1. Communication Competency and Counseling Practicum Mary Dankoski, Ph.D. Kathy Zoppi, Ph.D., M.P.H Shobha Pais, Ph.D. Scott Renshaw, M.D. Dustin Wright, M.S.

2. OBJECTIVES Attendees will understand… The assessment of communication competency at resident levels of training The utility of counseling practicum and competency assessment strategies

3. Communication In Family Medicine “Black Box” study (Stange et. al., 1998) Family assessment – 73% Answering patient questions – 71% Negotiation – 21% Counseling – 16% Patient Education – 18-26%

4. Distinction between interaction and relationship “Communication skills do not constitute the doctor-patient relationship” (Candib, 1995, p.213) Key concept of connection as lens (vs. separation) from feminist theory Patient and physician are not independent actors, but are mutually influential Emotional involvement of both is key

5. National consensus about communication training Patient-centered care improves health outcomes (Kalamazoo Consensus statement) Errors decreased by improved training (To Err is Human, IOM) Health Disparities (Unequal Treatment, IOM)

6. Communication competence As property of individual Assessment of individual skills, abilities, or behaviors (rating of trainee) As property of interaction Assessment focuses on interactional or dyadic qualities, including adaptation, control, collaboration (rating of interaction)

7. Communication competence: approaches Communication skills Conflict management Teamwork Teaching others (pts, students, peers) Epstein and Hundert, JAMA, 2002

8. Implication of relational viewpoint of assessment Focus is longitudinal Focus is cumulative Focus is on participants’ sense of connection, satisfaction May be observable by non-participants

9. Methods for Teaching Communication Didactic sessions (lectures/demonstrations) Standardized patients Role play Video-tape review (with real or SP) Co-counseling sessions Observed counseling sessions

10. Layered levels of communication competence Content level: topic management, nonverbal cues/clues Process: pacing, facilitation, congruence, nonverbal matching, affective displays Meta-process: mindfulness, self- observation, context-sensitivity

11. Why is communication competence important? Facilitation of information exchange Development of a healing relationship Mutual development of patient and physician (Candib, 1996)

12. “Ways of Knowing” and Medicine Traditional Medical Education Procedural and Separate Knowing Critical thinking, objectivity Limited for learning about person living the illness May be experienced as distant and sterile Actively exclude the self Practicum Training Connected Knowing Personal experience, context, empathy Collaboration Use of patient ’ s language Understanding of patient perspective Acknowledge effects of caring on provider (Belenky, Clinchy, Goldberger, & Tarule, 1986; Candib, 1995)

13. Theoretical Assumptions about Practicum The “ art of medicine ” lies in ability to integrate multiple ways of knowing Feminist-relational approach requires training in equalizing power relationships (Candib, 1995) Parallel process If we want residents to interact in this way with their patients, we need to interact in this way with our learners Group supervision opens the “ black box ”

14. Practicum Curriculum Goal The goal of practicum training is to improve resident physician communication and counseling skills through supervised counseling of patients by peers and behavioral faculty preceptors.

15. Curriculum Objectives Residents will increase knowledge of Basic counseling skills and methods Evidence-based behavioral medicine Residents will improve skills in Responding to patient questions Assessment of psychosocial and family context Integration of biomedical and psychosocial care Building relationships with patients and families

16. Curriculum Objectives Residents will demonstrate attitude change toward The importance of behavioral care in practice Greater self-confidence in counseling skills Greater mindfulness in patient care To provide an opportunity for faculty to evaluate resident’s communication and doctor-patient relationship skills

17. Selection of Patient Cases Residents invite their own patients who… Are medically or psychosocially complex Have an unclear social situation Are not compliant with medical advice Are difficult to manage or frustrating to providers Have “more going on here…” Residents have a ‘gut’ sense about abuse, assault, family unrest, prior psychological conditions

18. Practicum Format Pre-session (10-15 minutes) Resident presents brief history of patient Residents states his/her goals for the session Faculty intentionally do NOT make suggestions Resident counsels patient (25-30 minutes) Mid-session break (10-15 minutes) Resident reaction Faculty and peer feedback Faculty guidance and direction

19. Practicum Format Resident counsels patient (25-30 minutes) Post-Session (10-15 minutes) Resident reflections Session goals and expectations What he/she learned about the patient Personal thoughts or reactions to the patient How this information will help care for patient Peer and faculty feedback

20. Assessment Patient feedback (survey or interview?) Relational rating scale Four Habits analysis of interaction (research assistant) Faculty feedback Resident-self assessment

21. The process… Models negotiating a relational agenda Reduces hierarchical barriers Encourages residents to shift to a more open dialogue Opens new options for patient care

22. Residents shift…… FROM Monological dialogue Focused information gathering Doctor driven conversation ‘doing’ mind-set TO Open dialogue Actively listening Patient directed conversation ‘supporting’ mind- set

23. Feedback from Residents How did this session differ from other visits with this patient? There was no right/wrong answer; no ‘pill’ would fix the problem [shift away from ‘doing’] More personal, more time More emotional Patient did most of the talking [active listening, patient directed] Visit was ‘non-medical’ – I was looking for clues in her life about what support she will have when she has a child [supportive]

24. Feedback from Residents As a result of this visit, is there anything you will do differently next visit? Be more sensitive about not giving my formal talks but asking patient what she wants to know [patient directed] Have a greater degree of suspicion when a patient just answers everything is ‘ok’ [supportive] Pay more attention to psychosocial aspects of my patients Understand the environment (psychosocial) a little better

25. Feedback from Residents What comments/suggestions do you have about the process of live supervision? It is an excellent idea to do this throughout residency and give feedback before we go into private practice I like the immediate feedback of live supervision. It keeps me on track during the counseling session. Allow more debriefing time…also more ‘skeleton’ training in counseling prior would be helpful Fun, be feel like people (supervisors/peers) have hidden agenda/thoughts that they didn’t share

26. Feedback from Patients Was this visit different from previous visits with your doctor? In what ways? Normally examines you, but today he was a doctor, my friend, a listener, helped me with my problems [active listening, supportive] The other visits were like examinations…it helps to know people more in depth to understand why a person keeps smoking when they know they shouldn’t The other one was more medical [patient directed]

27. Feedback from Patients Will you do anything differently in relation to your health as a result of your visit today? Made me stop and think: “You count too, take time for you.” Think it will be easier to talk to him in the future. 6/7 patients reported they will change specific health behaviors because of this visit

28. Comments from Patients It’s better when you have someone to talk to. He’s easy to talk to and he’s a good listener. He doesn’t criticize. I like him. He’s a good doctor. Nice to be offered this because this time I was really stressed…. I know you can tell him and he understands and tries to help you.

29. Future Research Goals Evaluate outcomes: Does practicum improve Doctor/patient relationship? Patient health outcomes? Patient satisfaction? Resident competency in communication and relationship skills?