CANMEDS COMMUNICATION SKILLS: CAN THEY BE TAUGHT? Robin Dhillon MD MRCS MBA MAC Ortho Grand Rounds Dec 2011

CANMEDS CANMEDS COMMUNICATION SKILLS: COMMUNICATION SKILLS: CAN THEY BE TAUGHT?CAN THEY BE TAUGHT?

Robin Dhillon MD MRCS MBA

MAC Ortho Grand Rounds Dec 2011

AcknowledgementAcknowledgement

Materials provided by the CANMEDS Train-the-trainer program, Royal College of Physicians and Surgeons

Lara Cooke – CalgarySue Dojeiji – OttawaSuzanne Kurtz – WashingtonToni Laidlaw - Halifax

Copyright © 2006 The Royal College of Physicians and Surgeons of Canada. http://rcpsc.medical.org/canmeds. Reproduced with permission

Objectives

To review the evidence supporting the benefits of communication skills teaching

To introduce some strategies for teaching communication skills

To introduce some strategies for evaluating communication skills

WHY TEACH COMMUNICATION SKILLS?

Communication is a core clinical skill

Competency required by all medical licensing bodies

Estimated 200,000 consultations in a professional lifetime

Copyright © 2006 The Royal College of Physicians and Surgeons of Canada. http://rcpsc.medical.org/canmeds. Reproduced with permission

COMMUNICATION PROBLEMS

EXAMPLES OF COMMUNICATION PROBLEMS

Approximately ¼ of patients complete their opening statement

Average time for patient to complete opening statement = 36 seconds

“Whoa - way too much information!”


Doctors frequently interrupt patients

Average time before interruption Attending = 19- 24 seconds Resident = 12 seconds

“We’re running a little behind, so I’d like each of you to ask yourself, ‘Am I really that sick, or would I just

be wasting the doctor’s valuable time?’”


Doctors often pursue a ‘doctor-centered,’ closed approach to information gathering

“Ah, Mr. Bromley. Nice to put a face on a disease.”


Doctors provide less information to patients than patients want

One quarter to one third of patients report receiving less information than they want

“There’s no easy way I can tell you this, so I’m sending you to someone who can.”


Doctors often use language that patients don’t understand

Doctors rarely ask their patient to volunteer their ideas and often inhibit their expression

“Let the healing begin!”


Doctors overestimate the time given to explanation and planning

“It’s your ear, nose and throat.”


Patient non-adherence is expensive

$7 – $9 BILLION dollars per year in Canada

“Give it to me straight, Doc. How long do I have to ignore your advice?”


Numerous reports of patient dissatisfaction with the patient/doctor relationship

A large percentage of malpractice suits result from poor communication

2010 CMPA Annual Report

“The doctor is in court on Tuesdays and Wednesdays.”

ACCREDITING BODIES NOW REQUIRE COMMUNICATION TEACHING FOR ACCREDITATION

OF RESIDENCY PROGRAMS

Royal College of Physicians and Surgeons of Canada (CanMEDS 2000 & Phase IV, 2005)

Accreditation Council for Graduate Medical Education (2002)

Royal College of General Practitioners (UK, 2004)

COMPARATIVE STUDY OF 9 URBAN HOSPITALS RE: JOINT REPLACEMENT SURGERY

Some invested heavily in hiring and training for relational competence (ie, ability to interact with others to accomplish goals)

Others looked for most highly qualified individuals (neglect of relational competence most pronounced in physician hiring)

Significant differences were found between hospitals re levels of coordination among care providers

Hoffer Gittel J 2003, Hoffer-Gittel et al 2000

Higher coordination between care providers significantly improved patient care.

Eg, increase in coordination enabled: 31% reduction in length of stay 22% increase in pt perceived quality of care 7% increase in postoperative relief from pain 5% increase in postoperative mobility

Hoffer Gittel 2003, Hoffer-Gittel et al, 2000

9 HOSPITAL COMPARATIVE STUDY

9 HOSPITAL COMPARATIVE STUDY

Conclusion:“…those in positions that require high levels of

functional expertise also tend to need high levels of relational competence to integrate their work with others.”

Hoffer-Gittel et al 2000

“It’s not just individual brilliance that matters anymore. It’s coordinated effort.”

Participant in Hoffer-Gittel et al 2000 study

Research Findings - EVIDENCE….

Enhancing communication leads to better outcomes: understanding & recall symptom relief adherence & concordance physiological outcomes patient safety patient satisfaction doctor satisfaction

costs complaints and malpractice litigation

THE BENEFITS OF GOOD COMMUNICATION

For the physician: alleviation of burnout and stress reduced frequency of malpractice

complaints satisfaction

So…..

Now that we understand the skill is important, how do

we teach AND practice it?

OVERALL GOAL OF ALL COMMUNICATION TEACHING AND LEARNING

Improving communication in practice to a professional level of competence

• Behavior = what we do anyway vs

• Professional competence = awareness & attention intentionality ability to reflect on & articulate and it’s evidence based

2 ESSENTIAL CONTEXTS FOR COMMUNICATION TEACHING

Formal curriculum Dedicated communication sessions, modules

Informal curriculum ‘In-the-moment’ teaching (follow-through in

clinic, hospital, and other real world contexts) Modeling (intentional and unintentional) ‘Hidden’ curriculum of how students are

treated and see us treating others

WHAT IT TAKES TO LEARN COMMUNICATION SKILLS, CHANGE BEHAVIOR

Essentials needed: systematic delineation & definition of skills observation of learners with patients (video) well-intentioned, detailed, descriptive feedback

(reflection) practice and rehearsal of skills (SP’s, volunteers) planned reiteration and deepening of skills

Small group or one-on-one learning formatIncorporation of research, cognitive and attitudinal material

INFORMAL CURRICULUM PROVIDES FOLLOW THROUGH IN REAL LIFE (or not)

To reinforce and deepen previous learning To validate applicability in the ‘real world’ To learn new skills To learn to apply skills & capacities in

increasingly complex situations To move toward professional level of

competence

WHY ARE COMMUNICATION PROCESS SKILLS SO ADAPTABLE?

Context changesContent changes

Levels of intensity, intention, & awareness shift

BUT Communication process skills remain the same from year 1 through clerkship, postgraduate,

CME

TYPES OF COMMUNICATION SKILLS

Content skills - what you say

Process skills - how you communicate - how you structure interaction - how you relate to patients - nonverbal skills

Perceptual skills - what you are thinking - what you are feeling

- medical problem solving - attitudes, assumptions, intentions,

biases - capacities (compassion, mindfulness)

MODELLING IS FUNDAMENTAL TO SUCCESS OF FORMAL COMMUNICATION PROGRAMS

Students of medicine learn first and foremost from what they see and experience, rather than from what’s written in the syllabus…

Suchman and Williamson, 2003

WHAT ARE WE MODELLING?

Skills* Attitudes, beliefs, values Capacities (eg, compassion, integrity,

flexibility, mindfulness)In what contexts?

Difficult situations (complex case, breaking bad news, death and dying, medical error, adverse outcomes)

Everyday run-of-the-mill consultations, patient education and prevention

Same focus as in formal curriculumSame focus as in formal curriculum

WHAT ARE WE MODELLING?

How we use communication skills and relational competencies with patients

How we interact with other professionals and support staff

How we treat the learners themselves What we choose to focus on and discuss

with learners during rounds & in clinical settings

MODELLING THAT OVERIDES EFFECTIVE COMMUNICATION

‘Forget that open-ended stuff - we’ll be here all day if you start there. Just follow the questions I gave you…’

‘Forget about the patient’s problem list - we don’t deal with all of that. Just go for the chief complaint…’

‘Don’t give me that patient perspective mumbo jumbo - I just want to know “the facts”…’

MODELLING TO ADVANTAGE - CHALLENGES

Junior doctors’ being there to observe Inconsistent modelling - some good, some not

Residents identified few role models for communication and relational competence

Infrequency of ‘deliberate’ modelling Talking about communication in a structured

way ‘Modelers don’t know how to make skills

explicit’ Hesitancy to talk about communication, what’s

good Residents can come up with ‘gestalt’ of what role

models are doing, but don’t see how you do it

TAUGHT SKILL RETENTION VS DEVELOPMENT WITH EXPERIENCE ALONE

Doctors 5 years out of medical school still strong in information gathering (taught) but weak in explanation and planning skills (experience only) discovering pt’s views/expectations - 70% no

attempt negotiation - 90% no attempt encouraging questions - 70 % no attempt repetition of advice - 63% no attempt checking understanding - 89% no attempt categorizing information - 90% no attempt

Maguire et al 1986

DIFFICULTIES OF WORKING IN-THE-MOMENT

Achieving satisfactory re-rehearsal Obtaining feedback from patients Discussing sensitive issues in front of

patients

Availability of time (patients’ and clinicians’)

Multiplicity of tasks (including patient care) Wide range of teaching agendas

EXAMPLES OF POSTGRADUATE MODELLING TO ADVANTAGE

During surgical rounds senior surgeon asked for 2 additional pieces of information after learner’s presentation of patient: ‘What questions will this patient want me to answer?’ ‘What concerns does this patient have that I need to address?’

During bedside teaching, an internal medicine staff doctor explicitly distinguished between teaching about problem solving and patient care

Endocrinologist focused attention on what he wanted junior doctors to emulate Asked questions about communication just as he did about PE

or medical problem solving or medical technical knowledge Reflected on what he was doing often Thought out loud, invited learners to think with him Talked about his own errors or mistakes and how he handled

them

MORE EXAMPLES OF POSTGRADUATEMODELLING TO ADVANTAGE

Nephrologist invited junior doctors to do a video review focusing on his communication skills with a patient

Director of orthopedic surgery residency program invited a communication specialist and residents to do a ‘roast’ focused on how he communicated with patients

Director of anesthesiology residency program developed a version of the Calgary-Cambridge Guides for pre-op interaction with patients and included it in the daily faculty evaluation protocol for residents (she saw changes in both faculty and residents, as a result)

When consultations went badly, a senior oncology surgeon read through the C-C pocket guide to review what he might have missed re communication skills

AND MORE EXAMPLES

General practice doctor joined forces with an oncologist and a simulated patient to organize and facilitate lunchtime ‘improve’ simulations based on residents’ current communication dilemmas

Family medicine doctor initiated monthly ‘communication rounds’ for cross specialty training

Instead of just discussing, senior doctor demonstrated alternative approach in mini-simulation away from the patient or with the real patient; asked learners to do same

Junior doctors modeled effective communication and relational competencies with medical students and then asked questions, talked about it.

Information Transfer

To improve patient adherence, outcome and patient satisfaction:

Clear information Easy to understand No medical jargon Mutual expectations Active patient role Non-verbal communication


To improve understanding and recall: Categorization Sign-posting Summarizing Repetition Diagrams Write it down


Categorization “We have 3 ways to manage your mild

carpal tunnel syndrome; first is a night-time splint; second is an anti-inflammatory; third is a cortisone injection”

“Lets talk about the splint…”


Signposting “We’ve talked about the splint (option 1),

lets talk about the anti-inflammatory (option 2)…”


Summarizing “So again, the options are the splint, the

medication and the cortisone injection” “What do you think of those options?”


Repetition Either you or the patient repeats at the

end of the interview Can aid recall by 30% “So what are those things we’re going to

do for the carpal tunnel syndrome again?


Write it down Good strategy for complex plan Good strategy if cognition a concern Good if you’re explaining a procedure to

the patient – they can keep the picture for reference and questions


Diagram “Here’s a picture of your hand looking at

your palm. These are muscles and bones. Here is the nerve that going from your forearm to your hand. It goes through a tunnel made of bone …”

Assessing Communication SkillsExperiences so far

Verbal

communication

Written

communication

Challenges

Successes – please

share!

Barriers

Steps for Assessment

1. Choose an assessment tool

2. Learn to use the assessment tool

3. Review methods for ALOBA

4. Evaluation and feedback “blueprint”

1. Choose an assessment tool Defines the objectives

Curriculum

Evaluation

Skills based

Validated

Examples of Communication Assessment Tools

Calgary Cambridge Observation GuideCalgary Cambridge Observation Guide

Kalamazoo Checklist

Brown Interview Checklist

SEGUE Framework

CALGARY-CAMBRIDGE GUIDES FRAMEWORK FOR THE MEDICAL CONSULTATION

Initiating the Session

Gathering Information

Physical Examination

Explanation/Planning

Closing the Session

Providing Structure

Building the Relationship

Kurtz, Silverman, Draper (2005)

ADVANTAGES OF C-C GUIDES

Accessible summary of skills - validated Framework for systematic skill development Memory aid to keep skills in mind, organized Basis for comprehensive feedback (no hit and

miss) – consistency across groups Common foundation for programs at all levels –

basis for helical, coherent curricula Learners know what’s on the exam get go Guidance with considerable latitude

Same guide = skills for communicating with patients, colleagues, learners

2. Learn to use the tool

Read it

Train your assessors (faculty)

Review skills with trainees

Elicit the skills

Video and discussion

3. Giving feedback - ALOBA

4. Evaluation and feedback “blueprint”

Outline your curriculum and feedback

process

Link your objectives with your

assessment

Choose your assessment methods

Remember…

What are you trying to measure

OSCE with SP

Objective structured clinical examination

Standardized patient

Assessment under controlled settings

Difficult, infrequent or sensitive communication

Components can be evaluated e.g., Explanation and planning

Feedback provided by examiner and/or SP

Formative and summative

Multiple source feedback

Increasingly being used

Multiple raters

Patients, other health professionals,

peers

Can be an onerous process

Get information on what you don’t

see

Prime team members early on

Portfolios and logbooks

Track ongoing learning of communication competencies

Very good for written communication skills

Discharge summaries

Consultation letters

Operative reports

Promote reflection on practice

Tool for self-directed enhancement

Potential for misrepresentation

IN CLOSING

Communication skills in medicine are more than a “toolbox” of devices.

Rather, they are a means of developing dialogue and rapport with patients that enhance human connection.

This human connection is integral in maintaining joy in practice.

Documents

CANMEDS COMMUNICATION SKILLS: CAN THEY BE TAUGHT? Robin Dhillon MD MRCS MBA MAC Ortho Grand Rounds Dec 2011