How to maintain quality in and develop doctors communication skills

1. How to maintain quality in and develop doctors communication skills

4. “Clinical communication teaching - why bother?” we’ve got enough to do already, it can’t be learnt, it doesn’t fit the real world Jonathan Silverman Aarhus, 2012

5. Only 5-6 students Over 700 half day sessions And a facilitator Each with an actor Complex audio-visual IT

6. Plan: clinical communication teaching - why bother? • Are there problems in communication in medicine? • Are there solutions to those problems? • Do they make a difference to outcomes of care? • Can you teach it? • Is it retained? • So what is it?

7. Plan: clinicalcommunication teaching - why bother? • Are there problems in communication in medicine?

8. Are there problems in communication between doctors and patients? • what different communication patterns do you see? • what outcome do you predict the patterns will have on whether the interview is effective? • initiating the interview • gathering information • explanation and planning • building therelationship • structuring the interview • closing the interview VTS_06_1.VOB VTS_05_1.VOB

9. Initiating the interview 1. Not discovering the reasons for the patient's attendance Gathering information 2. Early closed questioning preventing listening Clinicalhypo-competence

10. 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) • Mauksch et al (2008): literature review to explore the determinants of efficiency in the medical interview. 3 domains emerged from their study that can enhance communication efficiency: rapport building, upfront agenda setting and picking up emotional cues

11. Are there problems in communication between doctors and patients? • initiating the interview • gathering information • explanation and planning • building the relationship

12. Explanation and planning 3. Recall and understanding • use of jargon • monologue • speeding up • not incorporating patient’s perspective 4. Shared decision making • not involving patients in decision making to the level that they would wish • shared decision making not done

13. Are there problems in communication between doctors and patients? • initiating the interview • gathering information • explanation and planning • building the relationship Cues

14. Facilitative skills Open questions Open directive questions Listening Pauses/use of silence Minimal prompts/encouragement Summarising The emergence of cues • Goldberg et al 1993; Wilkinson 1991; Maguire et al 1996: Zimmerman et al, 2003

15. 5. Not picking up and exploring cues Levinson (2000) • patients gave cues throughout the interview from the opening to the closing minute • doctors only responded to patient cues in 38% of cases in surgery and 21% in primary care • where the cue was missed, half of the patients brought up the same issue a second or third time and in all of these cases, the physician again missed these further opportunities to respond. Zimmerman et al (2007) • a systematic review, documenting 58 original quantitative and qualitative research articles demonstrating patient expressions of cues and/or concerns, all based on the analysis of audio or videotaped medical consultations. • overall conclusion - physicians missed most cues and adopted behaviours that discouraged disclosure. Rogers and Todd (2000) • oncologists preferentially listen for and respond to certain disease cues over others • pain amenable to specialist cancer treatment is recognised, other pains are not acknowledged or dismissed

16. Are there problems in communication between doctors and patients?

17. Are there problems in communication between doctors and patients? • initiating the interview • gathering information • explanation and planning • relationship building

18. Building the relationship 6. Empathy and non-verbal behaviour

19. Plan: Clinical communication teaching - why bother? • Are there problems in communication in medicine? • Are there solutions to those problems?

20. Are there solutions to these problems? • initiating the interview • gathering information • explanation and planning • building the relationship • structuring the interview • closing the interview

21. Are there solutions to these problems? • initiating the interview • gathering information • explanation and planning • building the relationship • structuring the interview • closing the interview

22. Plan: Clinical communication teaching - why bother? • Are there problems in communication in medicine? • Are there solutions to those problems? • Do they make a difference to outcomes of care?

23. 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

24. Medico-legal issues • 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) • Relationship between judgments of surgeons' voice tone and their malpractice claims history. (Ambadyet al 2002) • Scores achieved in patient-physician communication and clinical decision making on a national licensing examination predicted complaints to medical regulatory authorities (Tamblyn et al 2007)

25. Clinical competence The ability to integrate: • knowledge • communication • physical examination • problem-solving THE ESSENCE OF CLINICAL PRACTICE

26. Research into clinical communication • More effective interviews: accuracy efficiency supportiveness • Enhanced patient and health professional satisfaction • Improved health outcomes for patients

27. Effective clinical communication High quality healthcare to We cannot ignore the central importance of

28. Plan: Clinical communication teaching - why bother? • Are there problems in communication in medicine? • Are there solutions to those problems? • Do they make a difference to outcomes of care? • Can you teach it?

29. Communication is a core clinical skill

30. Skills and attitudes Final common pathway = skills

31. Can you learn communication? Communication is a clinical skill It is a series of learnt skills Experience is a poor teacher

32. Communication skills teaching and learning is different • Closely bound to self-esteem, self-concept, personality • More complex than simpler procedural skills • No achievement ceiling • Don’t start from scratch

33. Can you learn communication? It can be taught and learnt We know which methods work

34. 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)

35. 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

36. How do we change our behaviour in the interview? Knowledge is important but only allows you to know about communication Experiential teaching is required to know how to communicate

37. 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

38. Plan: Clinical communication teaching - why bother? • Are there problems in communication in medicine? • Are there solutions to those problems? • Do they make a difference to outcomes of care? • Can you teach it? • Is it retained?

39. Plan: Clinical communication teaching - why bother? • Are there problems in communication in medicine? • Are there solutions to those problems? • Do they make a difference to outcomes of care? • Can you learn it? • Is it retained? • So what is it?

40. Clinical Communication Skills (CCS)

41. Key components of CCS • Core medical interviewing skills • Specific communication issues and challenges • Communicating with others • relatives • interpreters • Professional communication skills • other professionals • presentation skills

42. Martin von Fragstein, Jonathan Silverman, Annie Cushing, Sally Quilligan, Helen Salisbury & Connie Wiskin on behalf of the UK Council for Clinical Communication Skills Teaching in Undergraduate Medical Education UK consensus statement on the content of communication curricula in undergraduate medical education Medical Education 2008 42(11): p. 1100-7

45. THE CALGARY-CAMBRIDGE GUIDESTO THE MEDICAL INTERVIEW Kurtz, Silverman and Draper (2005; 2nd Ed.)Teaching and Learning Communication Skills in Medicine Radcliffe Medical PressSilverman,Kurtz and Draper (2005; 2nd Ed.)Skills for Communicating with Patients Radcliffe Medical PressKurtz, Silverman, Benson and Draper (2003) Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides Academic Medicine;78(8):802-809

46. Initiating the session Gathering information Providing structure Building the relationship Physical examination Explanation and planning Closing the session

47. 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

48. Specific communication issues and challenges • culture and social diversity • gender • dealing with emotions • age related issues – the elderly, children • the three way interview • breaking bad news • the sexual history • the psychiatric interview • the telephone interview • low literacy patients • sensory impaired patients • death and dying, bereavement • complaints • ethics • health promotion and prevention

49. INITIATING THE SESSION

50. Establishing initial rapport Greets patient and obtains patient’s name Introduces self, role and nature of interview; obtains consent Demonstrates interest, concern and respect, attends to patient’s physical comfort Identifying the reason(s) for the consultation Identifies the patient’s problems or the issues that the patient wishes to address with appropriate opening question (e.g. “What problems brought you to the hospital?” 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