Strategies And Tools to Teach Patient Centered Interactions: Larry Mauksch, M.Ed Senior Lecturer Department of Family Medicine University of Washington Consultant and Trainer Blending Efficiency And Quality

Goals Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Barriers To Learning Patient Centered Communication

US Prevalence (2001) of Multiple Risk Factors in Adults ≥ 18 Am J Prev Med (2S) Number of Risk Factors Estimated US percent Mean 1.7 per person Mental Distress High 2.03; Low 1.67 Chronic Disease Yes 1.75; No 1.67

Stages of Activation Hibbard et al Health Services Research 2007, 42(4) Level of activation (age 45 or older, 2.9 chronic conditions) diabetes, HTN, lung, cholesterol, arthritis, heart Percent (cumulative) May be overwhelmed and unprepared to play an active role in their own health 12 May lack knowledge and confidence about self management 29 (41) Taking action but may lack confidence and skill to support self management 37 (78) Mastered self management but may not maintain behaviors at times of stress 22

Mental Disorders in Primary Care J of Fam Practice (1), 41-47

Primary Care Realities

Time Demands in Primary Care Am J Public Health. 2003;93:635–64; Ann Fam Med 2005;3:

Why Learn Communication Skills?

Teamwork The solution

Estimating Panel Size in Primary Care with Team-Based Task Delegation Ann Fam Med (5)

Why Are High Functioning Teams Essential To Primary Care

Hierarchy of Interactional Behaviors

Transdisciplinary Functions and Roles in Primary Care Role Function PCPNurseMedical Assistant PharmBehavioral health Care Management Relationship Agenda setting and activation Self management- simple Self management- complex Primary care counseling Plan confirmation and care integration Proactive follow-up and stepped care Intensity: 5 =always; 4= often; 3 = periodic; 2 = support; 1 = reinforce and connect Larry Mauksch, M.Ed UW Family Medicine

Relationship Communication and Efficiency: Creating a clinical model from a literature review Mauksch et al, July , Arch of Intern Med SMS: problem solving

Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Polite Interruption Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Observation Form Purpose and Training

Relationship Communication and Efficiency Mauksch et al, July , Arch of Intern Med

Visit Organization

Upfront Collaborative Agenda Setting Brock, Mauksch, et al. JGIM, Nov, 2011; Mauksch et al, Fam, Syst, Health, 2001

UW Family Medicine Residency (Mauksch et al Families Systems, Health, 2001) Community RCT Brock, Mauksch et al JGIM, Nov Residents; 7 faculty 162 patients48 physicians, 1460 patients; two systems Brief reading, video, written learning confirmation, skill reinforcement 2 hr training w/demo & practice; handout, 2 hrs coaching/wk for 4 weeks, no reinforcement for 6 months Higher patient satisfaction More MD prioritization MDs charted more problems More f/u requests No difference in visit lengths EF MDs showed more upfront elicitations (“something else”*) EF Patients more likely to say “that’s it” EF Patients & MDs had fewer “oh by the ways” Shorter visits 90 seconds (NS) No diff in pt / MD satisfaction

Agenda Creation

Diving or Agenda Setting

Agenda Setting Missteps and corrections

Relationship Communication and Efficiency Mauksch et al, July , Arch of Intern Med Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Explore the Patient Perspective When:

Exploring Patient Perspective: Core Skills and attitudes Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Relationship Communication and Efficiency Mauksch et al, July , Arch of Intern Med Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Co-creating a Plan

The Decision Making Phase

Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Communication Training: Why Faculty Development -Egnew TR, Wilson HJ. Patient Educ Couns. May 2009;79(2): Egnew TR, Wilson HJ.. Fam Med. Feb 2011;43(2): Holmboe ES, Ward DS, Reznick RK, et al. Acad Med. 2011;86(4):1-8. Weissmann PF, Branch, WT, Gracey, CF., et al Acad Med. Jul 2006;81(7):

Wenrich, MJ, Jackson, MB., Ajam, KS. et al Academic Medicine. July, TEACHERS AS LEARNERS: THE IMPACT OF BEDSIDE TEACHING ON THE CLINICAL SKILLS OF CLINICIAN-TEACHERS

STFM Residency Competency Assessment Toolkit

Henry SG, Holmboe ES, Frankel RM. Evidence-based competencies for improving communication skills in graduate medical education: A review with suggestions for implementation Med Teacher May 2013 Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Interdisciplinary Direct-Observation Precepting Model (2x2) Valerie Ross MS, Larry Mauksch, M.Ed Mark Beard MD, Jane Huntington MD (in press, May 2012, Family Medicine) What topics were discussed in precepting after being observed that would not have been addressed in traditional precepting?

Direct Observation: Methods, Time Demand, Pros and Cons Faculty Time Demand Educational Pros Educational Cons Direct observation in the room High Loss of income or other activity Clear view Can teach on the fly Trainee initially self conscious Risk of upstaging relationship Video reviewHigh Loss of income or other activity Trainee self observes, strong educational options Delayed practice Requires technical expertise and expense Closed circuitModerate Some income loss or other activity Fast practice Faculty development Distraction, time limitation, Reliability? PeerVery Low++Observations ++reflection ++Practice Less depth versatility Reliability? You are observedLowRole modeling Observer self Faculty growth Passive trainee role

TEAM COMMUNICATION TRAINING

Common Training Sequence Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Patient Template: Teamlet training Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Design, Dissemination, and Evaluation of an Advanced Communication Elective at Seven U.S. Medical Schools Larry Mauksch, MEd, Stuart Farber, MD, and H. Thomas Greer, MD Academic Medicine, (currently online ahead of print- to be published, June 2013)  Primary site directors: Kristin Bell MD, Kathy Zoppi PhD, MPH, Peter Lewis MD, Alan Adelman MD, David Henderson MD, Samuel Romano PhD, Jill Fenske MD, Len Hass PhD, Gail Marion PA-C, PhD, William McCann, PsyD  Funded by Arthur Vining Davis Foundations Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Please rate your skills a) before, b) after, c) looking back prior to the start 1= very poor 2= some skill use but awkward 3= comfortable with skill use 4= strong and confident 5= highly competent and creative

Please rate your skills on… n = 22 Mean Pre (Retro) Post Net % rating skills higher post course* p* Developing a relationship Being present Agenda setting 2.55 (1.95) Eliciting that patient’s world view 2.50(2.14) Expressing empathy Eliciting family, spiritual, cultural influences on behavior

Please rate your skills on… MeanPrePost Net % rating skill higher post course* p* Helping patients with health behavior change Creating a plan with patient investment Help patients with Mental health / substance abuse Helping patients with relationship problems Time management

Student Feedback: POVE Course Components 1. Detracted from my educational experience 2. Neutral value 3. Mild value 4. Moderate value 5. Strong Value 6. Highest Value

Student Feedback: POVE Course Components Reviewing video with faculty 5.60 Repeated skill practice with real patients 5.30 Reviewing video with partner 5.20 Being observed-feedback from primary faculty 5.10 Observing partner and categorizing behavior 4.90 Being observed- feedback from partner 4.80

Student Feedback: POVE Course Components Creating a video essay 4.70 Didactic presentations 4.40 Creating teaching tape 4.30 Being observed, getting feedback from other faculty 3.80 Reading material 3.60

Common and Better Video: Faculty development primer

Bibliography Arnold RW, Losh DP, Mauksch LB, et al. Lexicon creation to promote faculty development in medical communication. Patient Educ Couns 2009;74: Brock DM, Mauksch LB, Witteborn S, Hummel J, Nagasawa P, Robins LS. Effectiveness of Intensive Physician Training in Upfront Agenda Setting. J Gen Intern Med. Nov, Chunchu K, Mauksch L, Charles C, Ross V, Pauwels J. A patient centered care plan in the EHR: improving collaboration and engagement. Fam Syst Health. Sep 2012;30(3): Egnew TR, Mauksch LB, Greer T, Farber SJ. Integrating communication training into a required family medicine clerkship. Acad Med 2004;79: Egnew TR, Wilson HJ. Faculty and medical students' perceptions of teaching and learning about the doctor-patient relationship. Patient Educ Couns. May 2009;79(2): Egnew TR, Wilson HJ. Role modeling the doctor-patient relationship in the clinical curriculum. Fam Med. Feb 2011;43(2): Epstein RM, Mauksch L, Carroll J, Jaen CR. Have you really addressed your patient's concerns? Fam Pract Manag 2008;15: Losh DP, Mauksch LB, Arnold RW, et al. Teaching inpatient communication skills to medical students: an innovative strategy. Acad Med 2005;80:

Bibliography Continued Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, Communication, and Efficiency in the Medical Encounter: Creating a Clinical Model From a Literature Review. Arch Intern Med 2008;168: Mauksch LB, Hillenburg L, Robins L. The established focus protocol: training for collaborative agenda setting and time management in the medical interview. Families, Systems and Health 2001;19: Mauksch L, Farber S, Greer HT. Design, Dissemination, and Evaluation of an Advanced Communication Elective at Seven U.S. Medical Schools. Acad Med. Apr Mauksch, L., Safford, B. Engaging Patients in Collaborative Care Plans, Family Practice Management, in press (May-June 2013) Robins, L. Wittetborn, S., Miner, L. Mauksch, L. Edwards, K. Brock, D. Identifying Transparency in Physician Communication, Patient Education and Counselling, in press Ross, V., Mauksch, L., Huntington, J., Beard, M. Interdisciplinary Direct Observation: Impact on precepting, residents, and faculty, Family Medicine, in press. Schirmer JM, Mauksch L, Lang F, et al. Assessing communication competence: a review of current tools. Fam Med 2005;37: