How to maintain quality in and develop doctors communication skills “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 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Each with an actor And a Over 700 facilitator half day sessions Only 5-6 students Complex audiovisual IT UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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? UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Plan: clinical communication teaching - why bother? 1. Are there problems in communication in medicine? UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Are there problems in communication between doctors and patients? • initiating the interview • gathering information • explanation and planning • building the relationship • structuring the interview • what different communication patterns do you see? • what outcome do you predict the patterns will have on whether the interview is effective? • closing the interview UNIVERSITY OF CAMBRIDGE School of Clinical Medicine VTS_05_1.VOB VTS_06_1.VOB Initiating the interview 1. Not discovering the reasons for the patient's attendance Gathering information 2. Early closed questioning preventing listening Clinical hypo-competence UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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 Are there problems in communication between doctors and patients? • initiating the interview • gathering information • explanation and planning • building the relationship UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Are there problems in communication between doctors and patients? • initiating the interview • gathering information • explanation and planning Cues • building the relationship UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Facilitative skills • Open questions • Open directive questions • Listening • Pauses/use of silence • Minimal prompts/encouragement • Summarising Goldberg et al 1993; Wilkinson 1991; Maguire et al 1996: Zimmerman et al, 2003 UNIVERSITY OF CAMBRIDGE The emergence of cues School of Clinical Medicine 5. Not picking up and exploring cues Levinson (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 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Are there problems in communication between doctors and patients? UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Are there problems in communication between doctors and patients? • initiating the interview • gathering information • explanation and planning • relationship building UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Building the relationship 6. Empathy and non-verbal behaviour UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Plan: Clinical communication teaching - why bother? 1. Are there problems in communication in medicine? 2. Are there solutions to those problems? UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Are there solutions to these problems? • initiating the interview • gathering information • explanation and planning • building the relationship • structuring the interview • closing the interview UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Are there solutions to these problems? • initiating the interview • gathering information • explanation and planning • building the relationship • structuring the interview • closing the interview UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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? UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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) Clinical competence The ability to integrate: • knowledge • communication • physical examination • problem-solving THE ESSENCE OF CLINICAL PRACTICE UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Research into clinical communication • More effective interviews: accuracy efficiency supportiveness • Enhanced patient and health professional satisfaction • Improved health outcomes for patients UNIVERSITY OF CAMBRIDGE School of Clinical Medicine We cannot ignore the central importance of Effective clinical communication UNIVERSITY OF CAMBRIDGE to High quality healthcare School of Clinical Medicine 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? UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Communication is a core clinical skill UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Skills and attitudes Final common pathway = skills UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Can you learn communication? Communication is a clinical skill It is a series of learnt skills Experience is a poor teacher UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Can you learn communication? It can be taught and learnt We know which methods work UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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 trials Evaluation and the Health Professions 30 (1) UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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? UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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? UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Clinical Communication Skills (CCS) UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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 2008 42(11): p. 1100-7 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine UNIVERSITY OF CAMBRIDGE School of Clinical Medicine THE CALGARY-CAMBRIDGE GUIDES TO 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 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine Initiating the session Gathering information Providing structure Physical examination Explanation and planning Closing the session Building the relationship Initiating the session preparation establishing initial rapport identifying the reasons for the consultation Providing structure making organisation overt attending to flow Gathering information exploration of the patient’s problems to discover the: Building the relationship biomedical perspective the patient’s perspective background information - context Physical examination Explanation and planning providing the correct type and amount of information aiding accurate recall and understanding achieving a shared understanding: incorporating the patient’s illness framework planning: shared decision making Closing the session ensuring appropriate point of closure forward planning using appropriate non-verbal behaviour developing rapport involving the patient 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 UNIVERSITY OF CAMBRIDGE School of Clinical Medicine 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 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 Thank you UNIVERSITY OF CAMBRIDGE School of Clinical Medicine