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