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School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Strategies for implementing clinical communication training in every day practice - how to do it?
Jonathan Silverman
Aarhus
2012
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Bringing the Hidden Curriculum out of hiding:
Strategies for bridging the gap in teaching and learning about
communication
EACH St Andrews
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Teaching Communication Skills in the Context of
Clinical Care
Marcy Rosenbaum, PhDDr. Harold A. Myers Distinguished ProfessorAssociate Professor of Family MedicineOffice of Consultation and Research in Medical Education
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Why you are so important
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Introduction/reflection
In pairs, discuss what experiences learners may have with the “hidden curriculum” and their impact on development and retention of effective communication
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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.
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Are communication skills and traditional history taking mutually incompatible?
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
The Leicester OSCE
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Are communication skills and traditional history taking mutually incompatible?
Have you seen this problem?
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Three elements of gathering clinical information
What you think and feelPerception
Biomedical
Patient’s perspective
What you discuss, record and present
Content
Clinical reasoning
Feelings
How you communicateProcess
Open
Directive
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Three elements of gathering clinical information
What you think and feelPerception
How you communicateProcess
What you discuss, record and present
ContentPatient’s perspective
Feelings
Open
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Three elements of gathering clinical information
What you think and feelPerception
How you communicateProcess
What you discuss, record and present
Content
Biomedical
Clinical reasoning
Directive
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Communication skills teaching model
versus
Traditional medical history model
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Confusion over
Process
Content
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Communication model (process)
• Initiating the session• Gathering information• Building relationship• Structuring the interview• Explanation and planning• Closing the session
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
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
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Confusion between process and content (2):
Communication skills teachers have introduced their own new content
content to be discovered:
the bio-medical perspective (disease)
sequence of events symptom analysisrelevant systems review
background information - context
past medical historydrug and allergy historyfamily historypersonal and social historyreview of systems
content to be discovered:
the patient’s perspective (illness experience)
ideas and beliefs concerns and feelings
expectations effects on life
content to be discovered:
the bio-medical perspective the patient’s perspective (disease) (illness) sequence of events ideas and beliefssymptom analysis concernsrelevant functional enquiry expectations
effects on life feelings
background information - contextpast medical historydrug and allergy historyfamily historypersonal and social historyreview of systems
So what’s the solution
Are communication skills and traditional history taking mutually incompatible?
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Effective history taking
is essential to the practice of
high quality medicine
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Effective communication
is essential to the practice of
high quality medicine
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Effective clinical method
is essential to the practice of
high quality medicine
A Comprehensive Clinical Method
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)
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
• observing senior doctors
• feedback on presentations
• conducting interviews themselves(Observation and feedback rarely occurs)
How Doctors Learn in Clinical Years
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Modeling
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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?”
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Staffing
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Cues in Staffing
In small groups,
1. Based on the learner’s presentation cue, “diagnose” what the communication issue(s) might be that the learner is struggling with
2. Discuss what skills you could recommend for the learner to use
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Cues in staffing
1. “This patient had so many problems I had a hard time sorting it out and it took a long time”
2. “The patient seemed kind of upset but I’m not sure why”
3. “He is a very difficult historian”
4. “I explained to her that she needs to take the medication regularly which she has not been doing”
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Cues in staffing
1. “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?
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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.
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Observation of learners
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Observation sheetContent(CC, pmh)
Effective behaviors that you see
Behaviors you don’t’ see or that could benefit from change
Greeting(8:50 am) CC PMH9:05
introduced self
good eye contact asked appropriate specifics
("Can you describe that?") open-ended questions good paraphrasing("what I hear you saying…")
Didn't mention student status
Interrupted too quickly("daughter…how severe pain") no follow-up(can't afford to be sick)