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How to maintain quality in and develop doctors communication skills
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Transcript of 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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Over 700 half day sessionsEach with an
actor
And a facilitator
Only 5-6 students
Complex audio-visual IT
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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?
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Plan: clinical communication teaching - why bother?
1. Are there problems in communication in medicine?
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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?
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School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Are there problems in communication between doctors and patients?
• initiating the interview• gathering information• explanation and planning• building the relationship
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Are there problems in communication between doctors and patients?• initiating the interview• gathering information• explanation and planning• building the relationship
Cues
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UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Are there problems in communication between doctors and patients?
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Are there problems in communication between doctors and patients?• initiating the interview• gathering information• explanation and planning• relationship building
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
6. Empathy and non-verbal behaviourBuilding the relationship
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Plan: Clinical communication teaching - why bother?
1. Are there problems in communication in medicine?
2. Are there solutions to those problems?
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Are there solutions to these problems?
• initiating the interview• gathering information• explanation and planning• building the relationship• structuring the interview• closing the interview
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Are there solutions to these problems?
• initiating the interview• gathering information• explanation and planning• building the relationship• structuring the interview• closing the interview
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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?
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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)
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
The ability to integrate:
• knowledge • communication • physical examination• problem-solving
THE ESSENCE OF CLINICAL PRACTICE
Clinical competence
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Research into clinical communication
• More effective interviews: accuracy efficiency supportiveness
• Enhanced patient and health professional satisfaction
• Improved health outcomes for patients
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
We cannot ignore the central importance of
Effective clinical
communication
High quality healthcareto
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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?
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Communication is a core clinical skill
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Skills and attitudes
Final common pathway = skills
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Can you learn communication?
Communication is a clinical skill
It is a series of learnt skills
Experience is a poor teacher
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
It can be taught and learnt
We know which methods work
Can you learn communication?
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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?
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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 learn it?
5. Is it retained?
6. So what is it?
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Clinical Communication Skills (CCS)
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
Explanation and planning
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
Explanation and planning
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
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
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Thank you