Transcript Communication Competency Counseling Practicum

Communication Competency
and Counseling Practicum
Mary Dankoski, Ph.D.
Kathy Zoppi, Ph.D., M.P.H
Shobha Pais, Ph.D.
Scott Renshaw, M.D.
Dustin Wright, M.S.
OBJECTIVES
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Attendees will understand…
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The assessment of communication
competency at resident levels of training
The utility of counseling practicum and
competency assessment strategies
Communication In Family
Medicine
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“Black Box” study
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(Stange et. al., 1998)
Family assessment – 73%
Answering patient questions – 71%
Negotiation – 21%
Counseling – 16%
Patient Education – 18-26%
Distinction between
interaction and relationship
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“Communication skills do not constitute the
doctor-patient relationship” (Candib, 1995,
p.213)
Key concept of connection as lens (vs.
separation) from feminist theory
Patient and physician are not independent
actors, but are mutually influential
Emotional involvement of both is key
National consensus about
communication training
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Patient-centered care improves health
outcomes
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Errors decreased by improved training
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(Kalamazoo Consensus statement)
(To Err is Human, IOM)
Health Disparities
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(Unequal Treatment, IOM)
Communication competence
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As property of
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individual
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Assessment of
individual skills,
abilities, or
behaviors (rating of
trainee)
As property of
interaction
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Assessment focuses
on interactional or
dyadic qualities,
including adaptation,
control,
collaboration (rating
of interaction)
Communication competence:
approaches
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Communication skills
Conflict management
Teamwork
Teaching others (pts, students, peers)
Epstein and Hundert, JAMA, 2002
Implication of relational
viewpoint of assessment
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Focus is longitudinal
Focus is cumulative
Focus is on participants’ sense of
connection, satisfaction
May be observable by non-participants
Methods for Teaching
Communication
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Didactic sessions
(lectures/demonstrations)
Standardized patients
Role play
Video-tape review (with real or SP)
Co-counseling sessions
Observed counseling sessions
Layered levels of
communication competence
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Content level: topic management,
nonverbal cues/clues
Process: pacing, facilitation,
congruence, nonverbal matching,
affective displays
Meta-process: mindfulness, selfobservation, context-sensitivity
Why is communication
competence important?
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Facilitation of information exchange
Development of a healing relationship
Mutual development of patient and
physician (Candib, 1996)
“Ways of Knowing” and
Medicine
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Traditional Medical
Education
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Practicum Training
Connected Knowing
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Personal experience, context,
empathy
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Critical thinking, objectivity
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Collaboration
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Limited for learning about person
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Use of patient’s language
living the illness
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Understanding of patient
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May be experienced as distant and
perspective
sterile
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Acknowledge effects of caring
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Actively exclude the self
on provider
(Belenky, Clinchy, Goldberger, & Tarule, 1986; Candib, 1995)
Procedural and Separate
Knowing
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Theoretical Assumptions about
Practicum
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The “art of medicine” lies in ability to
integrate multiple ways of knowing
Feminist-relational approach requires training
in equalizing power relationships (Candib, 1995)
Parallel process
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If we want residents to interact in this way with
their patients, we need to interact in this way
with our learners
Group supervision opens the “black box”
Practicum Curriculum Goal
The goal of practicum training is to
improve resident physician
communication and counseling skills
through supervised counseling of
patients by peers and behavioral
faculty preceptors.
Curriculum Objectives
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Residents will increase knowledge of
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Residents will improve skills in
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Basic counseling skills and methods
Evidence-based behavioral medicine
Responding to patient questions
Assessment of psychosocial and family context
Integration of biomedical and psychosocial care
Building relationships with patients and
families
Curriculum Objectives
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Residents will demonstrate attitude
change toward
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The importance of behavioral care in practice
Greater self-confidence in counseling skills
Greater mindfulness in patient care
To provide an opportunity for faculty to
evaluate resident’s communication and
doctor-patient relationship skills
Selection of Patient Cases
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Residents invite their own patients who…
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Are medically or psychosocially complex
Have an unclear social situation
Are not compliant with medical advice
Are difficult to manage or frustrating to
providers
Have “more going on here…”
Residents have a ‘gut’ sense about abuse,
assault, family unrest, prior psychological
conditions
Practicum Format
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Pre-session (10-15 minutes)
 Resident presents brief history of patient
 Residents states his/her goals for the session
 Faculty intentionally do NOT make suggestions
Resident counsels patient (25-30 minutes)
Mid-session break (10-15 minutes)
 Resident reaction
 Faculty and peer feedback
 Faculty guidance and direction
Practicum Format
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Resident counsels patient (25-30
minutes)
Post-Session (10-15 minutes)
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Resident reflections
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Session goals and expectations
What he/she learned about the patient
Personal thoughts or reactions to the patient
How this information will help care for patient
Peer and faculty feedback
Assessment
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Patient feedback (survey or interview?)
Relational rating scale
Four Habits analysis of interaction
(research assistant)
Faculty feedback
Resident-self assessment
The process…
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Models negotiating a relational agenda
Reduces hierarchical barriers
Encourages residents to shift to a more
open dialogue
Opens new options for patient care
Residents shift……
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FROM
Monological dialogue
Focused information
gathering
Doctor driven
conversation
‘doing’ mind-set
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TO
Open dialogue
Actively listening
Patient directed
conversation
‘supporting’ mindset
Feedback from Residents
How did this session differ from other visits
with this patient?
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There was no right/wrong answer; no ‘pill’ would fix the
problem [shift away from ‘doing’]
More personal, more time
More emotional
Patient did most of the talking [active listening, patient
directed]
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Visit was ‘non-medical’ – I was looking for clues in her life
about what support she will have when she has a child
[supportive]
Feedback from Residents
As a result of this visit, is there anything you will do
differently next visit?
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Be more sensitive about not giving my formal talks
but asking patient what she wants to know
[patient directed]
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Have a greater degree of suspicion when a patient
just answers everything is ‘ok’ [supportive]
Pay more attention to psychosocial aspects of my
patients
Understand the environment (psychosocial) a little
better
Feedback from Residents
What comments/suggestions do you have
about the process of live supervision?
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It is an excellent idea to do this throughout residency and
give feedback before we go into private practice
I like the immediate feedback of live supervision. It keeps
me on track during the counseling session.
Allow more debriefing time…also more ‘skeleton’ training in
counseling prior would be helpful
Fun, be feel like people (supervisors/peers) have hidden
agenda/thoughts that they didn’t share
Feedback from Patients
Was this visit different from previous visits
with your doctor? In what ways?
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Normally examines you, but today he was a
doctor, my friend, a listener, helped me with my
problems [active listening, supportive]
The other visits were like examinations…it helps
to know people more in depth to understand
why a person keeps smoking when they know
they shouldn’t
The other one was more medical [patient
directed]
Feedback from Patients
Will you do anything differently in
relation to your health as a result of
your visit today?
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Made me stop and think: “You count too,
take time for you.” Think it will be easier
to talk to him in the future.
6/7 patients reported they will change
specific health behaviors because of this
visit
Comments from Patients
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It’s better when you have someone to talk to.
He’s easy to talk to and he’s a good listener.
He doesn’t criticize.
I like him. He’s a good doctor.
Nice to be offered this because this time I
was really stressed….
I know you can tell him and he understands
and tries to help you.
Future Research Goals
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Evaluate outcomes: Does practicum improve
 Doctor/patient relationship?
 Patient health outcomes?
 Patient satisfaction?
 Resident competency in communication and
relationship skills?