Transcript Aucun titre de diapositive - OUTCOMEREA: promotion et

How To Teach
Communication Skills
Élie AZOULAY MD PhD, Medical ICU, Saint-Louis Hospital,
ESICM Barcelona, September 2006
Introduction
• Communication is an important component of patient care.
• Improvements in provider-patient communication can have
beneficial effects : patient's key concerns must be directly
and specifically solicited and addressed.
• To be effective, the clinician must gain an understanding of
the patient's perspective on his or her illness.
• Traditionally, communication in medical school curricula
was incorporated informally as part of rounds and faculty
feedback, without a specific focus on skills of
communicating. This left important communication gaps.
• Ready access to quality information and thoughtful patientdoctor discussions allow to address patients' overall needs
and to share complex information.
To improve global visit
satisfaction, communication
skills training programs may
need to be longer and more
intensive, teach a broader
range of skills, provide
ongoing performance feedback.
A five-point framework
1. The evidence that clinicians experience
communication difficulties
2. Communication Skills Training Programs
3. Optimal duration of a training program
4. Long term impact of Communication Skills
Training Programs
5. Teaching communication skills to ICU
clinicians
The evidence that clinicians
experience communication difficulties
Fallowfield et al. J Clin Oncol. 1998
• It has long been recognized that difficulties in the effective
delivery of health care can arise from problems in
communication between patient and provider.
• < 35% of senior doctors had received communications training.
• Time, experience, and seniority had not improved skills.
• Most had problems with
– giving complex information,
– obtaining informed consent,
– handling ethnic and cultural differences.
• Many patients, when they fear that their prognosis is poor,
do not ask for precise information and do not hear it if it is
provided by the doctor
• Study of patients with untreatable small cell lung cancer
shows that doctors and patients collude in behaviour that
fosters a false optimism about recovery
• By focusing on the "treatment calendar" patients ignore the
issue of prognosis
• Patients' false optimism:
– doctors withholding information
– lack of communication skills
• Are patients victims of doctors' behaviors ?
Teaching medical students what
they think they already know
Fadlon et al. Educ Health (Abingdon). 2004 Mar;17(1):35-41
• Focus groups and a short evaluation questionnaire filled in
by 56 first year medical students before and after a
workshop in interviewing skills were used.
• When communication skills are taught in an informal,
unstructured manner, medical students might view this
knowledge as unspecialized, repetitive, and even boring.
• Introducing a structured model can overcome two kinds of
problems: 1) over-confident students are formally
introduced to unique aspects of medical interviewing, 2)
those who lack confidence are offered a lifeline in the form
of a structured model.
• Methodology from the linguistic research that allows both the
quantitative and qualitative study of language.
• Analysis of the language of 40 doctors and their patients
during 373 complete primary-care consultations.
• Doctors do not use jargon suggests that they are aware of the
need to avoid it, but it does not follow that they are easily
understood by patients.
• Some doctors used language associated with social power,
implying that consultations may be less democratic than is
appropriate. .
• There was substantial evidence that the doctors used
language to express emotions (eg, anxiety), to diminish
threats (eg, words such as "little"), and to reassure patients.
It denotes a therapeutic use of language.
A five-point framework
1. The evidence that clinicians experience
communication difficulties
2. Communication Skills Training Programs
3. Optimal duration of a training program
4. Long term impact of Communication Skills
Training Programs
5. Teaching communication skills to ICU
clinicians
Teaching methods
• Learner- vs. patient- vs. skill-centered
• The cognitive approach aims to improve physicians'
knowledge and skills.
• The behavioral approach offers learners the
opportunity to practice these appropriate skills through
practical exercises and role plays.
• The affective approach allows participants to express
attitudes and feelings that communicating about
difficult issues evoke.
• And … more !
What Are Communication Skills
Training Programs ?
COURSES
1. Theoretical information
2. Patients' or VP rating
feedback to doctors
3. Training Programs
– structured feedback,
– interactive group demonstrations
/ exercises
– discussion in groups of four led by
trained facilitators.
– case discussion, role playing,
simulation-based education
4. Problem-defining or
emotion-handling skills
5. Posttraining consolidation
workshops
MATERIALS
1. Video review of interviews,
2. Computer-assisted program
3. Videos or written
preparatory information
4. Audiotaping of the
consultation
5. Provision of decision aids
Only
Training!!!
A program to improve physicians'
detection of distress in patients (HADS)
• One-hour theoretical information course, then randomization
to 2 communication skills training programs or to a waiting
list: a 2.5-day basic training program consolidated by 6
consolidation workshops (3-hour)
• Physicians' ability to detect patients' distress was measured
through computing differences between physicians' ratings of
patients' distress and patients' self-reported distress.
• No change was observed.
• There is a need for more than theoretical information
Feedback from patients
• A crossover study in which trainees were their own
control individuals, and standardized patients
provided feedback after the first interview.
• Trainees improved their informing skills after
being provided feedback.
• Their skills improved in :
– 1) promoting more trust
– 2) making parents feel less dependent.
Group versus individual Teaching
Parish et al. Teach Learn Med. 2006 Spring;18(2):92-8
• With both review formats, most students had a positive
learning experience (80%), found it less stressful than they
expected (67%), and would not have preferred to do the
review the other way (84%).
• Students randomized to individual reviews had a
significantly higher level of satisfaction with the amount of
time for the session and the amount of feedback they
received and were more likely to view the session as a
positive learning experience.
• Students' comments indicated that they appreciated the
value of peer review in a group setting.
• Virtual scenarios provide students with a
controllable, secure and safe learning
environment.
• It provide also with the opportunity for extensive
repetitive practice with feedback without
consequence to patients.
Simulated Crisis to Improve Comm.
Skills: oral versus video-assisted oral feedback
Savoldelli et al. Anesthesiology. 2006 Aug;105(2):279-85.
• Simulated crisis with or without debriefing on nontechnical
skills in 42 anaesthesia residents.
• Exposure to a simulated crisis without constructive
debriefing by instructors offers little benefit to trainees.
• The provision of oral feedback, either assisted or not assisted
with videotape review, resulted in significant improvement.
The addition of video review did not offer any advantage
over oral feedback alone.
• Provision of an audiotape of their primary adjuvant
treatment consultation to 628 women newly diagnosed with
breast cancer and 40 oncologists from six centers in Canada. .
• Patients receiving the consultation audiotape had significantly
better recall of having discussed side effects of treatment than
patients who did not receive the audiotape.
• Audiotape benefit was not significantly related to patient
satisfaction with communication, mood state, or quality of life
at 12 weeks postconsultation.
Beside oral communication:
provision of written materials
Damian and Tattersall. Lancet. 1991 Oct 12;338(8772):923-5
• Letters provide a permanent record of the consultation,
which can be kept for future reference, and encourage
greater patient involvement in their care.
• RCT in Australia: to assess the role of personal letters to
patients outlining their consultation.
• Patients receiving letters were more satisfied with the
amount of information given, and tended to have greater
and more accurate recall of the consultation.
• A survey of referring doctors revealed general support for
the idea of sending to cancer patients letters.
Who may benefit?
•
•
•
•
•
•
•
Under graduated students
Interns and residents
Fellows
Senior intensivists
Nurses
All other ICU clinicians
… patients ?
Communication skills training courses for
SENIOR cancer doctors: a study in Nordic countries
Finset et al. Psychooncology. 2003 Oct-Nov;12(7):686-93
• Evaluation at baseline/course completion/follow-up after 2
to 6 years in 155 physicians
• 94% of the physicians were satisfied with the course.
• At follow-up they reported that they had learnt basic skills
(i.e. to listen and to pose open-ended questions).
• Communication skills courses for senior clinicians with no
previous formal training in this field should emphasise
basic communication skills as well as the handling of
difficult situations in doctor-patient interaction.
Parameters
Comprehension of
 Diagnoses
 Prognosis
 Treatments
 All three items understood
Satisfaction
 CCFNI score
HAD score
Global score
Anxiety score
Depression score
All patients
Juniors
Seniors
P
89.5
88.5
70.1
67
88.2
85
67.7
64.5
90.8
91
72.5
69.4
0.64
0.13
0.47
0.47
20 (18-25)
20 (18-25) 21 (18-25) 0.67
21 (14.7-27)
13 (9-16)
9 (5-12)
21 (14-27) 22 (16-22) 0.97
13 (9-16) 13 (9-16) 0.74
8 (5-13)
9 (5-12) 0.90
Effect of communications training
on medical student performance.
Yedidia et al. JAMA. 2003 Sep 3;290(9):1157-65
• Comprehensive communications curricula were developed at
3 US medical schools using an established educational model
for teaching and practicing core communication skills and
engaging students in self-reflection on their performance.
• 138 randomly selected medical students in the comparison
cohort, and 155 students in the intervention cohort.
Standardized patients assessed student performance.
• Communications curricula significantly improved third-year
students' overall communications competence as well as
their skills in relationship building, organization and time
management, patient assessment, and negotiation and
shared decision making-tasks that are important to positive
patient outcomes.
Doctor-nurse substitution in primary care
Laurant et al. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271.
• To evaluate patient outcomes (satisfaction), process of care,
and resource utilisation including cost.
• Meta-analysis of 25 articles (16 studies)
• No differences were found in health outcomes for patients,
process of care, resource utilisation or cost.
• Patient health outcomes were similar for nurses and doctors
but patient satisfaction was higher with nurse-led care.
Nurses tended to provide longer consultations, give more
information to patients and recall patients more frequently
than did doctors.
• Appropriately trained nurses can produce as high quality
care as primary care doctors and achieve as good health
outcomes for patients.
And the Patient?
Improving patients' communication with doctors:
a systematic review of intervention studies.
Harrington et al. Patient Educ Couns. 2004 Jan;52(1):7-16
• 25 studies designed to increase patients' participation in
medical consultations.
• Overall, half of the interventions resulted in increased
patient participation. However, of the 10 written
interventions only two reported a significant increase in
question-asking or patient satisfaction.
• There were significant improvements in other outcomes:
–
–
–
–
perceptions of control over health,
preferences for an active role in health care,
recall of information,
adherence to recommendations and attendance.
A five-point framework
1. The evidence that clinicians experience
communication difficulties
2. Communication Skills Training Programs
3. Optimal duration of a training program
4. Long term impact of Communication Skills
Training Programs
5. Teaching communication skills to ICU
clinicians
8 hour intervention
Optimal duration of training programs
• A 8-hour intervention from John Hopkins
Roter et al. Arch of Intern Med. 1995 Sep 25;155
• Patients of trained physicians reported reduction in
emotional distress for as long as 6 months.
• A 24-h psychological training program on comm. skills
• Razavi et al. Eur J Cancer. 1993;29A(13):1858-63.
• significant effect on attitudes, especially on those related to
self concept, and on the level of occupational stress.
• A 3-day program improve nurses' communication skills
• Wilkinson et al. Psychooncology. 2003 Dec;12(8):747-59
• training can lead to clinically relevant behavioural change
and improvements in perceived confidence in
communication and dissemination of skills.
A five-point framework
1. The evidence that clinicians experience
communication difficulties
2. Communication Skills Training Programs
3. Optimal duration of a training program
4. Long term impact of Communication Skills
Training Programs
5. Teaching communication skills to ICU
clinicians
Posttraining consolidation workshops
facilitate the transfer of acquired skills to
clinical practice.
Razavi et al. J Clin Oncol. 2003 Aug 15;21(16):3141-9
• RCT: Efficacy of six 3-hour consolidation workshops
conducted after a 2.5-day basic training program
• Training efficacy was assessed through audiotaped interviews
at baseline and after consolidation workshops
• Communication skills and patients' perceptions of
communication skills were assessed using a questionnaire.
• Communication skills improved significantly in the
consolidation-workshop group:
– increase in open questions, decrease in premature reassurance
– increase in acknowledgements, empathy, and in negotiations.
• Patients interacting with physicians who benefited from
consolidation workshops reported higher scores concerning
their physicians' understanding of their disease.
A five-point framework
1. The evidence that clinicians experience
communication difficulties
2. Communication Skills Training Programs
3. Optimal duration of a training program
4. Long term impact of Communication Skills
Training Programs
5. Teaching communication skills to ICU
clinicians
The Intensive Care Unit
• A place where we care for severely ill patients, with
uncertain prognoses.
• A place where we are facing to relatives with distress who
need assistance and information
• A place where (too) many people work, not always together
• A place where we have the task to implement difficult
decisions
• A place where death is frequent, and still frequently
perceived as a failure
If you think that this is the ICU-waiting room, please open the doors
The crowded Flow, Montreal
Behind the doors …
Family satisfaction = communication skills
Junior doctors
Contradictions
The role of each one
Referring physician
Time
S T O P
Proactive process of communication:
just an example of intervention
• An initial formal multidisciplinary meeting was held within 72h
including the physician, nurse, house officer and the family.
• The meeting had four primary objectives:
– 1) to review the medical facts and options for treatment;
– 2) to discuss the patient’s perspectives on death and dying, dependence,
loss of function, and the acceptability of the risks and ICU discomforts
– 3) to agree on a care plan;
– 4) to agree on criteria of success of this care plan.
• The timing of subsequent meetings was “a-la-carte”.
• A weekly multidisciplinary case review was held.
4-y follow-up
Number (%) or Median (ranges) No leaflet Leaflet
P
n=88
n=87
v a lue
Poor comprehension
36 (40.9)
10 (11.5) <0.0001
 diagnosis
13 (14.7)
3 (3.4)
0 .0 2
 prognosis
11 (12.5)
7 (8)
0 .2 0
 treatment
31 (35.2)
6 (6.9)
<0.0001
CCFNI
23 (19-27) 21 (18-26) 0.08
• Interventional studies of intensive communication with families of
patients dying in the ICU diminished the use of ineffective
treatments.
Lilly CM, et al. Am J Med 2000;109(6):469-75.
Dowdy MD, et al. Crit Care Med 1998;26(2):252-9.
Schneiderman et al. Crit Care Med 2000;28(12):3920-4.
Studdert et al. Intensive Care Med 2003;29(9):1489-97
Burns JP, et al. Crit Care Med 2003;31(8):2107-17.
• (Advance directives did not)
Family-centered care during the family conference
Effectiveness of the information provided
Empowerment about surrogacy
Involvement in care if family is willing
Shared decision-making model
Prevention of caregiver breakdown
Conclusion
• Most current trainings are inadequate or not evaluated.
• The literature confirms the usefulness of learner-centred,
skills-focused, and practice-oriented communication skills
training programs organised in small groups of a maximum 6
participants and lasting at least 20 hours.
• However, it is unlikely that any future advances will negate
the need and value of compassionate and empathetic two-way
communication between clinician and patient.
• Educational programs should be rigorously evaluated to
identify best educational practices.
• A lot is still to do in the intensive care units, the oncology
literature is certainly a model to learn and teach from.
Thank you for your attention