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

2. Disclosures  Receive consultation fees and honoraria for consultation and training provided to academic and health care organizations with a focus on communication, teamwork, competency assessment, self management support  Co-owner of MedFAD.com, a for profit competency assessment software company Larry Mauksch, M.Ed University of Washington Department of Family Medicine

3. Objectives 1) Participants will learn a Communication, Relationship and Efficiency model based on a published literature review 2) Participants will learn to use the Patient Centered Observation Form (PCOF) for training students, residents and faculty 3) Participants will be able to design a competency based curriculum using direct observation and teamwork focused on interpersonal and communication skills.

4. Communication Training: Why Faculty Development Most physician faculty(others), too) including humanistic role models, lack the vocabulary to describe how they communicate. A lack of training in [communication] assessment reduces inter rater reliability and is confusing to trainees There is a disconnect between communication skills taught in early medical school and what trainees observe in clinical settings Faculty may be be reluctant to assess because they suffer from evaluation PTSD -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.

5. It is more about you than the tool van der Vleuten et al The assessment of professional competence: building blocks for theory development. Best Pract Res Clin Obstet Gynaecol. Dec 2010;24(6):703-719 Trained faculty offer formative assessment influenced by context and focused on need in ways that checklists can not provide Multiple observations with purposeful sampling by multiple expert raters offering authentic assessments may provide a more valid picture of “does” than quantitative tools

6. Miller’s Assessment Pyramid Contextual assessment Entrustable professional activities Qualitative measure relying on faculty expertise Does Discrete KSAs Standardized Discrete tools Shows how Knows How Knows Impact on the patient Miller, G. E. The assessment of clinical skills/competence/performance. 1990 Acad Med 65(9 Suppl): S63-7. Van Vleuten and Schuwirth. Assessing professional competence: from methods to program. Medical Education, 2005, 309-17 6

7. Henry, Holmboe, Frankel. Evidence-based competencies for improving communication skills in graduate medical education: A review with suggestions for implementation. Med Teach. May 2013;35(5):395-403. Competency— ” ability to… Take accurate and complete patient historiesPatient Care 3, level 1 Communicate with other doctorsComm 3, L 1-5: SBP 4, L 3 Communicate w/ other health care team members Comm 3, L 1-5; SPB 4, L 3 Set agendasCommunication 2, Level 3 Assess and improve patient adherencePatient Care 2, Level 2-5 Deliver diagnostic and prognostic newsCommunication 2, Level 2,4 Elicit patients’ beliefs, perspectives, concernsC 1, L 2; C 2, L 3; Prof 3, L 2 Treatment plansPC 1, L 2-3; PC 2 L 2-3; PC 4, L 4; Prof 3, L 3 Establish rapport and demonstrate empathyC 1 L 2-4; PC 4, L4; Prof 3, L 1 Manage conflict and negotiate with patientsCommunication 1, Level 4 Basic patient counseling skillsCommunication 2, Level 4 Counseling families and caregiversCommunication 2, Level 4

8. Caveats about the PCOF Transcends competencies and sub-competencies Reliability is achieved across multiple observations ( at least 10) Does not assess context

9. Results Agreement with experts on better and common cases by the order in which they were seen.

10. Observation Form Purpose and Training The value Structures vision Creates and standardizes vocabulary Primarily for formative assessment and to strengthen the “observer self” (mindfulness) Online training: http://uwfamilymedicine.org/pcof

11. PCOF Use Behavior in either of the columns to the right of thick vertical line is in the competent range Observers mark accurately and avoid giving the benefit of the doubt Feedback is best: When solicited Specific, rather than general Curious, not judgmental Larry Mauksch, M.Ed University of Washington Department of Family Medicine

12. Relationship Communication and Efficiency: Creating a Clinical Model from a Lit Review Mauksch et al, 2008, Arch of Intern Med, 168 (13) 1387-1395 Ongoing influence Rapport and Relationship Mindfulness Topic Tracking Empathic response to cues Sequential 1. Upfront collaborative agenda setting 2. Hypothesis testing and understanding the patient perspective 3. Co-creating a plan SMS: problem solving

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

14. EEE: Polite Interruption Excuse yourself (acknowledge and/or apologize) Empathize with the problem that is being cut off Explain why you are interrupting Planning time use Finishing an important topic (topic tracking) Stopping to explore an important cue Larry Mauksch, M.Ed University of Washington Department of Family Medicine

15. Interruption: Important cue Mr. Fredricks, forgive me for stopping you. You just said something about wondering if your thigh pain was in your bones and perhaps serious. Can we go back to that? It sounds like you have some important concerns that I want understand further.

16. Practice EEE: Polite Interruption Excuse yourself (acknowledge and/or apologize) Empathize with the problem that is being cut off Explain why you are interrupting Planning time use Finishing an important topic (topic tracking) Stopping to explore an important cue Larry Mauksch, M.Ed University of Washington Department of Family Medicine

17.  Common MA and MD agenda setting video goes here

18. Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Ongoing influence Rapport and Relationship Mindfulness Topic Tracking Empathic response to cues Sequential 1. Upfront collaborative agenda setting

19. Visit Organization Agenda collision AcuteChronic HM / Preventive SMS

20. Upfront Collaborative Agenda Setting Brock, Mauksch, et al. JGIM, Nov, 2011; Mauksch et al, Fam, Syst, Health, 2001 Identifies patient’s prioritiesOrganizes the visit Decreases chance that patients or providers will introduce “oh by the way” items Screens for mental disorders Facilitates shared decisions about time use between acute, chronic, and health maintenance care Does not lengthen the visit; protects time for planning Decreases clinician anxiety

21. Agenda Creation Avoid premature diving by patient or yourself When needed interrupt the patient or yourself: Acknowledge, Empathize Share reasoning If the list is greater than three items, the patient is screen positive for depression or anxiety Ask, “what is most important” Listen (feel) for the most important concern Orient the patient: “I know you are here to talk about ____. Before we get into_____ is there something else important to addresses today? Making a list will help us make the best use of time”.

22. Diving or Agenda Setting OldWhat are we doing today?How are you?What can I do for you?What is going on?Tell me about your ear pain. New What is on your list of concerns today? In addition to your ear pain is there something else? Let’s make a list of your concerns and then figure out how to make the best use of our time?

23.  Better MA and MD agenda setting video goes here

24. Agenda Setting Missteps and corrections Interrupt your self: “ I am getting ahead of myself” Provider diving Interrupt with an apology, empathy, and reason “I apologize for interrupting. Your sleep is a concern but before we talk about it, is there something else?” Patient diving Orient: “Lets plan the use of time before we use it” No orientation to purpose of agenda setting

25. Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Ongoing influence Rapport and Relationship Mindfulness Topic Tracking Empathic response to cues Sequential 1. Upfront collaborative agenda setting 2. Hypothesis testing and understanding the patient perspective Larry Mauksch, M.Ed University of Washington Department of Family Medicine

26. Explore the Patient Perspective When: Promoting self management and behavior change Detecting clues about thoughts or feelings Family or cultural influences are suspected Psychosocial factors may be present There are unexplained medical symptoms You sense distrust in the health system Desired change does not occur Contemplating a major health care decision

27. Exploring Patient Perspective: Core Skills and attitudes Curiosity Empathy Remembering, when patients do not do something, there is always a reason Cultural humility Attitudes Reflective listing Open ended, focused questions Skills Larry Mauksch, M.Ed University of Washington Department of Family Medicine

28. Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Ongoing influence Rapport and Relationship Mindfulness Topic Tracking Empathic response to cues Sequential 1. Upfront collaborative agenda setting 2. Hypothesis testing and understanding the patient perspective 3. Co-creating a plan Larry Mauksch, M.Ed University of Washington Department of Family Medicine

29. Co-creating a Plan Assess patient’s preferred decision role State clinical issue / decision to be made Describe options Discuss pros and cons Discuss uncertainties Assess patient understanding Ask for patient preferences Resolve decision differences Plan respects patient goals and values

30. Larry Mauksch, M.Ed University of Washington Department of Family Medicine  Video that combines teachback and AVS creation goes here.

31. Closing the visit QuestionsTeachbackAfter visit summary Combine Teachback and AVS and share the screen

32. Common and Better Video: Faculty development primer Common Missing core skills Should not be bad caricature Better if observer rates it and doesn’t see much to improve Better Re-create the scenario but with core skills Should be better, but not perfect Make both videos the same length

33. 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

34. Barriers To Learning Patient Centered Communication Focus on tangible markers in health care training Limited vocabulary to describe “intangible” skills Fear loss of control of time Limited team development to reinforce skill use Stigma and hidden curriculum

35. 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

36. 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

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

38. Primary Care Realities Primary Care patients average 3-6 problems per visit Indigent primary care populations have a greater illness burden Half of adults have two or more chronic illnesses 75% of US health care dollars go to care for chronic illness

39. Time Demands in Primary Care Am J Public Health. 2003;93:635–64; Ann Fam Med 2005;3:209-214. 2500 patients Conservative time estimates Ten most common Chronic illnesses Well controlled 3.5 hrs/day Poorly controlled 10.5 hrs/day Preventive care Level A and B recommendations 7.4 Hours per day

40. Why Learn Communication Skills? Time management and organization Promote self management Behavioral health Health Literacy Decrease litigation risk What patients want Better outcomes Safety

41. Teamwork The solution

42. Big Five Teamwork Behaviors Leasure et al “No I in Teamwork” Acad Med. 2013;88:585–592 LeadershipMutual performance monitoringBackup behaviorAdaptabilityTeam orientation

43. Estimating Panel Size in Primary Care with Team-Based Task Delegation Ann Fam Med 2012 10(5) 396-400

44. Levels of MA/LPN(RN?) Activity LimitedWarm Engaged Activating Relationship/EmpathyXXX Vitals/ Visit prepXXXX Update Meds/ check refillsXX Agenda/Priority/OrganizeXX Activate / Questions?XX Prev/HCM/screeningX Initial history (Scribe)X SMS: goal/action planX Proactive f/u (registry mgmt)X Closure/navigationXX Frequency++++++++

45. Why Are High Functioning Teams Essential To Primary Care Too much work for one person Collaboration produces better outcomes Effective teams help sustain healthy behaviors in their members Fewer errors

46. Hierarchy of Interactional Behaviors Reflective listening Explores beliefs Strengthens coping ability Therapeutic Goal setting Problem solving Confidence building Behavior change reinforcement Self management support Diagnosis Education Time management Anxiety reduction Communication Listening Empathy Patients feel known Building trust Relationship

47. Transdisciplinary Functions and Roles in Primary Care Role Function PCPNurseMedical Assistant PharmBehavioral health Care Management Relationship555555 Agenda setting and activation 435244 Self management- simple 434322 Self management- complex 342345 Primary care counseling 341254 Plan confirmation and care integration 344345 Proactive follow-up and stepped care 354334 Intensity: 5 =always; 4= often; 3 = periodic; 2 = support; 1 = reinforce and connect Larry Mauksch, M.Ed UW Family Medicine

48. TEAM COMMUNICATION TRAINING Team members reinforce use of communication skills in one another Shared learning of skills builds team function

49. Mastering a Skill Domain Practice Real situations Learned from expert: description demonstration Feedback Specific Sensitive Developmentally appropriate Reflection Promotes analysis Synthesis Integration

50. Common Training Sequence Introduction to PCOF Group rating and discussion of C/B Videos Teamlet members observe each other using extended appointment slots Groups meet to share learning and set goals Within teamlets Across teamlets Recurrent observations and team meetings for reinforcement Do the cycle again to learn more skills and achieve more goals Larry Mauksch, M.Ed University of Washington Department of Family Medicine

51. Patient Template: Teamlet training 9:40 MA gets next patent and repeat cycle two more times 9:30 to 9:40 debrief encounter 8:45 -9:30 8:45 to 9:00 MA interview patient and MD observes 9:00 to 9:30 MD interviews patient and MA observes 8:40-8:45 MA bring patient to exam room and explains teamlet training- at some point is joined by MD, ARNP or PA 8:30-8;40 discuss needs of first three patients Larry Mauksch, M.Ed University of Washington Department of Family Medicine

52. 1) Skills on the PCOF Those done well Wonder about doing something differently 2) Overlap with Lean approach Going where the action is Value stream thinking- study the present, plan the future Standard work Raising skills to the ceiling of role capacity Work supported by coaching Reveal waste Change designed by folks who do the work

53. 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. 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):199-209. 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. Losh DP, Mauksch LB, Arnold RW, et al. Teaching inpatient communication skills to medical students: an innovative strategy. Acad Med 2005;80:118-24.

54. 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. Mauksch L, Farber S, Greer HT. Design, Dissemination, and Evaluation of an Advanced Communication Elective at Seven U.S. Medical Schools. Acad Med. June 2013, 88(6) 843-851. Mauksch, L., Safford, B. Engaging Patients in Collaborative Care Plans, Family Practice Management, May-June 2013. Robins, L. Wittetborn, S., Miner, L. Mauksch, L. Edwards, K. Brock, D. Identifying Transparency in Physician Communication, Patient Education and Counselling, 2011, 83 73-79. 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.