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13/10/2016

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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?



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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






• 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?





• structuring the interview

• closing the interview

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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






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


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Are there solutions to these problems? Plan: Teaching communication in healthcare ‐ why bother?


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



2. What is there to learn?• Can we define what it is we wish people to learn, with all the different


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


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


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






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


• 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


• 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.







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







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