Strategies for implementing clinical communication training in every day practice - how to do it?

1. Strategies for implementing clinical communication training in every day practice - how to do it? Jonathan Silverman Aarhus 2012

2. Bringing the Hidden Curriculum out of hiding: Strategies for bridging the gap in teaching and learning about communicationEACH St Andrews

3. Teaching Communication Skills in the Context of Clinical Care Marcy Rosenbaum, PhD Dr. Harold A. Myers Distinguished Professor Associate Professor of Family Medicine Office of Consultation and Research in Medical Education

4. Why you are so important

5. Introduction/reflection • Formal teaching of communication skills occurs in undergraduate and intern level • During their clinical work as doctors, their experiences can contradict and not reinforce the communication skills they have been previously taught

6. Introduction/reflection In pairs, discuss what experiences learners may have with the “hidden curriculum” and their impact on development and retention of effective communication

7. Problems of ‘in the moment’ teaching: • achieving satisfactory re-rehearsal • obtaining constructive feedback from patients unused to this method of working • discussing sensitive issues in front of the patient • the availability of time in the ‘real’ world for both professionals and patients • the multiplicity of tasks – including patient care itself – that require attention • the wide range of possible teaching agendas, including issues concerning clinical reasoning, physical examination, investigations, treatment alternatives, etc.

8. Are communication skills and traditional history taking mutually incompatible?

9. The Leicester OSCE

10. Are communication skills and traditional history taking mutually incompatible? Have you seen this problem?

11. How you communicate Process Open Directive Three elements of gathering clinical information Biomedical Patient’s perspective What you discuss, record and present Content Clinical reasoning Feelings What you think and feel Perception

12. How you communicate Process Open Three elements of gathering clinical information Patient’s perspective What you discuss, record and present Content Feelings What you think and feel Perception

13. How you communicate Process Directive Three elements of gathering clinical information Biomedical What you discuss, record and present Content Clinical reasoning What you think and feel Perception

14. Dilemmas in history taking teaching • The students are being taught a different approach to what we practice on the wards • They don’t seem to know what questions to ask • They seem to concentrate on patient’s ideas, concerns and expectations

15.  Communication skills teaching model versus Traditional medical history model

16. Confusion over Process Content

17. Communication model (process) • Initiating the session • Gathering information • Building relationship • Structuring the interview • Explanation and planning • Closing the session

18. 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

19. Confusion between process and content (1): • 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 • The issue of how learner’s are observed (if they are) • GP/psychiatry/psychology v real doctors

20. Gathering Information • process skills for exploration of the patient’s problems • patient’s narrative • question style: open to closed cone • attentive listening • facilitative response • picking up cues • clarification • time-framing • internal summary • appropriate use of language • additional skills for understanding patient’s perspective

21. 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

22. Confusion between process and content (2): • Communication skills teachers have introduced their own new content

23. content to be discovered: • 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

24. content to be discovered: • the patient’s perspective • (illness experience) • ideas and beliefs • concerns and feelings • expectations • effects on life

25. content to be discovered: • 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

26. Are communication skills and traditional history taking mutually incompatible? So what’s the solution

27. Effective history taking is essential to the practice of high quality medicine

28. Effective communication is essential to the practice of high quality medicine

29. Effective clinical methodis essential to the practice of high quality medicine

30. A Comprehensive Clinical Method

31. A Comprehensive Clinical Method The explicit integration of traditional clinical method with effective communication skills to enable doctor and patient, in partnership, rationally to explore, diagnose and manage both: disease (the bio-medical cause of sickness in terms of underlying pathophysiology) and illness (the individual patient’s unique experience of sickness)

32. Why integrate communication training into everyday practice • Reinforce and validate content and skills emphasized in previous education • Address more advanced communication skills and issues • Address interviewing challenges identified by learners

33. observing senior doctors feedback on presentations conducting interviews themselves (Observation and feedback rarely occurs) How Doctors Learn in Clinical Years

34. Opportunities to teach communication in the context of clinical care • Modeling for learners • Staffing: Responses to learner presentations • Observation of learner interactions with patients and feedback

35. Modeling

36. Modeling communication: Strategies for maximizing learning Outpatient or Inpatient - Especially useful with advanced tasks 1) Prime learner before observation “Please pay attention to the way I…..” “What aspects of the clinical encounter do you have questions about?” 2) Conscious awareness of communication choices while modeling Have a plan, consider the skills you use 3) Debriefing after observation is key “What did you notice (analyze skills used), what do you have questions about, what would you use in future?”

37. Staffing

38. Cues in Staffing In small groups, Based on the learner’s presentation cue, “diagnose” what the communication issue(s) might be that the learner is struggling with Discuss what skills you could recommend for the learner to use

39. Cues in staffing “This patient had so many problems I had a hard time sorting it out and it took a long time” “The patient seemed kind of upset but I’m not sure why” “He is a very difficult historian” “I explained to her that she needs to take the medication regularly which she has not been doing”

40. Cues in staffing • “This patient had so many problems I had a hard time sorting it out and it took a long time” What communication issues does learner have? What skills could address them?

41. Initiating the session: • 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 Gathering information • Asks about patient ideas, concerns, and expectations (ICE) • Periodically summarises to verify own understanding of what the patient has said; invites patient to correct interpretation or provide further information.

42. Staffing Additional strategies for assess and address learner communication needs Priming before patient encounters if need for certain process skills can be anticipated Asking learner how the interaction went with the patient Asking learner what they were trying to accomplish with patient and did they feel they achieved it Problem solve with learner about skills that could be helpful

43. Observation of learners

44. Observation of learners Though it takes more time, can give clearer picture of communication strengths and challenges Observation can be done in brief forays – at the beginning of patient encounter or during explanation phase after staffing

45. Observation of learner Example of resident with mother of asthmatic adolescent patient On observation sheet, write down what you see, including specific phrases, questions and responses – both effective and less effective

46. Observation sheet