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Talking about health
Teaching communication in healthcare ‐ why bother?
Jonathan Silverman
2. Konferenz der Österreichischen Plattform Gesundheitskompetenz
Sprechen Sie Gesundheit? – Kommunikation als Motor für Gesundheitskompetenz
Vienna, October 2016
http://www.each.eu/
About to change its name from European to International
Talking about health
Teaching communication in healthcare ‐ why bother?
Jonathan Silverman
2. Konferenz der Österreichischen Plattform Gesundheitskompetenz
Sprechen Sie Gesundheit? – Kommunikation als Motor für Gesundheitskompetenz
Vienna, October 2016
The National Strategy For Changing Healthcare Communication in Austria
The Austrian Platform Health Literacy
The School will through inspirational teaching and training, educate individuals who:• will become exceptional doctors or biomedical scientists• combine a depth of scientific understanding with outstanding clinical
and communication skills• demonstrate a caring, compassionate and professional approach to
patients and the public• are equipped to become future international leaders of their profession
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School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Over 700 half day sessionsEach with an
simulated patient(actor)
And a facilitator
Only 5-6 students
Complex audio-visual IT
School of Clinical Medicine
UNIVERSITY OFCAMBRIDGE
Over 700 half day sessionsEach with an
actor
And a facilitator
Only 5-6 studentsComplex audio-
visual IT
One half day for each student every 5-6 weeks for 3 years
26 sessions per student
2 ½ hour separate stand alone final assessment
Failure = repeat the final year
So why bother?
Let me tell you a story
What were the 4 doctors doing that was interfering
with their effectiveness?
Addenbrookes:Centre of excellence, attracts the very brightest, from many different
countries, and from different educational systems. Highly cognitive and intelligent and
perfectionist
Communication is a core clinical skill
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The ability to integrate:
• knowledge
• physical examination/technical skills
• problem‐solving
• communication
Clinical competence
The prize on offer from effective communication
• Not just being supportive
• Improves clinical performance
• Improves outcomes for patients
• Improves health outcomes for health professionals
Not easy to get the medical interview right
• highly skilled
• complex
• multi‐faceted
• professional challenge
Needs careful attention and cannot be left to chance
The central importance of
Effective clinical
communication
High quality healthcareto
Plan: Teaching communication in healthcare ‐ why bother?
1. Why bother with communication learning and teaching?• Are there problems at the moment with healthcare communication?• Can communication skills overcome these problems?• Do they make a difference to healthcare outcomes?
2. What is there to learn?• Can we define what it is we wish people to learn with all the different
issues and contexts within which health professionals work?
3. Can you learn communication?• Isn’t it all a matter of learning by experience or just personality?
4. How do you learn communication?• Do we know effective ways to teach this subject?
Plan: Teaching communication in healthcare ‐ why bother?
1. Why bother with communication learning and teaching?• Are there problems at the moment with healthcare communication?• Can communication skills overcome these problems?• Do they make a difference to healthcare outcomes?
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Are there problems in communication between doctors and patients?
• initiating the interview
• gathering information
• explanation and planning
• building the relationship
• what different communication patterns do you see?
• what outcome do you predict the patterns will have on whether the interview is effective?
Initiating the interview1. Not discovering the reasons for the patient's attendance
Gathering information2. Early closed questioning preventing listening
Clinical hypo‐competence
• 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)
• 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
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
Explanation and planning
1. Recall and understanding
• use of jargon
• monologue
• speeding up
• not incorporating patient’s perspective
2. Shared decision making
• not involving patients in decision making to the level that they would wish
• shared decision making not done
Are there solutions to these problems?
• initiating the interview
• gathering information
• explanation and planning
• building the relationship
• structuring the interview
• closing the interview
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Are there problems in communication between doctors and patients?
The patient‐centred consultation
Patient presents problem:gathering information - parallel search of two frameworks
The bio-medical perspective The patient’s perspective(Disease framework) (Illness framework)
Sequence of events Ideas & beliefsSymptoms & signs Concerns & feelingsInvestigations ExpectationsUnderlying pathology Effects on life
Differential diagnosis Understanding the patient’s uniqueexperience of illness
Integration of the two frameworksCollaborative explanation and planning: shared understanding and decision
making
Patient presents problem:gathering information - parallel search of two frameworks
The bio-medical perspective The patient’s perspective(Disease framework) (Illness framework)
Integration of the two frameworksCollaborative explanation and planning: shared understanding and decision
making
Are there problems in communication between doctors and patients?
• initiating the interview
• gathering information
• explanation and planning
• building the relationship
Cues
Facilitative skills Goldberg et al 1993; Wilkinson 1991; Maguire et al 1996: Zimmerman et al, 2003
Open questions
Open directive questions
Screening questions
Listening
Pauses/use of silence
Minimal prompts/encouragement
Summarising
The emergence of cues and concerns
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Cues and concerns
A verbal or non‐verbal hint which suggests an underlying emotion which would need clarifying by the health
professionalDel Piccolo et al 2006
Hints to patient's concerns and thoughts about the cause of the illness
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
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.
Cues
Facilitative questions linked to a cue increase the probability of further cues
Zimmerman et al 2003
Silence or minimal prompts most likely to precede disclosure
Eide H et al 2004
Open questions linked to a cue are 4.5 times more likely to lead to further significant disclosure than unlinked open questions
Facilitative skills
Open questionsOpen directive questionsScreening questionsListeningPauses/use of silence Minimal promptsSummarising
Picking up cues
• Acknowledging/reflection/paraphrasing
• Checking
• Clarifying
• Exploring
• Educated guesses
• Empathy
Cues ‐ will it take more time ?
• Consultations which were cue based were shorter that those in which cues were missed
o GP consultations 12.5%
o Surgical consultation were 10.7% shorter
Levinson et al 2000
• In oncology consultations, addressing cues reduced consultation times by 10‐12%.
Butow et al 2002
Are there problems in communication between doctors and patients?
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Are there solutions to these problems? Plan: Teaching communication in healthcare ‐ why bother?
1. Why bother with communication learning and teaching?• Are there problems at the moment with healthcare communication?• Can communication skills overcome these problems?• Do they make a difference to healthcare outcomes?
Research into clinical communication
• More effective interviews:
accuracy
efficiency
supportiveness
• Enhanced patient and health professional satisfaction
• Improved health outcomes for patients
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
Plan: Teaching communication in healthcare ‐ why bother?
1. Why bother with communication learning and teaching?• Are there problems at the moment with healthcare communication?• Can communication skills overcome these problems?• Do they make a difference to healthcare outcomes?
2. What is there to learn?• Can we define what it is we wish people to learn, with all the different
issues and contexts within which health professionals work?
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 200842(11): p. 1100‐7
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Any course in medical education
The communication curriculum
Core process skills
A secure platform for tackling each specific communication issue
Context of the interaction changes Content of the communication varies
But the process skills themselves remain the same
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• health promotion and prevention
Not different skills but same skills used differently
A Comprehensive Clinical Method
The explicit integration of traditional clinical method with effective communication skills
to enable doctor and patient, in partnership, rationally toexplore, diagnose and manage both:
disease
(the bio-medical cause of sickness in terms of underlyingpathophysiology) and
illness
(the individual patient’s unique experience of sickness)
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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 (2013; 3rd 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
Initiating the session
Gathering information
Physical examination
Explanation and planning
Closing the session
Providing structure
Building the relationship
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
preparationestablishing initial rapportidentifying 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 closureforward planning
INITIATING THE SESSION
Establishing initial rapport
Greets patient and obtains patient’s name
Introduces self, role and nature of interview; obtains consent
Demonstrates interest, concern and respect, attends to patient’s physical comfort
Identifying the reason(s) for the consultation
Identifies the patient’s 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 patient’s opening statement, without interrupting or directing patient’s response
Checks and screens for further problems (e.g. “so that’s headaches and tiredness, what other problems have you noticed?” or “is there anything else you’d like to discuss today as well?”)
Negotiates agenda taking both patient’s and physician’s needs into account
GATHERING INFORMATION
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Exploration of patient’s problems
Encourages patient to tell the story of the problem(s) from when first started to thepresent in own words (clarifying reason for presenting now)
Uses open and closed questions, appropriately moving from open to closed
Listens attentively, allowing patient to complete statements without interruption andleaving space for patient to think before answering or go on after pausing
Facilitates patient's responses verbally and non–verbally e.g. use of encouragement,silence, repetition, paraphrasing, interpretation
Picks up verbal and non–verbal cues (body language, speech, facial expression, affect);checks out and acknowledges as appropriate
Clarifies statements which are vague or need amplification (e.g. “Could you explainwhat you mean by light headed")
Periodically summarises to verify own understanding of what the patient has said;invites patient to correct interpretation or provide further information.
Uses concise, easily understood language, avoids or adequately explains jargon
Plan: Teaching communication in healthcare ‐ why bother?
1. Why bother with communication learning and teaching?• Are there problems at the moment with healthcare communication?• Can communication skills overcome these problems?• Do they make a difference to healthcare outcomes?
2. What is there to learn?• Can we define what it is we wish people to learn with all the different
issues and contexts within which health professionals work?
3. Can you learn communication?• Isn’t it all a matter of learning by experience or just personality?
Think of somebody with really excellent communication skills
Now think of somebody in the same field with not so effective communication skills
Can you change the 2nd person to be more like the 1st person?
Can communication skills be learned?
Communication is a core clinical skill
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• communication is a clinical skill
• it is a series of learnt skills
• experience is a poor teacher
Communication skills teaching and learning is different
• Closely bound to self-esteem, self-concept, personality
• More complex than simpler procedural skills
• No achievement ceiling
• Don’t start from scratch
Can communication skills be learned?
• there is conclusive evidence that communication skills can be taught
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)
Aspergren K (1999)
Overwhelming evidence for positive effect of communication training
Medical students, residents, junior doctors, senior doctors
Specialists and general practice equally
Those at the bottom end improve most
Can communication skills be learned?
• there is conclusive evidence that communication skills can be taught
• and that communication skills teaching is retained
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Stillman et al (1977) demonstrated that trained students maintained their post-training superiority over their non-trained peers at follow up a year later
Maguire et al (1986) followed up their original students five years after their training. They found that both groups had improved but those given communication skills training had maintained their superiority in key skills such as using open questions, clarification, picking up verbal cues and coverage of psychosocial issues. These effects were found in interviews with patients with both psychiatric and physical illnesses
Bowman FM et al (1992) showed that the improvement in interviewing skills of established general practitioners following an interview training course was maintained over a two year follow-up period
Oh et al (2001) showed that trained medicine residents use of patient-centred interviewing skills significantly improved after an intensive course and these improvements were maintained for 2 years.
Plan: Teaching communication in healthcare ‐ why bother?
1. Why bother with communication learning and teaching?• Are there problems at the moment with healthcare communication?• Can communication skills overcome these problems?• Do they make a difference to healthcare outcomes?
2. What is there to learn?• Can we define what it is we wish people to learn with all the different
issues and contexts within which health professionals work?
3. Can you learn communication?• Isn’t it all a matter of learning by experience or just personality?
4. How do you learn communication?• Do we know effective ways to teach this subject?
A subtle mixture of
1. values, attitudes and intentions
2. knowledge
3. skills
But communication values, knowledge and skills are only turned into practice through behaviour change
Production and dissemination of guidelines
Lecturing
E‐learning
Production and dissemination of guidelines
Lecturing
E‐learning
All important but by themselves will not lead to actual change
in practice
How to learn?
Knowledge is important but only allows you to know about communication
Experiential teaching is required to know how to communicate
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How to learn – lessons from the evidence
• observation of learners
• video or audio recording and review
• well‐intentioned feedback
• rehearsal
• active small group or 1:1 learning
What experiential material is available to you?
• videos of real consultations
• real patients
• simulated patients
• role‐play
Choosing Teaching Methods
Cognitive Learning
Lectures
Reading
Demonstrations
Seminars
E‐ learning
Experiential Learning
Audio/video recording
Real patients
Simulated patients
Roleplay
Reinforced by:
Reflection, feedback, re‐rehearsal
Plan: Teaching communication in healthcare ‐ why bother?
1. Why bother with communication learning and teaching?• Are there problems at the moment with healthcare communication?• Can communication skills overcome these problems?• Do they make a difference to healthcare outcomes?
2. What is there to learn?• Can we define what it is we wish people to learn with all the different
issues and contexts within which health professionals work?
3. Can you learn communication?• Isn’t it all a matter of learning by experience or just personality?
4. How do you learn communication?• Do we know effective ways to teach this subject?
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