EXPLANATION AND
PLANNING PILOT
SEMINAR
2005-2006
TUTOR NOTES
Communication teaching year 3
Seminar on Explanation and planning
Revised seminar developed by Shazli Khan, Andrew Bartlam, Simon Cocksedge
September 2005
The aims of this pilot seminar are to remind students of basic communication skills within
the Calgary Cambridge framework and to move them on from gathering information to
consider the explanation and planning part of the interview.
The session aims to be lively and fast moving using a variety of different styles of small
group teaching.
The lead tutor needs to let the students know at least 1 week prior to the session that we
will be covering asthma and gastroscopy.
Materials required – tutor, flip chart, simulated patient, placebo inhaler, Peak Flow chart
(male/female), handouts, copies of roles for students.
Objectives of the Session
 To be familiar with a framework to use for consultation skills
 To understand the importance of the explanation and planning part of the interview.
 To be able to gauge the amount and type of information to give a patient.
 To be able to provide explanations that are simple and easy to remember.
 To understand the importance of relating the explanation to the patients perspective
 To develop a shared understanding of the problem with your patient (relating the
explanation to the patients perspective)
 To involve the patient with planning to the extent that the patient feels comfortable.
 To continue to build the relationship and support the patient, empathetically.
Overview & timings
00:00
14:30
00:05
14:35
00:15
14:45
00:35
15:05
00:55
15:25
1:05
15:35
1:20
15:50
2:20
16:50
2:30
Group Introductions
Brain storm on communication skills learnt so far
Group discussion on Calgary-Cambridge: Revision of Calgary-Cambridge
using posters. Explain objectives of today’s session and its place in the CalgaryCambridge framework.
Group discussion on Explanation and Planning
a) WHY – tutor can use references that are in the hand-out, do this as a brainstorm using the group as a whole
b) HOW - divide the students into pairs and get them to brain-storm how to give
explanations and how to plan management with patients. Then get each group to
present the results of their discussion to the rest of the group.
NB. Give handout out at the end!
Role-play: Explaining Gastroscopy - Student sheet and patient sheet.
Explain the task to the students
Get the students into groups of no more than three (student, patient, observer).
The student has met a patient on the day unit who they had seen whilst in general
practice. The patient is unclear about gastroscopy and the student has to try to
explain the procedure using the skills they discussed earlier. Observers to note
down things that work or don’t work. Reflect in trios on how this went.
Group-feedback
Reflect on the role-play session linking theory with what the students have come
up with. Then go on to introduce the next session.
Break
SP role
Give each student has a student information sheet. The students will be acting as
a ‘collective’ medical student - taking it in turns to talk with/ask questions of the
SP, ideally sitting near the SP. They should have a chance to practice interpreting
the peak flow results, explaining the diagnosis of asthma. They should also have
the opportunity to explain how the treatment works (blue inhaler only) and to
demonstrate how to use an inhaler. After each student’s contribution, pause and
reflect on the moment. Do not forget to use the instant feedback from the SP. Try
to get positive comments first before what can be done differently. The turnover
of students should be rapid.
Summary and Close: What are the main learning points – go round the
group asking them to say one thing they have learnt
Make sure you give the handouts to the students at the end.
Students to do evaluation sheets before they go. Suggest speaking to asthma
nurse at practice for more inhaler information.
End – tutor’s meeting if arranged
Explanation and planning - Gastroscopy Role
Patient Sheet
You have come to the day case unit for a gastroscopy. You are in your early forties
and have a 1 year history of intermittent heartburn. The symptoms are worse after
food (particularly fatty food) and on lying flat in bed. You have tried some
medication from the chemist and your GP to no effect (you cannot remember the
names).
Your GP said that you needed to have procedure to look into your stomach and check
it out.
You smoke 40 per day, drink 6 units daily as well as having 2 kids and a spouse.
You are worried as you did not really understand what the procedure entails and were
too anxious to ask the Dr for more details and signed the consent anyway. You are
also worried as you had a terrible general anaesthetic when you had a broken arm
pinned 20 years ago (very sick afterwards). Also one of your great aunts had cancer
of the stomach and she was a heavy smoker too. Also, will you need an operation
afterwards? You don’t know what they are looking for, but are scared that they could
find something serious.
You have spotted one of the medical students you spoke to after your GP told you that
you needed this procedure. You are hoping they can help you understand.
Explanation and planning – Gastroscopy Role
Student Sheet
You are spending the day on the day case unit, speaking to patients and then
observing the procedures they are having done. You spot a patient who you
interviewed at your GP placement, who is hailing you over.
You remember something about him/her having dyspepsia and the GP wanting him to
undergo a gastroscopy. You wonder what he/she wants.
STUDENT INFORMATION – Mr/Mrs Williams
You will be following the same patient during 2 consultations. They
have been given a new diagnosis of asthma. You will be giving
information and planning management. There are specific tasks at
each consultation but at each stage consider;
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How to provide the correct amount and type of information
How to aid recall and understanding
How to achieve a shared understanding
How to achieve a shared decision
1st Consultation
You will be seeing a patient who has seen the GP recently complaining of breathing
problems. They have had tests done (charted own PEFR) which show the likely
diagnosis is asthma [the PEFR readings are 35% below predicted]. The patient is
attending their follow up appointment – you are on your community day and your GP
has asked you to see this patient before he/she sees the GP. You will be working as
a group interviewing this SP – ie you will take it in turns to talk with this patient.
Specific Tasks
1. Establish the reasons for visit
2. Explain the test results
3. Explain the diagnosis
4. Describe the treatment (salbutamol only)
5. Describe how blue inhalers work
6. Demonstrate a blue inhaler
EXPLANATION AND PLANNING SESSION – HANDOUT
Why are explanation and planning important?
By now you should be comfortable with the gathering information part of the
interview and be developing a sound knowledge base with which to formulate
differential diagnoses. However this all goes to waste if you cannot explain the
diagnosis, investigations and treatment to the patient and achieve a shared
understanding. The evidence backs this up:
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
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Boreham and Gibson (1978) – Australian general practice study showed that despite a
lack of basic knowledge in the patient and a strongly expressed desire to gain
information about their illness, the majority of patients did not obtain even basic
information concerning the diagnosis, prognosis, causation or treatment of their
condition.
Tuckett at al (1985) – only 10% of patients failed to recall key points from a
consultation- refuted earlier prejudice that it is not worth telling patient’s much as they
recall little
Hall et al (1988) – reviwed evidence and found that the amount of information imparted
by physicians was the most dramatic positive predictor of patient satisfaction,
compliance, recall and understanding,
Kindelan and Kent (1987) – study showed patients in UK general practice placed the
highest value on information about diagnosis, prognosis and causation, but doctors
overestimated desire for treatment information.
Stewart (1995) – pre-operative education from an anaesthetist about post-operative pain
control  less use of analgesia and shorter in-patient stays.
Haynes (1996) Between 10-90% (average 50%) of patients do not take drugs as
prescribed by their doctor.
Nekhyludov et al (2005) – study of women prior to their 1st screening mammogram
74% wanted to be involved in decision making regarding their participation in screening
How do you give information?
Provide the correct amount and type of
information at the right time
 Chunk and check
 Assess patient’s starting point
 Ask patient what other information
would be helpful
 Give explanation at appropriate times:
avoid giving advice or reassurance
prematurely.
 Check patient feels able to converse ie
not tired, in pain, anxious, nauseated etc
Aid accurate recall and understanding
 Organise explanations
 Use categorisation or sign-posting
 Use repetition and summarising –
especially to check at the end
 Appropriate language: concise easily
understood statements, avoid jargon
 Use visual methods for conveying
information eg leaflets, diagrams
 Check patients’ understanding of
information or plans made: get the
patient to restate in their own words
Achieving a shared understanding: incorporating
the patient’s perspective
 Link explanations to patient’s illness
framework/existing knowledge:
previously elicited ideas, concerns and
explanations.
 Provide opportunities and encourages
patient to contribute
 Pick up & respond to verbal and nonverbal cues
 Elicit patient’s beliefs, reactions and
feelings
Planning: Shared decision making
 Share own thinking as appropriate
 Involve the patient –do not give
directives, offer suggestions and choices,
listen to patient’s ideas
 Explore management options
 Ascertain the level of involvement
patient wishes to have in decision
making
 Negotiate a mutually acceptable plan
 Check with the patient – if accepts plan,
and all concerns have been addressed
Simulated Patient Script Asthma
Simulated patient role – explanation & planning
Patient’s name
Setting
Mr/Mrs John/Jane
Williams
GP surgery
Course
Sessions
Age
Sex
Other info
Explanation and
Planning
M/F
You will remain with the same small group for the session.
Background
You are a full time teacher in a primary school. You teach mainly 7-8 year
olds and have always enjoyed work. You consider yourself generally fit
although most winters you get a cold which “goes onto your chest” and you
see your GP. You smoke 20 cigarettes a day and have done for x years
(make it up). You don’t do much exercise as it makes your chest feel tight.
You are otherwise fit and well but do get occasional flare ups of eczema for
which the GP gives you creams.
Current Situation
You have had a recent cold but ended up being short of breath when walking
the dog, and your partner has noticed you wheezing. You have had the dog
for a long time and don’t think his presence has any affect on your breathing.
Your partner complains that you cough at night and your doctor had given you
a grey tube to blow into to measure the strength of your breath which you
checked morning and evening for 2 weeks. You plotted the results and
handed them in last week.
1st Consultation
The students will be working as a group for this consultation and each asking
you questions in turn. The students are practising explaining a diagnosis and
giving further information. You are happy to see the student for an explanation
of your test results. The student will not talk about treatment but will state that
the GP will be seeing them next to discuss this.
You have attended to see your GP for the result of the test & are keen to
know the results. The students have been asked to see to you by your GP
before you go in to see your GP.
You will be told that you have asthma. We expect they will talk a lot during this
role – if you are unsure ask questions about what they tell you. You may have
considered whether this is a hereditary problem, as you have children and are
concerned for them. No one else in your family has had asthma and you
really do not know much about it except for the fact that it affects your
breathing, and can be severe – you once saw a child from school rushed in to
hospital gasping for breath who did not come home for several days. Also you
have read about people dying from asthma. You are interested in health
problems and are keen to have as much information as possible – in
particular, you would like to know what asthma does to the lungs. You will
consider stopping smoking.
The students will also explain to you how to treat asthma, and should describe
blue inhalers only.
You want the student to explain how to use the inhalers, how it works and
when to use it. You also want to know what are the options if your breathing
worsens – “do you need to go to hospital?” You are happy for the student to
explain things to you. If you know anything about inhalers pretend that you
don’t and, if asked to use the placebo inhaler, please use it badly!
The Calgary – Cambridge
Framework
Our aim is to develop your skills as students so you can be both effective
diagnosticians and excellent communicators. Too much emphasis on one
without the other can give confusing messages. At this stage of your
career development, knowledge of diseases is limited, so we can focus
more on the process of communication. However, we want you to learn
these skills within a framework that will still be useful when you acquire
more knowledge of disease. This is why we have adopted the CalgaryCambridge framework, which is used in a large number of medical
schools across the world. It has many similarities with the model
Manchester have been using for the last few years.
Initiating the Session
• preparation
• establishing initial rapport
• identifying the reason(s) for the consultation
Gathering information
Providing
• exploration of the patient’s problems to discover the:
Structure
 biomedical perspective
• making
organisation
overt
Building the
relationship
 the patient’s perspective
 background information - context
•
using
appropriate
non-verbal
behaviour
•
developing
rapport
•
involving
the patient
Physical examination
• attending to
flow
Explanation and planning
• providing the correct amount and type 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
We have adapted this framework with the kind permission of Dr Jonathan Silverman,
University of Cambridge