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Evelyn van Weel-Baumgarten , Department of Primary and Community Care
,
NIJMEGEN
Is linking research, teaching and practice in communication
in health care the way forward?
Disclosure of Relevant Financial
Relationships:
Evelyn van weel-Baumgarten has no
financial relationships to declare
The problem?
• Research
• Teaching and transfer
• A patient story: the challenge of every-day practice
• Links
• Physicians
• Nurses
• Other healthcare professionals
• Patients
• Teachers
• Students/learners
• Researchers
Audience?
Adequate doctor-patient communication
contributes to
• More accurate diagnosis
• Better adherence to treatment
• More effectiveness and
• Less problems in patient safety
• Less legal issues
• Lower costs
Influence of doctor-patient relationship on health
outcomes: the physician
• Physicians adopting a warm, friendly and reassuring
manner are more effective than those who remain
formal with their patients.
• What makes it effective?
Di Blasi
Integrating correct medical content with adequate communication skills: outcome of guideline concordant care for depression
Adequate intervention (accurate diagnosis, treatment with AD)
Inadequate intervention
GP skilled in communication
Positive effect after 3 and 12 months
No effect
GP NOT skilled in communication
No effect No effect
van Os et al
• A patient is seen as a person
attention for context
exploring emotional cues
• Involvement of the patient
room for the patient’s story
active role beyond the consultation
Person/patient centeredness
Balint, Engel, Stewart, Epstein and others
• Emphasis on a dialogue
showing empathy
adjusting information to
patient’s context
framing in a positive way
involvement in decisions
on management
empowering
Person/patient centeredness
• The person of the doctor
awareness of our influence on practice of medicine
Person/patient centeredness
Quality of physician patient communication
Griffin, Kinmonth et al, Stuart
• important during all stages of a clinical consultation
Effective
• mutual understanding of each others’ explanatory
models of illness and disease taking into account
patient’s ideas, concerns, and expectations : common
ground
• clear information
Quality of physician patient communication
Griffin, Kinmonth, Stuart
• Effect on outcomes: well-being, anxiety and
depression but also on blood pressure; cholesterol;
HbA1c and even on mortality
• And reduces costs through fewer diagnsostic tests
and referrals
Placebo effects
The words and how they are used
• cause cognitive and emotional changes
• have neurobiological underpinnings and actual effects on the brain and body
Benedetti
Placebo studies
Placebo effects
through:
• Conditioning
• Manipulating expectations
• Influencing patients’ affective state and stress
levels
Benedetti, Bensing
Empathy
• better outcomes
• quicker recovery
affective statements
reduce anxiety and uncertainty
temper emotional arrousal
lead to increased recall of medical information
The difference:
• 38 seconds and affective statements related to emphasizing
non-abandonment and providing reassurance of medical
support. Bensing, van Dulmen; van Osch, van Dulmen
Placebo - healing power of clinicians?
• Lessons learnt can be used in teaching of
clinical communication skills
• But not as a trick/isolated skill in a one-off
• Relationships matter
Stewart
Summarizing:
research shows that adequate communication
impacts positively on health and outcomes
so
Let’s just teach it
Doctor-patient relationship and teaching / learning
communication skills
• Communication skills can be learnt
• Many medical schools have implemented
Communication skills training/ Blueprints, Canmeds
• Criteria for curriculum development for Medical
Education
Silverman, Van Herwaarden, Kern
What to teach:
• Process Skills for gathering
information/exploration of the
patient’s problems including
patient perspective (common
ground)
• Skills for explanation and
planning
• Specific communication issues
and challenges
Models
• Lectures?
Attention span declines after 15-20 minutes
Retention rate 5% - 10% - 50% for group discussions
Lacks possibility to address individual needs and adjust
Good for transmitting knowledge / as an introduction if….
Clear and well structured
Interactive
Used in combination with other teaching
methods/discussions
Related to real life problems/challenges:
How to teach: traditional teaching?
Intermezzo
• Stand-up and turn to some-one you don’t know
• Shake hands and introduce yourself briefly (1 minute
pp max)
• Name
• Where you are from and what ‘your main
bloodgroup’ is
• Researcher, Teacher, Clinician, Student, Patient
• A first new link!
• Lectures?
Attention span declines after 15-20 minutes
Retention rate 5% - 10% - 50% for group discussions
Lacks possibility to address individual needs and adjust
Good for transmitting knowledge / as an introduction if….
Clear and well structured
Interactive
Used in combination with other teaching
methods/discussions
Related to real life problems/challenges:
How to teach: traditional teaching?
How to teach
• Skills-training (experiential learning) with feedback
• Using crucial components to change behavior
Meeting needs of learners
Activating prior knowledge
Interactive learning and opportunities to practice
Peer interaction
Aspegren, Davis , Mazmanian, Steinart
How to teach
Experiential teaching methods
• role play
• simulated patients/actors
• real patients
Effective feedback
• direct
• video
Integrated in the curriculum
Longitudinal
Assessment
Effective feedback
• Outcome led
• Well intentioned
• Specific
• Descriptive
• Focussed on skills
• Based on choices not solutions
• Limited amount
Clinical practice is a challenge:
teaching ≠ learning ≠ application in practice
Transfer is not easy
Transfer : ‘a rough ride’ • Near – Far
• Far transfer only achieved when knowledge and
skills are used in every-day work Yamnill & McLean, Van Baalen
Clinicians/Role models
• very powerful, probably even more than training of
communication
• during rotations students receive mixed messages
when observing clinicians/role models Egnew, Essers
Transfer to the clinical context in family medicine
residents
Cognitive and Emotional space
Phase 1
Confrontation
with the effect of
a behavior
Phase 2
Becoming
conscious of own
behavior
Phase 3
Searching for
alternative
behavior
Phase 4
Personalization
of new behavior
Phase 5
Internalization
and clinical
integration
Safety
van den Eertwegh et al.
Important for transfer in a hospital setting
in the right circumstances confrontation leeds to • reflection • increased self-awareness In that case experienced as transformative learning
van den Eertwegh et al.
What helps
• Feedback
• Role models with attention for and sensitive to
communication
• Safe learning environment
• Structured ‘peer group meetings’ coached by
neutral person, experienced and knowledgeable in
communication
• Notion of awareness of communication in a
department
van den Eertwegh et al.
Normalising exchange
Open door?
• Regular meetings for exchange
• Including them in our routines
• Researchers teaching and
• Teachers involved in research
• Involving each other and clinicians of all
relevant practice contexts
• Ad policymakers?
• Involving multiple stakeholders : clinicians,
educators, learners, patients
• And policymakers?
Why:
• Outcomes easier to transfer, more feasible
and sustainable (more commitment, more
relevant)
Participatory research
Patient involvement
As full partners
Defining problems / formulating
research questions together
Co-creating solutions
Patients. clinicians, educators, etc.
Implementation science
• Looks at if and why interventions –
guidelines/training programmes do or do not work
in a specific context
with attention for policy
• Possibility to adapt interventions to specific needs
before introduction
• http://www.fp7restore.eu/
Classroom sessions
Mix training of separate skills with full consultations
• mimicking length and complexity of clinical practice
• feedback by clinicians of that setting
• choices informed by clinicians, faculty AND students
Examples:
whole single consultations
surgeries
farmacotherapy
Van Weel-Baumgarten et al.
Teaching in clinical practice
• With clinicians who know and show the principles of
effective communication skills; give effective
feedback
• Start dialogue
To change climate – involving
clinicians , learners and educators as well as
(local) policy makers
Health care and policy
Clinicians are assessed
quality indicators, registration systems
comply with insurance rules and regulations
Education in an environment where this counts
If that lacks attention - appreciation for communication
no (sustained) change for learners
For changes and sustainability:
• solutions need discussion and involvement of policy makers
3. Doctor’s visit, 1663. Jan Steen 5. 17th-century artwork of two Dutch doctors, Boekelman Cornelis (l.) and Jan Six , 1699. By Jurriaen Pool
(1666-1745). Nurse by Isaac Israels 1865-1934 Chirurgijn. by Teniers the younger (Flemish) 1610-1690 6. Titus, 1655. Rembrandt 1606 -1669: 7. La Berceuse, 1889. van Gogh 12. Village doctor, Teniers the younger 13. Doctor as god and as man Golzius 1600-1625 (ook als devil 15. Self Portrait Rembrandt 1630 17. Barber. Teniers de younger, 18. Sad man. Van Gogh, 1890 19. The Sick Girle. Gabriel Metsu 1629-1667 21. Anatomische les van dr N Tulp, 1632. Rembrandt 23. Schoolteacher, 1668. Jan Steen 25. Boerhaave theater Leiden around 1600 29. Girl with pearl ear ring. Vermeer 1665-1667 30. Schoolteacher. Jan Steen, 1663-1665 32. Fisch transforming in birds. Escher, 1878-1972 34. Van Goyen 1569-1656 35. Anatomy lesson by dr Ruys, 1670. Adriaen Backer 37. Hospital ward in Arles, 1889. Van Gogh 40. Victory Boogie Woogie, 1942-1944. Mondriaan 43. Selfportrait, 1932. Dick Ket, 1902-1940 47. Waterfall, 1961. Escher 1878-1972 49. Regents of the ‘Elisabeth Gasthuis’, 1641. Frans Hals 51. Red tree, 1908. Mondriaan
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