teaching communication skills: the calgary‐cambridge model · plan: teaching communication...

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Teaching Communication Skills: the Calgary‐Cambridge model

Jonathan Silverman

Association for Palliative Medicine Undergraduate Education Special Interest Forum

September 13th 2017

Institute of Public Health, Cambridge

http://www.each.eu/

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Plan: Teaching Communication Skills: the Calgary‐Cambridge model

1. What skills do we need to drive a Ford Focus

2. What additional skills do we need to drive a Ferrari

3. How to learn to drive

Core communication skills

More complex situation‐specific skills

How to teach communication

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Two human beings

stent arrhythmia

arterioles interventions

ischaemia MIBI scan

antiplatelet drug

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What emotion do you have?

And whose fault is it?

And is it a problem we’ve known about for years?

Initiating the interview1. Discovering the reasons for the patient's attendance

Gathering information2. Avoiding early closed questioning and actively listening

The prevention of clinicalhypo‐competence

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• 54% of patients’ complaints and 45% of their concerns are not elicited (Stewart et al 1979)

• in 50% of visits, the patient and the doctor do not agree on the nature of the main presenting problem (Starfield et al 1981)

• consultations with problem outcomes are frequently characterised by unvoiced patient agenda items (Barry et al 2000)

• doctors frequently interrupt patients so soon after they begin their opening statement that patients fail to disclose significant concerns (Beckman and Frankel 1984, Marvel et al 1999 )

• Mauksch et al (2008): literature review to explore the determinants of efficiency in the medical interview. 3 domains emerged from their study that can enhance communication efficiency: rapport building, upfront agenda setting and picking up emotional cues

• Robinson et al (2016): Compared to “Do you have any questions?”, “any other concerns?” were significantly more likely to generate agenda items, especially when positioned ‘early’ vs. ‘late’ during visits

What would happen if we simply manage to implement:

• Managing the beginning of new and review consultations

• Effective listening and open history taking

• Discovering the patient’s ideas and concerns

• Lack of inappropriate jargon

• Interactivity in explanation phase

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Two human beings

What emotion do you have?

And whose fault is it?

How do you feel for the doctor?

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What would happen if we simply manage to implement:

• Managing the beginning of new and review consultations

• Effective listening and open history taking

• Discovering the patient’s ideas and concerns

• Lack of inappropriate jargon

• Interactivity in explanation phase

• Basic courtesy, removing hubris

• Effective non‐verbal communication

• Understanding that people have feelings and demonstrating empathy

Demonstrating empathy overtly

Improved clinical outcomes

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Evidence for empathyWissow et al (1994) found that paediatricians’ use of supportive statements (compliments, approval, concern, empathy, encouragement and reassurance) was positively associated with parents’ disclosure of psychosocial problems.

Wasserman et al (1984) found that empathic statements led to increased satisfaction and reduction in maternal concerns.

Dimoska et al (2008) have shown that patients seeing an oncologist who was rated as warmer and discussed a greater number of psychosocial issues had better psychological adjustment and reduced anxiety

Kim et al (2004) demonstrated in Korea that patient‐perceived physician empathy significantly influenced satisfaction and compliance.

Cox et al (2011) showed that when physicians expressed empathy, patients’ weight‐related attitudes and behaviours improved.

Rakel et al (2011) found that physician empathy had significant effects on reducing the duration and patient reported severity of the common cold.

Hojat et al (2011) correlated physician empathy scores on a self completed empathy scale with HBA 1C and LDL‐cholesterol tests and found a positive relationship between physicians’ empathy and patients’ clinical outcomes.

In a study of 20,961 patients, Canale et al (2012) compared physician empathy scores with clinical outcomes for patients with diabetes: significantly lower rate of metabolic complications

Two more examples

1

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Cues

A verbal or non‐verbal hint which suggests an underlying emotion which would need clarifying by the health professional

Del Piccolo et al 2006

Hints to patient's concerns and thoughts about the cause of the illness

Facilitative skills Goldberg et al 1993; Wilkinson 1991; Maguire et al 1996: Zimmerman et al, 2003

Open questions

Open directive questions

Screening questions

Listening

Pauses/use of silence

Minimal prompts/encouragement

Summarising

The emergence of cues and concerns

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Not picking up and exploring cues

Levinson (2000)

• patients gave cues throughout the interview from the opening to the closing minute

• doctors only responded to patient cues in 38% of cases in surgery and 21% in primary care

Zimmerman et al (2007)

• a systematic review, documenting 58 original quantitative and qualitative research articles demonstrating patient expressions of cues and/or concerns, all based on the analysis of audio or videotaped medical consultations.

• overall conclusion ‐ physicians missed most cues and adopted behaviours that discouraged disclosure.

Rogers and Todd (2000)

• oncologists preferentially listen for and respond to certain disease cues over others

• pain amenable to specialist cancer treatment is recognised, other pains are not acknowledged or dismissed

Cues

Facilitative questions linked to a cue increase the probability of further cues

Zimmerman et al 2003

Silence or minimal prompts most likely to precede disclosure

Eide H et al 2004

Open questions linked to a cue are 4.5 times more likely to lead to further significant disclosure than unlinked open questions

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Facilitative skills

Open questionsOpen directive questionsScreening questionsListeningPauses/use of silence Minimal promptsSummarising

Picking up cues

• Acknowledging/reflection/paraphrasing

• Checking

• Clarifying

• Exploring

• Educated guesses

• Empathy

Cues ‐ will it take more time ?

• Consultations which were cue based were shorter that those in which cues were missed

o GP consultations 12.5%

o Surgical consultation were 10.7% shorter

Levinson et al 2000

• In oncology consultations, addressing cues reduced consultation times by 10‐12%.

Butow et al 2002

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Picking up and responding to cues

Improved efficiency

Two more examples

2

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Kind, safe and excellent

No decision about me without me

Safe, kind and excellent together

PATIENTS’ PREFERENCES MATTER

Stop the silent misdiagnosis

Al Mulley, Chris Trimble, Glyn Elwyn

2012

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Health care may be the only industry in which giving customers whatthey really want would save money.

Well‐informed patients consume less medicine – and not just a little bitless, but much less. When doctors accurately diagnose patientpreferences, an enormous source of waste – the delivery of unwantedservices – is eliminated.

It is particularly notable that when doctors accurately diagnose thepreferences of patients struggling with long‐term conditions, thosepatients are far more likely to keep their conditions under control,leading to fewer hospitalisations and emergency department visits(Wennberg and Marr 2010).

The potential financial gain from stopping the silent misdiagnosis iscomparable in magnitude to the potential financial gain from improvedadherence to evidence‐based clinical guidelines.

Where shared decision making was of higher quality, patients referred for invasive treatment were more likely to change to a less invasive treatment option.

Langseth et al, 2012

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The concept of core skills

Many difficult communication challenges in cancer care

(such as cultural diversity or shared decision making or breaking bad news)

It’s not so much worrying about each individual issue

but concentrating on core skills

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Martin von Fragstein, Jonathan Silverman, Annie Cushing, Sally Quilligan, Helen Salisbury & Connie

Wiskin on behalf of the UK Council for Clinical Communication Skills Teaching

in Undergraduate Medical Education

UK consensus statement on the content of communication curricula in undergraduate

medical education

Medical Education 200842(11): p. 1100‐7

The communication curriculum

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The communication curriculum

Core process skills

A secure platform for tackling each specific communication issue

Context of the interaction changes Content of the communication varies

But the process skills themselves remain the same

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Specific communication issues and challenges

• culture and social diversity • gender • dealing with emotions• age related issues – the elderly, children• the three way interview • breaking bad news• the sexual history• the psychiatric interview• the telephone interview• low literacy patients • sensory impaired patients• death and dying, bereavement• Complaints• health promotion and prevention

Not different skills but same skills used differently

THE CALGARY‐CAMBRIDGE GUIDES

TO THE MEDICAL INTERVIEW

Kurtz, Silverman and Draper (2005; 2nd Ed.)Teaching and Learning Communication Skills in Medicine Radcliffe Medical Press

Silverman, Kurtz and Draper (2013; 3rd Ed.)Skills for Communicating with Patients Radcliffe Medical Press

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

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Why have a guide?

skillswhat are the skills that we are trying to promote?

structurehow do we organise communication skills?

validitywhat evidence is there that these skills make a differencein doctor-patient communication?

breadthwhat is the scope of the communication curriculum?

Initiating the session

Gathering information

Physical examination

Explanation and planning

Closing the session

Providing structure

Building the relationship

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exploration of the patient’s problems to discover the:

biomedical perspective the patient’s perspective

background information - context

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

Providing structure


preparationestablishing initial rapportidentifying the reasons for the consultation

making organisation overt

attending to flow

using appropriate non-verbal behaviour

developing rapport

involving the patient

ensuring appropriate point of closureforward planning

INITIATING THE SESSION

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Establishing initial rapport

Greets patient and obtains patient’s name

Introduces self, role and nature of interview; obtains consent

Demonstrates interest, concern and respect, attends to patient’s physical comfort

Identifying the reason(s) for the consultation

Identifies the patient’s problems or the issues that the patient wishes to address with appropriate opening question (e.g. “What problems brought you to the hospital?”

Listens attentively to the patient’s opening statement, without interrupting or directing patient’s response

Checks and screens for further problems (e.g. “so that’s headaches and tiredness, what other problems have you noticed?” or “is there anything else you’d like to discuss today as well?”)

Negotiates agenda taking both patient’s and physician’s needs into account

GATHERING INFORMATION

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Exploration of patient’s problems

Encourages patient to tell the story of the problem(s) from when first started to thepresent in own words (clarifying reason for presenting now)

Uses open and closed questions, appropriately moving from open to closed

Listens attentively, allowing patient to complete statements without interruption andleaving space for patient to think before answering or go on after pausing

Facilitates patient's responses verbally and non–verbally e.g. use of encouragement,silence, repetition, paraphrasing, interpretation

Picks up verbal and non–verbal cues (body language, speech, facial expression, affect);checks out and acknowledges as appropriate

Clarifies statements which are vague or need amplification (e.g. “Could you explainwhat you mean by light headed")

Periodically summarises to verify own understanding of what the patient has said;invites patient to correct interpretation or provide further information.

Uses concise, easily understood language, avoids or adequately explains jargon

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Breaking Bad News

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Closing the session

Providing structure


Preparation:

• set up appointment as soon as possible• allow enough uninterrupted time; ensure no interruptions• use a comfortable, familiar environment• encourage patient to invite spouse, relative, friend, as

appropriate• be adequately prepared re clinical situation, records, patient’s

background• put aside your own “baggage” and personal feelings wherever

possible

Beginning the session / setting the scene

• summarise where things have got to, check with the patient• discover what has happened since last seen• calibrate how the patient is thinking/feeling• negotiate agenda

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Sharing the information• assess the patient’s understanding first: what the patient already

knows, is thinking or has been told

• gauge how much the patient wishes to know

• give warning first that difficult information is coming

• give basic information, simply & honestly; repeat important points

• relate your explanation to the patient’s perspective

• do not give too much information too early; don’t pussyfoot but do not overwhelm

• give information in small “chunks”; verbally categorise information•

• watch the pace, check repeatedly for understanding and feelings

• use language carefully: avoid jargon

• be aware of your own nonverbal behaviour throughout

Being sensitive to the patient

• read and respond to the patient’s non-verbal cues: face/body language, silences, tears

• allow for “shut down”

• keep pausing to give patient opportunity to ask questions

• gauge patient’s need for further information and give more information as requested,

• encourage expression of feelings early

• respond to patient’s feelings and predicament with acceptance, empathy and concern

• specifically elicit all the patient’s concerns

• check understanding of information given ("would you like to run through what are you going to tell your wife?")

• do not be afraid to show emotion or distress

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Planning and support• identify a plan for what is to happen next

• give hope tempered with realism

• emphasise partnership with the patient

• emphasise quality of life

• safety net

Follow up and closing• summarise and check with patient for understanding, additional

questions

• set up early further appointment, offer telephone calls, etc.

• identify support systems; involve relatives and friends

• offer to see/tell spouse or others

• make written materials available





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Not easy to get the medical interview right

• highly skilled

• complex

• multi‐faceted

• professional challenge

Needs careful attention and cannot be left to chance

Requires thoughtful consideration and planning

• there is conclusive evidence that communication skills can be taught

• and that communication skills teaching is retained

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Aspergren K (1999)

Overwhelming evidence for positive effect of communication training

Medical students, residents, junior doctors, senior doctors

Specialists and general practice equally

Those at the bottom end improve most

Effective training programmes

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Production and dissemination of guidelines

Lecturing

E‐learning

Production and dissemination of guidelines

Lecturing

E‐learning

All important but by themselves will not

lead to actual change in practice

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How to learn?

Knowledge is important but only allows you to know about communication

Experiential teaching is required to know how to communicate

How to learn – lessons from the evidence

• observation of learners

• video or audio recording and review

• well‐intentioned behaviourally specific feedback

• rehearsal

• active small group or 1:1 learning

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Over 700 half day sessionsEach with an

simulated patient (actor)

And a facilitator

Only 5-6 students

Complex audio-visual IT

Over 700 half day sessionsEach with an

actor

And a facilitator

Only 5-6 studentsComplex audio-

visual IT

One half day for each student every 5-6 weeks for 3 years

26 sessions per student

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2 ½ hour separate stand alone final assessment

Failure = repeat the final year

Formal teaching of clinical communication

Methods Continuum for Communication Skills Teaching facilitator-centred learner-centred didactic experiential leading to experiential leading to “in your head” deeper discussion/understanding change in behaviour

Getting the balance right between cognitive and experiential

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What we have lacked is the will tostay the course in driving throughthe cultural change.

teaching communication skills: the calgary‐cambridge model · plan: teaching communication...

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