Strategies for implementing
clinical communication training in
every day practice - how to do it?
Jonathan Silverman
Aarhus
2012
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Bringing the Hidden Curriculum
out of hiding:
Strategies for bridging the gap in
teaching and learning about
communication
EACH St Andrews
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Teaching Communication
Skills in the Context of
Clinical Care
Marcy Rosenbaum, PhD
Dr. Harold A. Myers Distinguished Professor
Associate Professor of Family Medicine
Office of Consultation and Research in Medical
Education
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Why you are so important
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Introduction/reflection
In pairs, discuss what experiences learners may
have with the “hidden curriculum” and their
impact on development and retention of
effective communication
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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.
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Are communication skills and traditional history
taking mutually incompatible?
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
The Leicester OSCE
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Are communication skills and traditional history
taking mutually incompatible?
Have you seen this problem?
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Three elements of gathering clinical
information
How you communicate
Process
Open
Directive
What you discuss,
record and present
Content
What you think and feel
Perception
Biomedical
Patient’s perspective
Clinical reasoning
Feelings
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Three elements of gathering clinical
information
How you communicate
Process
What you discuss,
record and present
Content
Open
Patient’s perspective
What you think and feel
Perception
Feelings
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Three elements of gathering clinical
information
How you communicate
Process
What you discuss,
record and present
Content
What you think and feel
Perception
UNIVERSITY OF
CAMBRIDGE
Directive
Biomedical
Clinical reasoning
School of
Clinical Medicine
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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine

Communication skills teaching
model
versus
Traditional medical history
model
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Confusion over
Process
Content
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Communication model (process)
• Initiating the session
• Gathering information
• Building relationship
• Structuring the interview
• Explanation and planning
• Closing the session
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Confusion between process and content (2):

Communication skills teachers have introduced their
own new content
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
content to be discovered:
the bio-medical perspective
(disease)
sequence of events
symptom analysis
relevant systems review
background information - context
past medical history
drug and allergy history
family history
personal and social history
review of systems
content to be discovered:
the patient’s perspective
(illness experience)
ideas and beliefs
concerns and feelings
expectations
effects on life
content to be discovered:
the bio-medical perspective
(disease)
the patient’s perspective
(illness)
sequence of events
symptom analysis
relevant functional enquiry
ideas and beliefs
concerns
expectations
effects on life
feelings
background information - context
past medical history
drug and allergy history
family history
personal and social history
review of systems
Are communication skills and traditional history
taking mutually incompatible?
So what’s the solution
Effective history taking
is essential to the practice of
high quality medicine
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Effective communication
is essential to the practice of
high quality medicine
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Effective clinical method
is essential to the practice of
high quality medicine
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
• observing senior doctors
• feedback on presentations
• conducting interviews themselves
(Observation and feedback rarely occurs)
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Modeling
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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?”
School of
UNIVERSITY OF
CAMBRIDGE
Clinical Medicine
Staffing
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Cues in Staffing
In 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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Cues in staffing
1.
“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”
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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?
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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.
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Staffing
Additional 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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Observation of learners
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
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
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Observation sheet
Content
(CC, pmh)
Effective behaviors that you
see
Behaviors you don’t’ see or
that could benefit from
change
Greeting
(8:50 am)
introduced self
Didn't mention student status
CC
good eye contact
asked appropriate specifics
("Can you describe that?")
Interrupted too quickly
("daughter…how severe pain")
open-ended questions
PMH
9:05
good paraphrasing
("what I hear you saying…")
UNIVERSITY OF
CAMBRIDGE
no follow-up
(can't afford to be sick)
School of
Clinical Medicine