Failure to clarify Information • Intonation

13. Summarisation • Prepare • 2 Exercises through different stages • Language focus e.g. holiday brochure • Clinical context (x-ray report)with a 3 stage dictation • Verbatim • Reader summarises –Writer Verbatim • Both Summarise • Practice • Clinical Scenarios • 3 stages with decreasing time minutes for written summary and then verbally communicate to another student • Issues: • Confidence • Spelling • Mishearing and clarifying • Accents

14. Situation Background Assessment Recommendation (SBAR) Prepare Reache whispers Types of communication (written/verbal) and their benefits SBAR Practice Script creation from clinical notes (using summarisation skills from previous day) in an SBAR format Haig KM, Sutton S, Whittington J. 2006. SBAR: A shared mental model for improving communication between clinicians. JtComm J Qual Patient Saf 32(3):167–175.

15. Telephone Skills Prepare Good features of telephone skills Using scripts in an SBAR format from earlier session Students give information to a tutor with other students observing and feeding back. Practice Multiple opportunities to practice with corrections as necessary (Purposely scheduled all groups in 1 room to emulate a busy work environment)

16. Team Working Prepare Comparison of different care systems -Identify all staff involved in the diagnosis, care and management of a patient with Diabetes (Initially only identified role of Dr/nurse then identified 40 professional roles) Team/Group Dynamics Practice Build the tallest freestanding tower out of newspaper and sticky tape that doesn’t collapse or fall down – Reflection on own role in the group and the effectiveness of the team http://www.belbin.com/rte.asp?id=396

17. Practical Application of Skills PRODUCE Hospital skills labs are used to create a ward environment Consultants and simulated patients used to simulate an emergency admission ward round Students take histories, and present to a consultant During day students also assess ill patients (sim-man) and then must call a Consultant giving them information using SBAR format. After each scenario feedback is given by simulated patient, consultants and tutors

18. Additional communication sessions • Taught as separate days ; • Breaking bad news (Simulated patients) • Complaints (Simulated patients) • Interview skills (Mock panels) • Presentation skills

19. Evaluation • From: • Observation (tutors and external specialists) • Questionnaire and Semi-structured interviews (participants now working)

20. Feedback 'Really useful at that time and I still appreciate the usefulness of it.‘ 'I enjoyed actually those simulation sessions with professional you know actors they’re really useful sessions, they’re really useful‘ “Reache actually train you for like swimming. They teach you all the skills you need for the time that you need to swim, so that you are able to swim.” “I mean without that (communication skills training), however we could never have worked. I mean yes later on at work you may learned it but, this is different to be really equipped with all this knowledge”

21. Success Factors • Multi-disciplinary team (Must have a Linguist/Language teacher) • Take apart linguistic and clinical aspects then reintegrate • Based on experience and research • Time intensive ( but time well spent) • Active learning • As realistic as possible • Effective feedback must be clear and direct (not subtle) The linguists identified language deficiencies that were seen as general communication problems by clinicians

22. SECC 5 day clinical communication skills course run in a relatively short period of time (2-3 weeks) Uses a Multi-disciplinary team of linguists, clinicians and simulated patients

23. Thank you for listening. Any questions?

24. Reache Whispers • Pass on the message task – • You should take the 5 red pills in the morning, 2 white pills 3 times a day, the blue pill in the evening and the purple pill if you feel sick!