1. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Teaching clinical communication - an amazing effort Yet why do we still feel we haven’t cracked it? Jonathan Silverman Utrecht 2011

2. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Teaching clinical communication - an amazing effort Yet why do we still feel we haven’t cracked it?

3. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching? 2.The central importance of integration 3.Why “communication” is the wrong name and “patient-centredness” is even worse 4.The problems with Calgary-Cambridge

4. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching? a)we work in rarefied isolation

5. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE

6. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching a)we work in rarefied isolation b)we are surrounded by inappropriate modelling

7. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching a)we work in rarefied isolation b)we are surrounded by inappropriate modelling c)we artificially separate communication from medical content

8. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching a)we work in rarefied isolation b)we are surrounded by inappropriate modelling c)we artificially separate communication from medical content d)we haven’t got assessment right e)we haven’t worked out how best to use the various teaching disciplines

9. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Who doesn’t teach it? Have teachers been trained? Do learners think it is an add-on? Do real clinicians model this? Does bedside teaching back it up? Is it rigorously assessed and by the correct methods? When doesn’t it occur? Do the teachers understand the research? Is there a planned curriculum? Is clinical communication integrated into all clinical challenges that learners learn?

10. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Learners still often perceive clinical communication teaching as an optional extra, not central to their learning

11. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching 2.The central importance of integration a)Integration with history taking skills b)Integration with practical skills c)Integration with specialty teaching d)Integration with the hidden curriculum

13. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching 2.The central importance of integration a)Integration with history taking skills b)Integration with practical skills c)Integration with specialty teaching d)Integration with the hidden curriculum e)The crucial role of assessment in integration

14. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching 2.The central importance of integration a)Integration with history taking skills b)Integration with practical skills c)Integration with specialty teaching d)Integration with the hidden curriculum e)The crucial role of assessment in integration

15. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching 2.The central importance of integration a)Integration with history taking skills

16. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Are communication skills and traditional history taking mutually incompatible?

17. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Are communication skills and traditional history taking mutually incompatible? Have you seen this problem?

18. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Communication skills teaching model versus Traditional medical history model 

19. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Three elements of gathering clinical information What you think and feel Perception Biomedical Patient’s perspective What you discuss, record and present Content Clinical reasoning Feelings How you communicate Process Open Directive

20. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Three elements of gathering clinical information What you think and feel Perception How you communicate Process What you discuss, record and present Content Patient’s perspective Feelings Open

21. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Three elements of gathering clinical information What you think and feel Perception How you communicate Process What you discuss, record and present Content Biomedical Clinical reasoning Directive

22. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Three elements of gathering clinical information What you think and feel Perception Biomedical Patient’s perspective What you discuss, record and present Content Clinical reasoning Feelings How you communicate Process Open Directive

23. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Communication model (process) Initiating the session Gathering information Building relationship Structuring the interview Explanation and planning Closing the session

24. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Traditional Medical History Model (content) Chief complaint History of the present complaint Past medical history Family history Personal and social history Drug and allergy history Systematic enquiry

25. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Confusion between process and content:  GP/psychiatry/psychology v real doctors  The issue of how learner’s are observed (if they are)  How to obtain information v. how to present info  How to obtain information v. how to write down info

26. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Another confusion between process and content Communication skills teachers have introduced their own new content

27. content to be discovered in gathering information: the bio-medical perspective (disease) sequence of events symptom analysis relevant systems review background information - context past medical history drug and allergy history family history personal and social history review of systems

28. content to be discovered in gathering information: the patient’s perspective (illness experience) ideas and beliefs concerns and feelings expectations effects on life

29. content to be discovered in gathering information: the bio-medical perspective the patient’s perspective (disease) (illness) sequence of events ideas and beliefs symptom analysis concerns relevant functional enquiry expectations effects on life feelings background information - context past medical history drug and allergy history family history personal and social history review of systems

30. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE So what’s the solution?

31. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Effective history taking is essential to the practice of high quality medicine

32. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Effective communication is essential to the practice of high quality medicine

33. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Effective clinical method is essential to the practice of high quality medicine

34. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE THE CALGARY- CAMBRIDGE GUIDES TO THE MEDICAL INTERVIEW Kurtz, Silverman, Benson and Draper (2003) Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides Academic Medicine;78(8):802-809

35. 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

36. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching 2.The central importance of integration a)Integration with history taking skills b)Integration with practical skills c)Integration with specialty teaching d)Integration with the hidden curriculum e)The crucial role of assessment in integration

37. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Assessment essential for driving the communication curriculum forward Assessment acts a tool for integration: it should place communication appropriately within all clinical challenges The crucial role of assessment in integration

38. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Assessment drives the curriculum motivates learners to learn legitimises the importance of the subject to learners encourages the acceptance of the subject by otherwise sceptical faculty

39. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Communication skills must be included in assessments, even if such skills are more difficult to quantify and assess than lower levels of learning Assessments should be matched to the learning objectives of the communication skills curriculum The methods of assessment should mirror the methods of instruction and not undermine the teaching

40. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Simulated Clinical Encounter Examination (SCEE)

41. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Description of the SCEE OSCE-style examination 10 stations –4 stations of history taking and clinical reasoning –3 stations of explanation and planning –3 stations of other inter-personal skills Simulated patients and examiners 2 hours 40 mins face-to-face testing time

42. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE What does the SCEE test? Process skills of doctor-patient communication Integrated with content and clinical reasoning Tests clinical competence in the medical interview

43. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching 2.The central importance of integration 3.Why “communication” is the wrong name and “patient-centredness” even worse

44. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 1.What undermines clinical communication teaching 2.The central importance of integration 3.Why “communication” is the wrong name and “patient-centredness” even worse 4.The problems with Calgary-Cambridge

45. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE The Calgary-Cambridge guides: the ‘teenage years’ THE CLINICAL TEACHER 2007; 4: 87–93 87

46. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 4.The problems with Calgary-Cambridge a)Different clinical contexts b)Flexibility

47. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Plan 4.The problems with Calgary-Cambridge a)Different clinical contexts b)Flexibility c)Reductionist d)Checklist e)Received wisdom

48. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Conclusion Integrate Collaborate Invest in faculty training