Transcript Making the Case for Teaching and Assessing Clinical Skills

Making the Case for Teaching and Assessing
Clinical Skills
University of North Carolina – Chapel Hill School of Medicine
November 10, 2011
Ann C. Jobe, MD, MSN
Executive Director
Clinical Skills Evaluation Collaboration
(CSEC)
A Little Context and
Perspective
United States Medical Licensing
Examination (USMLE)
• The USMLE is a single licensure pathway for all
individuals (graduates of US and international
medical schools) wanting to practice medicine in
the United States
• Implemented in early 1990’s
United States Medical Licensing
Examination (USMLE)
The USMLE is sponsored by
• the Federation of State Medical Boards of the
United States, Inc. (FSMB), and
• the National Board of Medical Examiners®
(NBME®)
A Look Back in Time
• Prior to late 1960’s – state boards made up
their own exams – different exams in each
state
• Late 1960’s - the Federation Licensing
Examination (FLEX) – a single examination
(Components 1 and 2), used by all states,
was developed by NBME for the Federation
of State Medical Boards (FSMB).
A Look Back in Time
• Educational Commission for Foreign
Medical Graduates (ECFMG) – from 1984
to 1993 had a separate examination,
developed by NBME, for international
graduates – Foreign Medical Graduate
Examination in the Medical Sciences
(FMGEMS)
A Look Back in Time
• Prior to the early 1990’s, there were three
separate licensing examinations in the US:
• FLEX – Components 1 and 2
• NBME – Parts 1, 2, and 3
• FMGEMS
A Look Back in Time
• USMLE - introduced in early 1990’s
• Single examination pathway for initial medical
license (graduates of US and international
medical schools)
• A national standardized series of exams to assure
minimal competency
United States Medical Licensing
Examination (USMLE)
• Each of the three Steps of the USMLE
complements the others
•
• No Step can stand alone in the
assessment of readiness for medical
licensure.
United States Medical Licensing
Examination (USMLE)
• Step 1
• understanding and application of important concepts of the
foundational sciences essential for the practice of medicine
• Multiple choice exam; computer-based delivery
• Step 2
• application of medical knowledge, skills, and understanding
of clinical science essential for the provision of patient care
under supervision
• Clinical Knowledge (CK)
• Multiple choice exam; computer-based delivery
• Clinical Skills (CS)
United States Medical Licensing
Examination (USMLE)
•Step 2CS
•Standardized patients used to assess an
examinee’s ability to
• gather information from patients,
• perform physical examinations,
• communicate their findings to patients and
colleagues
United States Medical Licensing
Examination (USMLE)
• Step 3
• application of medical knowledge and
understanding of biomedical and clinical science
essential for the unsupervised practice of
medicine
• Multiple choice exam and computerized case
simulations (CCS); computer-based delivery
Life Cycle of a Physician
in the United States
American Board of Medical Specialties (ABMS)
Specialty Boards
Board Certification
Exams
Recertification
q 7-10 yrs
NRMP Match
Medical School
Year 1
Year 2
Year 3
Year 4
Postgraduate
Training
3-7 yrs
Step 1 Step 2 CK Step 3
Step 2 CS
Licensure
United States Medical
Licensing Examination
(USMLE)
Fellowship
Maintenance of Certification (MOC)
Practice
Maintenance of Licensure (MOL)
Relicensure
q 1-3 yrs
State Licensing Authorities
Miller’s Pyramid
Action
DOES
Performance
SHOWS HOW
KNOWS HOW
KNOWS
Competence
Knowledge
Kirkpatrick Criteria
4. Results
Change in organizational practice
Benefits to patients/clients
3. Behavior
Transfer learning to workplace
Learners apply new knowledge and skills
2. Learning
Change attitudes/perceptions
Change knowledge/skills
1. Reaction
Customer satisfaction related to participation in
educational activities
COMPETENCY
• “Core Competencies”
Accreditation Council for Graduate Medical Education (ACGME)
American Board of Medical Specialties (ABMS)
•
•
•
•
•
•
Patient Care
Knowledge
Communication and Interpersonal Skills
Professionalism
Systems-Based Practice
Practice-Based Learning and Improvement
Correlations among Step
scores
Step l
Step 2 CK
Step 2 CS
Step 2 CK
~.65
---------
-----
Step 2 CS Data-gathering
Communication/IP skills
Spoken English proficiency
Patient note
.19
.09
.09
.20
.26
.16
.13
.30
-----
Step 3
~.50
~.70
N/A
The Improvement of
Assessment
National Board of Medical Examiners (NBME)
• First examinations in 1916 were voluntary:
“weeklong extravaganzas” (essay, laboratory,
oral, practical and bedside components)
• 1922 – 1950: Basic biomedical sciences - essay
questions; fundamentals of clinical medicine essay questions; observed patient encounters
and an oral examination
The Improvement of
Assessment
National Board of Medical Examiners (NBME)
1950’s:
• Essay questions replaced with “selected-response”
questions (MCQs);
• Studies of the bedside oral examination demonstrated
that the scores provided more information about the
examiner than the examinee. Due to this psychometric
unreliability, it was eliminated in 1964
The Improvement of
Assessment
National Board of Medical Examiners (NBME)
1960’s:
• number of test formats tried for final clinical examination
• motion pictures of clinical encounters projected to
examinees, who answered MCQs based on encounters
• Multi-step, latent-image management problems
1980’s:
• all parts of examinations were MCQs
A Look Back in Time
• Public concerns that “physicians don’t listen
to patients”
• State Medical Boards – most frequent
complaints related to communication
• Increase in medical liability suits –
estimated that a clinician’s communication
style and attitude were major factors in
nearly 75% of these suits
A Look Back in Time
• Only some medical schools had formal
courses to teach communication/clinical
skills
• More than 60% of graduating medical
students replied on the AAMC Graduation
Survey that they had never been observed
doing a complete history and physical
National Board of Medical
Examiners (NBME)
To protect the health of the public through state
of the art assessment of health professionals.
While centered on assessment of physicians, this
mission encompasses the spectrum of health
professionals along the continuum of education,
training and practice and includes research in
evaluation as well as development of
assessment instruments.
National Board of Medical
Examiners (NBME)
• Large scale development efforts,
partnering with medical schools in
pilots, to assess medical students’
clinical skills
• Utilized Standardized Patients (SPs)
Educational Commission for
Foreign Medical Graduates
(ECFMG)
The ECFMG promotes quality health care for
the public by certifying international medical
graduates for entry into U.S. graduate medical
education, and by participating in the evaluation
and certification of other physicians and health
care professionals.
Educational Commission for
Foreign Medical Graduates
(ECFMG)
• Large scale development efforts to provide an
assessment of International Medical Graduates’
clinical skills
• Implemented the Clinical Skills Assessment
(CSA) in 1998
• CSA – a national standardized assessment,
using Standardized Patients (SPs), required for
International Medical Graduates who wanted to
enter the U.S.
Clinical Skills Evaluation Collaboration
CSEC
• A Collaborative
Partnership,
established in
2003, between
the Educational
Commission for
Foreign Medical
Graduates
(ECFMG) and the
National Board of
Medical
Examiners
(NBME)
History of CSEC
• 1998
• Clinical Skills Assessment (CSA)
• June 2001
• Discussions regarding collaboration initiated
• May 2003
• CSEC Collaboration Agreement signed
• June 2004
• 1st administration of USMLE Step 2 Clinical Skills (CS)
Reaction to Step 2 CS
• State medical boards and the USMLE
Composite Committee felt strongly that a
national standardized assessment of clinical
skills, overseen by an external body, was
needed to validate the competency of
medical school graduates and to protect the
public
Reaction to Step 2 CS
• Large percentage of US medical schools,
medical students and the American Medical
Association (AMA) opposed the exam –
stating that the medical schools should
assess this and that the schools were doing
this
• Concern about expense (dollars and time)
for students
COMMUNICATION
• The essence of the
patient-physician
relationship
• Includes
communicating
verbally, non-verbally,
as well as actions and
interactions during a
physical examination
COMMUNICATION
• Effective
communication is
a cornerstone of
patient safety
Communication breakdown, whether between
care providers or between care providers
and their patients, is the primary root cause
of the nearly 3,000 sentinel events –
unexpected deaths and catastrophic injuries
– that have been reported to The Joint
Commission
“What Did the Doctor Say?”:
Improving Health Literacy to Protect Patient Safety
The Joint Commission, 2007
Communication Skills
• Numerous publications
confirm that poor skills in
patient communication are
associated with:
• Lower levels of patient
satisfaction
• Higher rates of complaints
• Increased risk of
malpractice claims
• Poorer health outcomes
Communication
• It is all about
COMMUNICATING
with patients and
families and health
professionals
• It is all about
improving
communication to
improve the quality
and safety of
health care
Communication – “It’s
About Time”
“Science and technology
have advanced
enormously over the
last decades but
ultimately the best
medical care requires
deep knowledge of
science as well as the
skills to communicate
effectively with patients.
Communication – “It’s
About Time”
“If the medical profession
wishes to maintain or
perhaps regain trust and
respect from the public, it
must meet patients’
needs with a renewed
commitment to
excellence in the
communication skills of
physicians. It is time to
make this commitment.”
Levinson W, Pizzo PA Patient-Physician
Communication – It’s About Time. JAMA, May 4,
2011; 305(17): 1802-3.
Communication – “It’s
About Time”
• “ABMS should incorporate
assessment of communication
into certification and
maintenance of certification.”
• “Better assessment tools are
needed to allow trainees and
practicing physicians to
measure their skills on basic
and more advanced
communication skills, such as
disclosing medical errors and
discussing patients’ end of life
care wishes.”
Levinson and Pizzo
Honoring Our Contract with
Society
• All health professions, to
fulfill our obligation to our
patients:
• Need to renew our
commitment to excellence
in communication skills
• Need to include results of
assessments of
communication skills into
licensure and certification
decisions
Why Does It Matter?
• Initiatives focused on
improving communication –
through teaching and
assessment - will be most
successful in improving the
quality and outcomes of
care provided by health
professionals
CSEC Today
• 244,571 examinees
(through 10-31-2011)
• 2,934,852 Standardized
Patient encounters
• 53% (130,160) USMGs
• 47% (114,411) IMGs
USMLE Step 2 Clinical
Skills
• Mastery of clinical
and communication
skills, as well as
cognitive skills, by
individuals seeking
medical licensure is
important to the
protection of the
public. (from USMLE
Bulletin of Information)
CSEC Centers
•
•
•
•
•
Atlanta
Chicago
Houston
Los Angeles
Philadelphia
ATLANTA, GEORGIA
CHICAGO, ILLINOIS
Chicago
HOUSTON, TEXAS
Houston
LOS ANGELES, CALIFORNIA
Los Angeles
PHILADELPHIA, PENNSYLVANIA
Philadelphia
Step 2 CS Examinees
• About 2,000 to 3,000
examinees each month
• About 400-600 examinees per
month at each Center
Step 2 CS Scheduling
• Centers run 5-6 days a week
• Minimum at each center is 2
“sessions” per day
– A “session” = 12 examinees
– AM1 Session & AM2 Session
• Several centers also run in the
evening - one PM Session
CSEC Centers
• “Full time” (12-15)
–
–
–
–
–
–
–
–
Center Manager
Assistant Center Manager
SP Operations Specialist (SPOS)
SP Trainers (6)
Facilities/Office Coordinator
End User Support Staff (IT/AV)
Chief Proctor/Proctors
Control Room Operators
• “Part time as needed”
– Standardized Patients
– Medical Advisor
– Receptionist
Step 2 CS Examinees
YEAR
TOTAL
USMGs
IMGs
2010
33,951
19,485
14,880
2009
34,837
18,983
15,854
2008
35,224
17,711
17,513
2007
33,832
17,711
16,121
2006
32,843
17,473
15,132
2005
31,939
17,671
14,268
2004
14,880
6,501
8,379
Step 2 CS Fees
USMG
(increase of $145(15%) over
7 year period)
•
•
•
•
•
•
IMG
(increase of $155 (13%)
over 7 year period)
2004-2006: $975 • 2004-2009:
$1,200
2007: $1,005
• 2010: $1,295
2008: $1,025
• 2011: $1,355
2009: $1,055
2010: $1,075
2011: $1,120
USMLE Step 2 Clinical
Skills
• The cases cover
common and
important situations
that a physician is
likely to encounter in
clinics, doctors’
offices, emergency
departments, and
hospital settings in
the United States.
• The cases that make up each administration of
the Step 2 CS examination are based upon an
examination blueprint.
• The sample of cases selected for each
examination reflects a balance of cases that is
fair and equitable across all examinees.
• On any examination day, the set of cases will
differ from the combination presented the day
before or the following day, but each set of cases
has a comparable degree of difficulty.
Presentation Categories
Case Content
Cardiovascular
Respiratory
Gastrointestinal
Musculoskeletal
Constitutional
Neurological
Psychiatric
Genitourinary
Women’s health
Case Acuity
Acute
Subacute/Chronic
Form
Patient age
Age less than 18
Age 18 – 44
Age 45 – 64
Age 65 +
Patient Gender
Male
Female
Other Case Formats
• Although there are no young children presenting
as patients, there may be cases in which an
examinee encounters - either in the examination
room or via the telephone - a parent or caregiver
of a child or other individual (e.g., an elderly
patient).
• Each Step 2 CS “session” includes 12 encounters
of twenty-five minutes each.
• 15 minutes with patient
• 10 minutes for patient note
• The examination lasts approximately 8 hours.
Two breaks are provided:
• 1st break is 30 minutes long (lunch)
• 2nd break is 15 minutes long (snack).
Registration Room
Orientation Room
Exam Room
Exam Room
Step 2 CS Components
• Communication and
Interpersonal Skills (CIS)
• Spoken English
Proficiency (SEP)
• Integrated Clinical
Encounter (ICE)
• Data gathering (DG)
• History & PE
• Patient note (PN)
Step 2 CS Components
• USMLE Step 2 CS is a
Pass/Fail examination
• Each of the three
subcomponents (CIS,
SEP, ICE) must be
passed in a single
administration in order to
achieve a passing
performance on Step 2
CS
Assessment of Communication
and Interpersonal Skills (CIS)
• CIS performance is assessed by the standardized
patients
• a global rating of these skills using a series of generic
rating scales
• same CIS scale for all 12 encounters
• 3 sub-components:
• Information gathering (questioning skills)
• Information sharing
• Professional manner and rapport
Assessment of Communication
and Interpersonal Skills (CIS)
Questioning skills/ Information Gathering examples include:
• use of open-ended questions, transitional statements,
facilitating remarks
• avoidance of leading or multiple questions, repeat
questions - unless for clarification, medical terms/jargon
unless immediately defined, interruptions when the
patient is talking
• accurately summarizing information from the patient
Assessment of Communication
and Interpersonal Skills (CIS)
Information-sharing skills - examples include:
• acknowledging patient issues/concerns and clearly
responding with information
• avoidance of medical terms/jargon unless immediately
defined
• clearly providing
• counseling when appropriate
• closure, including statements about what happens
next
Assessment of Communication
and Interpersonal Skills (CIS)
Professional manner and
rapport - examples include:
• asking about
• expectations, feelings, and
concerns of the patient
• support systems and impact of
illness, with attempts to explore
these areas
• showing
• consideration for patient
comfort during the physical
examination
• attention to cleanliness through
hand washing or use of gloves
Assessment of Communication
and Interpersonal Skills (CIS)
Professional manner and
rapport - examples
include:
• providing opportunity for the
patient to express feelings
and/or concerns
• encouraging additional
questions or discussion
• making
• empathetic remarks
concerning patient
issues/concerns
• patient feel comfortable
and respected during the
encounter
Assessment of Spoken English
Proficiency (SEP)
• SEP performance is assessed by the standardized
patients
• using rating scales; same scale for all 12 encounters
• based upon
• frequency of pronunciation or word choice errors that
affect comprehension
• amount of listener effort required to understand the
examinee's questions and responses
• clarity of spoken English communication within the
context of the doctor-patient encounter (e.g.,
pronunciation, word choice, and minimizing the need
to repeat questions or statements)
Scoring of the Step 2 Clinical
Skills Subcomponents
The ICE subcomponent includes assessment of:
• Data gathering (DG) - patient information
collected by history taking and physical
examination
• Documentation (PN) - completion of a patient note
summarizing the findings of the patient encounter,
diagnostic impression, and initial patient work-up
Scoring of the Step 2 Clinical
Skills Subcomponents
• Data gathering (DG) performance is assessed by
the standardized patients
• using checklists developed by committees of
clinicians and medical school clinical faculty
• checklists comprise the essential history and
physical examination elements for each specific
clinical encounter
Scoring of the Step 2 Clinical
Skills Subcomponents
• The patient note is rated/scored by trained
physician raters
• The patient note (PN) consists of three
areas
• Medical History and Physical Examination
• Differential Diagnosis (list up to 5)
• Diagnostic Workup
Scoring of the Step 2 Clinical
Skills Subcomponents
• Scored holistically
• Relevant and correct information
• Congruency/consistency with specific case –
based scoring guidelines
• Integration/synthesis of information
• Organization, coherence, cohesiveness, flow,
legibility
Performance on Step 2 CS

Failure rate for USMGs






2004-2005:
2005-2006:
2006-2007:
2007-2008:
2008-2009:
2009-2010:
4%
2%
3%
3%
3%
3%

Failure rate for IMGs

2004-2005: 17%







US Citizens: 11%
Foreign Citizens: 18%
2005-2006:
2006-2007:
2007-2008:
2008-2009:
2009-2010:
15%
23%
28%
27%
24%
Performance on Step 2 CS

Passing rate for USMGs (first takers)
2005-2006:
 2006-2007:
 2007-2008:
 2008-2009:
 2009-2010:

CIS
CIS
CIS
CIS
CIS
>99%; SEP >99%; ICE 98%
99%; SEP 100%; ICE 97%
99%; SEP >99%; ICE 98%
99%; SEP >99%; ICE 98%
99%; SEP >99%; ICE 98%
Performance on Step 2 CS

Passing rate for IMGs (first takers)
2005-2006:
 2006-2007:
 2007-2008:
 2008-2009:
 2009-2010:

CIS
CIS
CIS
CIS
CIS
93%;
87%;
81%;
84%;
87%;
SEP
SEP
SEP
SEP
SEP
98%;
99%;
92%;
94%;
95%;
ICE
ICE
ICE
ICE
ICE
89%
85%
86%
84%
85%
Standardized Patients in Step 2 CS
 Why use SPs  Less expensive than
physicians
 More available than real
patients or physicians
 Can be trained to be
standardized
Can Simulate Some Physical
Findings






Breathing difficulties
Acute abdomen
Joint and back pain
Hearing loss
Neurological findings
Petechiae, bruising
SPs Are Realistic
 Physicians are unable to distinguish between SPs
and real patients.
 Physicians demonstrate similar actions with SPs
as with real patients.
SPs Are Accurate
 SPs are more than 90% accurate in portraying
case details
 SPs more accurate than physicians
 Multiple SPs have little effect on examination
reliability
•
Elliot, DL and Hickam DH (1987). Evaluation of physical examination skills: reliability of
faculty observers and patient instructors. JAMA 258(23), 3405-3408.
Exam Room
SP Accuracy
• Live reviews and video
reviews of SPs (portrayal of
case and rating of
examinee)
• Categories:
• No error(s) or with minor
error(s) not impacting scoring
• More significant error(s) required remediation
• Substantial error possibly
impacting scoring – removed
from the exam
SP Accuracy
• 96.9% - no error or minor
error
• 3% - more significant error
• 0.06% - substantial error
Solving the Puzzle
Improving Quality and Safety in Health
Care
What makes me happy about this
exam


Assuring that patients
are protected by
increasing the levels
of quality and safety
in delivery of health
care
Consequential or
Educational validity –
impact on teaching in
medical schools
Consequential or Educational Validity
Impact on Curriculum

Almost all medical schools have clinical skills
centers – or share a center

Most schools utilize standardized patients for
teaching and assessment
Consequential or Educational Validity
Impact on Curriculum

Most schools have separate clinical skills,
“doctoring” or “introduction to clinical
medicine” courses – many have longitudinal
content and teaching in clinical skills

Most schools have several assessments of
clinical skills using SPs across the curriculum
– formative and summative
Medical School Requirements for
Class of 2011

129 medical schools

Record a passing score to graduate
 79

Record a score to graduate
 47

schools = 11,299 (61%)
schools = 6,845 (37%)
No requirement
3
schools = 309 (2%)
updated 10-21-2010
Reliability
Dependability of assessment scores –
consistency and reproducibility
 Similar to a signal-to-noise ratio where the
“signal” is good information and “noise” is
measurement error
 Reliability in .6 - .9 range is acceptable for
performance assessments

Internal Structure

Reliability – the reproducibility of the data or
scores on the assessment
 USMLE



Step 1 (2009)
Step 2 CK (2008)
Step 2 CS (2008-09)

ICE

CIS

SEP
 Step
3 (2009)
.94
.91
.74
.72
.78
.88
Outcomes Research

Does an examination/assessment
predict the quality of care delivered by
physicians in future practice? How does
performance on an assessment link to
desired outcomes?

Medical Council of Canada (MCC) exams
 Qualifying
examinations: QE1 (medical
knowledge) and QE2 (clinical skills)
 2 recent studies – published in 2007 and 2009
Outcomes Research

Tamblyn R, et al. JAMA 2007; 298 (9):
993-1001.

“Scores achieved in patient-physician
communication and clinical decision
making on a national licensing
examination predicted complaints to
medical regulatory authorities.”
Outcomes Research

Wenghofer E, et al. Medical Education
2009; 43: 1166-1173.

“Doctor scores on qualifying examinations
are significant predictors of quality-of-care
problems based on regulatory, practicebased peer assessment.”
What keeps me awake at night

“Physician by Number”
- JAMA “Piece of My
Mind” – July 8, 2009




“Kaplanization” of the
exam
Challenge to simulate
physical findings
“Binge and Purge”
phenomenon
Feedback to examinees
“Performing” – “On Stage”

“I go through the
motions for practice, but
I lack the ability to
discern subtle differences
in my findings. It’s a
performance: a didactic
routine with precise
directions to guide the
end result – reminiscent
of the paint-by-number
kits I loved as a child.”
Acronym approach

On Old Olympic
Terraced Tops….

ADCAVAMDIMSL
PAM HUGS FOSS SIQORAA
•
SIQORAA for setting intensity quality
onset radiation Aleviating fact and
aggravat fact
PAM for previouis episodes , Allergy,
medication
HUGS .illness, for hospitalisation, surgery,
system illness
FOSS for family med hist, Obg/gyn, sexual
activity and then sleep patterns and life
habits like cig alcohol..
This is an entry from a website discussion forum on
USMLE Step 2 CS
Rote and
perfunctory
performance
 Test taking
strategies to “get
points”

Lack of Physical Findings
Examinees are
aware of this
 Examinees tend to
“short-cut” PE
maneuvers
 Is this contributing
to the decline in
clinical skills,
especially PE

Physical Examination


Current Step 2 CS
assesses an examinee’s
ability to do physical
examination maneuvers
correctly
BUT does not effectively
assess the ability of an
examinee to discern
physical findings
How Best to Assess
Can an individual truly
distinguish normal from
abnormal physical
findings
 How well does an
individual synthesize
and integrate all the
information gathered
from a patient

Teaching to the Exam
This is a “High stakes” exam – required
for residency and licensure
 Like any important activity – Step 2 CS
(and other USMLE exams and
certification exams) have engendered
“secondary businesses” – that are
money makers……

What is Measured is Important
What methods of “teaching to the test”
result in acquisition of the best evidencebased clinical skills
 Do individuals who take review courses
acquire the “gold standard” clinical skills or
“test taking strategies”
 How do we insure that physicians maintain
the clinical skills that are important across
a professional lifetime

“Binge and Purge”

Should there be
more or additional
“high stakes”
assessments of
clinical skills



During residency
For certification
For maintenance
of licensure and
certification
Feedback

“Immediate feedback is
effective, delayed
feedback is less so.”
Duffy, Holmboe

Step 2 CS feedback is:



Not specific enough
Delayed
Is this another way that
leads to loss of the “best”
skills or retention of poor
skills?
Role Modeling vs Feedback

“Do as I say, not as I
do”

The impact of the
“hidden curriculum”
and role models
Challenges and Opportunities Ahead for
CSEC
“Even if you’re on
the right track,
you’ll get run over
if you just sit
there.”
Will Rogers
May - July 2011
• As of July 2011 – all
patient notes are typed
– no longer may
choose to write or type
the notes
• Increased realism in
portrayals of SP cases
– designed to enhance
the stimulus for
assessment of
examinee’s
communication skills
Launch 2004
Present
2012 Implementation
Doctor: I think you may
have cancer.
Doctor: I think you may
have cancer.
Doctor: I think you may
have cancer.
SP: OK
SP: I wasn’t expecting to
hear that. That is very
upsetting.
SP: I wasn’t expecting to
hear that. That is very
upsetting.
OR
SP: I looked it up online
and was shocked that
cancer might be possible,
but I also saw some other
possibilities. I wrote them
down and would like your
opinion.
June 2012
Six Function Model
Communication Skills Competency
1.
2.
3.
4.
Fostering the Relationship
Gathering Information
Providing Information
Helping the Patient with Making
Decisions
Basic
Advanced
5. Supporting Emotions
Basic
Advanced
6. Helping Patients with
Behavior Change
Six Function Model
Communication Skills Competency
1. Fostering the Relationship
2. Gathering Information
3. Providing Information
4. Helping the Patient with Making Decisions
5. Supporting Emotions
6. Helping Patients with Behavior Change
H. de Haes and J. Bensing, 2009
Assessment Construct
Comparison of Original and
Enhanced Construct for Step 2CS
CIS Original Construct
Professional Manner and
Rapport
Enhanced Construct
Fostering the Relationship
Supporting Emotions: Basic
Information Gathering
Gathering Information
Providing Information
Information Sharing
Making Decisions: Basic
Functions
Sub-Functions
Express interest in the patient
1. Fostering the Relationship
Treat the patient with respect
Listened and paid attention to the patient
Give the patient a chance to tell his/her story
2. Gathering Information
3. Providing Information
Explore the patient’s reaction to
illness/problem
Provide information related to the working
diagnosis
Provide information on next steps
4a. Making Decisions: Basic
4b. Making Decisions: Advanced
5a. Supporting Emotions: Basic
5b. Supporting Emotions: Advanced
6. Helping Patients With Behavior Change
Get the patient’s perspective on diagnosis and
next steps
Finalize plans for next steps
Sub-functions yet to be determined from video
review
Facilitate expression of implied or stated
emotion
Sub-functions yet to be determined from video
review
Sub-functions yet to be determined from video
review
June 2012
New Patient Note Format
• Assess “Data Interpretation”
– 1-3 Differential Diagnoses
– Pertinent “positive” and “negative”
History and PE findings that support
diagnosis or diagnoses
– List of plans for next steps in workup to confirm or rule-out diagnosis
or diagnoses
June 2012
June 2012
Enhanced/Challenging Communication
Skills
• Counseling patients about
behavioral change
• Delivering bad news
• Disclosing an error - apology
• Negotiating a treatment plan that
takes into consideration patient
values and preferences
Enhanced/Challenging Communication Skills
• Starting a medication assessing level of health
literacy – “teach back”
• Advanced directives
• Medication reconciliation
• Functional status assessment
Communicating with more than one person
in the room
• Elderly patient with adult
child
• Translator for patient that
cannot speak or
understand English
• Family conference
Communicating with other Health
Professionals
• Consultation with a
physician, pharmacist,
physician assistant, nurse
• Referral to a specialist
• “Hand-offs”
– Shift changes
– Hospital discharge
Team Assessment
• Standardized team
members – nurse,
physician, physician
assistant, social worker,
physical therapist,
pharmacist, occupational
therapist…..
Solving the Puzzle
Improving Quality and Safety in Health
Care
What is Measured is Important
Individual and organizational behavior
and focus changes in the lens of high
stakes examinations
 Measurement of pure knowledge is not
sufficient to determine if an individual
can do something or apply knowledge
 Longitudinal/repeated assessments are
the best way to sustain behavior
change

CSEC Vision Statement
CSEC will be a significant
contributor to a system in
which patients throughout
the world receive safe, highquality, patient-centered
health care services
delivered by health care
professionals who are highly
competent in clinical and
interpersonal skills
Take Home Message
High level skills in “bedside
medicine” – “clinical skills”




Ability to elicit a patient’s
story/history
Correct use of evidence-based PE
maneuvers in a focused manner
based on history
Ability to synthesize information
gathered
Ability to communicate and
negotiate plans for management
are the cornerstone of patient
safety and quality of care
Take Home Message

Effective communication is a
cornerstone of patient safety
and quality of care

Initiatives focused on
improving communication –
through teaching and
assessment - will be most
successful in improving the
quality and outcomes of
care provided by health
professionals
The Impact of the Prevailing
Culture

“Do as I say, not as I
do”

The impact of the
“hidden curriculum”
and role models
Culture – Like an Iceberg

What is seen

What is unseen
Curriculum

Seen


Formal curriculum –
what students are
taught
Unseen

Informal (Hidden)
curriculum – what
students experience
as expressions of
professional values
Cultures can be invisible to
those living in them

Question to fish –


What is it like
living in water?
Answer –

What is water?
An Opportunity to Move to a
New Excellence
Make the hidden
visible
 Match the
informal with the
formal curriculum
 How can I model
what I wish to
see?

The Impact of the Prevailing
Culture

The best approach to
insure the development
and maintenance of a
high level of
“bedside/clinical skills” is
to insure that everyone in
the organization supports
and role models “best
practices” in clinical skills
Commitment to Excellence in
Clinical Skills
One “Champion”
 or even better a few
“Champions”
 Or even better – an
Academy of Educators
committed to role
modeling the best of
clinical skills

Why Does It Matter?

Initiatives focused on
improving
communication –
through teaching and
assessment - will be
most successful in
improving the quality
and outcomes of care
provided by health
professionals
Change
“They always say time changes things,
but you actually have to change them
yourself.”
Andy Warhol
Final words
“Whether you think
you can, or think
you can’t, you are
right.”
Henry Ford
THANK YOU
Let us continue on
the journey
together –
improving how we
care for our
patients