Assessing Communication as a Clinical Competency Why Bother

Assessing Communication as a Clinical Competency Why Bother? Suzanne Kurtz, Ph. D College of Veterinary Medicine Washington State University March 14, 2008 Washington DC

ACKNOWLEDGEMENTS Kurtz S, Silverman J, Draper J (2005) Teaching and Learning Communication Skills in Medicine, 2 nd Ed. Radcliffe Publ: Oxford & San Francisco Silverman J, Kurtz S, Draper J (2005) Skills for Communicating with Patients, 2 nd Ed. Radcliffe Publ: Oxford & San Francisco Riccardi V & Kurtz (1983) Communication and Counselling in Health Care. Charles C Thomas, Springfield, Illinois Cindy Adams, Ph. D, University of Calgary

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Who’s Endorsing Communication in Veterinary Medicine? Ø Ø Ø Ø National Commission on Vet Econ Initiatives American Animal Hospital Association American & State Vet Med Associations American College of Veterinary Internal Medicine Veterinary Colleges - Canada, UK, USA, etc. Intl Conf on Communication in Vet Med National Board of Vet Med Examiners Vet Industry Partners

Evidence Base Human Medicine Enhancing communication leads to: Ø More effective consultations l l l Accuracy Efficiency Supportiveness Ø Better relationships (partnership) Ø Better coordination of care Kurtz, Silverman, Draper, 2005

Evidence Base: Improved Clinical Outcomes in human medicine Ø Enhancing communication leads to better outcomes: understanding & recall symptom relief physiological outcomes adherence patient safety patient satisfaction doctor satisfaction costs complaints and malpractice litigation

Evidence Base Veterinary Medicine Ø Ø PEW National Veterinary Education Program (1988) AVMA Market Study (1999) l Ø Brakke Management and Behavior Study (2000) l Ø Identified three business practices to increase practice income (employee longevity, employee satisfaction, and client satisfaction) Personnel Decision Study (2003) l Ø “Veterinarians are strong in scientific, technical and medical skills and lacking in communication and management skills necessary for success in practice. ” Identified non-technical competencies for career success (business acumen, work life balance, effective communication, and leadership skills) AVMA-Pfizer Business Practices Study (2005) l Identified client relationships as a pillar of financial success

Evidence Base Veterinary Medicine Ø Compliance range is between 23 -65% l Problems cited: • • Not enough information Relationship not established Client opinion not considered No follow up regarding patient well being Adams V (2002), AAHA (2004)

Evidence Base Veterinary Medicine Ø 50 -82% of complaints to CVO related to communication problems: l l l Client was misinformed Consent was not obtained Client felt disrespected Client felt like opinion did not matter Procedure was not explained College of Veterinarians of Ontario (2005)

What are we assessing? Clinical competence Knowledge base Ø Physical examination skills Ø Medical problem solving, diagnostic skills Ø Communication is a core clinical skill with considerable science behind it

Common (mis)perceptions Communication is a personality trait, either you have it or you don’t Ø Communication is a series of learned skills Ø l l Not a personality trait Anyone can learn who wants to

Results of Lit Review (human medicine) 81 high to medium quality articles included Overwhelming evidence for positive effect of communication skills training Ø Only 1 of 81 studies didn’t report positive effects Ø Med students, residents, junior drs, senior drs all improved Ø Specialists as likely to benefit as primary care drs Ø Aspegren, 1999

Evidence: Veterinary Medicine Significant improvement in veterinary students’ communication skills with increasing levels of training (p<. 0001) Ø No significant difference between no training and intermediate training Ø Clients’ recall highest in student group with highest level of communication training Ø Latham CE, Morris A Veterinary Record (2007)

Common (mis)perceptions Experience is a good teacher of communication skills Ø Experience alone tends to be a limited teacher of communication skills l It is a great reinforcer of habit - just doesn’t discern well between good and bad habits Ø

Our perception may be flawed What gets us into trouble is not what we don’t know. It’s what we know for sure that just ain’t so. Mark Twain

Taught skill retention vs development with experience alone Ø Doctors 5 years out of medical school still strong in information gathering (taught) but weak in explanation and planning skills (experience only) l discovering pt’s views/expectations 70% no attempt l negotiation 90% no attempt l encouraging questions 70% no attempt l repetition of advice 63% no attempt l checking understanding 89% no attempt l categorizing information 90% no attempt Maguire et al 1986

Evidence-based Rationale Veterinary Medicine Data gathering l Primarily closed questions l No open-ended questions in 25% of interviews Ø Empathy l Empathy statements in only 7% of appointments Ø Shaw, Adams, Bonnett, Roter 2003, 2004

What are we assessing? Behavior = what we do anyway vs Ø Professional competence = awareness & attention intentionality ability to reflect on & articulate with precision and it’s evidence based Ø Goal = to enhance communication in practice to a professional level of competence

What are we assessing? Skills* Ø Attitudes, beliefs, values Ø Capacities (eg, compassion, integrity, flexibility, mindfulness) Ø Ø In what circumstances? l l Difficult situations (complex case, breaking bad news, death and dying, medical error, adverse outcomes) Everyday run-of-the-mill consultations, client education, prevention

Types of Communication Skills Ø Content skills - what you say, info you gather & give Ø Perceptual skills - what you think, clinical reasoning - what you feel - attitudes, biases, intentions, assumptions Ø Process skills - how you question, respond, explain, plan - how you structure talk - how you relate to patients - nonverbal skills/behaviour

Do we know what skills are worth assessing? Many models available: Ø Calgary-Cambridge Guides Ø Patient-Centered Model Ø Macy Model Ø SEGUE Framework Ø Bayer-Fetzer Essential Elements Ø MAAS-Global

Numerous approaches to assessing communication are out there Ø Ø Boon H and Stewart M (1998) Patient-physician communication assessment instruments 1986 to 1996 in review. Patient Education and Counseling. 35: 161 -76. Cushing A (2002) Assessment of non-cognitive factors. In: GR Norman, CPM van der Vleuten and KJ Newble (eds) International Handbook of Research in Medical Education. Kluwer Academic Publishers, Dordrecht. Mac. Leod H (2004) Physician performance assessment and communication skills assessment. Unpublished review of the literature from 1990 to 2003. Task Force on Physician Communication Skills Assessment and Enhancement in Canada, Medical Council of Canada, Ottawa, Ontario Kurtz S, Silverman J, Draper J (2005) Assessing learners’ communication skills. In Teaching and Learning Communication Skills in Medicine (2 nd ed). Radcliffe Publishing: Oxford & San Francisco

CALGARY-CAMBRIDGE GUIDES FRAMEWORK FOR THE MEDICAL CONSULTATION Initiating the Session Providing Structure Gathering Information Building the Relationship Physical Examination Explanation/Planning Closing the Session Kurtz, Silverman, Draper (2005)

Calgary-Cambridge Guides Communication Process Skills Ø 56 process skills organized around framework (plus Options in Expl & Pl section = 15 more process & content skills: ) Ø Backbone of communication teaching and learning Ø Cross-disciplinary & cross-cultural application SEE HANDOUT

Same process skills for an array of communication issues Conflicted or difficult situations Ø Gender issues Ø Cultural issues Ø Generational differences Ø Ethical dilemmas Ø Performance reviews Ø

Advantages of Guides Ø Ø Ø Accessible summary of research evidence Comprehensive delineation of skills Memory aid to keep skills in mind, organized Framework for systematic skill development Basis for comprehensive feedback & evaluation Core content for training faculty, creating consistency Ø Common foundation for programs at all levels – basis for coherent, helical curricula from undergrad through CE Ø Ø Same skills pertain to effective teaching or communication with colleagues

What are we assessing? Knowledge – do you know it? Ø Competence – can you do it? Ø Performance – do you (choose to) do it in practice? Ø Results – what happens to pts, to drs? Ø Miller 1990

What forms can assessments take? Ø Knowledge – do you know it? l l MCQ, essay/short answer, oral, Objective Structured Video Exam…

What forms can assessments take? Ø Competence – can you do it? l OSCE using standardized simulated clients • Stand alone communication stations • Communication stations integrated with PE, medical problem solving, l Real interviews: • Series of live interviews with examiner present • Series of self-selected videotapes/DVDs submitted for expert assessment l Web-based OSCE (physicians link to simulated patient whom they interview online)

What form can assessments take? Ø Performance – do you (choose to) do it in practice? l l l Ø Videotapes/DVDs submitted with assessors randomly choosing tapes to be assessed Undercover simulated clients Real clients’ assessments Client and clinician do immediate assessment of same individual interview Colleagues’ assessments Results – what happens to pts, clients, drs? l l l Self assessment/report Chart audits Follow up studies re compliance, outcomes of care, etc.

Objectives of Assessment Ø Motivation l l l Drives what gets learned and taught Legitimizes importance of a subject Encourages acceptance by otherwise skeptial students and faculty Ø Progress check, certification that is valid and reliable Ø Educational impact

Formats for Feedback quantitative___________ __ evaluative feedback_____ number scores, good/bad global___________ _qualitative descriptive feedback “here’s what I see” _____ __detailed

Two types of assessment Ø Formative Ø Summative

What does it take to learn clinical communication skills, change? Knowledge doesn’t translate directly into performance Ø Essentials needed to learn skills, change: l Systematic delineation & definition of skills l Observation of learners communicating (video) l Well-intentioned, detailed, descriptive feedback l Practice and repeated rehearsal of skills l Planned reiteration and deepening of skills Ø Small group or one-on-one format

Teaching and learning communication skills is different Ø Closely bound to self concept Ø No one starts from scratch Ø No achievement ceiling Ø More complex than simpler procedural skills

Stages in skills learning/change not a linear progression Fully assimilated Consciously skilled Awkward Beginning Awareness Wackman et al 1976

What makes for effective feedback? 1 st Principles of Effective Communication Ø Ensures interaction not just transmission Ø Reduces unnecessary uncertainty Ø Requires planning, thinking in terms of outcomes Ø Demonstrates dynamism (engagement, flexibility, responsiveness) Ø Follows helical vs linear model Same principles apply to effective teaching

What makes for effective feedback? Agenda-Lead Outcome-Based Analysis (ALOBA)

Approaches to communication Ø Shot-Put Approach l l the well-conceived, well-delivered message is all that matters emphasis on telling, interaction/feedback not in picture Ø Frisbee Approach l l 2 central concepts • confirmation = to recognize, acknowledge or endorse another • mutually understood common ground emphasis on interaction, feedback, relationship A Barbour 2000

Example of an Integrated OSCE University of Calgary Day of exam 1 Interview with SC - videotaped l l examiner scores content checklist SC completes written feedback form (after interview) 2 Student thought time 3 Presentation of case to examiner with problem list, hypotheses, & ideas for PE 4 Performance of selected PE related to interview (PE unrelated to interview tested at other stations) 5 PE results given to student - student gives ideas re investigations 6 Investigation results given to student - student gives ideas re differential diagnosis

Integrated OSCE conti Within 12 days of exam: Ø Pairs of students meet with expert examiner to assess communication process skills (Calgary-Cambridge Guides) 1 View student’s videotaped interview, stopping tape periodically 2 Self, peer, and expert assessment (yes, yes but, no) 3 Compare results (not about reaching consensus) 4 Mini-tutorial re problem skills, strengths, next steps 5 Compare process skills with content checklist, hypotheses and differential, SC feedback Individually tailored remedial for unsatisfactory students; retake of exam (x 2 possible)

Concluding thoughts Ø Ø Ø Communication is core clinical skill Skills are appropriate focus for teaching and assessment Build on what’s already available (research, teaching and assessment models in human and vet medicine) Include educational impact in design of assessment Train faculty and learners to participate in feedback process to enhance communication learning Integrate communication with other clinical skills teaching and assessment