Transcript assessing communication as a clinical competency

Assessing Communication
as a Clinical Competency
Why Bother?
Suzanne Kurtz, PhD
College of Veterinary Medicine
Washington State University
March 14, 2008
Washington DC
ACKNOWLEDGEMENTS
Kurtz S, Silverman J, Draper J (2005)
Teaching and Learning Communication Skills in Medicine,
2nd Ed. Radcliffe Publ: Oxford & San Francisco
Silverman J, Kurtz S, Draper J (2005)
Skills for Communicating with Patients, 2nd Ed. Radcliffe
Publ: Oxford & San Francisco
Riccardi V & Kurtz (1983)
Communication and Counselling in Health Care. Charles C
Thomas, Springfield, Illinois
Cindy Adams, PhD, University of Calgary
AARRGGHH!!!
Who’s Endorsing Communication
in Veterinary Medicine?
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National Commission on Vet Econ Initiatives
American Animal Hospital Association
American & State Vet Med Associations
American College of Veterinary Internal Medicine
Veterinary Colleges - Canada, UK, USA, etc.
Intl Conf on Communication in Vet Med
National Board of Vet Med Examiners
Vet Industry Partners
Evidence Base
Human Medicine
Enhancing communication leads to:
 More effective consultations
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Accuracy
Efficiency
Supportiveness
 Better
relationships (partnership)
 Better coordination of care
Kurtz, Silverman, Draper, 2005
Evidence Base: Improved Clinical Outcomes
in human medicine
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Enhancing communication leads to better
outcomes:
 understanding
& recall
 symptom relief
 physiological outcomes
 adherence
 patient safety
 patient satisfaction
 doctor satisfaction
 costs
 complaints and malpractice litigation
Evidence Base
Veterinary Medicine
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PEW National Veterinary Education Program (1988)
AVMA Market Study (1999)
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Brakke Management and Behavior Study (2000)
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Identified three business practices to increase practice income
(employee longevity, employee satisfaction, and client satisfaction)
Personnel Decision Study (2003)
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“Veterinarians are strong in scientific, technical and medical skills and
lacking in communication and management skills necessary for success
in practice.”
Identified non-technical competencies for career success (business
acumen, work life balance, effective communication, and leadership
skills)
AVMA-Pfizer Business Practices Study (2005)
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Identified client relationships as a pillar of financial success
Evidence Base
Veterinary Medicine
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Compliance range is between 23-65%
 Problems cited:
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Not enough information
Relationship not established
Client opinion not considered
No follow up regarding patient well being
Adams V (2002), AAHA (2004)
Evidence Base
Veterinary Medicine
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50-82% of complaints to CVO related to
communication problems:
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Client was misinformed
Consent was not obtained
Client felt disrespected
Client felt like opinion did not matter
Procedure was not explained
College of Veterinarians of Ontario (2005)
What are we assessing?
Clinical competence
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Knowledge base
 Physical examination skills
 Medical problem solving, diagnostic skills
 Communication skills
Communication is a core clinical skill
with considerable science behind it
Common (mis)perceptions
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Communication is a personality trait, either you
have it or you don’t
 Communication is a series of learned skills
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Not a personality trait
Anyone can learn who wants to
Results of Lit Review (human medicine)
81 high to medium quality articles included
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Overwhelming evidence for positive effect of
communication skills training
 Only 1 of 81 studies didn’t report positive effects
 Med students, residents, junior drs, senior drs all
improved
 Specialists as likely to benefit as primary care drs
Aspegren, 1999
Evidence: Veterinary Medicine
Significant improvement in veterinary students’
communication skills with increasing levels of
training (p<.0001)
 No significant difference between no training
and intermediate training
 Clients’ recall highest in student group with
highest level of communication training
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Latham CE, Morris A Veterinary Record (2007)
Common (mis)perceptions
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Experience is a good teacher of communication
skills
 Experience alone tends to be a limited teacher
of communication skills
 It is a great reinforcer of habit - just doesn’t
discern well between good and bad habits
Our perception may be flawed
What gets us into trouble is not what we
don’t know. It’s what we know for sure
that just ain’t so.
Mark Twain
Taught skill retention
vs development with experience alone
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Doctors 5 years out of medical school still strong in
information gathering (taught) but weak in explanation and
planning skills (experience only)
 discovering pt’s views/expectations
70% no attempt
 negotiation
90% no attempt
 encouraging questions
70% no attempt
 repetition of advice
63% no attempt
 checking understanding
89% no attempt
 categorizing information
90% no attempt
Maguire et al 1986
Evidence-based Rationale
Veterinary Medicine
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Data gathering
 Primarily closed questions
 No open-ended questions in 25% of interviews
Empathy
 Empathy statements in only 7% of appointments
Shaw, Adams, Bonnett, Roter 2003, 2004
What are we assessing?
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Behavior = what we do anyway
vs
 Professional competence =
awareness & attention
intentionality
ability to reflect on & articulate with precision
and it’s evidence based
Goal = to enhance communication in practice
to a professional level of competence
What are we assessing?
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Skills*
 Attitudes, beliefs, values
 Capacities (eg, compassion, integrity, flexibility,
mindfulness)
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In what circumstances?
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Difficult situations (complex case, breaking bad news, death and
dying, medical error, adverse outcomes)
Everyday run-of-the-mill consultations, client education,
prevention
Types of Communication Skills
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Content skills
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Perceptual skills - what you think, clinical reasoning
- what you feel
- attitudes, biases, intentions, assumptions
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Process skills - how you question, respond, explain, plan
- how you structure talk
- how you relate to patients
- nonverbal skills/behaviour
- what you say, info you gather & give
Do we know
what skills are worth assessing?
Many models available:
 Calgary-Cambridge Guides
 Patient-Centered Model
 Macy Model
 SEGUE Framework
 Bayer-Fetzer Essential Elements
 MAAS-Global
Numerous approaches to assessing
communication are out there
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Boon H and Stewart M (1998) Patient-physician communication
assessment instruments 1986 to 1996 in review. Patient Education
and Counseling. 35: 161-76.
Cushing A (2002) Assessment of non-cognitive factors. In: GR
Norman, CPM van der Vleuten and KJ Newble (eds) International
Handbook of Research in Medical Education. Kluwer Academic
Publishers, Dordrecht.
MacLeod H (2004) Physician performance assessment and
communication skills assessment. Unpublished review of the
literature from 1990 to 2003. Task Force on Physician
Communication Skills Assessment and Enhancement in Canada,
Medical Council of Canada, Ottawa, Ontario
Kurtz S, Silverman J, Draper J (2005) Assessing learners’
communication skills. In Teaching and Learning Communication
Skills in Medicine (2nd ed). Radcliffe Publishing: Oxford & San
Francisco
CALGARY-CAMBRIDGE GUIDES
FRAMEWORK FOR THE MEDICAL CONSULTATION
Initiating the Session
Providing
Structure
Gathering Information
Building the
Relationship
Physical Examination
Explanation/Planning
Closing the Session
Kurtz, Silverman, Draper (2005)
Calgary-Cambridge Guides
Communication Process Skills
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process skills organized around framework
(plus Options in Expl & Pl section = 15 more process
& content skills:)
 Backbone
of communication teaching and
learning
 Cross-disciplinary & cross-cultural application
SEE HANDOUT
Same process skills for an array
of communication issues
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Conflicted or difficult situations
Gender issues
Cultural issues
Generational differences
Ethical dilemmas
Performance reviews
Advantages of Guides
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Accessible summary of research evidence
Comprehensive delineation of skills
Memory aid to keep skills in mind, organized
Framework for systematic skill development
Basis for comprehensive feedback & evaluation
Core content for training faculty, creating consistency
Common foundation for programs at all levels – basis for
coherent, helical curricula from undergrad through CE
Same skills pertain to effective teaching or communication
with colleagues
What are we assessing?
Knowledge – do you know it?
 Competence – can you do it?
 Performance – do you (choose to) do it in practice?
 Results – what happens to pts, to drs?
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Miller 1990
What forms can assessments take?
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Knowledge – do you know it?
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MCQ, essay/short answer, oral,
Objective Structured Video Exam…
What forms can assessments take?
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Competence – can you do it?
 OSCE using standardized simulated clients
• Stand alone communication stations
• Communication stations integrated with PE, medical problem
solving,
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Real interviews:
• Series of live interviews with examiner present
• Series of self-selected videotapes/DVDs submitted for expert
assessment
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Web-based OSCE (physicians link to simulated
patient whom they interview online)
What form can assessments take?
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Performance – do you (choose to) do it in practice?
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Videotapes/DVDs submitted with assessors randomly
choosing tapes to be assessed
Undercover simulated clients
Real clients’ assessments
Client and clinician do immediate assessment of same
individual interview
Colleagues’ assessments
Results – what happens to pts, clients, drs?
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Self assessment/report
Chart audits
Follow up studies re compliance, outcomes of care, etc.
Objectives of Assessment
 Motivation
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Drives what gets learned and taught
Legitimizes importance of a subject
Encourages acceptance by otherwise skeptial
students and faculty
 Progress
check, certification that is valid
and reliable
 Educational impact
Formats for Feedback
quantitative______________________ __
evaluative feedback_________
number scores, good/bad
global_____________________
_qualitative
descriptive feedback
“here’s what I see”
_________ __detailed
Two types of assessment
 Formative
 Summative
What does it take to learn
clinical communication skills, change?
Knowledge doesn’t translate directly into
performance
 Essentials needed to learn skills, change:
 Systematic delineation & definition of skills
 Observation of learners communicating (video)
 Well-intentioned, detailed, descriptive feedback
 Practice and repeated rehearsal of skills
 Planned reiteration and deepening of skills
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Small group or one-on-one format
Teaching and learning communication
skills is different
 Closely
bound to self concept
 No one starts from scratch
 No achievement ceiling
 More complex than simpler procedural skills
Stages in skills learning/change
not a linear progression
Fully assimilated
Consciously skilled
Awkward
Beginning Awareness
Wackman et al 1976
What makes for effective feedback?
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1st Principles of Effective Communication
Ensures interaction not just transmission
Reduces unnecessary uncertainty
Requires planning, thinking in terms of
outcomes
Demonstrates dynamism (engagement,
flexibility, responsiveness)
Follows helical vs linear model
Same principles apply to effective teaching
What makes for effective feedback?
Agenda-Lead Outcome-Based Analysis
(ALOBA)
Approaches to communication
 Shot-Put
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the well-conceived, well-delivered message is all that
matters
emphasis on telling, interaction/feedback not in picture
 Frisbee
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Approach
Approach
2 central concepts
• confirmation = to recognize, acknowledge or endorse
another
• mutually understood common ground
emphasis on interaction, feedback, relationship
A Barbour 2000
Example of an Integrated OSCE
University of Calgary
Day of exam
1 Interview with SC - videotaped
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examiner scores content checklist
SC completes written feedback form (after interview)
2 Student thought time
3 Presentation of case to examiner with problem list,
hypotheses, & ideas for PE
4 Performance of selected PE related to interview (PE
unrelated to interview tested at other stations)
5 PE results given to student - student gives ideas re
investigations
6 Investigation results given to student - student gives ideas
re differential diagnosis
Integrated OSCE conti
Within 12 days of exam:
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Pairs of students meet with expert examiner to assess
communication process skills (Calgary-Cambridge
Guides)
1 View student’s videotaped interview, stopping tape
periodically
2 Self, peer, and expert assessment (yes, yes but, no)
3 Compare results (not about reaching consensus)
4 Mini-tutorial re problem skills, strengths, next steps
5 Compare process skills with content checklist,
hypotheses and differential, SC feedback
Individually tailored remedial for unsatisfactory
students; retake of exam (x2 possible)
Concluding thoughts
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Communication is core clinical skill
 Skills are appropriate focus for teaching and assessment
 Build on what’s already available (research, teaching and
assessment models in human and vet medicine)
 Include educational impact in design of assessment
 Train faculty and learners to participate in feedback
process to enhance communication learning
 Integrate communication with other clinical skills teaching
and assessment