Veterinary Paper Final

8/9/2019 Veterinary Paper Final

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Radford et al Consultation Model Page 1 of 17

Development, teaching and evaluation of a consultation structure model for use in

veterinary education.

Alan Radford *, Paula Stockley, Jonathan Silverman, Sue Kaney, Ian Taylor, Rob Turner

and Carol Gray ** .

Author information.

* Corresponding author. Alan Radford, BSc, BVSc, PhD, is a research scientist and an

original coordinator of communications skills development and training at University of

Liverpool Veterinary Teaching Hospital, Leahust, Chester High Road, Neston, S. Wirral,

CH64 7TE, UK ([email protected]).

Paula Stockley, BSc, DPhil, is a research scientist and one of the original coordinators of

communications skills development and training at University of Liverpool Veterinary

Teaching Hospital, Leahust, Chester High Road, Neston, S. Wirral, CH64 7TE, UK

([email protected]).

Jonathan Silverman, FRCGP,Associate Clinical Dean, Clinical Skills Unit, School of

Clinical Medicine, Box 111, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 2SP, UK

Ian Taylor, BSc, MEd, Liverpool Evaluation and Assessment Unit, Centre for Lifelong

Learning, University of Liverpool, 150 Mount Pleasant, Liverpool, L69 3GD, UK.

Rob Turner, BA, Liverpool Evaluation and Assessment Unit, Centre for Lifelong Learning,

University of Liverpool, 150 Mount Pleasant, Liverpool, L69 3GD, UK.

Carol Gray, BVMS, runs the National Unit for the Advancement of Veterinary

Communication Skills (NUVACS) in the UK and is the current programme coordinator for

communications skill straining at the University of Liverpool Veterinary Teaching Hospital,

Leahust, Chester High Road, Neston, S. Wirral, CH64 7TE, UK ([email protected]).

** Names and information for other co-authors are listed below.

Lisa Bush (Veterinary undergraduate), Mark Glyde (University College Dublin), Anne Healy

(University College Dublin), Vicki Dale (University of Glasgow), Sue Kaney (Whiston

Hospital), Christine Magrath (Veterinary Defence Society), Sarah Marshall (Learning and

Teaching Support Network, University of Newcastle), Steve May (Royal Veterinary College,

London), Brian McVey (Small Animal Practitioner, Liverpool), Clare Spencer (Hills Pet


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Nutrition and representing University of Bristol), Ray Sutton (Actor Educators Inc.), John

Tandy (Veterinary Defence Society), Penny Watson (University of Cambridge) and Agnes

Winter (University of Liverpool).


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Introduction

It is now widely accepted that veterinary graduates should enter their profession with high

quality communication skills. However, until recently, this has not been reflected in

undergraduate training. Recently, the Veterinary Faculty at the University of Liverpool, in

collaboration with the professions indemnity insurers (Veterinary Defence Society), has

developed one of the first specific communication skills training courses for veterinary

undergraduates (1). For the first three years it has been run, the aim of this course has

been to increase the students awareness of the importance of good communication within

the veterinary profession. The course is based on best practice as currently defined in

medical education, making extensive use of actors as simulated clients. As well as

watching acted-out consultations, the students also role-play scenarios designed to expose

them to all aspects of the veterinary consultation (e.g. introductions, history taking, breaking

bad news, fee issues, dealing with anger). Feedback on the role-plays is facilitated by

members of staff.

Evaluation of the first year of this course has been published and has shown it achieves its

aims of increasing the students awareness of the importance of good communication with

their clients (1). However, regular facilitators became aware that the students learning

experience was very variable, and perhaps more importantly, could not be defined. This

was felt to be a critical block limitation to further development of the course, particularly in

the area of student learning and assessment. It was recognised that one of the major

blocks to further development was the lack of a teaching model suitable for the veterinary

consultation. Such models are routinely used in medical education (2). However, their direct

application to veterinary education is limited because they do not reflect the diversity of

clients with which the veterinary surgeon communicates (e.g. farmers, companion animal

owners), nor do they take into account the two important, and often difficult, areas of

euthanasia and finances.

The aim of this project was to develop a consultation model for veterinary education based

on the Calgary-Cambridge model of the medical consultation. The model was adapted,

recognising both the considerable overlap and also the likely differences between the

veterinary and medical consultation. Subsequently, this model has been used for the

training of communication skills facilitators and undergraduates. Here we present the model


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and provide results of evaluation of its use within the communication skills programme for

veterinary undergraduates at the University of Liverpool.

Methods

Developing a veterinary consultation model.

A two day residential workshop was hosted in August 2002 at Craxton-Wood hotel on the

Wirral. In order to maximise ownership of the workshop results, delegates were invited from

each of the veterinary schools in the UK and Ireland. Most delegates were already involved

in communications skills training at their own institutions, and represented people from all

areas of clinical practice including small animal, equine and farm animal veterinarians. To

further ensure that the products of the workshop were as broadly applicable as possible we

also invited an undergraduate student, a veterinary surgeon in small animal practice, a

representative from industry, and the director of the role-play actors used at Liverpool. The

workshop was co-facilitated by Dr Jonathan Silverman (one of the developers of the

Calgary-Cambridge model) and Dr Sue Kaney (teaching Communications Skills at

Liverpool Medical School). This consensus based approach has been used previously in

medical education (3).

The format of the workshop was briefly as follows. On day one, delegates were first asked

to develop their own structure for the veterinary consultation without referring to existing

published models. This was followed by a brief explanation of the Calgary-Cambridge

model and how it is used in medical education, together with how the model has been

adapted to the paediatric consultation. The Calgary-Cambridge model provides a

comprehensive repertoire of skills that is validated by research and theoretical evidence,

that takes into account the move to a more patient-centred and collaborative style of

consultation, while allowing considerable latitude for individual style and personality (4-6).

Day two of the workshop began with sessions looking at the requirements of the veterinary

consultation in the different areas of small animal, equine and farm animal practice.

Subsequently, in small groups, the Calgary-Cambridge model was adapted to the

Veterinary consultation. This was then formatted and agreed by all the delegates, and

named the guide to the veterinary consultation based on the Calgary - Cambridge model

(GVCCCM).


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The use of the model in the veterinary curriculum.

The Veterinary programme at the University of Liverpool is five years long. The model was

used at Liverpool Veterinary School during the 2003-2004 curriculum as part of the

communication skills training course for third year undergraduates, which is called unit 2. All

facilitators were trained in the details of the model, and how it can be used to structure

feedback in a half-day workshop session with actors. The model was first introduced to the

undergraduates semi-didactically in a half day, large group session, and then used to focus

facilitation, feedback and learning during a three-hour small group session in which role-

play was used to recreate communication scenarios. This learning experience was the

subject of a detailed evaluation, based on the responses of participating students to a

questionnaire completed under supervision, a few days after the event. In addition,

facilitators provided feedback on the impact of the model on teaching and learning

behaviour in small groups.

Results and Discussion

Developing a veterinary consultation model.

The result of the Craxton Wood workshop in the form of the GVCCM is summarised in

figure 1. It is this structure which facilitators use to direct feedback with students. It bears

strong resemblance to the Cambridge-Calgary model on which it was based, highlighting

the similarities between the medical and veterinary consultation, and supporting the use of

best medical practice in this field of veterinary education.

The detailed breakdown of skills used during the consultation is shown in figure 2. This

information is made available to the students on the internet. It is numbered according to

the original Calgary-Cambridge model with added sections identified by the number 0

(Preparation and Observation) or by letters following each number. This approach was

used to further reinforce the origins of this veterinary consultation model. The additions to

this document largely reflect the tripartite nature of the veterinary consultation (owner,

patient and veterinarian). These include the need to

attends to clients and animals physical comfort (3a),


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demonstrate understanding of animals importance and purpose to the owner

build a relationship with the client through their animal, by acknowledging and relating to

the animal (30a), and by taking into account the relationship between the client and the

animal when communicating with the client (30b).

Evaluation of the use of the GVCCCM in undergraduate education the

students perspective.

Results of the student evaluation of unit 2 were extremely positive. As in previous

evaluations, and despite some apprehension about the process before they took part, the

students particularly appreciated the opportunity to role-play with actors. The students

benefited from participating in the scenarios, from watching others do so, and from the

subsequent discussions held with the facilitator, actor and fellow students. The focus on

communication served to identify and reinforce positive aspects and highlight areas for

improvement. As a result, students emerged from unit 2 with their confidence raised, feeling

better prepared to cope with future demands.

These small group sessions were more appreciated than the semi-didactic, large group

session that was used to introduce the model to the students. Rather than provide

stimulation and guidance for the subsequent scenario session, the overall effect of this

session was off-putting. In addition, there was little evidence to support a positive impact of

the model, the students appearing to be neutral to its benefit. A copy of the full report is

available on request from the authors.

In light of this evaluation by the students, the Faculty has reconsidered its use of the

consultation model. As a result, the model is now introduced in first year when students are

first asked to think about consultations and develop their own structure before being shown

the GVCCCM. Using this approach, the students take on more ownership of the model,

which is then used to evaluate videoed consultations in second year and as the basis of

feedback for role played sessions in third and fourth year.


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Evaluation of the use of the GVCCCM in undergraduate education the

facilitators perspective.

Although the impact of the model directly on students was considered neutral, the model

has allowed positive changes to be made in curriculum design and facilitation.

In curriculum design, the model has provided a clear focus for scenario design and the

development of assessment. Role play scenarios are now developed with specific learning

objectives in mind and these can be based on the model. In addition, it provides a

curriculum around which assessment can be based. As a result, portfolio assessment of

communication skills has recently been introduced as a component of the final professional

exam at Liverpool. Students are required to use the model to assess both their own

consultations and those they see during clinical rotations. In this way, students are

assessed on their ability to evaluate communication, not on their ability to actually

communicate. In later years, it is planned to introduce communication role plays into an

objective, structured clinical exam in final year, during which student performance will be

assessed against the model.

After role-plays, informal feedback from facilitators has suggested that familiarity with the

model greatly facilitated feedback during group sessions. It allows facilitators to prioritise

feedback to students and contextualise it within the structure of the whole consultation. It

also allows group sessions to be structured, initially focussing on the early parts of the

consultation (e.g. preparation and opening the consultation) during their first role plays,

before moving on to more complex issues associated with gathering and giving information.

These benefits move communication skills training away from our early programme where

each students learning experience was very variable, towards a more structured and

defined experience. This has provided the basis to improve the students learning

experience. However, is has also bought the need for much greater facilitator training. In

order to make maximum use of the model during role plays, facilitators need to be very

comfortable with its use, initially to evaluate their own consultation and later in the

evaluation of others. This has generated a need for much more highly trained facilitators

than before the model was available, and is something that is being tackled at a national

level in the UK (see article by Carol Gray in same issue of JVME).


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Summary

Communication skills training is becoming recognised as an important part of the veterinary

curriculum. Before we had the model, facilitating was an easy task but the aims and

learning outcomes were ill defined and limited. The model opens up new and exciting

opportunities for teaching, learning and assessment of communication skills but will require

a cohort of facilitators skilled in the theory and use of the model. This necessarily places a

much greater emphasis on training of facilitators.

Developing the GVCCCM was an extremely rewarding academic exercise. Not only did it

generate a framework for future education, but its collaborative nature brought people

together to focus on communication training. This collaborative effort has been an

extremely valuable resource in the further development of communications skills training in

the UK, and is continued at regular national meetings. To the authors knowledge, the

GVCCCM is now being used at most of the veterinary schools in the UK and Ireland for

undergraduate education.

Acknowledgements

This project was funded by an educational grant from the Learning and Teaching Support

Network and further supported by Hills Pet Nutrition. The authors also wish to thank Dr

Rachel Howells from Cambridge Medical School for helpful discussions about the

adaptation of the Calgary-Cambridge model to the paediatric consultation.


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Figure legends

Figure 1. A summary flow diagram of the guide to the veterinary consultation based on the

Calgary - Cambridge model.

Boxes 2-9. Skills used in each section of the veterinary consultation based on the Calgary -

Cambridge model. Each point is numbered according to the original Calgary-Cambridge

model (1). Points beginning in zero or ending in a letter represent additions to the original

model.


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Figure 1


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Boxes 1 - 9

Box1; PREPARATION

Establishing context

0.a Familiarises with past history relating to client and animal(s).

0.b Anticipates potential conflicts or difficulties, relating to the client, the animal and tosystems infrastructures.

Creating a professional, safe and effective environment

0.c Ensures facilities / environment are professional and appropriate to anticipatedneeds.

Box 2; OBSERVATION

0.d Continuous observation of the animal, the client and the environment.


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Box 3; INITIATING THE CONSULTATION

Establishing initial rapport with client and animal

1. Greets the client (and animal if appropriate); obtains / confirms the clients nameand the name or identity of the animal(s).

2. Introduces self, role and nature of the consultation; obtains consent.

3. Demonstrates interest, concern and respect for the client and the animal.

3a. Attends to clients and animals physical comfort.

Identifying the reason(s) for the consultation

4. Identifies the clients problems or the issues that the client wishes to address withappropriate opening question. e.g. Whats the problem with Ginger today? orWhat can we do for you today?.

5. Listens attentively to the clients opening statement, without interrupting or directingthe clients response.

6. Checks and screens for further problems. e.g. So youve noticed a drop in milkyield.... is there anything else?

7. Negotiates agenda taking both the clients and veterinary surgeons needs intoaccount. e.g. So well look at the infected hoof first and then well talk about themilk yield.... is that okay?


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Box 4; GATHERING INFORMATION

Exploration of clients problems (includes long and short termhistory).

8. Encourages client to tell the story of the animals problem(s) from when firststarted to the present in their own words (clarifying reason for presenting now).

9. Uses open and closed questions, appropriately moving from open (Hows herappetite?) to closed (How often is she being sick?).

10. Listens attentively, allowing the client to complete statements without interruptionand leaving time for the client to think before answering or go on after pausing.

11. Facilitates the client's responses verbally and nonverbally. e.g. use of

encouragement, silence, paralinguistics, body language, eye contact, repetition,paraphrasing, interpretation.

12. Picks up verbal and nonverbal cues from the client (body language, speech, facialexpression); checks out and acknowledges as appropriate.

13. Clarifies statements that are vague or need amplification. e.g. Could you explainwhat you mean by drinking a lot.

14. Periodically summarises to verify own understanding of what the client has said;invites the client to correct interpretation or provide further information.

15. Uses concise, easily understood language, avoiding or adequately explaining

jargon.

Additional skills for understanding the clients perspective

16. Determines and acknowledges:

clients ideas (i.e. beliefs regarding cause) and concerns (i.e. worries) regardingeach problem.

clients expectations: goals, what help the client had expected for each problem.

effects: how each problem affects the clients life.

17. Encourages expression of the clients feelings and thoughts.


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Box 5; PROVIDING STRUCTURE TO THE CONSULTATION

Making organisation overt18. Summarises at the end of a specific line of inquiry to confirm understanding before

moving on to the next section.

19. Progresses from one section to another using signposting; includes rationale fornext section. e.g. I just need to ask you a few questions about Murphy before Iexamine him.

Attending to flow

20. Structures consultation in a logical sequence.

21. Attends to timing and keeping consultation on task.

Box 5; BUILDING THE RELATIONSHIP WITH THE CLIENT

Non-verbal behaviour

22. Demonstrates appropriate nonverbal behaviour e.g. eye contact, posture andposition, movement, facial expression, use of tone.

23. If reads, writes notes or uses computer, does in a manner that does not interferewith dialogue or rapport.

Developing rapport

24. Acknowledges clients views and feelings; accepts legitimacy; is not judgmental.

24aDemonstrates understanding of animals importance and purpose. e.g. showsunderstanding of the current economic environment in which farming clients work,

or the unique relationship that can exist between a companion animal and itsowner.

25. Uses empathy to communicate understanding and appreciation of the clients andanimals feelings or predicament.

26. Provides support to the client: expresses concern, understanding, willingness tohelp; acknowledges coping efforts and appropriate animal care; offers partnership.

27. Deals sensitively with embarrassing and disturbing topics and physical pain,including when associated with physical examination of the animal.

Involving the client

28. Shares thinking with client to encourage clients involvement. e.g. What Imthinking now is........

29. Explainsrationale for questions or parts of physical examination that could appearto be irrelevant.

Involving the animal (s)

30a. Acknowledges the animal and / or alerts animal to their presence.

30b. Relates to the animal taking into account the relationship between the client andthe animal. Approaches and handles the animal sympathetically.


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Box 6; EXPLANATION AND PLANNING

Providing the correct amount and type of information

Aims: to give comprehensive and appropriate informationto assess each individual clients information needsto neither restrict or overload

32. Assesses clients starting point: asks for clients prior knowledge early on when giving information, discoversextent of clients wish for information.

31. Chunks and checks: gives, in easily assimilated chunks, essential information regarding diagnosis andtreatment options, prognosis and financial implications; uses clients response as a guide to how to proceed.

33. Gives other information according to the clients wishes. e.g. aetiology.

34. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely.

34a. Prioritises information given: recognises that some information may be best provided at a later time.

Aiding accurate recall and understanding

Aims: to make information easier for the client to remember and understand

35. Organises explanation: divides into discrete sections, develops a logical sequence.

36. Uses explicit categorisation orsignposting. e.g. There are three important things that I would like to discuss.First... or Now, shall we move on to...

37. Uses repetition and summarising to reinforce information.

38. Uses concise, easily understood language, avoids or explains jargon.

39. Uses visual methods of conveying information: diagrams, models, written information and instructions.

40. Checks clients understanding of information given (or plans made).

Achieving a shared understanding: incorporating the clients perspective

Aims: to provide explanations and plans that relate to the clients perspectiveto discover the clients thoughts and feelings about information givento encourage an interaction rather than one-way transmission

41. Relatesexplanations to clients initial concerns. e.g. previously elicited ideas, concerns and expectations.

42. Provides opportunities and encourages the client to contribute, to ask questions, seek clarification or expressdoubts. Responds appropriately.

43. Recognises verbal and non-verbal cues e.g. clients need to contribute information or ask questions,information overload, distress.

44. Elicits client's beliefs, reactions and feelings regarding information given, terms used, financial implications;acknowledges (empathises) and addresses where necessary. e.g. I can see that this is upsetting for you.

Planning: appropriate shared decision making

Aims: to allow clients to understand the decision making processto involve clients in decision making to the level they wishto increase clients commitment to plans made

45. Shares own thoughts: ideas, thought processes and dilemmas.

46. Offers choices rather than giving directives.

47. Encourages clientto contribute their thoughts, ideas, suggestions and preferences.

48. Negotiates a mutually acceptable plan.

49. Encourages client to make decisions to the level that they wish informedconsent.

50. Checks with client if they accept plans, if concerns have been addressed.


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Box 7; CLOSING THE CONSULTATIONSummarising

51. Summarises session briefly and clarifies plan of care.

Forward planning

53. Safety nets, explaining possible unexpected outcomes, what to do if plan is notworking, when and how to seek help.

52. Contracts with client regarding the next steps for client, animal(s) and veterinarysurgeon.

54. Final check that client agrees and is comfortable with plan and asks if anycorrections, questions or other items to discuss.

54a. Says goodbye.


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References

1. Radford AD, Stockley P, Humphris G, Kaney S, Turner R, McGrath C, Gaskell CJ & Taylor

IR. (2003). The use of simulated clients in communication skills training for veterinaryundergraduates. VeterinaryRecord152: 422-427, 2003.

2. Kurtz SM, Silverman JD. The Calgary-Cambridge Referenced Observation Guides: anaid to defining the curriculum and organizing the teaching in communication trainingprogrammes. Med Educ30(2): 83-9, 1996.

3. Makoul G. Essential elements of communication in medical encounters: the Kalamazooconsensus statement. Acad Med 76(4):390-3, 2001.

4. Kurtz S, Silverman J, Benson J and Draper J (2003) Marrying Content and Process in

Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Academic Medicine78 (8): 802-9.

5. Kurtz, S., Silverman, J. and Draper, J. (2005) Teaching and learning communicationskills in medicine - 2nd edition, Radcliffe Publishing, Oxford.

6. Silverman, J., Kurtz, S. and Draper, J. (2005) Skills for communicating with patients - 2ndedition, Radcliffe Publishing, Oxford.

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