Clinical communication skills year 1 introduction
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Clinical communication skills year 1 introduction
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Clinical communication skills year 1 introduction
- 1. CCS Course Year 1 NRMSM Clinical Communication The Calgary Cambridge Guide 2012 MGM 2012
- 2. Clinical Communication Effective clinical communication is central to clinical competence and plays an essential role in high- quality healthcare Communication is a learnt skill Integration is vital (knowledge, communication, practical skills including physical examination, problem solving) Teaching and assessment of clinical communication have become formal components of undergraduate medical curriculae MGM 2012
- 3. Clinical Communication There is overwhelming evidence for the positive effect of communication training It enables more effective interviews, enhanced patient and professional satisfaction AND improved health outcomes for patients eg adherence, patient safety and medico-legal issues Teaching and research in communication are inter- dependent MGM 2012
- 4. Special Issues in Communication Age-specific areas Cultural and social diversity Handling of emotions and challenging situations Specific clinical contexts eg psychiatry, work in emergency medicine Specific explanation and planning skills eg informed consent, risk management, health promotion and behaviour change Dealing with uncertainty Sensitive issues – breaking bad news, bereavement, sexual issues, areas involving stigmatisation eg child abuse, HIV infection Communication with colleagues and inter- professional communicationMGM 2012
- 5. Barriers to effective communication Personal attitudes Language Time constraints Working environment Lack of knowledge and inconsistency Human failings (tiredness, stress) MGM 2012
- 7. This is Trinity College…… MGM 2012
- 8. And back at NRMSM – communication and topical issues in our context…… MGM 2012
- 9. Overview of the Calgary- Cambridge Guides These assist in providing a comprehensive clinical method which can be used successfully in many contexts MGM 2012
- 10. Clinical Method: The “Map” 1. What information are you trying to obtain and how you are going to do this ?– the basics of: symptom analysis (problem/s) relevant background information – 1st Year (Initiating the session, Gathering information, Building the relationship, Providing structure) 2. Introduction to the Physical examination – 2nd and 3rd Year 3. Explanation and Planning – includes lifestyle and behaviour modification, management of disease – some in 2nd and 3rd Year, but mainly in the clinical years MGM 2012
- 11. Initiating the session Gathering information Physical examination Explanation and planning Closing the session Providing structure Building the relationship MGM 2012
- 12. The content of the medical interview Patient’s problem list 1. 2. 3. Exploration of patient’s problems: Biomedical perspective sequence of events, symptom analysis, relevant systems review Patient’s perspective ideas, concerns, expectations, effects on life, emotions, beliefs, “ICE” Background information - context Past medical history Family history Personal and social history Drug and allergy history Systems review MGM 2012
- 13. 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 Initiating the session Gathering information Physical examination Explanation and planning Closing the session Providing structure Building the relationship preparation establishing initial rapport identifying 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 closure forward planning MGM 2012
- 14. Initiating the interview - establishing rapport Greet and check patient’s name and details Introduce yourself Explain your role as a student Gain consent Explain the nature and timing of interview Ensure patient comfort and appropriate setting Non-verbal communication is vital MGM 2012
- 15. Initiating the interview – getting an overview Start off with an opening question – use an open enquiry technique If you only get a brief answer, acknowledge and ask further information or for narrative Listen attentively - “wait time” is NB Use verbal and non-verbal facilitation Pick up patient’s cues Summarise disease and illness Screen for other complaints Approach is collaborative MGM 2012
- 16. Gathering information – delving deeper Signpost to sequence of events Encourage narrative thread Use open questioning methods Listen attentively Use a facilitative approach – process skills Use more focused open questions Pick up disease and illness cues Clarify and time-frame Summarise disease and illness MGM 2012
- 17. Gathering information – delve even deeper Signpost to: Analysis of each symptom (start with an open question) Chronological history of events Relevant systems review Signpost to: Questions on “ICE” (ideas, concerns and expectations) and feelings/beliefs/effects on activities of daily living MGM 2012
- 18. content to be discovered: the bio-medical perspective the patient’s perspective (disease) (illness) sequence of events ideas and concerns symptom analysis expectations relevant systems review effects feelings and thoughts background information - context past medical history drug and allergy history social history family history systems review MGM 2012
- 19. Gathering Information process skills for exploration of the patient’s problems (the bio-medical perspective and the patient’s perspective) •patient’s narrative •question style: open to closed cone •attentive listening •facilitative response •picking up cues •clarification •time-framing •internal summary •appropriate use of language •additional skills for understanding patient’s perspective MGM 2012
- 20. Providing Structure Makes organisation overt Summarises and relates to conceptual framework Moves from one section to another using signposting Allows reflection on what “went well” Attends to flow Makes sequence logical Attends to timing and keeping the interview on track MGM 2012
- 21. Building the Relationship Appropriate non-verbal behaviour – eye contact, expression, posture Ensure note-taking does not interfere with rapport Accept patient’s views Be non-judgemental and sensitive Provide or offer support Involve the patient – share thinking and explain rationale for questions or parts of the examination MGM 2012
- 22. Closing the Session Give any provisional information clearly (avoid jargon) Check patient understanding and acceptance of explanation and plans Provide opportunity for questions and discussion Summarise the session and contract with patient re next steps MGM 2012
- 23. PATIENT PRESENTS CUES OF UNWELLNESS DOCTOR SEARCHES TWO PARALLEL AGENDAS DOCTOR’S AGENDA History Physical Examination Laboratory Investigation PATIENT’S AGENDA: Ideas Fears Expectations Effect on function DIFFERENTIAL DIAGNOSIS UNDERSTANDING ILLNESS EXPERIENCE INTEGRATIO N THE PATIENT- CENTRED CLINICAL METHOD MGM 2012
- 24. Summary: Exploration of both the doctor’s and the patient’s perspective Sequence of events – open enquiry, narrative, LISTEN, clarify and time-frame, respond to cues, summarise and clarify biomedical perspective Further analysis of each problem and systems review (more applicable in clinical years) and signpost to: Discovering the background information – here may use increasingly directed questions and signpost to: Further exploration of patient’s perspective MGM 2012
- 25. How is communication taught? Students are exposed to a range of learning activities which are experiential in nature Components include active small group learning, observation and review (may include video/audio recording), constructive feedback and rehearsal with simulated patients and the group using common scenarios Communication is integrated into the curriculum, with a spiral approach and increasing complexity MGM 2012
- 26. Further details for our introductory CCS sessions Personal details and background Clarify Medical terms eg diarrhoea, constipation, stomach-ache Semi-medical terms eg wind, dizziness, indigestion Non-medical terms eg sharp, chronic Diagnosis eg migraine, allergy, asthma Symptoms vs signs MGM 2012
- 27. Presenting problem PAIN Duration Site, radiation Severity Character Frequency, periodicity Progression Precipitating/relieving factors Associated symptoms MGM 2012
- 28. Systems review General Cardiovascular Respiratory Gastrointestinal Nervous Psychiatric Skin, locomotor MGM 2012
- 29. Systems review General symptoms These are often non-specific – may indicate various conditions or multi-system disease Fatigue Malaise Fever Sleep disturbance Skin, nail or hair changes MGM 2012
- 30. Past medical history Severe illnesses, visits to other doctors or admissions Surgical operations Accidents Pregnancies Medical examinations Occupation, insurance Some examples : rheumatic fever, measles, whooping cough, TB, jaundice MGM 2012
- 31. Medication and allergies Treatment Prescribed OTC Recreational Traditional or alternative Allergies - NB MGM 2012
- 32. Family history Ask about parents and siblings first NB not only wrt to current condition but any illness Specific conditions Genogram, genetic advice Quantifying risk Indication of cause or agent MGM 2012
- 33. Personal and social history Home: Ask about spouse and children, domestic arrangements Work: Occupation, environmental factors Habits: Alcohol, tobacco - details Diet: caffeine, salt etc Exercise Other: travel, hobbies, pets MGM 2012
- 34. Summary: Objectives of training sessions Exploring the “what” of communication Exploring the “how” of communication and using the Calgary-Cambridge guides to help organise teaching and learning Exploring our own skills and reflecting on these Becoming aware of the structure in the medical interview, and of process as well as content Increasing our confidence in our own abilities Deepening our awareness of the patient’s perspective and the importance of doctor-patient communication in our own setting/s and the South African context as a whole MGM 2012
- 35. Summary: Sessions and Assessment CCS sessions in Year 1 with simulated patients You will be assessed in an OSCE (more emphasis on process skills than on content in Year 1) In the sessions, you will be expected to be able to concisely sum up your assessment of the patient’s problem/s after a patient-centred interview, using…. a basic bio-medical and patient perspective, and providing some background information or context MGM 2012
- 36. References: Teaching clinical communication: A mainstream activity or just a minority sport? Silverman, J Patient Education and Counselling 2009; 76: 361-367 UK consensus statement on the content of communication curricula in undergraduate medical education Von Fragstein, Silverman et al Medical Education 2008; 42: 1100-1107 Agenda-led Outcome-based Analysis Kurtz SM, Silverman JD, Draper J (2005) Teaching and Learning Communication Skills in Medicine (Second Edition). Radcliffe Publishing (Oxford and San Francisco) Previous lecture by Dr Mergan Naidoo, Family Medicine MGM 2012
- 37. Session 2 – Learning Objectives Exploration of what makes a good doctor From the doctors’ perspective From the patients’ perspective Exploration of the doctor-patient relationship Understanding of the importance of the medical interview/ clinical method Understanding of a patient-centred method MGM 2012
- 38. Discussion with the class Individual motivation for becoming a doctor Any role-models? Discussion of previous medical encounters....what was it like to be the patient? On what attributes did you judge the doctor? MGM 2012
- 39. Analysis of doctor-patient encounters Initiating the session Gathering information Closing the session MGM 2012
- 40. All students will receive a copy of the Calgary-Cambridge guide in this week’s sessions – please retain it as it will be used in subsequent years and in Family Medicine. Bring your guide to all communication sessions! Thank you for your attention! MGM 2012
- 41. Author: Dr Margy Matthews Clinical Skills Co-ordinator Room 283 matthewsm@ukzn.ac.za Administrator: Wandile Ext 4611 Skills Lab MGM 2012
Notas del editor
- So back to clinical method So far we have really only started the process of how to interview patients and what you are looking for You have interviewed real patients, worked with your associate supervisors on the wards, worked with simulated patients, and had a chance to look at the cardiovascular and respiratory symptoms and signs PowerPoints and videos on the ER Web How has that gone? Confused? Need help? Has it all happened, have you seen your clinical supervisors yet? We now want to move you help you by looking at what information in general you are trying to obtain and how you are going to obtain it. Both in terms of interviewing the patient and examining them And the key areas that we are going to cover are: symptom analysis background information introduction to the physical examination
- You have been mostly concentrating on initiating the session plus some gathering information, particularly of the narrative. You have also been considering how to provide structure for the patient and how to build the relationship
- This is a reminder of what information you are looking for. At the end of the day, this is the information you need to present a patient’s story to a colleague or to write information in the notes
- And we have been giving you an overall structure to help you organise what you are trying to do And by now, I hope you know that you need to do different things in the initiating the session phase from the gathering information phase and you need to intentionally and purposefully employ different skills. You also know that you need to spend a lot of time building the relationship and structuring the whole session Show some evidence for each part!!
- Particularly concentrate on explaining nature and timing of interview and not a wee chat
- Now we look at how to get an overview of the issues before exploring any one in more depth. picking up and responding to patient cues shortens rather than lengthens visits (Levinson et al 2000) The importance of screening – why open directive questions about a specific symptom work in the opposite direction than in the gathering information part of the history (Beckman and Frankel) Joos – screening and planning in internal medicine reduces the length of the visit
- Then I hope most of you have been looking at how to develop the sequence of events by encouraging the narrative and asking open questions. I am sure the value of picking up disease and illness cues has come up as well as summarising both disease and illness resolution of symptoms of chronic headache is more related to the patient’s feeling that they were able to discuss their headache and problems fully at the initial visit with their doctor than to diagnosis, investigation, prescription or referral (The Headache Study Group 1986)
- consultations using a structured exploration of patients' beliefs about their illness and medication and specifically addressing understanding, acceptance, level of personal control and motivation leads to improved clinical control or medication use even three months after the intervention ceased (Dowell et al 2002) This is the first of the new areas that Paul is going to tell you about. How to analyse each symptom and then discover the relevant systems review. My two additions in terms of process here are: the need to explain to the patient exactly what you want them to help you with . Please always signpost this change in direction by saying something like “I’d like now to discover some more detail about the chest pain that you are having”. the need to always start open and then move closed . So start with “can you tell me more about the chest pain please” and then move into specific closed questions later to gather information about areas you have not discovered yet
- Again, let us look at content first. All these areas are very important. They provide the context in which the patient’s current problems occur. Please however do not confuse the background information with the patient’s perspective. Ideas concerns and expectations are not the same as the social history for instance. Quote orthopaedic ward and banter about home life but not discovering what the patient was concerned about
- 2. Do remember not to confuse content with how you obtain it – always start with an open question and move eventually to closed questions as a cone which you repeat repeatedly – first for PMH etc 3. And always remember that even in areas such as past medical history and family history, both disease and illness issues will come out and will need you to be sensitive in exploring further: e.g. my father died of cancer last week, response “good” or “any one else with cancer in the family”