1. 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

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

3. Objectives: Participants will Larry Mauksch, M.Ed University of Washington Department of Family Medicine

4. Barriers To Learning Patient Centered Communication

5. US Prevalence (2001) of Multiple Risk Factors in Adults ≥ 18 Am J Prev Med 2004 27(2S) 18-24 Number of Risk Factors Estimated US percent 010 133 241 314 43 Mean 1.7 per person Mental Distress High 2.03; Low 1.67 Chronic Disease Yes 1.75; No 1.67

6. Stages of Activation Hibbard et al Health Services Research 2007, 42(4) 1443-63 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

7. Mental Disorders in Primary Care J of Fam Practice 200150(1), 41-47

8. Primary Care Realities

9. Time Demands in Primary Care Am J Public Health. 2003;93:635–64; Ann Fam Med 2005;3:209-214.

10. Why Learn Communication Skills?

11. Teamwork The solution

12. Why Are High Functioning Teams Essential To Primary Care

13. Hierarchy of Interactional Behaviors

14. TEAM COMMUNICATION TRAINING

15. Paired Observation and Video Editing (POVE) Learners work in pairs alternating roles as observer and “doctor” They see 3-6 patients per day for 3 weeks 40-60 patients in all Students use an observation form to structure their vision and feedback Visits videotaped: Students review tapes regularly and learn video editing Students get a series of mini talks on core communication topics Faculty review tapes with students, discuss and respond to questions Student final products: 1) Video essay- show baseline, struggles, growth and mastery 2) Teaching Video- Write, act, film, Edit and teach communication skills

16. 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

17. Please rate your skills on… n = 22 Mean Pre (Retro) Post Net % rating skills higher post course* p* Developing a relationship 3.554.4545.002 Being present 3.504.09 27.056 Agenda setting 2.55 (1.95) 4.2741.004 Eliciting that patient’s world view 2.50(2.14) 3.5945.000 Expressing empathy 3.644.2732.016 Eliciting family, spiritual, cultural influences on behavior 2.553.3236.029

18. Please rate your skills on… MeanPrePost Net % rating skill higher post course* p* Helping patients with health behavior change 2.323.4541.001 Creating a plan with patient investment 2.363.6845.002 Help patients with Mental health / substance abuse 2.323.2341.004 Helping patients with relationship problems 2.183.3645.002 Time management 1.863.3264.000

19. 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

20. 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

21. 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

22. Observation Form Purpose and Training

23. Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Larry Mauksch, M.Ed University of Washington Department of Family Medicine

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

26. Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Larry Mauksch, M.Ed University of Washington Department of Family Medicine

27. Visit Organization

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

29. UW Family Medicine Residency (Mauksch et al Families Systems, Health, 2001) Community RCT Brock, Mauksch et al JGIM, Nov 2011 10 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

30. Agenda Creation

31. Agenda Setting Missteps and corrections

32. Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Larry Mauksch, M.Ed University of Washington Department of Family Medicine

33. Explore the Patient Perspective When:

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

35. Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Larry Mauksch, M.Ed University of Washington Department of Family Medicine

36. Co-creating a Plan

37. The Decision Making Phase

38. Common and Better Video: Faculty development primer

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

40. Communication Training: Why Faculty Development -Egnew TR, Wilson HJ. Patient Educ Couns. May 2009;79(2):199-206. -Egnew TR, Wilson HJ.. Fam Med. Feb 2011;43(2):99-105. 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):661-667.

41. Wenrich, MJ, Jackson, MB., Ajam, KS. et al Academic Medicine. July, 2011. TEACHERS AS LEARNERS: THE IMPACT OF BEDSIDE TEACHING ON THE CLINICAL SKILLS OF CLINICIAN-TEACHERS

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

43. Programmatic Competency Pathway created by Judy Pauwels, MD and Larry Mauksch, M.Ed 43

44. Formative Competency Assessment

45. Atul Gwande, MD New Yorker, Oct 2011 Annals of Medicine Search: “Gwande Coaching” Personal Best: Top athletes and singers have coaches, should you?Gwande Coaching Davidoff F. Music lessons: what musicians can teach doctors (and other health professionals). Ann Intern Med. Mar 15 2011;154(6):426-429.

46. 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?

47. STFM Residency Competency Assessment Toolkit http://www.stfm.org/rctoolkit/

48. Direct observation: Logistics

49. 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

50. Toward Patient Centered Teamwork: Promoting Cultural Change Educational Goal Understand core concepts (Facts; Knowing) Skill learning (Knowing; comprehension ) Enhance self awareness (Doing; application) Team ownership and reinforcement (Doing; analysis) Cultural change (Synthesis) Educational Strategy or Tool Read to create vocabulary Group discusses “Common” and “Better” Video with vocabulary tutoring Rate video with PCOF,Online training to increase vocabulary and skill recognition Maximize structured direct observation: Observe others, be observed Video and rate self Team critique of video Follow patients across team encounter Share learning and establish goals Leaders as video role models, champions System wide training Inter-clinic sharing

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

52. Consenting patients

54. Activity in the room- Entry

55. Activity in the room-Seating Exam table Counter MA/RN MD B A Door

56. Observer behavior during interview

58. Giving Feedback

60. Bibliography Arnold RW, Losh DP, Mauksch LB, et al. Lexicon creation to promote faculty development in medical communication. Patient Educ Couns 2009;74:179-83. 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, 2011. Egnew TR, Mauksch LB, Greer T, Farber SJ. Integrating communication training into a required family medicine clerkship. Acad Med 2004;79:737-43. 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):199-206. Egnew TR, Wilson HJ. Role modeling the doctor-patient relationship in the clinical curriculum. Fam Med. Feb 2011;43(2):99-105. Epstein RM, Mauksch L, Carroll J, Jaen CR. Have you really addressed your patient's concerns? Fam Pract Manag 2008;15:35-40. Kim S, Spielberg F, Mauksch L, et al. Comparing narrative and multiple-choice formats in online communication skill assessment. Med Educ 2009;43:533-41. Losh DP, Mauksch LB, Arnold RW, et al. Teaching inpatient communication skills to medical students: an innovative strategy. Acad Med 2005;80:118-24.

61. 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;168:1387-95. 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;19:147-57. 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;37:184-92. *Weissmann, P., Branch, W. Gracey, et al. Role Modeling Humanistic Behavior: Learning bedside manner from the experts. Academic Medicine, 2006, 81, 661-667