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

School of Clinical Medicine

UNIVERSITY OFCAMBRIDGE

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

Jonathan SilvermanAarhus2012



Bringing the Hidden Curriculum out of hiding:

Strategies for bridging the gap in teaching and learning about

communication

EACH St Andrews



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



Why you are so important



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



Introduction/reflection

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



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.



Are communication skills and traditional history taking mutually incompatible?



The Leicester OSCE




Have you seen this problem?



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







Content Patient’s perspective

Feelings

Open







Content

Biomedical

Clinical reasoning

Directive



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



Communication skills teaching model versus

Traditional medical history model



Confusion over

Process

Content



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



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



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



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



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


the patient’s perspective (illness experience)

ideas and beliefs concerns and feelings

expectations effects on life


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




Effective history taking is essential to the practice of

high quality medicine



Effective communication is essential to the practice of




Effective clinical method is essential to the practice of


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)



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



• observing senior doctors

• feedback on presentations

• conducting interviews themselves(Observation and feedback rarely occurs)

How Doctors Learn in Clinical Years



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



Modeling



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?”



Staffing



Cues in StaffingIn 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



Cues in staffing1. “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”



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?



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.



StaffingAdditional 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



Observation of learners



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



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



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)

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

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