How to maintain quality in and develop doctors communication skills

How to maintain quality in and develop

doctors communication skills

School of Clinical Medicine

UNIVERSITY OFCAMBRIDGE

“Clinical communication teaching -

why bother?”we’ve got enough to do already,

it can’t be learnt,it doesn’t fit the real world

Jonathan Silverman

Aarhus, 2012

Over 700 half day sessionsEach with an

And a facilitator

Only 5-6 students

Complex audio-visual IT

Plan: clinical communication teaching - why bother?

1. Are there problems in communication in medicine?

2. Are there solutions to those problems?

3. Do they make a difference to outcomes of care?

4. Can you teach it?

5. Is it retained?

6. So what is it?

Plan: clinical communication teaching - why bother?

Are there problems in communication between doctors and patients?

• initiating the interview• gathering information• explanation and planning• building the relationship• structuring the interview• closing the interview

• what different communication patterns do you see?

• what outcome do you predict the patterns will have on whether the interview is effective?

VTS_05_1.VOB VTS_06_1.VOB

Initiating the interview1. Not discovering the reasons for the patient's attendanceGathering information2. Early closed questioning preventing listening

Clinical hypo-competence

54% of patients’ complaints and 45% of their concerns are not elicited (Stewart et al 1979)

in 50% of visits, the patient and the doctor do not agree on the nature of the main presenting problem (Starfield et al 1981)

only a minority of health professionals identify more than 60% of their patients' main concerns (Maguire et al 1996)

consultations with problem outcomes are frequently characterised by unvoiced patient agenda items (Barry et al 2000)

doctors frequently interrupt patients so soon after they begin their opening statement that patients fail to disclose significant concerns (Beckman and Frankel 1984, Marvel et al 1999 )

Mauksch et al (2008): literature review to explore the determinants of efficiency in the medical interview. 3 domains emerged from their study that can enhance communication efficiency: rapport building, upfront agenda setting and picking up emotional cues

• initiating the interview• gathering information• explanation and planning• building the relationship

Explanation and planning

3. Recall and understanding • use of jargon• monologue• speeding up• not incorporating patient’s perspective

4. Shared decision making • not involving patients in decision making to the

level that they would wish• shared decision making not done

Are there problems in communication between doctors and patients?• initiating the interview• gathering information• explanation and planning• building the relationship

Facilitative skills• Open questions

• Open directive questions

• Listening

• Pauses/use of silence

• Minimal prompts/encouragement

• Summarising

The emergence of cuesGoldberg et al 1993; Wilkinson 1991; Maguire et al 1996: Zimmerman et al, 2003

5. Not picking up and exploring cuesLevinson (2000)• patients gave cues throughout the interview from the opening to the closing minute• doctors only responded to patient cues in 38% of cases in surgery and 21% in

primary care • where the cue was missed, half of the patients brought up the same issue a second

or third time and in all of these cases, the physician again missed these further opportunities to respond.

Zimmerman et al (2007) • a systematic review, documenting 58 original quantitative and qualitative research

articles demonstrating patient expressions of cues and/or concerns, all based on the analysis of audio or videotaped medical consultations.

• overall conclusion - physicians missed most cues and adopted behaviours that discouraged disclosure.

Rogers and Todd (2000)• oncologists preferentially listen for and respond to certain disease cues over others • pain amenable to specialist cancer treatment is recognised, other pains are not

acknowledged or dismissed

Are there problems in communication between doctors and patients?• initiating the interview• gathering information• explanation and planning• relationship building

6. Empathy and non-verbal behaviourBuilding the relationship

Plan: Clinical communication teaching - why bother?

Are there solutions to these problems?

Research evidence to validate the use of specific communication skills:• process of the interview

• satisfaction

• recall and understanding

• adherence

• outcome: decreased patient

concern

symptom resolution

physiological outcome

Medico-legal issues

Patients of obstetricians with a high frequency of malpractice claims are more likely to complain of feeling rushed and ignored and receiving inadequate explanation, even by their patients who do not sue. (Hickson et al 1994)

Relationship between judgments of surgeons' voice tone and their malpractice claims history.

(Ambady et al 2002)

Scores achieved in patient-physician communication and clinical decision making on a national licensing examination predicted complaints to medical regulatory authorities

(Tamblyn et al 2007)

The ability to integrate:

• knowledge • communication • physical examination• problem-solving

THE ESSENCE OF CLINICAL PRACTICE

Clinical competence

Research into clinical communication

• More effective interviews: accuracy efficiency supportiveness

• Enhanced patient and health professional satisfaction

• Improved health outcomes for patients

We cannot ignore the central importance of

Effective clinical

communication

High quality healthcareto

Communication is a core clinical skill

Skills and attitudes

Final common pathway = skills

Can you learn communication?

Communication is a clinical skill

It is a series of learnt skills

Experience is a poor teacher

Communication skills teaching and learning is different

• Closely bound to self-esteem, self-concept, personality

• More complex than simpler procedural skills

• No achievement ceiling

• Don’t start from scratch

It can be taught and learnt

We know which methods work

Can you learn communication?

Aspergren K (1999) Teaching and Learning Communication Skills in Medicine: a review with quality grading of articles Medical Teacher 21 (6)

Smith S, Hanson J, Tewksbury L et al (2007)Teaching Patient Communication Skills to Medical Students: a review of randomised controlled trialsEvaluation and the Health Professions 30 (1)

Aspergren K (1999) Teaching and Learning Communication Skills in Medicine: a review with quality grading of articles Medical Teacher 21 (6) Overwhelming evidence for positive effect of

communication training

Medical students, residents, junior doctors, senior doctors

Specialists and general practice equally

How do we change our behaviour in the interview?

Knowledge is important but only allows you to know about communication

Experiential teaching is required to know how to communicate

The need for experiential learning

• active small group or 1:1 learning • observation of learners• video or audio recording and review• well-intentioned feedback • rehearsal

5. Is it retained?

4. Can you learn it?

5. Is it retained?

6. So what is it?

Clinical Communication Skills (CCS)

Key components of CCS• Core medical interviewing skills

• Specific communication issues and challenges

• Communicating with others– relatives– interpreters

• Professional communication skills– other professionals– presentation skills

Martin von Fragstein, Jonathan Silverman, Annie Cushing, Sally Quilligan, Helen Salisbury & Connie

Wiskin on behalf of the UK Council for Clinical Communication Skills Teaching in

Undergraduate Medical Education

UK consensus statement on the content of communication curricula in undergraduate

medical education

Medical Education 200842(11): p. 1100-7

THE CALGARY-CAMBRIDGE GUIDESTO THE MEDICAL INTERVIEW

Kurtz, Silverman and Draper (2005; 2nd Ed.)Teaching and Learning Communication Skills in Medicine Radcliffe Medical Press

Silverman, Kurtz and Draper (2005; 2nd Ed.)Skills for Communicating with Patients Radcliffe Medical Press

Kurtz, Silverman, Benson and Draper (2003) Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides Academic Medicine;78(8):802-809

Initiating the session

Gathering information

Physical examination

Closing the session

Providing structure

Building the relationship

exploration of the patient’s problems to discover the:

biomedical perspective the patient’s perspective

background information - context

providing the correct type and amount of informationaiding accurate recall and understandingachieving a shared understanding: incorporating the

patient’s illness frameworkplanning: shared decision making

Initiating the session

Gathering information

Physical examination

Closing the session

Providing structure

Building the relationship

preparationestablishing initial rapportidentifying the reasons for the consultation

making organisation overt

attending to flow

using appropriate non-verbal behaviour

developing rapport

involving the patient

ensuring appropriate point of closure forward planning

Specific communication issues and challenges

• culture and social diversity • gender • dealing with emotions• age related issues – the elderly, children• the three way interview • breaking bad news• the sexual history• the psychiatric interview• the telephone interview• low literacy patients • sensory impaired patients• death and dying, bereavement• complaints• ethics • health promotion and prevention

INITIATING THE SESSION

Establishing initial rapport

Greets patient and obtains patient’s name Introduces self, role and nature of interview; obtains consent Demonstrates interest, concern and respect, attends to patient’s physical comfort

Identifying the reason(s) for the consultation

Identifies the patient’s problems or the issues that the patient wishes to address with appropriate opening question (e.g. “What problems brought you to the hospital?” Listens attentively to the patient’s opening statement, without interrupting or directing patient’s responseChecks 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

Thank you

How to maintain quality in and develop doctors communication skills

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