1. IT TAKES A VILLAGE! Lessons learned from communication skills training Charlotte Nath, EdD, RNJeannie Sperry, PhD Holli Neiman-Hart, MDBarbara Kirby, BA West Virginia University Family Medicine

3. Behavioral Objectives for Session: 1.Describe barriers and solutions for communication assessment 2.Discuss advantages and disadvantages of various strategies 3.Generate possible strategies for your own institution

4. Getting Historical: Evolution of Communication training at WVU SOM 1)2000-2005 Health Literacy 2)2006-09 Expand to wider context; added videotaping review and direct observation 3)2010- 2012 Refined Curriculum: more comprehensive and competency based

5. Assessments: Past and Present Written: Knowledge and attitude Patient satisfaction surveys Clinical -Direct observation in clinic -Video taping Simulation Audio taping/transcription Orientation OSCEs Self-assessment/Peer assessment

6. Knowledge (PGY1) Pre Post 2006 2007 Pre Post Figure 2. Knowledge of health literacy was assessed. Total scores (8 items, 1 point each) were calculated and averaged for each cohort. Residents demonstrated great knowledge and slightly improved scores for all questions after orientation (p>0.05).

7. Attitudes (PGYI) 2006 PGYI 2007 PGYI I routinely consider patient literacy when giving instructions. The clinic is an appropriate place to identify literacy problems. I feel confident that I can recognize low literacy in my patients. I know how to adjust my communication for low literacy patients to assure understanding. Figure 3. Attitudes about using communication skills with patients with limited literacy were positive and maintained or improved for both classes before and after the intervention in all but one case.

8. Health literacy scenarios

9. Patient satisfaction Pre-2009 My doctor took the time to discuss things with my family and me. 3.95 out of 5 Old evaluation had lower scores: Harder to understand than CARES? 2009- How was your doctor at explaining things clearly? 4.73 out of 5 CARES

11. How to measure clinical communication skills? Master clinicians often don’t have language to teach what they know about communication skills Observation forms Structures vision Creates vocabulary Improves self-reflection

12. SEGUE- 6 cards

13. Electronic Medical Record Use Regularly describes use of EMR to patient Maintains eye contact with patient during majority of time while using EMR. Positions monitor to be viewed by patient Points to screen 7a. Uses 0 or 1 elements. 7b. Uses 2 elements 7c. Uses 3 or 4 elements Notes: Physical Exam Prepares patient before physical exam actions and describes exam findings during the exam (“I am going to ___ ” then “your lungs sound healthy”) 8a. Never 8b. some of the time, up to half the time 8c. Most of the time Patient Centered Observation Form (Larry Mauksch)

14. Current communication curriculum Residents Year 1 Orientation: -Competency assessment Health literacy OSCE Office Simulation (agenda setting) -Good/better videos and checklists Google POVE PGYIs: Frequent direct observation via closed circuit Remediation prn Residents Year 2 and 3 -Direct observation and review with senior faculty (MD) 4/yr -Videotape PGYII: self-assess and review with behavioral faculty (2/yr) -Videotape PGYIII: self-assess -PGYIII Observe PGY1 and give feedback

15. Direct or video observations

16. Lessons learned from video precepting Flexibility: pts cxl, review time thwarted… Role confusion: observer or preceptor? Inefficiency Teaching satisfaction High Skilled teacher – Preceptor sandwich: (+, needs work, +) “ Dr Dattola is meticulous, detailed, constructive… Tells us what we did well, what needs improved, what was missing. Reviews our notes and contacts us re missing components. Reviews plan of care. His efforts with us enhances our program immeasurably. “

17. While looking for communication skills, we found... Professionalism problems Medical knowledge problems Documentation problems (no PE?!)

18. Latest in technology? Sort of…

19. Why Bother? ACGME requirement to perform live or recorded observation and feedback Can address all core competencies Can bill level 4 Observers develop mentoring role Early Remediation

20. How to make it happen New PD in town 2010 – No warning for residents re video today – No nonsense approach to yes we can – Video observations summary during “role call” – Assertive advocacy for faculty time and equipment – Sleeves up when review needed Culture of observation – Institutional faculty development series in 2011 – Departmental chair is increasing focus on faculty precepting skills as part of promotion and tenure process as well as salary enhancement plan – faculty development on providing feedback

21. FUTURE DIRECTIONS (aka TO DO…) 1.Observation norms for expected performance at each level of training 2.Competency expectations for each visit type 1.PGY re well child, adult depression, OB, etc 2.Psy re depression, anxiety, smoking, etc 3.Develop “dot phrases” for PGY notes to standardize assessing and documenting substance use, mood: FM DEP, FM ANX, FM ETOH 4.Psychology post doc as “personal trainer”

22. Small group discussion Share your experiences in small groups (10 minutes): 1.How do you assess communication skills? 2.What barriers have you faced? 3.How have you overcome barriers? 4.What do your assessments mean?

23. Ongoing (Unanswered) Questions: Given barriers to extensive assessment, what outcomes are most important to assess? Is it learner’s ability to perform the behavior, the actual performance of the behavior, or a secondary desired outcome (patient health)? Is patient satisfaction sufficient as a measureable outcome? Do we need to examine patient outcomes in terms of disease management? Do we need to examine outcomes in terms of number of patient visits or team-based skills?

24. “Skills in Communication for Vulnerable Populations: Competencies in Health Literacy and Integrated Care” West Virginia University Dept of Family Medicine Supported by: US DHHS/HRSA/Bureau of Health Professions Grant/Contract# #D58HP15645