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Teaching clinical communication an amazing effort
Yet why do we still feel we
haven’t cracked it?
Jonathan Silverman
Utrecht 2011
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Teaching clinical communication an amazing effort
Yet why do we still feel we haven’t
cracked it?
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching?
2.
The central importance of integration
3.
Why “communication” is the wrong name
and “patient-centredness” is even worse
4.
The problems with Calgary-Cambridge
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching?
a)
we work in rarefied isolation
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching
a)
we work in rarefied isolation
b)
we are surrounded by inappropriate modelling
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching
a)
we work in rarefied isolation
b)
we are surrounded by inappropriate modelling
c)
we artificially separate communication from medical content
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching
a)
we work in rarefied isolation
b)
we are surrounded by inappropriate modelling
c)
we artificially separate communication from medical content
d)
we haven’t got assessment right
e)
we haven’t worked out how best to use the various teaching
disciplines
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Do real
clinicians
model this?
Is there a
planned
curriculum?
Does bedside
teaching back it
up?
Do learners
think it is an
add-on?
Is clinical communication
integrated into all clinical
Who doesn’t teach
When
doesn’t
challenges that learners
it?
it occur?
learn?
Have teachers been
trained?
UNIVERSITY OF
CAMBRIDGE
Do the teachers
understand the
research?
Is it rigorously
assessed and by
the correct
methods?
School of
Clinical Medicine
Learners still often perceive
clinical communication teaching
as an optional extra,
not central to their learning
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching
2.
The central importance of integration
a)
Integration with history taking skills
b)
Integration with practical skills
c)
Integration with specialty teaching
d)
Integration with the hidden curriculum
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching
2.
The central importance of integration
a)
Integration with history taking skills
b)
Integration with practical skills
c)
Integration with specialty teaching
d)
Integration with the hidden curriculum
e)
The crucial role of assessment in integration
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching
2.
The central importance of integration
a) Integration with history taking skills
b)
Integration with practical skills
c)
Integration with specialty teaching
d)
Integration with the hidden curriculum
e) The crucial role of assessment in integration
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching
2.
The central importance of integration
a) Integration with history taking skills
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Are communication skills and traditional history
taking mutually incompatible?
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Are communication skills and traditional history
taking mutually incompatible?
Have you seen this problem?
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine

Communication skills teaching model
versus
Traditional medical history model
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Three elements of gathering clinical
information
How you communicate
Process
Open
Directive
What you discuss,
record and present
Content
What you think and feel
Perception
Biomedical
Patient’s perspective
Clinical reasoning
Feelings
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Three elements of gathering clinical
information
How you communicate
Process
What you discuss,
record and present
Content
Open
Patient’s perspective
What you think and feel
Perception
Feelings
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Three elements of gathering clinical
information
How you communicate
Process
What you discuss,
record and present
Content
What you think and feel
Perception
UNIVERSITY OF
CAMBRIDGE
Directive
Biomedical
Clinical reasoning
School of
Clinical Medicine
Three elements of gathering clinical
information
How you communicate
Process
Open
Directive
What you discuss,
record and present
Content
What you think and feel
Perception
Biomedical
Patient’s perspective
Clinical reasoning
Feelings
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Communication model (process)
• Initiating the session
• Gathering information
• Building relationship
• Structuring the interview
• Explanation and planning
• Closing the session
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Traditional Medical History Model (content)
• Chief complaint
• History of the present complaint
• Past medical history
• Family history
• Personal and social history
• Drug and allergy history
• Systematic enquiry
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Confusion between process and content:

GP/psychiatry/psychology v real doctors

The issue of how learner’s are observed (if they are)

How to obtain information v. how to present info

How to obtain information v. how to write down info
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Another confusion between process and
content
Communication skills teachers have introduced their
own new content
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
content to be discovered in gathering information:
the bio-medical perspective
(disease)
sequence of events
symptom analysis
relevant systems review
background information - context
past medical history
drug and allergy history
family history
personal and social history
review of systems
content to be discovered in gathering information:
the patient’s perspective
(illness experience)
ideas and beliefs
concerns and feelings
expectations
effects on life
content to be discovered in gathering information:
the bio-medical perspective
(disease)
the patient’s perspective
(illness)
sequence of events
symptom analysis
relevant functional enquiry
ideas and beliefs
concerns
expectations
effects on life
feelings
background information - context
past medical history
drug and allergy history
family history
personal and social history
review of systems
So what’s the solution?
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Effective history taking
is essential to the practice of
high quality medicine
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Effective communication
is essential to the practice of
high quality medicine
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Effective clinical method
is essential to the practice of
high quality medicine
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
THE CALGARY- CAMBRIDGE GUIDES
TO THE MEDICAL INTERVIEW
Kurtz, Silverman, Benson and Draper (2003)
Marrying Content and Process in Clinical Method Teaching: Enhancing
the Calgary-Cambridge Guides
Academic Medicine;78(8):802-809
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Initiating the session
preparation
establishing initial rapport
identifying the reasons for the consultation
Providing
structure
making
organisation
overt
attending to
flow
Gathering information
exploration of the patient’s problems to discover the:
Building the
relationship
 biomedical perspective  the patient’s perspective
 background information - context
Physical examination
Explanation and planning
providing the correct type and amount of information
aiding accurate recall and understanding
achieving a shared understanding: incorporating the
patient’s illness framework
planning: shared decision making
Closing the session
ensuring appropriate point of closure
forward planning
using
appropriate
non-verbal
behaviour
developing
rapport
involving
the patient
Plan
1.
What undermines clinical communication teaching
2.
The central importance of integration
a) Integration with history taking skills
b)
Integration with practical skills
c)
Integration with specialty teaching
d)
Integration with the hidden curriculum
e) The crucial role of assessment in integration
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
The crucial role of assessment in integration
Assessment essential for driving the
communication curriculum forward
Assessment acts a tool for integration: it
should place communication appropriately
within all clinical challenges
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Assessment drives the curriculum
motivates learners to learn
legitimises the importance of the subject to
learners
encourages the acceptance of the subject by
otherwise sceptical faculty
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Communication skills must be included in
assessments, even if such skills are more
difficult to quantify and assess than lower levels
of learning
Assessments should be matched to the learning
objectives of the communication skills
curriculum
The methods of assessment should mirror the
methods of instruction and not undermine the
teaching
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Simulated Clinical Encounter Examination
(SCEE)
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Description of the SCEE
• OSCE-style examination
• 10 stations
– 4 stations of history taking and clinical reasoning
– 3 stations of explanation and planning
– 3 stations of other inter-personal skills
• Simulated patients and examiners
• 2 hours 40 mins face-to-face testing time
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
What does the SCEE test?
• Process skills of doctor-patient communication
• Integrated with content and clinical reasoning
• Tests clinical competence in the medical interview
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching
2.
The central importance of integration
3.
Why “communication” is the wrong name
and “patient-centredness” even worse
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
1.
What undermines clinical communication teaching
2.
The central importance of integration
3.
Why “communication” is the wrong name
and “patient-centredness” even worse
4.
The problems with Calgary-Cambridge
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
The Calgary-Cambridge
guides: the ‘teenage
years’
THE CLINICAL TEACHER 2007; 4: 87–93 87
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
4.
The problems with Calgary-Cambridge
a)
Different clinical contexts
b)
Flexibility
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Plan
4.
The problems with Calgary-Cambridge
a)
Different clinical contexts
b)
Flexibility
c)
Reductionist
d)
Checklist
e)
Received wisdom
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine
Conclusion
Integrate
Collaborate
Invest in faculty training
UNIVERSITY OF
CAMBRIDGE
School of
Clinical Medicine