How to maintain quality in and develop doctors communication skills

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE “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

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Over 700 half day sessions Each with an actor And a facilitator Only 5-6 students Complex audio- visual IT

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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?

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan: clinical communication teaching - why bother? 1.Are there problems in communication in medicine?

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Are there problems in communication between doctors and patients? initiating the interview gathering information explanation and planning building the relationship structuring the interview closing the interview what different communication patterns do you see? what outcome do you predict the patterns will have on whether the interview is effective? VTS_05_1.VOB VTS_06_1.VOB

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Initiating the interview 1. Not discovering the reasons for the patient's attendance Gathering information 2. Early closed questioning preventing listening Clinical hypo-competence

 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

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Are there problems in communication between doctors and patients? initiating the interview gathering information explanation and planning building the relationship

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Are there problems in communication between doctors and patients? initiating the interview gathering information explanation and planning building the relationship Cues

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Facilitative skills Open questions Open directive questions Listening Pauses/use of silence Minimal prompts/encouragement Summarising The emergence of cues Goldberg et al 1993; Wilkinson 1991; Maguire et al 1996: Zimmerman et al, 2003

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Are there problems in communication between doctors and patients?

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Are there problems in communication between doctors and patients? initiating the interview gathering information explanation and planning relationship building

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 6. Empathy and non-verbal behaviour Building the relationship

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan: Clinical communication teaching - why bother? 1.Are there problems in communication in medicine? 2.Are there solutions to those problems?

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Are there solutions to these problems? initiating the interview gathering information explanation and planning building the relationship structuring the interview closing the interview

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Are there solutions to these problems? initiating the interview gathering information explanation and planning building the relationship structuring the interview closing the interview

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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?

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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

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)

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE The ability to integrate: knowledge communication physical examination problem-solving THE ESSENCE OF CLINICAL PRACTICE Clinical competence

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Research into clinical communication More effective interviews: accuracy efficiency supportiveness Enhanced patient and health professional satisfaction Improved health outcomes for patients

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE We cannot ignore the central importance of Effective clinical communication High quality healthcare to

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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?

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Communication is a core clinical skill

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Skills and attitudes Final common pathway = skills

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Can you learn communication? Communication is a clinical skill It is a series of learnt skills Experience is a poor teacher

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE It can be taught and learnt We know which methods work Can you learn communication?

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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)

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

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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?

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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?

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Clinical Communication Skills (CCS)

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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 (11): p

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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):

Initiating the session Gathering information Physical examination Explanation and planning Closing the session Providing structure Building the relationship

exploration of the patient’s problems to discover the:  biomedical perspective  the patient’s perspective  background information - context 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 Initiating the session Gathering information Physical examination Explanation and planning Closing the session Providing structure Building the relationship preparation establishing initial rapport identifying the reasons for the consultation making organisation overt attending to flow using appropriate non-verbal behaviour developing rapport involving the patient ensuring appropriate point of closure forward planning

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 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

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

School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Thank you