Communicator - McMaster University`s Faculty of Health Sciences

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CANMEDS
COMMUNICATION SKILLS:
CAN THEY BE TAUGHT?
Robin Dhillon MD MRCS MBA
MAC Ortho Grand Rounds Dec 2011
Acknowledgement
Materials provided by the CANMEDS Train-the-trainer
program, Royal College of Physicians and Surgeons
Lara Cooke – Calgary
Sue Dojeiji – Ottawa
Suzanne Kurtz – Washington
Toni Laidlaw - Halifax
Copyright © 2006 The Royal College of Physicians and Surgeons of Canada.
http://rcpsc.medical.org/canmeds. Reproduced with permission
Objectives



To review the evidence supporting the benefits of
communication skills teaching
To introduce some strategies for teaching
communication skills
To introduce some strategies for evaluating
communication skills
WHY TEACH COMMUNICATION SKILLS?
Communication is a core clinical skill
 Competency required by all medical
licensing bodies
 Estimated 200,000 consultations in a
professional lifetime

Copyright © 2006 The Royal College of Physicians and Surgeons of Canada.
http://rcpsc.medical.org/canmeds. Reproduced with permission
COMMUNICATION PROBLEMS
EXAMPLES OF COMMUNICATION PROBLEMS

Approximately ¼ of patients complete their
opening statement
Average time for patient to complete
opening statement = 36 seconds
“Whoa - way too much information!”
EXAMPLES OF COMMUNICATION PROBLEMS

Doctors frequently interrupt patients
Average time before interruption
Attending = 19- 24 seconds
Resident = 12 seconds
“We’re running a little behind, so I’d like each of you
to ask yourself, ‘Am I really that sick, or would I just
be wasting the doctor’s valuable time?’”
EXAMPLES OF COMMUNICATION PROBLEMS

Doctors often pursue a ‘doctor-centered,’ closed
approach to information gathering
“Ah, Mr. Bromley. Nice to put a face on a disease.”
EXAMPLES OF COMMUNICATION PROBLEMS

Doctors provide less information to patients
than patients want
One quarter to one third of patients report
receiving less information than they want
“There’s no easy way I can tell you this, so I’m
sending you to someone who can.”
EXAMPLES OF COMMUNICATION PROBLEMS


Doctors often use language that patients don’t understand
Doctors rarely ask their patient to volunteer their ideas and
often inhibit their expression
“Let the healing begin!”
EXAMPLES OF COMMUNICATION PROBLEMS

Doctors overestimate the time given to
explanation and planning
“It’s your ear, nose and throat.”
EXAMPLES OF COMMUNICATION PROBLEMS

Patient non-adherence is expensive
$7 – $9 BILLION dollars per year in Canada
“Give it to me straight, Doc. How long do I have to ignore your advice?”
EXAMPLES OF COMMUNICATION PROBLEMS


Numerous reports of patient dissatisfaction
with the patient/doctor relationship
A large percentage of malpractice suits
result from poor communication
2010 CMPA Annual Report
“The doctor is in court on Tuesdays and Wednesdays.”
ACCREDITING BODIES NOW REQUIRE COMMUNICATION
TEACHING FOR ACCREDITATION OF RESIDENCY PROGRAMS



Royal College of Physicians and Surgeons of Canada
(CanMEDS 2000 & Phase IV, 2005)
Accreditation Council for Graduate Medical Education
(2002)
Royal College of General Practitioners (UK, 2004)
COMPARATIVE STUDY OF 9 URBAN HOSPITALS
RE: JOINT REPLACEMENT SURGERY



Some invested heavily in hiring and training for relational
competence (ie, ability to interact with others to accomplish
goals)
Others looked for most highly qualified individuals (neglect of
relational competence most pronounced in physician hiring)
Significant differences were found between hospitals re levels
of coordination among care providers
Hoffer Gittel J 2003, Hoffer-Gittel et al 2000
9 HOSPITAL COMPARATIVE STUDY


Higher coordination between care providers
significantly improved patient care.
Eg, increase in coordination enabled:
 31%
reduction in length of stay
 22% increase in pt perceived quality of care
 7% increase in postoperative relief from pain
 5% increase in postoperative mobility
Hoffer Gittel 2003, Hoffer-Gittel et al, 2000
9 HOSPITAL COMPARATIVE STUDY
Conclusion:
“…those in positions that require high levels of functional expertise also
tend to need high levels of relational competence to integrate their
work with others.”
Hoffer-Gittel et al 2000
“It’s not just individual brilliance that matters anymore.
It’s coordinated effort.”
Participant in Hoffer-Gittel et al 2000 study
Research Findings - EVIDENCE….

Enhancing communication leads to better outcomes:
 understanding & recall
 symptom relief
 adherence & concordance
 physiological outcomes
 patient safety
 patient satisfaction
 doctor satisfaction
 costs
 complaints and malpractice litigation
THE BENEFITS OF GOOD COMMUNICATION

For the physician:
 alleviation
of burnout and stress
 reduced frequency of malpractice complaints
 satisfaction
So…..
Now that we understand the skill is important, how do
we teach AND practice it?
OVERALL GOAL OF ALL COMMUNICATION
TEACHING AND LEARNING

Improving communication in practice to a
professional level of competence
•
•
Behavior = what we do anyway
vs
Professional competence =
awareness & attention
intentionality
ability to reflect on & articulate
and it’s evidence based
2 ESSENTIAL CONTEXTS
FOR COMMUNICATION TEACHING

Formal curriculum
 Dedicated

communication sessions, modules
Informal curriculum
 ‘In-the-moment’
teaching (follow-through in clinic, hospital,
and other real world contexts)
 Modeling (intentional and unintentional)
 ‘Hidden’ curriculum of how students are treated and see us
treating others
WHAT IT TAKES TO LEARN
COMMUNICATION SKILLS, CHANGE BEHAVIOR

Essentials needed:
 systematic
delineation & definition of skills
 observation of learners with patients (video)
 well-intentioned, detailed, descriptive feedback (reflection)
 practice and rehearsal of skills (SP’s, volunteers)
 planned reiteration and deepening of skills
Small group or one-on-one learning format
Incorporation of research, cognitive and attitudinal material
INFORMAL CURRICULUM PROVIDES
FOLLOW THROUGH IN REAL LIFE (or not)





To reinforce and deepen previous learning
To validate applicability in the ‘real world’
To learn new skills
To learn to apply skills & capacities in increasingly
complex situations
To move toward professional level of competence
WHY ARE COMMUNICATION PROCESS SKILLS SO ADAPTABLE?
Context changes
Content changes
Levels of intensity, intention, & awareness shift
BUT
Communication process skills remain the same
from year 1 through clerkship, postgraduate, CME
TYPES OF COMMUNICATION SKILLS

Content skills
- what you say

Process skills
- how you communicate
- how you structure interaction
- how you relate to patients
- nonverbal skills

Perceptual skills - what you are thinking
- what you are feeling
- medical problem solving
- attitudes, assumptions, intentions, biases
- capacities (compassion, mindfulness)
MODELLING IS FUNDAMENTAL TO SUCCESS
OF FORMAL COMMUNICATION PROGRAMS
Students of medicine learn first and foremost from what
they see and experience, rather than from what’s written
in the syllabus…
Suchman and Williamson, 2003
WHAT ARE WE MODELLING?
Skills*
 Attitudes, beliefs, values
 Capacities (eg, compassion, integrity, flexibility,
mindfulness)
In what contexts?

 Difficult
situations (complex case, breaking bad news,
death and dying, medical error, adverse outcomes)
 Everyday run-of-the-mill consultations, patient education
and prevention
Same focus as in formal curriculum
WHAT ARE WE MODELLING?




How we use communication skills and relational
competencies with patients
How we interact with other professionals and support
staff
How we treat the learners themselves
What we choose to focus on and discuss with learners
during rounds & in clinical settings
MODELLING THAT OVERIDES
EFFECTIVE COMMUNICATION



‘Forget that open-ended stuff - we’ll be here all day if you
start there. Just follow the questions I gave you…’
‘Forget about the patient’s problem list - we don’t deal with all
of that. Just go for the chief complaint…’
‘Don’t give me that patient perspective mumbo jumbo - I just
want to know “the facts”…’
MODELLING TO ADVANTAGE - CHALLENGES


Junior doctors’ being there to observe
Inconsistent modelling - some good, some not
 Residents
identified few role models for communication
and relational competence

Infrequency of ‘deliberate’ modelling
 Talking
about communication in a structured way
 ‘Modelers don’t know how to make skills explicit’
 Hesitancy to talk about communication, what’s good

Residents can come up with ‘gestalt’ of what role models are
doing, but don’t see how you do it
TAUGHT SKILL RETENTION
VS DEVELOPMENT WITH EXPERIENCE ALONE

Doctors 5 years out of medical school still strong in information
gathering (taught) but weak in explanation and planning skills
(experience only)
 discovering
pt’s views/expectations - 70% no attempt
 negotiation - 90% no attempt
 encouraging questions - 70 % no attempt
 repetition of advice - 63% no attempt
 checking understanding - 89% no attempt
 categorizing information - 90% no attempt
Maguire et al 1986
DIFFICULTIES OF WORKING IN-THE-MOMENT






Achieving satisfactory re-rehearsal
Obtaining feedback from patients
Discussing sensitive issues in front of patients
Availability of time (patients’ and clinicians’)
Multiplicity of tasks (including patient care)
Wide range of teaching agendas
EXAMPLES OF POSTGRADUATE
MODELLING TO ADVANTAGE

During surgical rounds senior surgeon asked for 2 additional pieces
of information after learner’s presentation of patient:




‘What questions will this patient want me to answer?’
‘What concerns does this patient have that I need to address?’
During bedside teaching, an internal medicine staff doctor explicitly
distinguished between teaching about problem solving and patient
care
Endocrinologist focused attention on what he wanted junior doctors
to emulate




Asked questions about communication just as he did about PE or medical
problem solving or medical technical knowledge
Reflected on what he was doing often
Thought out loud, invited learners to think with him
Talked about his own errors or mistakes and how he handled them
MORE EXAMPLES OF POSTGRADUATE
MODELLING TO ADVANTAGE




Nephrologist invited junior doctors to do a video review
focusing on his communication skills with a patient
Director of orthopedic surgery residency program invited a
communication specialist and residents to do a ‘roast’ focused
on how he communicated with patients
Director of anesthesiology residency program developed a
version of the Calgary-Cambridge Guides for pre-op
interaction with patients and included it in the daily faculty
evaluation protocol for residents (she saw changes in both
faculty and residents, as a result)
When consultations went badly, a senior oncology surgeon read
through the C-C pocket guide to review what he might have
missed re communication skills
AND MORE EXAMPLES




General practice doctor joined forces with an oncologist and a
simulated patient to organize and facilitate lunchtime ‘improve’
simulations based on residents’ current communication dilemmas
Family medicine doctor initiated monthly ‘communication
rounds’ for cross specialty training
Instead of just discussing, senior doctor demonstrated
alternative approach in mini-simulation away from the patient
or with the real patient; asked learners to do same
Junior doctors modeled effective communication and relational
competencies with medical students and then asked questions,
talked about it.
Information Transfer
To improve patient adherence, outcome and patient
satisfaction:

Clear information

Easy to understand

No medical jargon

Mutual expectations

Active patient role

Non-verbal communication
Information Transfer
To improve understanding and recall:

Categorization

Sign-posting

Summarizing

Repetition

Diagrams

Write it down
Information Transfer
Categorization
 “We have 3 ways to manage your mild carpal
tunnel syndrome; first is a night-time splint; second is
an anti-inflammatory; third is a cortisone injection”
 “Lets talk about the splint…”
Information Transfer
Signposting
 “We’ve talked about the splint (option 1), lets talk
about the anti-inflammatory (option 2)…”
Information Transfer
Summarizing
 “So again, the options are the splint, the medication
and the cortisone injection”
 “What do you think of those options?”
Information Transfer
Repetition
 Either you or the patient repeats at the end of the
interview
 Can aid recall by 30%
 “So what are those things we’re going to do for the
carpal tunnel syndrome again?
Information Transfer
Write it down
 Good strategy for complex plan
 Good strategy if cognition a concern
 Good if you’re explaining a procedure to the
patient – they can keep the picture for reference
and questions
Information Transfer
Diagram
 “Here’s a picture of your hand looking at your
palm. These are muscles and bones. Here is the
nerve that going from your forearm to your hand. It
goes through a tunnel made of bone …”
Assessing Communication Skills
Experiences so far

Verbal communication

Challenges

Written communication

Successes – please share!

Barriers
Steps for Assessment
1.
Choose an assessment tool
2.
Learn to use the assessment tool
3.
Review methods for ALOBA
4.
Evaluation and feedback “blueprint”
1. Choose an assessment tool

Defines the objectives
 Curriculum
 Evaluation

Skills based

Validated
Examples of Communication Assessment Tools

Calgary Cambridge Observation Guide

Kalamazoo Checklist

Brown Interview Checklist

SEGUE Framework
CALGARY-CAMBRIDGE GUIDES
FRAMEWORK FOR THE MEDICAL CONSULTATION
Initiating the Session
Providing
Structure
Gathering Information
Building the
Relationship
Physical Examination
Explanation/Planning
Closing the Session
Kurtz, Silverman, Draper (2005)
ADVANTAGES OF C-C GUIDES







Accessible summary of skills - validated
Framework for systematic skill development
Memory aid to keep skills in mind, organized
Basis for comprehensive feedback (no hit and miss) –
consistency across groups
Common foundation for programs at all levels – basis for
helical, coherent curricula
Learners know what’s on the exam get go
Guidance with considerable latitude
Same guide = skills for communicating with patients, colleagues,
learners
2. Learn to use the tool

Read it

Train your assessors (faculty)

Review skills with trainees
 Elicit
the skills
 Video
and discussion
3. Giving feedback - ALOBA
4. Evaluation and feedback “blueprint”

Outline your curriculum and feedback process

Link your objectives with your assessment

Choose your assessment methods

Remember…
 What
are you trying to measure
OSCE with SP

Objective structured clinical examination

Standardized patient

Assessment under controlled settings

Difficult, infrequent or sensitive communication

Components can be evaluated

e.g., Explanation and planning

Feedback provided by examiner and/or SP

Formative and summative
Multiple source feedback

Increasingly being used

Multiple raters
 Patients,
other health professionals, peers

Can be an onerous process

Get information on what you don’t see

Prime team members early on
Portfolios and logbooks

Track ongoing learning of communication competencies

Very good for written communication skills

Discharge summaries

Consultation letters

Operative reports

Promote reflection on practice

Tool for self-directed enhancement

Potential for misrepresentation
IN CLOSING



Communication skills in medicine are more than a
“toolbox” of devices.
Rather, they are a means of developing dialogue and
rapport with patients that enhance human connection.
This human connection is integral in maintaining joy in
practice.
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