powerpoint_prof suzanne kurtz

8/13/2019 Powerpoint_Prof Suzanne Kurtz

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Raising the BarRaising the Bar

on Clinical Communication in Medicineon Clinical Communication in Medicine

Suzanne Kurtz, PhDSuzanne Kurtz, PhDWashington State UniversityWashington State University

University of Calgary (Professor Emeritus)University of Calgary (Professor Emeritus)

Frontiers in Medical and Health Sciences Education ConferenceFrontiers in Medical and Health Sciences Education ConferenceDecember 11, 2009December 11, 2009

Hong KongHong Kong


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TEACH/LEARN COMMUNICATION SKILLS?TEACH/LEARN COMMUNICATION SKILLS?

AARRGGHH!!!AARRGGHH!!!


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Look whoLook whos endorsing communications endorsing communication

teaching and learning nowteaching and learning now

Royal College of Physicians and Surgeons of CanadaRoyal College of Physicians and Surgeons of Canada

College of Family Physicians of CanadaCollege of Family Physicians of CanadaAssociation of American Medical CollegesAssociation of American Medical Colleges

American Board of PediatricsAmerican Board of PediatricsWorld Federation for Medical EducationWorld Federation for Medical Education

Commission for Grads of Foreign Medical CollegesCommission for Grads of Foreign Medical Colleges

Licensing bodiesLicensing bodies

Accreditation boardsAccreditation boards


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WhoWhos endorsings endorsing conticonti

Funding agencies & Pharmaceutical companiesFunding agencies & Pharmaceutical companies

Health InsurersHealth InsurersPatient advocacy groupsPatient advocacy groups

ResearchersResearchers

Medical educatorsMedical educators

Learners at all levels of medical educationLearners at all levels of medical education

Health care providersHealth care providers

And many more internationally!And many more internationally!


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COMPONENTS OF CLINICAL COMPETENCECOMPONENTS OF CLINICAL COMPETENCE

Knowledge baseKnowledge base

Diagnostic skills, problem solvingDiagnostic skills, problem solving Physical examination skillsPhysical examination skills

Communication skillsCommunication skills

What happened?What happened?


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Evidence Based RationaleEvidence Based Rationale

Enhancing communication leads to better outcomes:Enhancing communication leads to better outcomes:

understanding & recallunderstanding & recall

adherenceadherence

symptom reliefsymptom relief

physiological outcomesphysiological outcomes patient safetypatient safety

patient satisfactionpatient satisfaction

doctor satisfactiondoctor satisfaction

costscosts

complaints and malpractice litigationcomplaints and malpractice litigation


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EvidenceEvidence--based Rationalebased Rationale

Enhancing communication leads toEnhancing communication leads to

more effective consultations for Dr & patient:more effective consultations for Dr & patient: AccuracyAccuracy

EfficiencyEfficiency SupportivenessSupportiveness

Relationships characterized by partnershipRelationships characterized by partnership

Improving communication leads to betterImproving communication leads to bettercoordination of care (within practice team, withcoordination of care (within practice team, with

patient/ptpatient/pt

s family, etc)s family, etc)


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Global PhenomenonGlobal Phenomenon

Responding to these developmentsResponding to these developments

clinicians around the globe expressclinicians around the globe expressenthusiasm for:enthusiasm for:

Enhancing their own communication skillsEnhancing their own communication skills Enhancing their ability to teach those skillsEnhancing their ability to teach those skills


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PURPOSEPURPOSE

To offer medical practitioners and educators aTo offer medical practitioners and educators a

practical, evidencepractical, evidence--based conceptual frameworkbased conceptual frameworkfor enhancing communication in medicinefor enhancing communication in medicine

33--Part Framework:Part Framework:

Underlying assumptionsUnderlying assumptions

Contexts, goals, paradigms,1Contexts, goals, paradigms,1stst principlesprinciples One approach for delineating specific skills thatOne approach for delineating specific skills that

make a difference to outcomes of caremake a difference to outcomes of care


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To beginTo begin

Revisiting how we think aboutRevisiting how we think about

communication, because the way we thinkcommunication, because the way we thinkhas a significant impact on what we dohas a significant impact on what we do


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11stst Common AssumptionCommon Assumption

Communication is aCommunication is a softsoft social skill, ansocial skill, an

optional addoptional add--on extra with no scientificon extra with no scientificbackingbacking

Hey, I donHey, I don

t need communication trainingt need communication training

II

learned to talk years agolearned to talk years ago


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Common assumptionsCommon assumptions

Myth 1: Communication is an optional addMyth 1: Communication is an optional add--on, anon, an

extra and anyway thereextra and anyway there

s no science behind its no science behind it

Communication is a core clinical skillCommunication is a core clinical skill

and thereand theres considerable science behind its considerable science behind it


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22ndnd Common AssumptionCommon Assumption

Communication is a personality trait, eitherCommunication is a personality trait, either

you have it or you donyou have it or you dontt


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Myth 2: Communication is a personality trait, eitherMyth 2: Communication is a personality trait, either

you have it or you donyou have it or you don

tt

Communication is a series of learned skillsCommunication is a series of learned skills

Not a personality traitNot a personality traitAnyone can learn who wants toAnyone can learn who wants to


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For the Doubters:For the Doubters:

A Review that quality graded 180 articlesA Review that quality graded 180 articlesInternal reliabilityInternal reliability

PrecisionPrecision

External ValidityExternal Validity

Only high to medium quality studies included in analysisOnly high to medium quality studies included in analysis81 studies qualified:81 studies qualified:

31 randomized trials31 randomized trials

38 open effect studies38 open effect studies 12 descriptive studies12 descriptive studies

AspegrenAspegren, 1999, 1999


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Results of the Lit ReviewResults of the Lit Review

Overwhelming evidence for positive effect ofOverwhelming evidence for positive effect ofcommunication skills trainingcommunication skills training

Only 1 of 81 studies didnOnly 1 of 81 studies didnt report positive effectst report positive effects

Med students, residents, juniorMed students, residents, junior drsdrs, senior, senior drsdrs allallimprovedimproved

Specialists as likely to benefit as primary careSpecialists as likely to benefit as primary care drsdrs

AspegrenAspegren, 1999, 1999


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33rdrd Common AssumptionCommon Assumption

Experience is an effective teacher ofExperience is an effective teacher of

communication skillscommunication skills All I need is a little more practice...All I need is a little more practice...

IIll get this later, on my ownll get this later, on my own


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MYTH 3: Experience is an effective teacher ofMYTH 3: Experience is an effective teacher ofcommunication skillscommunication skills

Experience alone tends to be a poor teacherExperience alone tends to be a poor teacher

of communication skillsof communication skills It is a greatIt is a great reinforcerreinforcerof habitof habit --just doesnjust doesnt discernt discern

well between good and bad habitswell between good and bad habits


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TAUGHT SKILL RETENTION VSTAUGHT SKILL RETENTION VS

DEVELOPMENT WITH EXPERIENCE ALONEDEVELOPMENT WITH EXPERIENCE ALONE

Doctors 5 years out of medical school still strong inDoctors 5 years out of medical school still strong in

information gathering (taught) but weak in explanationinformation gathering (taught) but weak in explanationand planning skills (experience only)and planning skills (experience only) discovering ptdiscovering pts views/expectationss views/expectations -- 70% no attempt70% no attempt

encouraging questionsencouraging questions -- 70% no attempt70% no attempt repetition of advicerepetition of advice -- 63% no attempt63% no attempt

checking understandingchecking understanding -- 89% no attempt89% no attempt

categorizing informationcategorizing information -- 90% no attempt90% no attemptMaguire et al 1986Maguire et al 1986


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Self perception can be inaccurateSelf perception can be inaccurate

Drs. interrupt patients withinDrs. interrupt patients within

18 seconds18 seconds (Beckman & Frankel 1984)(Beckman & Frankel 1984)

23 seconds23 seconds (Marvel et al 1999)(Marvel et al 1999)

12 seconds12 seconds (Rhoads et al 2001)(Rhoads et al 2001)

Actual time patients take to tell storyActual time patients take to tell story Primary care: Up to 150 seconds, most < 60Primary care: Up to 150 seconds, most < 60 secssecs

(Beckman & Frankel 1984)(Beckman & Frankel 1984)

Tertiary care: Mean time 92 seconds, 78% within 2 minTertiary care: Mean time 92 seconds, 78% within 2 min((LangewitzLangewitz et al, 2002)et al, 2002)


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Problems with Self PerceptionProblems with Self Perception conticonti

Doctors overestimate time spent onDoctors overestimate time spent on

patient education by up to 900%patient education by up to 900%((WaitzkinWaitzkin 1984)1984)

Picking up and responding to patient cuesPicking up and responding to patient cuesshortensshortens rather than lengthens interviewsrather than lengthens interviews

(Levinson et al 2000)(Levinson et al 2000)


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Does patient centered care take more time?Does patient centered care take more time?

7.8 min = average consultation for Drs who7.8 min = average consultation for Drs who

dondont use patient centered skillst use patient centered skills

8.5 min = average consultation for Drs who8.5 min = average consultation for Drs who

have mastered patient centered skillshave mastered patient centered skills

10.9 min = average consultation for Drs who are10.9 min = average consultation for Drs who are

learning patient centered skillslearning patient centered skillsStewart 1985Stewart 1985


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Missed Opportunities for EmpathyMissed Opportunities for Empathy

Analysis of 20 transcribed audioAnalysis of 20 transcribed audio--recordedrecorded

consultationsconsultations 384 opportunities for empathy384 opportunities for empathy

Physicians responded empathically to 39 ofPhysicians responded empathically to 39 of

them (otherwise provided little emotionalthem (otherwise provided little emotionalsupport)support)

50% of these occurred in last 1/3 of interview50% of these occurred in last 1/3 of interviewdespite even distribution of opportunitydespite even distribution of opportunity

throughout interviewthroughout interview

Morse et al 2008


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Approaches to CommunicationApproaches to Communication

ShotShot--Put ApproachPut Approach wellwell--conceived, wellconceived, well--delivered message is all thatdelivered message is all that

mattersmatters emphasis on telling, feedback not in pictureemphasis on telling, feedback not in picture

Frisbee ApproachFrisbee Approach 2 central concepts2 central concepts

confirmation = to recognize, acknowledge or endorseconfirmation = to recognize, acknowledge or endorseanotheranother

mutually understood common groundmutually understood common ground

emphasis on interaction, feedback, relationshipemphasis on interaction, feedback, relationshipA Barbour 2000A Barbour 2000


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Paradigm ProgressionParadigm Progression

Doctor centered careDoctor centered care

Patient centered carePatient centered care Relationship centered careRelationship centered care

Same paradigm progression pertains to educationSame paradigm progression pertains to education


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Comparative study of 9 urban hospitalsComparative study of 9 urban hospitals

Some invested heavily in hiring and training forSome invested heavily in hiring and training for

relational competencerelational competence Others looked for highly qualified individualsOthers looked for highly qualified individuals

Significant differences were found betweenSignificant differences were found between

hospitals regarding levels of coordination amonghospitals regarding levels of coordination amongcare providerscare providers

HofferHoffer GittelGittel J 2003,J 2003, HofferHoffer--GittelGittel et al 2000et al 2000


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9 hospital comparative study9 hospital comparative study conticonti

ConclusionsConclusions

those in positions that require high levels of functionalthose in positions that require high levels of functionalexpertise also tend to need high levels of relationalexpertise also tend to need high levels of relationalcompetence to integrate their work with others.competence to integrate their work with others.

ItIts not just individual brilliance that matters anymore.s not just individual brilliance that matters anymore.ItIts coordinated efforts coordinated effortHofferHoffer--GittelGittel et al 2000et al 2000


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1st Principles of Effective Communication1st Principles of Effective Communication

Ensures interaction not just transmissionEnsures interaction not just transmission

Reduces unnecessary uncertaintyReduces unnecessary uncertainty

Requires planning, thinking in terms of outcomesRequires planning, thinking in terms of outcomes

Demonstrates dynamism (engagement, flexibility,Demonstrates dynamism (engagement, flexibility,

responsiveness)responsiveness) Follows helicalFollows helical vsvs linear modelinglinear modeling

Same principles apply to effective teaching &Same principles apply to effective teaching &learninglearning


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33--Part FrameworkPart Framework

Underlying assumptionsUnderlying assumptions

Historical contexts, goals, shiftingHistorical contexts, goals, shiftingparadigms, 1paradigms, 1stst principlesprinciples

Skills that make a differenceSkills that make a difference


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WHAT IT TAKES TO LEARN COMMUNICATIONWHAT IT TAKES TO LEARN COMMUNICATION

Knowledge of skills is importantKnowledge of skills is importantbut does not translatebut does not translatedirectly into performancedirectly into performance

Essentials needed to learn skills, change:Essentials needed to learn skills, change:

Systematic, evidenceSystematic, evidence--based delineation & definition ofbased delineation & definition ofskillsskills

observation of learners with patients (video)observation of learners with patients (video)

wellwell--intentioned, detailed, descriptive feedbackintentioned, detailed, descriptive feedback

practice and rehearsal of skillspractice and rehearsal of skills planned reiteration/review and deepening of skillsplanned reiteration/review and deepening of skills

Small group or oneSmall group or one--toto--one teaching formatone teaching format


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What communication skills are important?What communication skills are important?


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TYPES OF COMMUNICATION SKILLSTYPES OF COMMUNICATION SKILLS

Content skillsContent skills -- what you saywhat you say

Process skillsProcess skills -- how you communicatehow you communicate how you structure interactionhow you structure interaction

how you relate to patientshow you relate to patients

nonverbal skills/behaviornonverbal skills/behavior

Perceptual skillsPerceptual skills -- what you are thinking & feelingwhat you are thinking & feeling

clinical reasoningclinical reasoning attitudes, biases, assumptions, intentionsattitudes, biases, assumptions, intentions

emotionsemotions

Capacities: compassion, mindfulness, integrity,Capacities: compassion, mindfulness, integrity, respect,etcrespect,etc))

CALGARYCALGARY CAMBRIDGE GUIDESCAMBRIDGE GUIDES


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CALGARYCALGARY--CAMBRIDGE GUIDESCAMBRIDGE GUIDESFRAMEWORK FOR THE MEDICAL CONSULTATIONFRAMEWORK FOR THE MEDICAL CONSULTATION

Initiating the Session

Gathering Information

Physical Examination

Explanation/Planning

Closing the Session

ProvidingStructure

Building theRelationship

Kurtz, Silverman, Draper (2005)


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CalgaryCalgary--Cambridge GuidesCambridge Guides

Communication Process SkillsCommunication Process Skills

56 process skills organized around framework56 process skills organized around framework

(plus 15 process & content skills:(plus 15 process & content skills: Options inOptions in ExplExpl & Pl& Plsection)section)

30+ years in the making so far30+ years in the making so far Used in all medical specialtiesUsed in all medical specialties

Used across contexts and disciplinesUsed across contexts and disciplines

Used from year 1 through advanced CMEUsed from year 1 through advanced CME

Used across cultures; translated into over manyUsed across cultures; translated into over manylanguageslanguages


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ADVANTAGES OF CADVANTAGES OF C--C GUIDESC GUIDES

Accessible summary of skills and of theAccessible summary of skills and of theresearch evidence (3research evidence (3rdrd lit review in progress)lit review in progress)

Memory aid to keep skills in mind, organizedMemory aid to keep skills in mind, organized Guidance with considerable latitudeGuidance with considerable latitude

Framework for systematic skill developmentFramework for systematic skill development

Common foundation for programs at all levelsCommon foundation for programs at all levels

Basis for comprehensive feedback (no hitBasis for comprehensive feedback (no hitand miss)and miss)

Core content for faculty training, creatingCore content for faculty training, creating

consistency across preceptorsconsistency across preceptors


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2 ESSENTIAL CONTEXTS2 ESSENTIAL CONTEXTS

FOR COMMUNICATION TEACHINGFOR COMMUNICATION TEACHING

Formal curriculumFormal curriculum

Dedicated communication sessions, modulesDedicated communication sessions, modules Informal curriculumInformal curriculum

InIn--thethe--momentmoment teaching (followteaching (follow--through inthrough in

clinic, hospital, and other real world contexts)clinic, hospital, and other real world contexts) ModellingModelling (intentional and unintentional)(intentional and unintentional)

HiddenHidden curriculum of how students are treatedcurriculum of how students are treatedand see us treating othersand see us treating others


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WHAT ARE WE MODELLING?WHAT ARE WE MODELLING?

How we use communication skills and relationalHow we use communication skills and relationalcompetencies with patientscompetencies with patients

How we treat the learners themselvesHow we treat the learners themselves

How we interact with other professionals andHow we interact with other professionals andsupport staffsupport staff

What we choose to focus on and discuss withWhat we choose to focus on and discuss withlearners during rounds & in clinical settingslearners during rounds & in clinical settings


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Examples of PostgraduateExamples of Postgraduate

Modeling to AdvantageModeling to Advantage

During surgical rounds senior surgeon asked for 2During surgical rounds senior surgeon asked for 2additional pieces of information after learneradditional pieces of information after learners presentations presentationof patient:of patient: What questions will this patient want me to answer?What questions will this patient want me to answer? What concerns does this patient have that I need to address?What concerns does this patient have that I need to address?

When a consultation was not going well, a senior oncologyWhen a consultation was not going well, a senior oncologysurgeon read through the Csurgeon read through the C--C pocket guide to review whatC pocket guide to review whathe might have missed re communication skillhe might have missed re communication skill


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More ExamplesMore Examples

Director of Anesthesiology Residency ProgramDirector of Anesthesiology Residency Programdeveloped a version of the Calgarydeveloped a version of the Calgary--Cambridge GuidesCambridge Guidesfor prefor pre--op interaction with patients and included it in theop interaction with patients and included it in thedaily faculty evaluation protocol for residents; as a result,daily faculty evaluation protocol for residents; as a result,she saw changes in both faculty and residentsshe saw changes in both faculty and residents

Family medicine doctor initiated monthlyFamily medicine doctor initiated monthly communicationcommunicationroundsrounds for cross specialty trainingfor cross specialty training


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OVERALL GOALOVERALL GOAL

Improving communicationImproving communication in practicein practice to ato aprofessionalprofessional level of competencelevel of competence

Behavior = what we do anywayBehavior = what we do anyway

vsvs

Professional competence =Professional competence =

awareness & attentionawareness & attention

intentionalityintentionalityability to reflect on & articulateability to reflect on & articulate

and itand its evidence baseds evidence based


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WE KNOW THERE ARE PERSISTENTWE KNOW THERE ARE PERSISTENT

PROBLEMS WITH PATIENT ADHERENCEPROBLEMS WITH PATIENT ADHERENCE

Patients do not adhere to medication plans: on average 50%Patients do not adhere to medication plans: on average 50%do not take their meds at all or take them incorrectlydo not take their meds at all or take them incorrectly((MeichenbaumMeichenbaum and Turk 1987, Butler et al 1996)and Turk 1987, Butler et al 1996)

The cost ofThe cost of nonadherencenonadherence is enormous:is enormous:In Canada $5 billion yearly on wasted meds, further relatedIn Canada $5 billion yearly on wasted meds, further relatedcosts of 7 to 9 billion,costs of 7 to 9 billion, egeg, extra visits to doctors, lab tests,, extra visits to doctors, lab tests,additional meds, hospital and nursing home admissions, lostadditional meds, hospital and nursing home admissions, lostproductivity, premature deathproductivity, premature death ((CoambsCoambs et al 1995)et al 1995)


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RELATED PROBLEMSRELATED PROBLEMS

egeg, RECALL & UNDERSTANDING, RECALL & UNDERSTANDINGThere are significant problems with patientsThere are significant problems with patients recall and understandingrecall and understandingof the information that doctors impartof the information that doctors impart ((TuckettTuckett et al 1985, Dunn et alet al 1985, Dunn et al

1993)1993)

Physicians give sparse information to their patients, with mostPhysicians give sparse information to their patients, with most patientspatientswanting their doctors to provide more information than they dowanting their doctors to provide more information than they do

((WaitzkinWaitzkin 1984,1984, PinderPinder 1990,1990, BeiseckerBeisecker andand BeiseckerBeisecker 1990, Jenkins1990, Jenkinset al 2001, Richard andet al 2001, Richard and LussierLussier 2003)2003)

Doctors consistently use jargon that patients do not understandDoctors consistently use jargon that patients do not understand((SvarstadSvarstad 1974,1974, HadlowHadlow and Pitts 1991)and Pitts 1991)

Doctors overestimate the time they give to explanation and plannDoctors overestimate the time they give to explanation and planninging

by up to 900%by up to 900% ((WaitzkinWaitzkin et al 1984,et al 1984, MakoulMakoul et al 1995)et al 1995)

WE KNOW THAT IMPROVINGWE KNOW THAT IMPROVING


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WE KNOW THAT IMPROVINGWE KNOW THAT IMPROVING

SPECIFIC COMMUNICATION SKILLS IMPROVESSPECIFIC COMMUNICATION SKILLS IMPROVES

ADHERENCE AND HEALTH OUTCOMESADHERENCE AND HEALTH OUTCOMES


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RECALL AND UNDERSTANDINGRECALL AND UNDERSTANDING

Asking patients to repeat in their own words what theyAsking patients to repeat in their own words what theyunderstand of the information they have just been givenunderstand of the information they have just been givenincreases their retention of that information by 30%increases their retention of that information by 30%

((BertakisBertakis 1977)1977)

Patient recall is increased by categorisation, signposting,Patient recall is increased by categorisation, signposting,

summarising, repetition, clarity and use of diagramssummarising, repetition, clarity and use of diagrams ((LeyLey1988)1988)

There is decreased understanding of information given ifThere is decreased understanding of information given ifthethe patientpatientss andand doctordoctor ss explanatory frameworks are atexplanatory frameworks are atodds and if this is not discovered and addressed during theodds and if this is not discovered and addressed during theinterviewinterview ((TuckettTuckett et al 1985)et al 1985)


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ADHERENCE AND OUTCOMESADHERENCE AND OUTCOMES

Patients who are viewed as partners, informed of treatmentPatients who are viewed as partners, informed of treatmentrationales and helped in understanding their disease arerationales and helped in understanding their disease aremore adherent to plans mademore adherent to plans made (Schulman 1979)(Schulman 1979)

Doctors can increase adherence to treatment regimens byDoctors can increase adherence to treatment regimens byexplicitly asking patients about knowledge, beliefs,explicitly asking patients about knowledge, beliefs,

concerns and attitudes to their own illnessconcerns and attitudes to their own illness (Inui et al 1976,(Inui et al 1976,MaimanMaiman et al 1988)et al 1988)

Discovering patientsDiscovering patients expectations leads to greater patientexpectations leads to greater patientadherence to plans made whether or not thoseadherence to plans made whether or not thoseexpectations are met by the doctorexpectations are met by the doctor ((EisenthalEisenthal andand LazareLazare1976,1976, EisenthalEisenthal et al 1990)et al 1990)


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ADHERENCE AND OUTCOMESADHERENCE AND OUTCOMES (CONTI)(CONTI)

Giving pts opportunity to discuss their concerns rather thanGiving pts opportunity to discuss their concerns rather thansimply answer closed questions leads to better control ofsimply answer closed questions leads to better control of

hypertensionhypertension ((OrthOrth et al 1987)et al 1987)

Patients coached in asking questions of and negotiatingPatients coached in asking questions of and negotiatingwith their doctor not only obtain more information butwith their doctor not only obtain more information but

actually have better BP control in hypertension and betteractually have better BP control in hypertension and betterblood sugar control in diabetesblood sugar control in diabetes (Kaplan et al 1989,(Kaplan et al 1989, RostRost et al 1991)et al 1991)

In a 2 hour tutorial, doctors working with hypertensiveIn a 2 hour tutorial, doctors working with hypertensive

patients were taught to focus more on considering theirpatients were taught to focus more on considering theirpatientpatients ideas and on patient education. Their patientss ideas and on patient education. Their patientsunderstanding of their condition improved, complianceunderstanding of their condition improved, complianceincreased, and hypertension control remained better 6increased, and hypertension control remained better 6

months after the tutorialmonths after the tutorial (Inui 1976)(Inui 1976)


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ADHERENCE AND OUTCOMESADHERENCE AND OUTCOMES (CONTI)(CONTI)

When theWhen the drdr--pt relationship is a negotiated process, inpt relationship is a negotiated process, inwhich there is increased understanding of and agreementwhich there is increased understanding of and agreementupon a proposed treatment, higher levels of complianceupon a proposed treatment, higher levels of complianceand improved health can be achievedand improved health can be achieved ((CoambsCoambs et al, 1995)et al, 1995)

Consultations using a structured exploration of patients'Consultations using a structured exploration of patients'beliefs about their illness and medication and specificallybeliefs about their illness and medication and specificallyaddressing understanding, acceptance, level of personaladdressing understanding, acceptance, level of personal

control and motivation leads to improved clinical control orcontrol and motivation leads to improved clinical control ormedication use even three months after the interventionmedication use even three months after the interventionceasedceased (Dowell et al 2002)(Dowell et al 2002)


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SYMPTOMSSYMPTOMS

Resolution of symptoms of chronic headache isResolution of symptoms of chronic headache ismore related to the patientmore related to the patients feeling that they weres feeling that they were

able to discuss their headache and problems fullyable to discuss their headache and problems fullyat the initial visit with their doctor than to diagnosis,at the initial visit with their doctor than to diagnosis,

investigation, prescription of referralinvestigation, prescription of referral (The Headache(The Headache

Study Group 1986)Study Group 1986) A decreased need or analgysia after myocardialA decreased need or analgysia after myocardial

infarction is related to information giving andinfarction is related to information giving and

discussion with the patient (Mumford et al 1982)discussion with the patient (Mumford et al 1982)


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DefinitionDefinition conticonti

RCC recognizes that communication takesRCC recognizes that communication takes

places within organizational contexts and isplaces within organizational contexts and isinfluenced by organizational or practice policiesinfluenced by organizational or practice policiesand processes and by how people within theand processes and by how people within the

organization or practice treat each otherorganization or practice treat each other

SuchmanSuchman 20012001


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COMPARATIVE STUDY OF 9 URBAN HOSPITALSCOMPARATIVE STUDY OF 9 URBAN HOSPITALS

RE JOINT REPLACEMENT SURGERYRE JOINT REPLACEMENT SURGERY

Some invested heavily in hiring and training for relationalSome invested heavily in hiring and training for relationalcompetence (competence (ieie, ability to interact with others to, ability to interact with others toaccomplish goals)accomplish goals)

Others looked for most highly qualified individuals (neglectOthers looked for most highly qualified individuals (neglectof relational competence most pronounced in physicianof relational competence most pronounced in physician

hiring)hiring)

Significant differences were found between hospitals reSignificant differences were found between hospitals relevels of coordination among care providerslevels of coordination among care providers

HofferHoffer GittelGittel J 2003,J 2003, HofferHoffer--GittelGittel et al 2000et al 2000


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9 HOSPITAL COMPARATIVE STUDY9 HOSPITAL COMPARATIVE STUDY (CONT)(CONT)

Higher coordination between care providers significantlyHigher coordination between care providers significantlyimproved patient care.improved patient care.

EgEg, increase in coordination enabled:, increase in coordination enabled:

31% reduction in length of stay31% reduction in length of stay

22% increase in quality of service pts perceived22% increase in quality of service pts perceived

7% increase in postoperative freedom from pain7% increase in postoperative freedom from pain

5% increase in postoperative mobility5% increase in postoperative mobility

HofferHoffer GittelGittel 2003,2003, HofferHoffer--GittelGittel et al, 2000et al, 2000


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9 HOSPITAL COMPARATIVE STUDY9 HOSPITAL COMPARATIVE STUDY CONTCONT

Conclusion:Conclusion:

those in positions that require high levels of functionalthose in positions that require high levels of functionalexpertise also tend to need high levels of relationalexpertise also tend to need high levels of relationalcompetence to integrate their work with others.competence to integrate their work with others.

HofferHoffer--GittelGittel et al 2000et al 2000

ItIts not just individual brilliance that matters anymore.s not just individual brilliance that matters anymore.

ItIts coordinated effort.s coordinated effort.

Participant inParticipant in HofferHoffer--GittelGittel et al 2000 studyet al 2000 study


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RESEARCH FINDINGSRESEARCH FINDINGS ((conticonti ))

The medical perspective and patientThe medical perspective and patientss

perspective are differentperspective are different -- they requirethey requiredifferent managementdifferent management

Including patient perspective improves careIncluding patient perspective improves care

Patients who arePatients who are activeactive partnerspartners have betterhave betteroutcomesoutcomes

RelationshipRelationship--centered care (partnership)centered care (partnership)makes sensemakes sense


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YES, BUTYES, BUT

Can you teach/learn communication skills?Can you teach/learn communication skills?


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AspegrenAspegren K (1999) Teaching and LearningK (1999) Teaching and Learning

Communication Skills in Medicine: A review withCommunication Skills in Medicine: A review with

Quality Grading of Articles.Quality Grading of Articles. Medical TeacherMedical Teacher 21(6)21(6)

FOR THE DOUBTERS


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DEFINITIONS OF RCCDEFINITIONS OF RCC contcont

the social role and privileges of the healer seem to bethe social role and privileges of the healer seem to befounded on meaningfulfounded on meaningful relationshipsrelationships in health care,in health care,

not just technically appropriate transactions withinnot just technically appropriate transactions withinthese relationships.these relationships.

Beach & Inui with The RelationshipBeach & Inui with The Relationship--Centered Care Research Network.Centered Care Research Network.RelationshipRelationship--Centered Care: A Constructive Reframing. 2005Centered Care: A Constructive Reframing. 2005


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COMMUNICATION SKILLS TEACHING &COMMUNICATION SKILLS TEACHING &

LEARNING IS DIFFERENTLEARNING IS DIFFERENT

Closely bound to self concept, self esteem,Closely bound to self concept, self esteem,

personalitypersonality More complex than simpler procedural skillsMore complex than simpler procedural skills

No achievement ceilingNo achievement ceiling DonDont start from scratcht start from scratch

Faculty with limited formal communicationFaculty with limited formal communicationtrainingtraining

STAGES IN SKILLS LEARNING/CHANGESTAGES IN SKILLS LEARNING/CHANGE


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STAGES IN SKILLS LEARNING/CHANGESTAGES IN SKILLS LEARNING/CHANGE

helical process, not linear progressionhelical process, not linear progression

Integrated/AssimilatedIntegrated/Assimilated

Consciously skilledConsciously skilled

AwkwardAwkward

Beginning AwarenessBeginning Awareness

WackmanWackman et al 1976et al 1976


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WHAT IT TAKES TO LEARN COMMUNICATIONWHAT IT TAKES TO LEARN COMMUNICATION

Knowledge of skillsKnowledge of skillsbut does not translate directly intobut does not translate directly intoperformanceperformance

Essentials needed to learn skills, change:Essentials needed to learn skills, change:

systematic delineation & definition of skillssystematic delineation & definition of skills

observation of learners with clients (video)observation of learners with clients (video)

wellwell--intentioned, detailed, descriptive feedbackintentioned, detailed, descriptive feedback

practice and rehearsal of skillspractice and rehearsal of skills

planned reiteration and deepening of skillsplanned reiteration and deepening of skills evaluation of skillsevaluation of skills


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What communication skills are important?What communication skills are important?


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I iti ti th S i


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Providing

Structure

Initiating the Session

preparation

establishing initial rapportidentifying the reason(s) for the consultation

providing the correct amount and type of information

aiding accurate recall and understanding

achieving a shared understanding: incorporating the patients

illness framework

planning: shared decision making

Closing the Session

Building the

relationship

Gathering information

Physical examination

Explanation and planning

makingorganisationovert

attending toflow

exploration of the patients problems to discover the:o biomedical perspective o the patients perspective

o background information- context

ensuring appropriate point of closureforward planning

usingappropriatenon-verbal

behaviour

developingrapport

involvingthe patient

ADVANTAGES OF GUIDESADVANTAGES OF GUIDES


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ADVANTAGES OF GUIDESADVANTAGES OF GUIDES

Accessible summary of skillsAccessible summary of skills -- validatedvalidated

Framework for systematic skill developmentFramework for systematic skill development Memory aid to keep skills in mind, organizedMemory aid to keep skills in mind, organized

Guidance with considerable latitudeGuidance with considerable latitude

SAME PROCESS SKILLS NEEDED FOR ALLSAME PROCESS SKILLS NEEDED FOR ALL


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SAME PROCESS SKILLS NEEDED FOR ALLSAME PROCESS SKILLS NEEDED FOR ALL

THESE COMMUNICATION ISSUESTHESE COMMUNICATION ISSUES

Cultural & socioeconomic differencesCultural & socioeconomic differences

Explaining risk & benefitsExplaining risk & benefits Special needs clients (elderly, young,Special needs clients (elderly, young,

challenged, low literacy)challenged, low literacy)

Prevention, health promotionPrevention, health promotion

Giving bad news, death and dyingGiving bad news, death and dying

Gender differencesGender differences EthicsEthics

CO C O OC SS S SWHY ARE COMMUNICATION PROCESS SKILLS


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WHY ARE COMMUNICATION PROCESS SKILLSWHY ARE COMMUNICATION PROCESS SKILLS

SO ADAPTABLE?SO ADAPTABLE?Context changesContext changes

Content changesContent changes

Levels of intensity, intention, & awareness shiftLevels of intensity, intention, & awareness shift

BUTBUTCommunication process skills remain the sameCommunication process skills remain the same



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FOR COMMUNICATION TEACHINGFOR COMMUNICATION TEACHING

Formal curriculumFormal curriculum

Dedicated communication sessions, modulesDedicated communication sessions, modules Informal curriculumInformal curriculum

InIn--thethe--momentmoment teaching (followteaching (follow--through inthrough in

clinic, hospital, and other real world contexts)clinic, hospital, and other real world contexts) ModellingModelling (intentional and unintentional)(intentional and unintentional)

HiddenHidden curriculum of how students are treatedcurriculum of how students are treatedand see us treating othersand see us treating others


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PatientPatient--Centered CareCentered Care

The medical perspective and patientThe medical perspective and patientssperspective are differentperspective are different -- they requirethey requiredifferent managementdifferent management

Including patient perspective improvesIncluding patient perspective improvescarecare

Patients who arePatients who are activeactive partnerspartners havehavebetterbetter outcomesoutcomes

Yes but is this practical?Yes but is this practical?


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Yes, but is this practical?Yes, but is this practical?

The question of timeThe question of time


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If learners are going to integrate and propagateIf learners are going to integrate and propagatepatterns of relating that they experience inpatterns of relating that they experience in

medical training, then it is incumbent upon eachmedical training, then it is incumbent upon eachof us (as faculty, fellows, or junior doctors) toof us (as faculty, fellows, or junior doctors) tobecome more mindful of our own behaviorbecome more mindful of our own behavior -- toto

become more explicitly aware of and intentionalbecome more explicitly aware of and intentionalabout the values and skills we enact in our dayabout the values and skills we enact in our day--toto--day workday work In other words, to help ourIn other words, to help our

learners learn and change their behavior, welearners learn and change their behavior, wemust commit ourselves to our own continuousmust commit ourselves to our own continuouslearning and behavior change.learning and behavior change.

SuchmanSuchman & Williamson 2003& Williamson 2003


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DefinitionDefinition conticonti

Four sets of relationships are foundational in healthFour sets of relationships are foundational in healthcare and healing:care and healing: Clinician with patient, client, significant othersClinician with patient, client, significant others Clinician with other care givers (colleagues, team)Clinician with other care givers (colleagues, team)

Clinician with community (practice, hospital, town)Clinician with community (practice, hospital, town)

Clinician with self (thought processes; emotionalClinician with self (thought processes; emotionalintelligence; intentions, biases, beliefs, values; attitudesintelligence; intentions, biases, beliefs, values; attitudesand capacities; self concept)and capacities; self concept)

Adapted from Beach & Inui & the Relationship Centered Care ReseaAdapted from Beach & Inui & the Relationship Centered Care ResearchrchNetwork, 2005Network, 2005

powerpoint_prof suzanne kurtz

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