How to maintain quality in and develop doctors communication
skills
Slide 2
Slide 3
Slide 4
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Clinical communication teaching - why
bother? weve got enough to do already, it cant be learnt, it doesnt
fit the real world Jonathan Silverman Aarhus, 2012
Slide 5
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Over 700 half day sessions Each with an
actor And a facilitator Only 5-6 students Complex audio- visual
IT
Slide 6
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Plan: clinical communication teaching - why
bother? 1.Are there problems in communication in medicine? 2.Are
there solutions to those problems? 3.Do they make a difference to
outcomes of care? 4.Can you teach it? 5.Is it retained? 6.So what
is it?
Slide 7
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Plan: clinical communication teaching - why
bother? 1.Are there problems in communication in medicine?
Slide 8
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Are there problems in communication between
doctors and patients? initiating the interview gathering
information explanation and planning building the relationship
structuring the interview closing the interview what different
communication patterns do you see? what outcome do you predict the
patterns will have on whether the interview is effective?
VTS_05_1.VOB VTS_06_1.VOB
Slide 9
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Initiating the interview 1. Not discovering
the reasons for the patient's attendance Gathering information 2.
Early closed questioning preventing listening Clinical
hypo-competence
Slide 10
54% of patients complaints and 45% of their concerns are not
elicited (Stewart et al 1979) in 50% of visits, the patient and the
doctor do not agree on the nature of the main presenting problem
(Starfield et al 1981) only a minority of health professionals
identify more than 60% of their patients' main concerns (Maguire et
al 1996) consultations with problem outcomes are frequently
characterised by unvoiced patient agenda items (Barry et al 2000)
doctors frequently interrupt patients so soon after they begin
their opening statement that patients fail to disclose significant
concerns (Beckman and Frankel 1984, Marvel et al 1999 ) Mauksch et
al (2008): literature review to explore the determinants of
efficiency in the medical interview. 3 domains emerged from their
study that can enhance communication efficiency: rapport building,
upfront agenda setting and picking up emotional cues
Slide 11
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Are there problems in communication between
doctors and patients? initiating the interview gathering
information explanation and planning building the relationship
Slide 12
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Explanation and planning 3. Recall and
understanding use of jargon monologue speeding up not incorporating
patients perspective 4. Shared decision making not involving
patients in decision making to the level that they would wish
shared decision making not done
Slide 13
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Are there problems in communication between
doctors and patients? initiating the interview gathering
information explanation and planning building the relationship
Cues
Slide 14
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Facilitative skills Open questions Open
directive questions Listening Pauses/use of silence Minimal
prompts/encouragement Summarising The emergence of cues Goldberg et
al 1993; Wilkinson 1991; Maguire et al 1996: Zimmerman et al,
2003
Slide 15
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE 5. Not picking up and exploring cues
Levinson (2000) patients gave cues throughout the interview from
the opening to the closing minute doctors only responded to patient
cues in 38% of cases in surgery and 21% in primary care where the
cue was missed, half of the patients brought up the same issue a
second or third time and in all of these cases, the physician again
missed these further opportunities to respond. Zimmerman et al
(2007) a systematic review, documenting 58 original quantitative
and qualitative research articles demonstrating patient expressions
of cues and/or concerns, all based on the analysis of audio or
videotaped medical consultations. overall conclusion - physicians
missed most cues and adopted behaviours that discouraged
disclosure. Rogers and Todd (2000) oncologists preferentially
listen for and respond to certain disease cues over others pain
amenable to specialist cancer treatment is recognised, other pains
are not acknowledged or dismissed
Slide 16
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Are there problems in communication between
doctors and patients?
Slide 17
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Are there problems in communication between
doctors and patients? initiating the interview gathering
information explanation and planning relationship building
Slide 18
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE 6. Empathy and non-verbal behaviour
Building the relationship
Slide 19
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Plan: Clinical communication teaching - why
bother? 1.Are there problems in communication in medicine? 2.Are
there solutions to those problems?
Slide 20
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Are there solutions to these problems?
initiating the interview gathering information explanation and
planning building the relationship structuring the interview
closing the interview
Slide 21
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Are there solutions to these problems?
initiating the interview gathering information explanation and
planning building the relationship structuring the interview
closing the interview
Slide 22
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Plan: Clinical communication teaching - why
bother? 1.Are there problems in communication in medicine? 2.Are
there solutions to those problems? 3.Do they make a difference to
outcomes of care?
Slide 23
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Research evidence to validate the use of
specific communication skills: process of the interview
satisfaction recall and understanding adherence outcome: decreased
patient concern symptom resolution physiological outcome
Slide 24
Medico-legal issues Patients of obstetricians with a high
frequency of malpractice claims are more likely to complain of
feeling rushed and ignored and receiving inadequate explanation,
even by their patients who do not sue. (Hickson et al 1994)
Relationship between judgments of surgeons' voice tone and their
malpractice claims history. (Ambady et al 2002) Scores achieved in
patient-physician communication and clinical decision making on a
national licensing examination predicted complaints to medical
regulatory authorities (Tamblyn et al 2007)
Slide 25
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE The ability to integrate: knowledge
communication physical examination problem-solving THE ESSENCE OF
CLINICAL PRACTICE Clinical competence
Slide 26
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Research into clinical communication More
effective interviews: accuracy efficiency supportiveness Enhanced
patient and health professional satisfaction Improved health
outcomes for patients
Slide 27
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE We cannot ignore the central importance of
Effective clinical communication High quality healthcare to
Slide 28
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Plan: Clinical communication teaching - why
bother? 1.Are there problems in communication in medicine? 2.Are
there solutions to those problems? 3.Do they make a difference to
outcomes of care? 4.Can you teach it?
Slide 29
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Communication is a core clinical skill
Slide 30
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Skills and attitudes Final common pathway =
skills
Slide 31
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Can you learn communication? Communication
is a clinical skill It is a series of learnt skills Experience is a
poor teacher
Slide 32
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Communication skills teaching and learning
is different Closely bound to self-esteem, self-concept,
personality More complex than simpler procedural skills No
achievement ceiling Dont start from scratch
Slide 33
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE It can be taught and learnt We know which
methods work Can you learn communication?
Slide 34
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Aspergren K (1999) Teaching and Learning
Communication Skills in Medicine: a review with quality grading of
articles Medical Teacher 21 (6) Smith S, Hanson J, Tewksbury L et
al (2007) Teaching Patient Communication Skills to Medical
Students: a review of randomised controlled trials Evaluation and
the Health Professions 30 (1)
Slide 35
Aspergren K (1999) Teaching and Learning Communication Skills
in Medicine: a review with quality grading of articles Medical
Teacher 21 (6) Overwhelming evidence for positive effect of
communication training Medical students, residents, junior doctors,
senior doctors Specialists and general practice equally
Slide 36
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE How do we change our behaviour in the
interview? Knowledge is important but only allows you to know about
communication Experiential teaching is required to know how to
communicate
Slide 37
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE The need for experiential learning active
small group or 1:1 learning observation of learners video or audio
recording and review well-intentioned feedback rehearsal
Slide 38
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Plan: Clinical communication teaching - why
bother? 1.Are there problems in communication in medicine? 2.Are
there solutions to those problems? 3.Do they make a difference to
outcomes of care? 4.Can you teach it? 5.Is it retained?
Slide 39
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Plan: Clinical communication teaching - why
bother? 1.Are there problems in communication in medicine? 2.Are
there solutions to those problems? 3.Do they make a difference to
outcomes of care? 4.Can you learn it? 5.Is it retained? 6.So what
is it?
Slide 40
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Clinical Communication Skills (CCS)
Slide 41
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Key components of CCS Core medical
interviewing skills Specific communication issues and challenges
Communicating with others relatives interpreters Professional
communication skills other professionals presentation skills
Slide 42
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Martin von Fragstein, Jonathan Silverman,
Annie Cushing, Sally Quilligan, Helen Salisbury & Connie Wiskin
on behalf of the UK Council for Clinical Communication Skills
Teaching in Undergraduate Medical Education UK consensus statement
on the content of communication curricula in undergraduate medical
education Medical Education 2008 42(11): p. 1100-7
Slide 43
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE
Slide 44
Slide 45
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE THE CALGARY-CAMBRIDGE GUIDES TO THE MEDICAL
INTERVIEW Kurtz, Silverman and Draper (2005; 2nd Ed.) Teaching and
Learning Communication Skills in Medicine Radcliffe Medical Press
Silverman, Kurtz and Draper (2005; 2nd Ed.) Skills for
Communicating with Patients Radcliffe Medical Press 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
Slide 46
Initiating the session Gathering information Physical
examination Explanation and planning Closing the session Providing
structure Building the relationship
Slide 47
exploration of the patients problems to discover the:
biomedical perspective the patients perspective background
information - context providing the correct type and amount of
information aiding accurate recall and understanding achieving a
shared understanding: incorporating the patients 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
Slide 48
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Specific communication issues and
challenges culture and social diversity gender dealing with
emotions age related issues the elderly, children the three way
interview breaking bad news the sexual history the psychiatric
interview the telephone interview low literacy patients sensory
impaired patients death and dying, bereavement complaints ethics
health promotion and prevention
Slide 49
INITIATING THE SESSION
Slide 50
Establishing initial rapport Greets patient and obtains
patients name Introduces self, role and nature of interview;
obtains consent Demonstrates interest, concern and respect, attends
to patients physical comfort Identifying the reason(s) for the
consultation Identifies the patients problems or the issues that
the patient wishes to address with appropriate opening question
(e.g. What problems brought you to the hospital? Listens
attentively to the patients opening statement, without interrupting
or directing patients response Checks and screens for further
problems (e.g. so thats headaches and tiredness, what other
problems have you noticed? or is there anything else youd like to
discuss today as well?) Negotiates agenda taking both patients and
physicians needs into account
Slide 51
School of Clinical Medicine School of Clinical Medicine
UNIVERSITY OF CAMBRIDGE Thank you