Developing a 4 Year Longitudinal Communications Curriculum for Medical Students — Lessons from Penn State College of Medicine Peter Lewis, MD David Richard, MD Department of Family & Community Medicine Penn State College of Medicine STFM Annual Predoctoral Meeting Jacksonville FL January 30, 2010

Lecture-Discussion Objectives: By the conclusion of today’s lecture-discussion participants will be able to: Identify the associations between patient-centered communication and improved health and educational outcomes. Describe and apply patient-centered communication frameworks with a particular emphasis on motivational interviewing. Describe and apply a 4-Year Longitudinal Communications Curriculum for Medical Students. Partner with Seminar participants regarding the advancement of communications training at their respective medical schools.

Seminar Participants’ Introductions & Dialogue “Check-In”

Review of Evidence Linking Improved Communication Practices with Improved Educational & HealthCare Outcomes “Creating a culture of patient safety—the key is communication” . . . in studies by the Joint Commission on Patient Safety, 60 percent of medical errors are a result of a breakdown in communication. (PSCOM Medical Staff Bulletin Nov. 2009) “Interventions for providers to promote a patient-centered approach in clinical consultations”, Cochrane Review, 2009. Review of 17 studies showed that interventions that promote patient-centeredness lead to significant improvements of patient-centeredness during consultations. Most studies showed improved patient satisfaction. Further research is needed to assess long term changes in behaviors and health outcomes. A meta-analysis of MI (British Journal of General Practice, April, 2005) revealed: 1) a positive effect was noted in 74% of 72 studies; a negative effect in 0%; 2) the likelihood of a positive effect of the intervention increased with the number of sessions (40% with 1 session, 87% if 5 or more sessions); 3) medical doctors could effect change 83% of the time after training as compared to psychologists 79%; 4) positive effects were seen in 72% of studies involving behavioral change such as tobacco cessation, diabetes, weight loss, lipid lowering and asthma.

Relevance to predoctoral education The skills needed for the future delivery of patient-centered medical care in the rediscovered medical home model will increasingly depend upon the ability of medical students and physicians to communicate effectively with patients, family members, peers, and other healthcare professionals. Utilizing core communications skills common to a patient-centered interview such as open-ended questions, affirmation, reflective listening, and summarization as a contrast to the past and too-frequently present model of a biomedical and directive interview that is more physician-centered will enhance rapport building, doctor-patient relationships, ability to elicit the patient’s perspective and other dimensions of healthcare quality.

Traditional Training Biomedical Model Communication is a directive style and approach to patient care Why the patient’s role is central – whose problem is it anyway?

Narrative Techniques (Charon et. al) Review of Communication Systems with an Emphasis on Motivational Interviewing Narrative Techniques (Charon et. al) Institute for Healthcare Communication /Bayer Common Ground (Lang et. al) Relationship, Communication, and Efficiency (RCE) (Mauksch et. al) MI (Miller) and MI in the health care setting (Rollnick) Other(s)

Patient-centered Communication Focuses on the patient perspective Addressing the patient’s agenda is paramount Communication styles – do they matter? Asking LISTENING Informing

Patient-centered Care “If physicians view themselves as experts whose job is to get patients to behave in ways that reflect that expertise, both will continue to be frustrated…Once physicians recognize patients as experts on their own lives, they can add their medical expertise to what patients know about themselves to create a plan that will help patients achieve their goals.” Funnell & Anderson JAMA 2000; 284:1709

Critical: Institutional support for change Review of Process and Content of Communications Curricular Reform at Penn State College of Medicine How do we take a fragmented traditional approach of communications/history-taking into a longitudinal and patient-centered model? Critical: Institutional support for change Grant support – 2 internal Woodward grants (formal faculty training in Motivational Interviewing (MI) and development of videotaped scripts showing MI techniques)and 1 HRSA grant to develop a four year curriculum in communication skills

Integration of Communication Curriculum HRSA grant focused on importance of fundamental changes early in curriculum BUT must see applicability over all 4 years Use of faculty with advanced communication skills training

The FOCUS Foundation of empathy, respect and genuineness OARS (open-ended questions, affirmation, reflective listening, summarization) Communication must be patient-centered Understand the patient’s agenda and perspective – whose problem is it anyway? Skills acquisition and practice

OARS and patient agenda setting are initial focus 4-Year Longitudinal Communications Curriculum at Penn State College of Medicine Year 1 Foundations of Clinical Medicine I – first lecture is the second day of school Small group component begins in the first 2 weeks of school (groups of 10 students assigned to a single faculty for 2 years) OARS and patient agenda setting are initial focus PRACTICE and taping/review with trained standardized patients

Patient Project (led by Humanities Dept.) 4-Year Longitudinal Communications Curriculum at Penn State College of Medicine Year 1 (cont.) Clinical mentoring (physicians from multiple departments—majority in primary care) with faculty in dual role of instructor/advisor Patient Project (led by Humanities Dept.) Social Influences on Health course – how do we communicate with others in unique situations (cross-cultural sensitivity, disabilities, etc) Spring Primary Care Preceptorship Student-Run Free Medical Clinic (LionCare) OSCE

4-Year Longitudinal Communications Curriculum at Penn State College of Medicine Foundations of Clinical Medicine II course Advanced skills taught building upon year 1 experience (motivational interviewing, sexual history, cultural diversity,…) Utilizes plenary sessions, small group work, and standardized patients Continued and increased “real world” experiences in primary care offices and other clinical settings Student-Run Free Medical Clinic (LionCare) Medical Ethics & Professionalism OSCE

4-Year Longitudinal Communications Curriculum at Penn State College of Medicine Designed to address advanced training prior to starting clinical rotations (1 week course) Motivational Interviewing (MI) – specifically as it pertains to tobacco cessation – has been taught for the past 5 years Small Group faculty are all trained in advanced communication skills Plenary session, small group practice and 3 standardized patient encounters are utilized

MI in Behavior Change Curriculum Recognizes the importance of asking permission to discuss a topic Develop discrepancy between the patient’s current behavior and the desired behavior by avoiding argumentation, rolling with resistance, expressing empathy and supporting the patient’s self-efficacy Resist the Righting Reflex by listening to your patient and empowering her to change Rollnick, Miller, Butler “MI in Health Care”, 2008

Data are being collected on student use of MI 4-Year Longitudinal Communications Curriculum at Penn State College of Medicine Year 3 (continued) Completion of Tobacco Cessation Project, following MI training, by end of October Data are being collected on student use of MI Standardized Patient session in Family and Community Medicine clerkship Communications Seminar during Primary Care Clerkship utilizing SPs OSCE

4-Year Longitudinal Communications Curriculum at Penn State College of Medicine Family Medicine Outpatient and Inpatient Acting Internships Paired Observation & VideoEditing (POVE) elective Video Narrative (Humanities Department) CS of USMLE Step 2 Further opportunities?

Post-doctoral (Residency) Training & Faculty CE Family Medicine Residency is formally trained in MI (starting in 2008 with March of Dimes grant for tobacco cessation following pregnancy) in a workshop format Current NIH (NIDDK) grant to train study cohort of faculty in MI in care of patients with diabetes Faculty development utilizing IHC available and encouraged

Limitations Adequate time for student development of skills, particularly in preclinical years Student understanding of the intricacies of communication Mentors who exhibit the tenets of patient-centered communication

Future Curricular Review Academic year 2011 at Penn State a new longitudinal curriculum will be in place Will utilize precepts of the Patient-centered Medical Home Allows continuity of didactics over time and experience with given faculty to solidify patient-centered communication skills

Sharing of Seminar Participants’ Communications Curricula and Teaching What can you share with us about your school’s communication endeavors?

Seminar Participants’ Dialogue “Check-Out”