Clinical Collaboration Training Mindfulness and Communication Skills in

Clinical Collaboration Training: Mindfulness and Communication Skills in a Family Medicine Residency William J. Mc. Cann, Psy. D & Gail Marion, PA-C, Ph. D Department of Family & Community Medicine Wake Forest University School of Medicine Forest Lang, MD Department of Family Medicine East Tennessee State University

The plan for today. . . Overview of the Clinical Collaboration Training curriculum Describe the introduction to dynamic relaxation & mindfulness A brief practice of mindfulness meditation Introduction to Common Ground communication skills training and assessment An exercise in dynamic relaxation, mindfulness and assessment of communication skills

Clinical Collaboration Training Curriculum § Dynamic Relaxation Training & Mindfulness § One and a half hour introductory lecture § One hour lecture on dynamic relaxation and mindfulness in clinical practice § Nine, 20 minutes sessions with CD § Incorporation in other training i. e. delivering difficult news, collaborating with challenging patients, helping suicidal patients, comprehensive pain management, psychopharmacology § Introduction to Common Ground Communication Skills Training § 10 hours of lectures § Reading Assignments § The Relaxation Response: Foreword: Twenty-fifth Anniversary Update. Herbert Benson § Mindful Practice. Ronald M. Epstein § Calibrating the Physician: Personal Awareness and Effective Patient Care. Dennis H. Novack, et al. § Guidelines for using Common Ground Rating Forms (Family Medicine Interview Study Group, ETSU, 2001). § Shadowing § Videotaping

Conditions For Which Relaxation Training Has Had Positive Outcomes Angina Hypertension Arrhythmias Infertility Allergic skin reactions Insomnia Anxiety Nausea & vomiting Depression Nervousness Asthma Pain Herpes simplex Postoperative swelling Cough Premenstrual syndrome Constipation Rheumatoid arthritis Diabetes Side effects of cancer Ulcers Side effects of HIV/AIDS Dizziness Any condition caused by or complicated by stress Fatigue

Evidence of Effectiveness (Bernstein, D. A. , Borkovec, T. D. , and Hazlett-Stevens, H. 2000) Progressive relaxation training (PRT) when use with systematic desensitization is effective in the treatment of specific phobias. PRT is effective in the treatment of generalized anxiety disorder and panic disorder because it helps to reduce tension, anxiety, and physiological arousal. PRT may also be effective as part of treatment programs for depression. With high blood pressure current research remains somewhat inconsistent. Migraine and tension headaches can be reduced with the aid of PRT is an effective chronic pain management strategy. Promising results have also been shown in the use of PRT to treat insomnia, irritable bowels syndrome, and improved general well-being.

Some research on relaxation The use of music-assisted relaxation in the reduction of children’s distress associated with bone marrow aspirations was evaluated. Analysis of the data indicated strong trends for reductions in anticipatory fear, experienced fear, and experienced pain. A strong trend for reduction in anticipatory behavioral distress was found.

Biological Goals of Dynamic Relaxation Training 1. Increase awareness of psychophysiological states 2. Decrease frequency, intensity, and duration of acute episodes of psychophysiological arousal 3. Decrease chronic psychophysiological tension

Psychophysiological reactivity involves the changes in biological and emotional parameters (affective, autonomic, and neuroendocrine) which occur when individuals are exposed to internal or external behavioral challenges or stimulation.

Mindfulness is. . . The clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception. Nyanaponika Thera, 1972 Keeping one’s consciousness alive to the present reality. Hanh, 1976 The state of being attentive to and aware of what is taking place in the present. Brown & Ryan, 2003 The awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment to moment. Kabat-Zinn, 2003

The current review of meditation state and trait indicates considerable discrepancy among results, a fact most likely related to the lack of standardized designs for assessing meditation effects across studies, the variegated practices assayed, and a lack of technical expertise applied in some of the early studies. Cahn, BR, Polich, J. 2006

Some research on meditation/mindfulness § 20 participants with extensive Insight meditation experience had thicker brain regions associated with attention, interoception and sensory processing. This suggests that meditation might offset age-related cortical thinning (Lazar, Kerr, Wasserman, et al. , 2005). § Mindfulness-Based Stress Reduction appears effective for chronic pain, anxiety disorders, general psychological well-being, psoriasis, and recurrent depression (Grossman, Niemann, Schmidt, & Walach, 2004). § Mindfulness-Based Stress Reduction in cancer care – A review reports improvements in mood, sleep quality and reductions in stress. A dose-response effect has been observed (Smith, Richardson, et al. )

More research on meditation/mindfulness § Results from this prospective randomized controlled pilot study suggest that an 8 week MBSR intervention may be effective for reducing stress and increasing quality of life and self-compassion in health care professionals (Shapiro, Astin, et al. , 2005). § An 8 -week meditation-based stress reduction intervention on premedical and medical students (Shapiro, Schwartz, & Bonner, 1998) found: – reduced self-reported state and trait anxiety – reduced reports of overall distress including depression – increased scores on overall empathy levels

And more research on meditation/mindfulness § Anxiety selectively disrupts visuospatial working memory (Shackman, Issidoros, et al. , 2006) § Event-related brain potentials (ERPs) meditation studies are sparse but suggest increased attentional resources and stimulus processing speed or efficiency (Cahn & Polich, 2006). § After a 3 month retreat, practicing mindfulness meditation for 16 hours a day, practitioners could detect short single-light flashes and required a shorter interval to differentiate between successive flashes correctly (Brown, Forte, & Dysart, 1984) § Meditation reduced habitual responding (Wenk-Sormaz, 2005). § “Lamas assessed the emotion in faces much faster and more accurately than thousands of people I have tested over the years including lawyers, policemen, and judges” (Ekman, 2006).

For many people in the medical setting, it's really important to know how their patient is feeling, because the emotions about the illness -- the shame, the guilt, the embarrassment, the fear -- cause patients to take longer to improve, or to not comply with instructions. So it's very important to know how to [read emotions]. Then they can … say, "I sense that you're afraid right now, and it's important that I know what you're afraid of. " You can go right to the heart of it, and you should. Paul Ekman, Ph. D. Face to Face: The Science of Reading Faces Conversations with History: Institute of International Studies, University of California, Berkeley, 2004

Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients’ distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so they can act with compassion, technical competence, presence, and insight. Epstein, RM. JAMA. 1999; 282: 833 -839.

Characteristics of Mindful Practice Epstein RM. Mindful Practice. JAMA. 1999; 282 (9): 833 -839. [ Adoption of a beginner’s mind [ Critical curiosity [ Pre-attentive processing [ Active observation of oneself, the patient, and the problem [ Peripheral vision [ Courage to see the world as it is [ Willingness to examine and set aside categories and prejudices [ Humility to tolerate awareness of one’s areas of incompetence [ Connection between the knower and the known [ Compassion based on insight [ Presence

Yerkes-Dodson Curve (Yerkes, RM & Dodson, JD, 1908) Performance Optimal Performance Window Arousal

Goals for Training in Dynamic Relaxation and Mindfulness 1. Increase awareness of psychophysiological state. 2. Moderate arousal if necessary. 3. Increase awareness of physical style during clinical practice. 4. Increase awareness of expressive/semantic style throughout clinical practice with patients, attendings, staff and residents. 5. Increase awareness of internal cognitive and emotional states. 6. Increase awareness of the patient’s cognitive and emotional states. 7. Increase ability to incorporate communication skills, technical questioning and self, other, and field awareness into clinical practice.

Enhancing Vitality: Biological Self-Care C Recreation C Exercise C Sleep C Rest C Nutrition C Stimulation C Relaxation

Old Secret Ideas + Modern Technology = MAGIC! Discover The Most Effective System to Instantly Relax, Reduce Stress and Easily Enter the Deepest Meditation! You'll Learn How to: Instantly Meditate like the Greatest Gurus!

How to Practice Dynamic Relaxation Practice relaxation for 20 minutes, three times a week Practice relaxation during times of increased stress As you drift off to sleep each night, take five gentle full breaths As you wake in the morning, take five gentle full breaths Whenever you feel physically or mentally uncomfortable think the word re-lax with five gentle full breaths When you sigh continue with five gentle full breaths Look for opportunities to relax throughout the day – waiting in line, in a doctor’s office, at a red light – take a moment to take five gentle full breaths.

How to Practice Dynamic Relaxation Throughout the day, check in with your body and release any physical tension. Check your tension every hour on the hour. Be aware of graceful movement. During any activity – walking, running, sitting, cooking, cleaning, writing, driving –release any tension. Breathe, and see how gracefully you can do this activity Get involved in activities that relax the body – massage, hot baths, hot showers, saunas, whirlpools, yoga Schedule a weekly ritual that will reenergize and revitalize you. For example, every Wednesday take a 30 minute walk, a hot bath, do a 20 minute relaxation practice, watch a comedy on TV and go to bed ½ hour earlier.

Special Thanks! Gail Marion, PA-C, Ph. D Forrest Lang, MD Susan M. Grover, Ph. D, RN Michael Floyd, Ed. D Julie Schirmer, MSW Kim Marvel, Ph. D Betty Mc. Cord MD Kathleen Beine, MD Kathy Cole-Kelly, MSW

The Kalamazoo Consensus Statement Essential Elements of Communication in Medical Encounters Build a relationship Open the discussion Gather information Understand the patient’s perspective Share information Reach agreement Provide closure

Common Ground Communication Skills Lang, Mc. Cord, Harvill & Anderson, 2004 1. Rapport Building 2. Agenda Setting 3. Information Collection / Management 4. Active Listening (PPI) 5. Addressing Feelings 6. Reaching Common Ground

. . Existing communication assessment instruments vary considerably in their content, psychometric properties, and usability. No instrument received high ratings in all of those categories. . Only one of the instruments (Common Ground) that had strong psychometric properties had a relatively high rating on the Kalamazoo Consensus Statement elements. Assessing communication competence: A review of current tools. Schirmer, JM, Mauksch, L, et al. Fam Med 2005; 37(3): 184 -92.

Wake Forest University School of Medicine Common Ground Training Medical students first year DPR 3 rd year clerkships FM, GIM and PEDs - Introduction to CG and students score an encounter using the CG tool - Unannounced videotape of every student with a real patient - Use CG to have them self assess, peer assess and receive feedback from faculty - The last day students are evaluated during a SPA by FM faculty PA students - 1 st Year – 4 small group hour practice sessions and 5 SPAs - 2 nd year- SPAs and evaluated at site visits Family Medicine Residency: Human Behavior Rotation - 10 hours of CG training, 8 hours of shadowing, 2 patient videotapes HO 2 s Geriatric Out-Patient Rotation - Common Group Skills Reviewed and Reinforced During Rotation

Why effective interviewing skills are important Experience a sense of orderliness during the appointment Develop more satisfying relationships with patients Develop rapport and trust Gather information in an accurate and efficient manner Increase patient compliance with treatment regimen Improve disease outcomes Decrease in malpractice suits Increase significantly the satisfaction of both the patient and the physician at the end of the appointment

Rapport building skills? Verbal Rapport Building 1) Introductory (icebreakers) 2) Reinforcement of successive approximations 3) Statements of your personal support, collaboration, and commitment. 3) Concluding personal remarks. Non-verbal Rapport Building 1) Gestures (handshakes etc. ) 2) Voice tone, speed, interest 3) Eye contact, lean, body position

Rapport building. . . not!

Rapport building. . . ideal.

Agenda Setting Determine the patient’s complete agenda at the beginning of the interview. Then prioritize if patient has multiple agenda concerns. You know that you have performed complete agenda setting when (early in the interview) the patient responds to an inquiry about additional agenda items with, “That’s about it. ” Ask again at the end of the appointment.

Ask and you shall receive.

What are your priorities?

Active listening for full understanding of ideas, concerns, and expectations. “What are you worried about? ” – Direct statements of ideas & concerns – Expressions of feelings – Attempts to explain – Speech clues – Behavior clues – Personal story

Diabetes

What is she really saying?

Information Management Encouraging a collaborative conversation Facilitators Silence Open-ended questions Clarification Restatement Paraphrasing Reflection Closed-ended questions Summarization

The routine interrogation. . .

The usual interaction. . .

Productive silence. . .

Feelings? What feelings?

Common Ground. . . not.

Sample of available standardized instruments Designed for an observer: Common Ground Rating Form Kalamazoo Essential Elements: The Communication Checklist Medical Interview Skills Competency Evaluation (SEERS) The SEGUE Framework Designed for standardized patients: Rochester Communication Rating Scale, 2002 version Interpersonal Skills and Communication Skills Checklist Designed for real patients: Patient Assessment for Continuous Professional Development (ABIM) Patient Perception of Patient Centeredness

An exercise in relaxed and mindful communication skills assessment.

Mindfulness & Dynamic Relaxation in Clinical Practice Resident Feedback N = 19 (1 = minimally; 5 = a great deal) How many times did you practice deep relaxation? 3. 8 As a result has your ability to be alert and calm improved? 2. 7 Has your awareness of your own thoughts, feelings and reactions increased? 3 Has your awareness of your patient’s thoughts, feelings and reactions improved? 3

Mindfulness & Dynamic Relaxation in Clinical Practice Resident Feedback How would you rate your: N = 19 1 = poor; 5 = excellent Ability to relax deeply while listening to the CD = 3 Self-awareness of emotional and physical arousal during the day = 3. 4 Ability to relax quickly when feeling tense or hurried = 2. 8 Ability to be alert and calm when seeing clinic patients = 3. 2 A wareness of your own thoughts, feelings, and reactions = 3. 7 Awareness of your patients’ thoughts, feelings and reactions = 3. 7

Further feedback. . . Has dynamic relaxation and mindfulness training improved your ability to incorporate communication skills in your medical practice? – Yes = 13 – Tremendously, I need more practice – Somewhat – Kind of – Maybe – I think it would if I did it more. – NA

Any other comments about mindfulness and dynamic relaxation training? “Need more self-assertiveness to incorporate it daily-wish we had refresher course. ” “Nice life skill & component of the rotation. ” “I think it is very useful and with time I could improve. ” “Really enjoyed. I know it will be very helpful in both my professional and personal life. Thanks. ” “Simply discussing thought of being mindful was somewhat helpful. ” “I enjoyed it and it was very beneficial. ” “I think it helped more in my personal life as opposed to during appointments. ” “I need to practice more. It has great utility in anyone's life esp. those with high stress jobs/lifestyles. ”