Evelyn van Weel-Baumgarten , Department of Primary and Community Care

,

NIJMEGEN

Is linking research, teaching and practice in communication

in health care the way forward?

Disclosure of Relevant Financial

Relationships:

Evelyn van weel-Baumgarten has no

financial relationships to declare

The problem?

• Research

• Teaching and transfer

• A patient story: the challenge of every-day practice

• Links

Introducing a patient: Richard

• Physicians

• Nurses

• Other healthcare professionals

• Patients

• Teachers

• Students/learners

• Researchers

Audience?

Research

Adequate doctor-patient communication

contributes to

• More accurate diagnosis

• Better adherence to treatment

• More effectiveness and

• Less problems in patient safety

• Less legal issues

• Lower costs

Influence of doctor-patient relationship on health

outcomes: the physician

• Physicians adopting a warm, friendly and reassuring

manner are more effective than those who remain

formal with their patients.

• What makes it effective?

Di Blasi

Fields of research

• Integration

• Patient centeredness

• Placebo

Integrating correct medical content with adequate communication skills: outcome of guideline concordant care for depression

Adequate intervention (accurate diagnosis, treatment with AD)

Inadequate intervention

GP skilled in communication

Positive effect after 3 and 12 months

No effect

GP NOT skilled in communication

No effect No effect

van Os et al

• A patient is seen as a person

attention for context

exploring emotional cues

• Involvement of the patient

room for the patient’s story

active role beyond the consultation

Person/patient centeredness

Balint, Engel, Stewart, Epstein and others

• Emphasis on a dialogue

showing empathy

adjusting information to

patient’s context

framing in a positive way

involvement in decisions

on management

empowering

Person/patient centeredness

• The person of the doctor

awareness of our influence on practice of medicine

Person/patient centeredness

Quality of physician patient communication

Griffin, Kinmonth et al, Stuart

• important during all stages of a clinical consultation

Effective

• mutual understanding of each others’ explanatory

models of illness and disease taking into account

patient’s ideas, concerns, and expectations : common

ground

• clear information

Quality of physician patient communication

Griffin, Kinmonth, Stuart

• Effect on outcomes: well-being, anxiety and

depression but also on blood pressure; cholesterol;

HbA1c and even on mortality

• And reduces costs through fewer diagnsostic tests

and referrals

Placebo effects

The words and how they are used

• cause cognitive and emotional changes

• have neurobiological underpinnings and actual effects on the brain and body

Benedetti

Placebo studies

Placebo effects

through:

• Conditioning

• Manipulating expectations

• Influencing patients’ affective state and stress

levels

Benedetti, Bensing

Empathy

• better outcomes

• quicker recovery

affective statements

reduce anxiety and uncertainty

temper emotional arrousal

lead to increased recall of medical information

The difference:

• 38 seconds and affective statements related to emphasizing

non-abandonment and providing reassurance of medical

support. Bensing, van Dulmen; van Osch, van Dulmen

Placebo - healing power of clinicians?

• Lessons learnt can be used in teaching of

clinical communication skills

• But not as a trick/isolated skill in a one-off

• Relationships matter

Stewart

Summarizing:

research shows that adequate communication

impacts positively on health and outcomes

so

Let’s just teach it

Teaching

Doctor-patient relationship and teaching / learning

communication skills

• Communication skills can be learnt

• Many medical schools have implemented

Communication skills training/ Blueprints, Canmeds

• Criteria for curriculum development for Medical

Education

Silverman, Van Herwaarden, Kern

Teaching

• What

• How

• Transfer

What to teach:

• Process Skills for gathering

information/exploration of the

patient’s problems including

patient perspective (common

ground)

• Skills for explanation and

planning

• Specific communication issues

and challenges

Models

• Lectures?

Attention span declines after 15-20 minutes

Retention rate 5% - 10% - 50% for group discussions

Lacks possibility to address individual needs and adjust

Good for transmitting knowledge / as an introduction if….

Clear and well structured

Interactive

Used in combination with other teaching

methods/discussions

Related to real life problems/challenges:

How to teach: traditional teaching?

Intermezzo

• Stand-up and turn to some-one you don’t know

• Shake hands and introduce yourself briefly (1 minute

pp max)

• Name

• Where you are from and what ‘your main

bloodgroup’ is

• Researcher, Teacher, Clinician, Student, Patient

• A first new link!

• Lectures?

Attention span declines after 15-20 minutes

Retention rate 5% - 10% - 50% for group discussions

Lacks possibility to address individual needs and adjust

Good for transmitting knowledge / as an introduction if….

Clear and well structured

Interactive

Used in combination with other teaching

methods/discussions

Related to real life problems/challenges:

How to teach: traditional teaching?

How to teach

• Skills-training (experiential learning) with feedback

• Using crucial components to change behavior

Meeting needs of learners

Activating prior knowledge

Interactive learning and opportunities to practice

Peer interaction

Aspegren, Davis , Mazmanian, Steinart

How to teach

Experiential teaching methods

• role play

• simulated patients/actors

• real patients

Effective feedback

• direct

• video

Integrated in the curriculum

Longitudinal

Assessment

Effective feedback

• Outcome led

• Well intentioned

• Specific

• Descriptive

• Focussed on skills

• Based on choices not solutions

• Limited amount

Value of modern teaching methods?

• E learning

• Serious gaming

• Giant tablet training

Clinical practice is a challenge:

teaching ≠ learning ≠ application in practice

Transfer is not easy

Richard’s story continues

Transfer : ‘a rough ride’ • Near – Far

• Far transfer only achieved when knowledge and

skills are used in every-day work Yamnill & McLean, Van Baalen

Clinicians/Role models

• very powerful, probably even more than training of

communication

• during rotations students receive mixed messages

when observing clinicians/role models Egnew, Essers

Transfer to the clinical context in family medicine

residents

Cognitive and Emotional space

Phase 1

Confrontation

with the effect of

a behavior

Phase 2

Becoming

conscious of own

behavior

Phase 3

Searching for

alternative

behavior

Phase 4

Personalization

of new behavior

Phase 5

Internalization

and clinical

integration

Safety

van den Eertwegh et al.

Important for transfer in a hospital setting

in the right circumstances confrontation leeds to • reflection • increased self-awareness In that case experienced as transformative learning

van den Eertwegh et al.

What helps

• Feedback

• Role models with attention for and sensitive to

communication

• Safe learning environment

• Structured ‘peer group meetings’ coached by

neutral person, experienced and knowledgeable in

communication

• Notion of awareness of communication in a

department

van den Eertwegh et al.

Linking more?

Normalising exchange

Open door?

• Regular meetings for exchange

• Including them in our routines

• Researchers teaching and

• Teachers involved in research

• Involving each other and clinicians of all

relevant practice contexts

• Ad policymakers?

Research

• More Participatory research methods?

• Link with Implementation science?

• Involving multiple stakeholders : clinicians,

educators, learners, patients

• And policymakers?

Why:

• Outcomes easier to transfer, more feasible

and sustainable (more commitment, more

relevant)

Participatory research

Patient involvement

As full partners

Defining problems / formulating

research questions together

Co-creating solutions

Patients. clinicians, educators, etc.

Research

• More Participatory research methods

• Look at implementation science more?

Implementation science

• Looks at if and why interventions –

guidelines/training programmes do or do not work

in a specific context

with attention for policy

• Possibility to adapt interventions to specific needs

before introduction

• http://www.fp7restore.eu/

Teaching

• Suggestions for classroom sessions

• Workplace based learning

Classroom sessions

Mix training of separate skills with full consultations

• mimicking length and complexity of clinical practice

• feedback by clinicians of that setting

• choices informed by clinicians, faculty AND students

Examples:

whole single consultations

surgeries

farmacotherapy

Van Weel-Baumgarten et al.

Teaching in clinical practice

• With clinicians who know and show the principles of

effective communication skills; give effective

feedback

• Start dialogue

To change climate – involving

clinicians , learners and educators as well as

(local) policy makers

Health care and policy

Clinicians are assessed

quality indicators, registration systems

comply with insurance rules and regulations

Education in an environment where this counts

If that lacks attention - appreciation for communication

no (sustained) change for learners

For changes and sustainability:

• solutions need discussion and involvement of policy makers

Back to the patient

Linking

Clinical Practice

Research Teaching

Policy

• Questions

evelyn.vanweel-baumgarten@radboudumc.nl evelyn.vanweel-baumgarten@each.eu

3. Doctor’s visit, 1663. Jan Steen 5. 17th-century artwork of two Dutch doctors, Boekelman Cornelis (l.) and Jan Six , 1699. By Jurriaen Pool

(1666-1745). Nurse by Isaac Israels 1865-1934 Chirurgijn. by Teniers the younger (Flemish) 1610-1690 6. Titus, 1655. Rembrandt 1606 -1669: 7. La Berceuse, 1889. van Gogh 12. Village doctor, Teniers the younger 13. Doctor as god and as man Golzius 1600-1625 (ook als devil 15. Self Portrait Rembrandt 1630 17. Barber. Teniers de younger, 18. Sad man. Van Gogh, 1890 19. The Sick Girle. Gabriel Metsu 1629-1667 21. Anatomische les van dr N Tulp, 1632. Rembrandt 23. Schoolteacher, 1668. Jan Steen 25. Boerhaave theater Leiden around 1600 29. Girl with pearl ear ring. Vermeer 1665-1667 30. Schoolteacher. Jan Steen, 1663-1665 32. Fisch transforming in birds. Escher, 1878-1972 34. Van Goyen 1569-1656 35. Anatomy lesson by dr Ruys, 1670. Adriaen Backer 37. Hospital ward in Arles, 1889. Van Gogh 40. Victory Boogie Woogie, 1942-1944. Mondriaan 43. Selfportrait, 1932. Dick Ket, 1902-1940 47. Waterfall, 1961. Escher 1878-1972 49. Regents of the ‘Elisabeth Gasthuis’, 1641. Frans Hals 51. Red tree, 1908. Mondriaan