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A Novel Approach to Teaching Communication: Using the Cognitive-Behavioural Model (CBM)Claire De Souza1, Melinda Solomon2

1. Pediatric Psychiatrist; 2. Pediatric Respirologist Hospital for Sick Children, University of Toronto, Toronto, Canada

Background Questionnaire

Summary

ReferencesOutcomes

Qualitative Outcomes

Beck AT. The Current State of Cognitive Therapy: a 40 year Retrospective. Arch Gen Psychiatry. 2005; 62(9):953-9.

Beck R, Daughtridge and PD Sloane. Physician-Patient Communication in the Primary Care Office: A Systematic Review. J Am Board Fam Pract 2002;15:25-38.

Frank JR. (Ed). 2005. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada

Skeff KM, Stratos GA, Bergen MR. Evaluation of a Medical Faculty Development Program: A Comparison of Traditional Pre/Post and Retrospective Pre/Post Self-Assessment Ratings. Evaluation & The Health Professions 1992; 15(3):350-366.

Supported by the Educational Development Fund

Effective communication is fundamental to medical care and has been linked with improved therapeutic alliance, decreased medical error, and reduced work-related stress. We propose that the Cognitive Behavioural Model (CBM) may enhance communication by structuring the reflective process of a physician’s thoughts, feelings and behaviour, before, during, and after clinical encounters; and by serving as a tool to elicit a patient’s thoughts and feelings. To our knowledge, CBM has not been applied to teaching communication to physicians.

• Pediatric Respirology residents found CBM useful for difficult communication tasks.

• CBM aided in the process of reflection.

• Benefits continued 9 months after the course.

• CBM may be applied to teaching communication skills to physicians.

• The influence of a communication course often changes over time and upon reflection, trainees are often able to appreciate the impact on their clinical practice.

Cognitive Behavioural Model

Objectives1. To determine if a communication module utilizing CBM provides Respirology Residents novel tools to facilitate effective communication in subspecialty specific clinical scenarios by targeting knowledge, skills, and attitudes before/during/after scenarios, thereby building in reflective practice. 2. To combine the CanMEDS Medical Expert and Communication roles within one module.

Project Outline• Developed a course based on CanMEDs roles of Communicator and Medical Expert for Pediatric Respirology Residents (including Canadian and international graduates)• Survey completed by the 10 residents to determine a prioritized list of scenarios that the trainees feel ‘uncomfortable’ or unprepared to deal with • 3 highest ranked scenarios developed into detailed cases: breaking bad news, discussing medical errors, disclosing new diagnosis of Cystic Fibrosis• 1 hour introduction to module and CBM completed• Module: 3 two hour sessions• Brief didactic overview of medical information & CBM application• Interactive role play with standardized ‘parent’ (calm, distressed, angry) with 3 residents participating in each session • Feedback provided by standardized ‘parent’• Reflection & Discussion post encounter, assessing use of CBM

Evaluation• Session evaluations (10 item)• Pre and Post-questionnaire (18 item & 30 item respectively)• 8 month follow up questionnaire (30 item)• 9 month post Focus Group discussion

Sample Questions:1. I feel comfortable breaking bad news to patients and their families.2. I feel comfortable disclosing medical error.3. I feel comfortable handling a discussion about DNR status.4. I feel comfortable dealing with an angry patient / family member.5. I often feel stressed prior to a difficult clinical encounter.6. I often feel stressed during a difficult clinical encounter.7. I often feel stressed following a difficult clinical encounter.8. I would rather defer a difficult communication task to a colleague.9. I feel that learning about communication is important.10. Prior to a difficult clinical encounter, I reflect on how I will handle it.11. During a difficult clinical encounter, I pay attention to my thoughts, feelings & behaviour. 12. During a difficult clinical encounter, I pay attention to how the patient/family member is feeling and behaving.13. Following a difficult clinical encounter, I reflect on how I handled it.

Pre and Post Questionnaires• Residents noted a positive change in communication skills after receiving CBM training.• They had an increased comfort level in breaking bad news, and having a difficult

conversation with a patient / family member.• There was an increased perceived ability to communicate effectively in difficult clinical

encounters.• Feelings of stress prior to/during/after a difficult clinical encounter remained the same.

8 month Follow-up Questionnaire• They continued to note a positive change in communication skills with CBM training. • There continued to be an increased perceived ability to communicated effectively in difficult clinical encounters.• Stress levels decreased slightly regarding difficult clinical encounters.• Skills were maintained.• They ranked difficult clinical encounters (most least):

• Dealing with angry/ hostile / aggressive parents and/or family• Breaking bad news• Non-Adherence by patient/family• Disclosing medical error

9 months post course, residents felt that CBM was effective in teaching communication.• Residents were using CBM most frequently prior to and during clinical encounters.• Useful strategies included reflection and setting objectives for the encounter.• Most residents found CBM training alleviated feelings of stress prior to difficult clinical encounters, but both during and following remained the same. • Some residents gained a greater awareness of how their language may impact a clinical encounter: “I learned to never actually tell patients that you understand what they are going through because you really don’t.”• Most residents reported that the course increased their confidence and comfort level in communicating in difficult clinical encounters.• All residents felt that communication training should be considered an integral component of the fellowship, but suggested earlier and ongoing training.

Pre-Questionnaire Averages vs. Post-Questionnaire Averages

1

2

3

4

5

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13

Question #

Pre-Questions Post-Questions

Undecided

Strongly Agree

Strongly Disagree

Agree

Disagree

** *

* p = ≤ 0.05

Pre-Questionnaire Averages vs. Post-Questionnaire Averages

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2

3

4

5

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13

Question #

Pre-Questions Post-Questions

Undecided

Strongly Agree

Strongly Disagree

Agree

Disagree

** *

* p = ≤ 0.05

SOMETHING BAD WILL HAPPEN & I WON’T BE ABLE TO

HANDLE IT

FEEL ANXIOUS+ PHYSIOLOGICAL

AROUSAL

BEHAVIOUR

SITUATION

THOUGHTS / ATTITUDES

BEHAVIOURNON-VERBAL COMMUNICATION

DIFFICULT COMMUNICATION

TASK

STRESSFULCLINICAL SITUATION

AVOIDANCE

CHALLENGE THINKINGTO IMPROVE MOOD

(of MD and of Patient / Parent) (of MD and of Patient / Parent)

(of MD and of Patient / Parent)

CHALLENGE BEHAVIOUR TO IMPROVE MOOD

RELAXATION EXERCISES

Quantitative OutcomesPre and Post Questionnaires• Residents had increased comfort in breaking bad news, discussing DNR and dealing with angry parents after completion of the CBM communication module.• Level of stress prior to/during/following a clinical encounter was unchanged immediately post module.• Residents felt that CBM was useful for reflecting & for asking parents/patients questions.• Residents felt that their knowledge and skill regarding patient communication had improved with the course.

8 month Follow Up Questionnaires• Residents continued to ‘agree’ or ‘strongly agree’ that CBM training was helpful before, during and after a clinical encounter.

Acknowledgements• Radha MacCulloch

FEELINGS

THOUGHTSFEELINGS

Figure 3: CBM applied before / during / after clinical encounter

Figure 1: Cognitive Behavioural Model (CBM)

Figure 2: CBM applied to a stressful clinical encounter

CREATE AN ACTION PLAN TO IMPROVE MOOD

RELAXATION EXERCISES

CHALLENGE THINKINGTO IMPROVE MOOD