Evidencebased and Ready to Use DoctorPatient Communication Didactic

Evidence-based and Ready to Use Doctor-Patient Communication Didactic Curriculum ©Yvonne Murphy, MD, 2011 All materials may be used for teaching purposes with credit to the author.

Author’s Background n Medical school in Rochester, New York n Several teaching sessions with Dr. George Engel who n n first described the biopsychosocial model Family Medicine residency in Rochester, NY; three month rotation in biopsychosocial medicine Two year fellowship in Family Systems Medicine training as a marriage and family therapist as well as with Dr. Rick Bohtelo, author of Motivating Healthy Habits Trained with Tom Campbell, Susan Mc. Daniel, and Dave Seaburn who wrote Family Oriented Primary Care as well as with Cecil Carson, Howard Beckman, and Rich Frankel. 10 years at Mac. Neal Family Medicine Residency in Berwyn, IL; Director of Behavioral Science & Associate Program Director for Education

Now a little about you. Name, position, length of time teaching, type of learners (students, residents, etc) What were you hoping to get out of this session?

Educational Objectives: Participants will be able to: n 1. List commonly encountered clinical circumstances in medicine where specific doctor-patient communication skills can be described, demonstrated, and practiced. n 2. Explain how to use the session outline, slideshow presentation, demonstration materials, and skills checklist to conduct a teaching session for a specific communication skill n 3. Describe strategies for incorporating the doctor- patient communication skills didactic series into one’s own educational program.

Overview of the Curriculum ©Yvonne Murphy, MD, 2009 n 16 One Hour Didactic Sessions n For use with medical students, residents, fellows, allied health professionals, or practicing physicians n Each topic can be used individually or all 16 form a comprehensive curriculum n Designed using proven effective educational principles to maximize learning n Each includes research evidence and a reference list of the literature n Most could be expanded to 2 -3 hour workshops (see slide #33)

Overview of the Curriculum Topics of the 16 Modules ©Yvonne Murphy, MD, 2010 n Agenda Setting n Bad News n Behavior Change n Advance Directives n Language Barriers n Chronic Pain n Shared Decisions n Sexual History n Compliance n Angry Patient n Empathy n Medical Errors n Terminating n Family Meetings n Using EMR n Patient Satisfaction & Malpractice Risk

Teaches Skills Required for Creating the Patient Centered Medical Home ©Yvonne Murphy, MD, 2009 n Skills listed on the AAFP PCMH Checklist that are covered in this curriculum: Agenda setting n Shared decision making n Cultural competence n Motivational interviewing n Family engagement n Use of EMR technology n Patient satisfaction n n Other communication skills taught are also patient-centered

Fulfills ACGME Competencies ©Yvonne Murphy, MD, 2009 n ACGME Competencies addressed: Patient Care: Communicates effectively and demonstrates caring and respectful behaviors when interacting with patients and their families n Interpersonal and Communication Skills: Communicate effectively with patients, families, and the public across a broad range of socioeconomic and cultural backgrounds n Professionalism: Sensitivity and responsiveness to a diverse patient population… n

Fulfills Family Medicine ACGME Requirements ©Yvonne Murphy, MD, 2009 n Family Medicine ACGME Requirements addressed: n n n “…demonstrate cultural competence in caring for patients from varied ethnic and cultural backgrounds. ” “Essential elements to be integrated into the teaching of family care include: …behavioral counseling, human sexuality, end of life issues, …” (p. 18 ACGME Competencies/Patient Care/Family-Oriented Comprehensive Care Experience) End of Life issues also listed under The Older Patient (p 23) and SBP (p 33). Sexual Health also listed under Gynecology (p 25). “There must be instruction and development of skills in …the physician/patient relationship, patient interviewing skills, and counseling skills. ” n (p 28 ACGME Competencies/Medical Knowledge/Human Behavior and Mental Health) n “Regularly scheduled didactic sessions. ”

Contributes to Maintenance of Board Certification ©Yvonne Murphy, MD, 2009 n Meeting Board Certification Requirements: n March 26, 2009 - The American Board of Medical Specialties (ABMS) announces adoption of a new set of standards designed to further enhance physician qualification principles assessed through its ABMS Maintenance of Certification® (MOC) program. Assessment of communication skills as a standard for all physician diplomates with direct patient care - using a Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient survey (or other COMMOCapproved survey), and an approved peer survey

May Decrease Malpractice Risk ©Yvonne Murphy, MD, 2009 n Risk Management n A key factor in patient’s decision to pursue litigation is dissatisfaction and breakdowns in communication. n n Levinson W. et al. Physician-Patient Communication: The Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons. JAMA. 1997; 277: 553 -559. See references 6 -12 of the above article for more articles that support this. Levinson W. Physician-patient communication: a key to malpractice prevention. JAMA. 1994; 273: 1619 -1620. Beckman HB, et al. The Doctor-plaintiff Relationship: Lessons from Plaintiff Depositions. Arch Int Med. 1994; 154: 1365 -1370.

Additional Roles of a Doctor-Patient Communication Didactic Curriculum ©Yvonne Murphy, MD, 2009 n Addressing Individual Program or Hospital/Institutional Needs: Resident feedback (conferences or program) n Patient complaints or situations n Institutional or hospital initiatives (JCAHO initiatives on pain and patient safety/errors) n Patient Satisfaction n Quickly fill cancellations in lecture schedule n

Design – Underlying Educational Principles Robert Gagne’s Conditions of Learning n 1. Gain attention n 2. Inform learners of objectives n 3. Stimulate recall of prior learning n 4. Present the content n 5. Provide “learning guidance” n 6. Elicit performance (practice) n 7. Provide feedback n 8. Assess performance n 9. Enhance retention and transfer (c) MH Gelula, 2009; Used with author’s permission

Design – Underlying Educational Principles n Copeland et al: Attributes of the effective medical lecture Engaging the audience n Lecture clarity n Active Learning n (c) MH Gelula, 2009; Used with Author’s Permission

Overview of Design of Each Module ©Yvonne Murphy, MD, 2009 n Engage n Present evidence n Outline components of the skill n Demonstrate skill n Practice skill n My philosophy – communication skills can be taught and learned just as other skills such as lumbar puncture where we outline step by step instructions to guide the learner

Overview of Design – Engage ©Yvonne Murphy, MD, 2009 n Each session begins with a question or exercise for the audience to activate them and promote recall of prior knowledge: n n Give an example of a personal experience with the topic area (such as delivering bad news) Poll n n Make a list n n Example from Shared Decision Making: What clinical decisions did you make with patients in the past day? Example from Discussing Advance Care Planning and Endof-Life Care: Use a flip chart to list the audience’s barriers to discussing advance care planning. Other exercises n Cultural Competency Quiz

Overview of Design – Engage ©Yvonne Murphy, MD, 2009 n Slide presentations are limited to about 20 minutes. n Activities are changed at regular intervals throughout to promote attention. Introduction with engaging activity and educational objectives n Slides n Demonstration of skill (video, live) n Practice n

Overview of Design – Engage ©MH Gelula, 2009; Used with Author’s Permission Effective Learning gained with rest or change of activity Learning lost with rest or change of activity Rest or change in activity 0 10 20 30 Minutes(c)into lecture MH Gelula, 2009 40 50 60 Based on Bligh, 2000 18

Overview of Design – Evidence ©Yvonne Murphy, MD, 2009 n Present research findings to support use of that communication skill n Use of evidence-based practices, when possible n NEXT TWO SLIDES ARE EXAMPLES OF THIS FROM THE SHARED DECISION MAKING MODULE

Why use shared decision-making in clinical practice? (data 10/05 FP Management); ©Yvonne Murphy, MD, 2009 n 32% patients have chosen NOT to fill a prescription they n n considered unnecessary 21% have sought a second opinion because they thought their doctor’s recommendations were too aggressive 16% have chosen NOT to undergo a recommended diagnostic test they considered unnecessary 10% have chosen NOT to undergo a recommended surgical procedure 9% have changed doctors because they felt their doctor’s approach was too aggressive

Why use shared decision-making in clinical practice? Evidence ©Yvonne Murphy, MD, 2009 n 2005 Study Pediatrics n Parents presented with two vignettes in case of 2 ½ yo with AOM n More satisfaction with shared decision making n Decreased use immediate antibiotic (7% vs. 27%)

Overview of Design – Description of Communication Skill ©Yvonne Murphy, MD, 2009 n Break down into steps n Examples of wording as a guide n Checklist used for learning and giving feedback during practice n NEXT TWO SLIDES ARE EXAMPLES OF THIS FROM THE SHARED DECISION MAKING MODULE

Six Elements of Shared Decision. Making ©Yvonne Murphy, MD, 2009 n Physician presents the issue or decision to be made n Physician discusses the risks and benefits of each n n alternative (non technical language) Physician includes discussion of clinical uncertainties Physician assesses the patient’s (and family’s) experience, values and priorities among the alternatives Physician assesses patient’s understanding of above and their desired level of decision making participation Physician allows patient to voice a preference (decide), makes a recommendation and they come to an agreement

Principles of Use of Shared Decision Making ©Yvonne Murphy, MD, 2009 n Avoid adjectives (likely, rare). Describe proportions (one in 10) rather than probability (10% chance). n Use absolute (not relative) risk and patient oriented outcomes. n Frame both positively and negatively (chance of survival & chance of death) n Individualize risk when possible (risk calculators) n AAFP Prostate Cancer Screening example

Design – Demonstrate Skill ©Yvonne Murphy, MD, 2009 n Participants then identify the Six Elements of Shared Decision-Making in the Demonstration Video: n n List issue or decision (choices/alternatives) List risks and benefits of Alternative #1 n Alternative #2 n n n List clinical uncertainties List patient’s values/priorities among alternatives How did physician assess patient’s understanding? How did physician allow patient to voice a preference (decide)?

Design – Demonstrate Skill Shared Decision Making Video n This module has a video (available upon request from the author) of the physician discussing whether or not to discontinue antidepressant medication one year after a first episode of major depression which was successfully treated with a 40 year old woman.

Design – Practice Skill ©Yvonne Murphy, MD, 2009 n Role play in pairs use skills checklist to give feedback n Skills Exercise Scenario # 1 n Physician: A 45 -year-old man came in as a new patient with a sprained ankle. At his follow-up visit today, his sprain seems well healed, so you consider offering him some health maintenance screening. He is overweight and put on his Ambulatory History Form that he has a family history of diabetes. You would like to send him for a fasting blood sugar. Discuss this with him using shared decisionmaking. n Patient: You are a 45 -year-old man who hasn’t seen a doctor in many years. You sprained your ankle two weeks ago and so came into FPC for treatment. Today you are at your follow-up visit, and your ankle seems about back to normal. In fact, you didn’t really want to come back. Although you are aware that diabetes runs in your family, you don’t really like to think about having it yourself. As long as you don’t feel sick, you don’t feel you need to go to the doctor or take medications. n NEXT PAGE IS A CHECKLIST USED TO GIVE FEEDBACK

Physician presents the issue or decision to be made with choices/alternatives Physician gives rationale for patient participating in decision “I’d like us to make this decision together. ” “It helps me to know how you feel about this. ” “Two different people might choose to do it differently. ” Physician discusses the risks and benefits of alternative #1 Avoid adjectives (unlikely, rare) Frame both positively & negatively. Use absolute (not relative) risk and patient oriented outcomes. Describe proportions (one in 10) rather than probability (10% chance). Physician discusses the risks and benefits of alternative #2 Language patient can understand in digestible pieces. Physician includes discussion of clinical uncertainties “Most people with your condition respond well to this medication but not all. ” “The chance that X will help is X. ” Physician surveys and helps the patient clarify their experience, values, and priorities among the alternatives “How do you feel about taking this medicine/having this test/the possible consequences of doing X? ” Does patient desire input from family/friends/others? Physician assesses patient’s understanding of above and the level of participation in decision making desired “So tell me what you have understood so far about the information I’ve given so I can know if I explained it correctly. ” “How would you like us to decide? ” Physician allows patient to voice a preference (decide), makes a recommendation, and they come to common agreement Physician documents conversation and decision in chart

Using the Materials ©Yvonne Murphy, MD, 2009 n Components: n Session Outline (start with this) n Slides n Skills exercise On CD, each topic will have 2 -3 documents -1 -2 Word documents -1 Power. Point document

Using the Materials: Sample Session Outline ©Yvonne Murphy, MD, 2009 n Additional Materials Needed: n n n Arrange in advance for a patient to come live to the session with their physician (faculty or other physician experienced in shared decision making) to discuss a medical decision. A video taped encounter may be used as well. A video taped encounter of Dr. Murphy and a patient is available by request (contact Dr. Murphy at ymurphy@macneal. com). n Handout: n n n Slides printed as handout. Outline of Skills Exercise in Shared Decision Making (separate file) Copy of AAFP PSA Decision Aid (as an example of a decision aid) n One Hour Session Outline: n n n n 5 min Poll of Audience: -What clinical decisions did you make with patients in the past day or two? -Objectives 10 min Slide presentation on shared decision-making 10 min Live or video demonstration with audience filling in questions on handout. 5 min Debriefing of audience 15 min Skills Exercise (role play) with checklist in pairs; Time 5 min for role play & 2 min for feedback for each partner n 5 min Debrief role play, questions & feedback

Words to the Wise ©Yvonne Murphy, MD, 2009 n Many sessions require some preparation for the n n n demonstration in advance Review the timing of the session, the slides, and prepare a handout Read some of the references if you don’t have a working knowledge of the topic to facilitate smooth delivery PRACTICE THE PRESENTATION AHEAD; they are very carefully timed to fit into one hour Make sure all AV is working before starting Stick to the time allotted for each segment during the session

A Word about Role Play ©Yvonne Murphy, MD, 2009 n Most of the sessions have a role play to practice the skill being taught n I prefer the term “Skills Exercise” to role play and encourage you to use that term as it more accurately describes the purpose n I find it helps to remind learners that it’s better to practice with your colleague than with a real patient the first time you try to use any new skill n I also find that if you are positive and persistent about incorporating this part of the session, your learners will participate

Implementation within my Program ©Yvonne Murphy, MD, 2009 n FMRP 12 -12 -12 + 6 students and 3 fellows n Didactics = Noon conference (1 hour) daily n Large group (while eating lunch) n 18 month repeating curriculum n One per month with a few extra slots n Each session presented twice during a resident’s three year residency

Evidence for Effectiveness ©Yvonne Murphy, MD, 2010 n Each module has been presented to a group of medical students, residents, and faculty 3 or more times over past 8 years (except EMR-new module 2010) n Presentations consistently rate 4 -5 on a 5 point scale on relevancy, specific objectives, evidence presented, effectively case-based & audio visuals n Each module has been revised at least twice based on feedback and new literature searches

Evidence for Effectiveness ©Yvonne Murphy, MD, 2010 n Ratings by educators who have used: n Ease of Use n Session outline n Slide show n Skills exercise Easy or Very Easy n Effectiveness in Teaching n Structure of session n Information n AV materials n Skills exercise Effective or Very Effective N=23 -25 88% 79% 96% 100% 91%

Evidence for Effectiveness ©Yvonne Murphy, MD, 2010 n FEEDBACK FROM EDUCATORS WHO HAVE USED THIS CURRICULUM (N=25):

Evidence for Effectiveness ©Yvonne Murphy, MD, 2010 n Quote from a user of the materials: “So I followed your materials and presented agenda setting on 3/23. I did a role play with the chief resident. The presentation went very well. Just want to thank you so much because the materials are excellent, and the varied activities make it so engaging. The residency director liked it. It's been so helpful to me in getting started. ”

Evidence for Effectiveness ©Yvonne Murphy, MD, 2010 n Quotes from users of the materials: n Informally the residents and faculty have mentioned things like: “Useful”, “Excellent”, and “Wow! I really like this” n Quickly jump-starts their thinking about these particular areas, gives summaries that are easy to implement and practice

Expanding One Hour Format into a 2 -3 Hour Workshop ©Yvonne Murphy, MD, 2010 n Allows more in depth learning of a particular skill n Expand initial engaging activity to include every participant in the group or have each participant discuss or journal about their personal experience with the topic n Objectives, slide show, and demonstration remain the same n Expand time for discussion of the demonstration n Expand the time for skills exercise. Allow 10 minutes for the role play for each person. These could be done by each pair in front of the group (sequentially instead of simultaneously) with each person in the group filling out the checklist for feedback; Each pair could also repeat the exercise again after receiving feedback to further improve. The role play could also be taped for each learner to review either with the group or on their own.

Implementation in your Program ©Yvonne Murphy, MD, 2009 n How/Where would you fit this into your curriculum? Would you implement the entire series or just select topics? Which ones? n Longitudinal versus block/rotation? n Small or large group setting n Add to curriculum vs eliminate/substitute? n Whose buy in would you need? n n Administrative Faculty Learners

Assessment of Learned Skills ©Yvonne Murphy, MD, 2010 This curriculum’s main purpose is to teach communication skills, but these are ideas for subsequent assessment: At the end of a workshop or after some time has elapsed to practice following a one hour session, the skills checklist or outline of the skill could be used as an evaluation tool of either a role play, simulated patient, or live/taped patient encounter involving that skill for the learner. Many of the skills can be evaluated using a patient survey after a patient encounter. The skills can be directly observed by supervisors using a standardized checklist (many are available)

To Obtain Additional Copies of the Entire Curriculum on CD n Go to www. fmdrl. org n In the search box, type author’s name Yvonne Murphy and click go n Click on the word document entitled registration form n Complete it and Email to ymurphy@macneal. com n Fax to 708 -783 -0776 n

Contact Information for Dr. Murphy n I’m happy to answer any questions: n Yvonne Murphy, MD n Associate Program Director for Education n Co-Director Behavioral Science n Mac. Neal Family Medicine Residency Program n 3231 S. Euclid Avenue, 5 th Floor n Berwyn, IL 60402 n Fax 708 -783 -3656 n Ymurphy@macneal. com

Gratitude n This project was made possible by: n My husband Walt and my son Alec n Mary Talen, Ph. D, who provides so much encouragement n Minnie, my administrative assistant n My many mentors from residency and fellowship in Rochester, New York n Mac. Neal Family Medicine Residency Program