QUILT SEMINAR

AN APPRAISAL OF COMMUNICATION TEACHING AT POSTGRADUATE LEVEL

ACROSS HEALTHCARE CURRICULA

SRIKANT SARANGI

Cardiff University

Cardiff University, 10 March 2008

OUTLINE

• Introduction: Health Communication Research Centre (HCRC) and its Remit

• Patient-centredness and the communicative turn in healthcare delivery

• Rethinking `communication’: going beyond skills approach

• Background to the Project: fact finding & (mild) intervention in a consultative paradigm

• An overview of work in progress (Phases 1 & 2)

• Future agenda?

HEALTH COMMUNICATION RESEARCH CENTRE

The Health Communication Research Centre (HCRC) was established in 1997-98 as an interdisciplinary initiative, with a focus on Research and Research-led teaching/training in

healthcare (i) the interactional domain & (ii) the public domain.

www.cardiff.ac.uk/encap/hcrc

healthcom@cardiff.ac.uk

RESEARCH PROJECTS: AN OVERVIEW • Genetic Counselling & Genetic Testing• Genetic explanations, health and identity• Palliative Care• Primary Care: Antibiotics prescription• NHS DIRECT WALES (websites and telephone triage)• HIV/AIDS and Quality of Life• Obesity in the media• Illness narratives: chronic fatigue syndrome; young

people with IBD, Type 1 Diabetes• Professional examinations (OSCE, RCGP)• Problem-Based Learning in medical curriculum• Wales Asylum Seeking and Refugee Doctors (WARD)

programme

• Annual Conference on Communication, Medicine and Ethics (COMET) since 2003

• The Cardiff Lecture Series since 2000 (accessible via website www.cardiff.ac.uk/encap/hcrc

• Annual interdisciplinary workshops

• Annual Summer Schools

• Regular Health and Discourse Seminars (HEADS)

• Teaching/supervision input to medical and healthcare curricula

• Pilot projects in neglected areas of healthcare communication.

• Founding Journal: Communication & Medicine

HIGHLIGHTS OF HCRC ACTIVITIES

CONTRIBUTORS TO FIRST ISSUE

Atkinson, P. (Cardiff University) Barrett, R. J. (University of Adelaide) Cicourel, A. V. (University of California,

San Diego): Frankel, R. M. and Hourigan, N.

(Indiana University School of Medicine) Hamilton, H. E. (Georgetown

University) Hydén, L. and Baggens, C. (Linköping

University): Iedema, R., Sorensen, R., Braithwaite,

J. and Turnbull, E. (University of New South Wales):

Körner, H., Hendry, O., and Kippax, S. Li, H.Z., Krysko, M., Desroches, N.G.

and Deagle, G. (University of Northern British Columbia)

Roberts, C. (King’s College London), Sarangi, S. (Cardiff University) and Moss, B. (King’s College London)

DISCUSSION FORUM - Mishler, E. G. (Harvard Medical School)

COMETCHRONOLOGY

2003 Cardiff2004 Linköping, Sweden2005 Sydney, Australia2006 Cardiff2007 Lugano,

Switzerland2008 Cape Town, S Africa2009 Cardiff2010 Boston, USA2111 Nottingham, UK2112 Gent, Belgium

Return

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PATIENT-CENTREDNESS &

THE COMMUNICATIVE TURN IN HEALTHCARE DELIVERY

PATIENT-CENTREDNESS IN HEALTHCARE DELIVERY

• EVIDENCE-BASED MEDICINE (the dominant biomedical paradigm)

• NARRATIVE-BASED MEDICINE (cf. `ethnomedical perspective’ (Faberga 1975]; `biopsychosocial dimension’ [Engel 1977]; `cultural hermeneutic model’ [Good and Good 1981]; `voice of the lifeworld’ [Mishler 1984])

• PATIENT-ORIENTED EVIDENCE THAT MATTERS (POEM)

• MEDICAL HUMANITIES (ethics, philosophy, art, literature, language/communication etc.)

SETTING THE HEALTH COMMUNICATION SCENE

• Communication as the beneficiary of patient-centredness.

• Highlighting of communication issues in the reform of undergraduate medical training, based on General Medical Council’s (2002) Tomorrow’s Doctors.

• Striving for a balance between core and non-core training (including Interpersonal Communication Skills); also in Continuing Professional Development (see Good Medical Practice, GMC 2001).

• Parallel developments via Royal Colleges and other regulatory bodies.

• Recognition of communication failure leading to complaints/litigation;

• Medical uncertainties about new illnesses demanding new forms of communication;

• Increased level of patient access to health information (the `lay expert’, especially in the context of chronic illnesses).

COMMUNICATION IN HEALTHCARE AGENDA

Good Professional = Good Communicator?

CLIENT TYPES

THE COMMUNICATIVE RELATIONSHIP BETWEEN PROFESSIONAL & CLIENT:

THE CONUNDRUM

Good Communicator = Good Professional??

COMMUNICATION SKILLS: FOR & AGAINST

• Patient-centred communication skills: unveiled ideology or ecological practice?

• Artificial separation of consulting skills and communication skills in professional literature and teaching/training.

• Patient-centred models are measured, for example, by the number of open questions asked, levels of explanation offered on the assumption that patients and healthcare providers share the same communicative resources.

• Patients’ resistance or dispreference: Patients are primarily concerned with professionals’ technical expertise rather than their communication skills. (Burkitt Wright et al 2004)

• Recent critique: A triumph of evangelism over common

sense! There is not much evidence that communication skills training makes a difference. (Williams and Lau 2004)

• Attempt to throw the Communication Baby with the bath water!

• Communication/Discourse studies as an invisible discipline.

QUESTIONING THE RELEVANCE OF COMMUNICATION SKILLS

• Communication is not a PILL: Limitations of recipe-style training in A-to-Z of communication skills which treats symptoms rather than causes; one-sided view of communication where the patient remains absent; potential for de-skilling.

• Communicative Competence is not a driving licence that one passes for life:need for ongoing appraisal to reflect on new challenges.

• Communicative Fallacy: Models of medical interaction analysis work with a notion of form-function equivalence (e.g., open questions = patient-centredness) and thus ignore context sensitivity and the indexical dimension of language use.

COMMUNICATION IS MORE THAN A SET OF DIY SKILLS

• Communication is more than information transfer from sender to receiver via a transparent medium, channel.

• Language form does not determine function.

• There is no one-to-one correspondence between language form and function.

• Meaning is context dependent.

• Communication is jointly accomplished: moving away from a speaker/sender bias.

A BROADER VIEW OF COMMUNICATION

PROFESSIONAL PRACTICE AS EXPERT SYSTEM

• Possible relationship between professional theories and interaction theories (Peräkylä et al 2005)

• Different healthcare sites will prioritise different interactional features based upon their diagnostic and treatment regimes.

• Professionals’ knowledge of interaction is more sophisticated than what textbooks and training programmes suggest.

• Interaction is an essential component of the healthcare expert system. (Sarangi 2005, in press)

C = Code (linguistic, visual, non-verbal etc.)O = OrderlinessM = MessageM = MediationU = UnderstandingN = Narrative Style & StructureI = Inferencing & IntentionalityC = Context (micro- and macro-levels)A = Audience, AddresseeT = Tone (feeling, evaluation, key etc.)I = Identity & RoleO = Objective/GoalN = Norms (social, cultural, interpersonal)

(Sarangi 2004)

COMMUNICATION IS A REPERTOIRE OF VARIABLES

INTRODUCING THE PROJECT

PARTICIPATING SCHOOLS/COLLEAGUES

PARTICIPATING SCHOOLS

School of Medicine Palliative MedicineSchool of Medicine Palliative Medicine

School of HealthcareStudies

School of HealthcareStudies

School of Nursing & Midwifery Studies

School of Nursing & Midwifery Studies

School of MedicineInstitute of Medical

Genetics

School of MedicineInstitute of Medical

Genetics

School of PharmacySchool of Pharmacy

ENCAP

PARTICIPATING SCHOOLS & COLLEAGUES

• School of English Communication & Philosophy: Professor Srikant Sarangi (Director, HCRC)

• School of Medicine: Institute of Medical Genetics: Professor Angus Clarke (Director of MSc in Genetic Counselling); Dr Clara Gaff (Phase 1)

• School of Medicine: Palliative Medicine (Phase 1):

Dr Anthony Byrne (Director of MSc in Palliative Medicine); Professor Ilora Finlay

PARTICIPATING SCHOOLS & COLLEAGUES

• School of Nursing & Midwifery Studies: Dr Annette Lankshear (Director of Graduate Programmes); Dr Fran Baley (Phase 1); Ms Linda Cooper (Phase 2)

• School of Healthcare Studies: Dr Nikki Phillips (Director of MSc in Occupational Therapy, Physiotherapy and Radiography); Dr Tina Gambling; Ms Dinah Sweet; Ms Dawn Pickering

• School of Pharmacy: Dr Delyth James (Director of MSc in Community Pharmacy); Ms Karen Hodson (Director of MSc in Clinical Pharmacy)

MODES OF ENGAGEMENT

• Group Meetings

• Questionnaire data

• Joint data session

• Teaching input

• Co-supervision

• Participation in HEADS seminars, Interdisciplinary

Workshops, Summer Schools

• Recorded discussions with course directors

• Targeted data sessions (planned)

THE SCOPING EXERCISE

SO FAR…

A CHECK-LIST OF PERSPECTIVES

• The historical context

• Role of professional/regulatory bodies

• The institutional ethos

• How is communication conceptualised

• Linkage between postgraduate and

undergraduate provision

• Potential for intervention

• Challenges for implementation

• Avenues for teaching/training-led collaborative

research

THE HISTORICAL CONTEXT

Tracing the origin of communication teaching within each strand.

• Micro-skills training based on different models: psychoanalysis, Rogerian therapy, cognitive behavioural therapy, psychology etc.

• Patient-centredness as the main trigger for foregrounding communication issues

• In Genetic Counselling, given the complexities surrounding genetic disorders with no curative outcomes, and the long tradition of non-directive counselling, the onus has always been on communication issues.

THE ROLE OF PROFESSIONAL BODIES

The role of Professional bodies such as Royal Colleges, GMC, MNC, Department of Health and Learned Associations as well as directives arising out of government policy in bringing about communication teaching. Also recommendations from different Inquiries (e.g., Bristol Inquiry).

• Differential positioning of professional bodies

• Communicative consequences resulting from changes in the professional sphere (e.g. striving towards autonomy: `from taking doctor’s orders to mastering the art of nursing’)

• Levels of communication competencies (e.g. notion of `advanced communication’)

INSTITUTIONAL ETHOS

Rationale underlying current provision in communication teaching. What is included/excluded?

How does the Cardiff provision compare with communication teaching portfolios in other comparable institutions?

• Coverage of oral and written language/communication; sites of communication such as professional-patient encounters, multi-professional team work).

• Perceived fit between the multi-faceted role of communication in professional practice and the ways in which such communicative trajectories are reflected in the curriculum (e.g., current developments in professional practice).

INSTITUTIONAL ETHOS

• Needs-based, practice-led and research-informed (e.g., Pharmacy)

• Remaining responsive to what undergraduates bring with them in terms of knowledge, skills, attitude.

• Requiring prior exposure to professional practice so people make sense of communicative potential (e.g., work placement in Genetic Counselling)

• Flexibility to incorporate new input and design new assessments, thus allowing the possibility of uptake from the current project.

HOW IS COMMUNICATION CONCEPTUALISED?

As a skill-set? Confined to oral interaction between professionals and clients? Can communication skills be taught independent of consulting skills? Any evidence that communication skills teaching makes a difference? If not, is it because how communication is reduced to recipe-style skills?

• From `communication nowhere/somewhere’ to `communication everywhere’.

• Communication across the curriculum as a response to the limitations of recipe-style skills training: from itemised skills to skills clusters.

HOW IS COMMUNICATION CONCEPTUALISED?

• In favour of theme-driven curriculum: Communication now integral to other modules (e.g. diagnostic reasoning, compliance, multi agency/multi professional work)

• This marks a shift in communication as a skill to communication as a host of variables (gender, power, expertise, difficult patient etc.)

• The potential disadvantage associated with the shift of communication from `figure’ status to `ground’ status

• The risk of `taken-for-grantedness’ in the midst of professional concerns

• How to ensure adequate communication analytic

input?

LINKAGE BEWEEN UG & PG PROVISION

Progressive calibration of communication competencies expected of students at different end-points

• `I have done that’ syndrome• `Communication is a joking matter’: possible

trivialisation when drawing attention to basics without content (e.g., nonverbal, dress code etc.)

• The risk of duplication of input, thus making it non-cumulative

• Progressively incorporate complex variables: client-professional to multi-party encounters to multi-professional decision making to managing difficult consultations (complex diagnosis, ethnic/cultural differences etc.)

• More integrated, theme-based at PG level

FUTURE AGENDA?

SUMMARY POINTS

• Healthcare communication is constitutive (not an additive layer) of expert knowledge manifest in its scientific, clinical and organisational dimensions.

• Healthcare professionals have explicit and tacit levels of knowledge about interactional complexity in their specific professional settings.

SUMMARY POINTS

• Striving towards a balance between `check-list approach’, `theoretical approach’, `experiential approach’ and `analytical approach’.

• The analytic processes and outcomes are equally complex; there is a need to recognise different forms of analytic expertise and move towards discriminatory expertise, where possible.

POTENTIAL INTERVENTION & CHALLENGES

• The success story in MSc Genetic Counselling (teaching input and assessment) and its resource implications.

• Signs of change (e.g., MSc programmes in Pharmacy – Community Pharmacy and Clinic Pharmacy; New Nursing programme in Advanced Practice to include a higher dose of communication).

• How to implement an integrated, theme-oriented approach to communication at the level of teaching/assessment (apparent paradox in specific `Away Days’ devoted to communication teaching and role-play based prescriptive model for purposes of

learning and assessment).

POTENTIAL INTERVENTION & CHALLENGES

• Explore further scenario-based teaching (include discourse data [simulated or real-life] embedding professional tasks): layers of context and their analytic significance; comparative cases of `good’ and `bad’ communication; `when things go wrong’ scenarios and their consequence; apprentice-expert encounters; reflective learning potential of self role-plays vs. others-in-interaction.

• From intuitive `sense’ to analytic `sensibility’; shift from `how to communicate’ to `how to analyse communication’: in effect transform teachers’ clinical experience to communication expertise.

• Targeted data sessions planned as part of analytic capacity building in the spirit of complementary expertise.

POTENTIAL INTERVENTION & CHALLENGES

• How to translate descriptive, analytic insights into communication competencies for assessment purposes.

• Reaching beyond `already converts’ (communicatively speaking!)

• Widening access via continued participation in summer schools, workshops, HEADS seminars.

• Develop bibliographies of communication-based studies in each area.

• Maintain a portfolio of co-teaching and co-supervision.

AVENUES FOR COLLABORATIVE RESEARCH

• Value of teaching/training led research agenda, triggered by professional concerns.

• Such research will inevitably have impact on teaching and professional practice (e.g., Medication Review in Pharmacy).

• Analytic frameworks already exist which can be extended to different sites with minimum effort.

• Dissemination of findings in journals and at conferences (e.g., integrating communication skills and counselling skills in genetic counselling courses).

CHALLENGES FACING THE FUTURE AGENDA

• Negotiation of curricular space for communication (e.g., integration as core skill can lead to neglect).

• Responsiveness of students to new modes of teaching communication.

• Staffing resources [SS] and training of trainers.

• Difficulty in sustaining the ongoing programme of activities: the current inter-school scenario (in terms of losers and gainers) and lack of support.

• Can the barriers (not `obstacles’) be addressed at the university level?