Assessing Communication Assessing Communication as a Clinical Competencyas a Clinical Competency

Why Bother?Why Bother?

Suzanne Kurtz, PhDSuzanne Kurtz, PhDCollege of Veterinary Medicine College of Veterinary Medicine Washington State UniversityWashington State University

March 14, 2008March 14, 2008Washington DCWashington DC

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

Kurtz S, Silverman J, Draper J (2005) Kurtz S, Silverman J, Draper J (2005) Teaching and Learning Communication Skills in Medicine, Teaching and Learning Communication Skills in Medicine, 2nd Ed. 2nd Ed. Radcliffe Publ: Oxford & San FranciscoRadcliffe Publ: Oxford & San Francisco

Silverman J, Kurtz S, Draper J (2005) Silverman J, Kurtz S, Draper J (2005) Skills for Communicating with Patients, 2nd EdSkills for Communicating with Patients, 2nd Ed. Radcliffe . Radcliffe Publ: Oxford & San FranciscoPubl: Oxford & San Francisco

Riccardi V & Kurtz (1983) Riccardi V & Kurtz (1983) Communication and Counselling in Health Care.Communication and Counselling in Health Care. Charles C Charles C Thomas, Springfield, IllinoisThomas, Springfield, Illinois

Cindy Adams, PhD, University of CalgaryCindy Adams, PhD, University of Calgary

AARRGGHH!!!AARRGGHH!!!

Who’s Endorsing Communication Who’s Endorsing Communication in Veterinary Medicine?in Veterinary Medicine?

National Commission on Vet Econ InitiativesNational Commission on Vet Econ Initiatives American Animal Hospital AssociationAmerican Animal Hospital Association American & State Vet Med AssociationsAmerican & State Vet Med Associations American College of Veterinary Internal MedicineAmerican College of Veterinary Internal Medicine Veterinary Colleges - Canada, UK, USA, etc.Veterinary Colleges - Canada, UK, USA, etc. Intl Conf on Communication in Vet MedIntl Conf on Communication in Vet Med National Board of Vet Med ExaminersNational Board of Vet Med Examiners Vet Industry PartnersVet Industry Partners

Evidence BaseEvidence BaseHuman MedicineHuman Medicine

Enhancing communication leads to: Enhancing communication leads to: More effective consultationsMore effective consultations

AccuracyAccuracy EfficiencyEfficiency SupportivenessSupportiveness

Better relationships (partnership) Better relationships (partnership) Better coordination of careBetter coordination of care

Kurtz, Silverman, Draper, 2005

Evidence Base: Improved Clinical Outcomes Evidence Base: Improved Clinical Outcomes in human medicinein human medicine

Enhancing communication leads to better Enhancing communication leads to better outcomes: outcomes: understanding & recall understanding & recall symptom relief symptom relief physiological outcomes physiological outcomes adherenceadherence patient safetypatient safety patient satisfactionpatient satisfaction doctor satisfactiondoctor satisfaction

costs costs complaints and malpractice litigation complaints and malpractice litigation

Evidence BaseEvidence BaseVeterinary MedicineVeterinary Medicine

PEW National Veterinary Education Program (1988)PEW National Veterinary Education Program (1988) AVMA Market Study (1999)AVMA Market Study (1999)

““Veterinarians are strong in scientific, technical and medical skills and Veterinarians are strong in scientific, technical and medical skills and lacking in communication and management skills necessary for success lacking in communication and management skills necessary for success in practice.”in practice.”

Brakke Management and Behavior Study (2000) Brakke Management and Behavior Study (2000) Identified three business practices to increase practice income Identified three business practices to increase practice income

(employee longevity, employee satisfaction, and client satisfaction)(employee longevity, employee satisfaction, and client satisfaction)

Personnel Decision Study (2003)Personnel Decision Study (2003) Identified non-technical competencies for career success (business Identified non-technical competencies for career success (business

acumen, work life balance, effective communication, and leadership acumen, work life balance, effective communication, and leadership skills)skills)

AVMA-Pfizer Business Practices Study (2005) AVMA-Pfizer Business Practices Study (2005) Identified client relationships as a pillar of financial successIdentified client relationships as a pillar of financial success

Evidence BaseEvidence BaseVeterinary MedicineVeterinary Medicine

ComplianceCompliance range is between 23-65% range is between 23-65% Problems cited:Problems cited:

• Not enough informationNot enough information• Relationship not establishedRelationship not established• Client opinion not consideredClient opinion not considered• No follow up regarding patient well beingNo follow up regarding patient well being

Adams V (2002), AAHA Adams V (2002), AAHA (2004)(2004)

Evidence BaseEvidence BaseVeterinary MedicineVeterinary Medicine

50-82% of 50-82% of complaintscomplaints to CVO related to to CVO related to communication problems:communication problems: Client was misinformed Client was misinformed Consent was not obtainedConsent was not obtained Client felt disrespectedClient felt disrespected Client felt like opinion did not matterClient felt like opinion did not matter Procedure was not explainedProcedure was not explained

College of Veterinarians of Ontario College of Veterinarians of Ontario (2005)(2005)

What are we assessing?What are we assessing?Clinical competenceClinical competence

Knowledge base Knowledge base Physical examination skills Physical examination skills Medical problem solving, diagnostic skillsMedical problem solving, diagnostic skills Communication skillsCommunication skills

Communication is a core clinical skillCommunication is a core clinical skill

with considerable science behind itwith considerable science behind it

Common (mis)perceptionsCommon (mis)perceptions

Communication is a personality trait, either you Communication is a personality trait, either you have it or you don’thave it or you don’t

Communication is a series of learned skillsCommunication is a series of learned skills Not a personality traitNot a personality trait Anyone can learn who wants toAnyone can learn who wants to

Results of Lit Review (human medicine) Results of Lit Review (human medicine) 81 high to medium quality articles included81 high to medium quality articles included

Overwhelming evidence for positive effect of Overwhelming evidence for positive effect of communication skills trainingcommunication skills training

Only 1 of 81 studies didn’t report positive effectsOnly 1 of 81 studies didn’t report positive effects Med students, residents, junior drs, senior drs all Med students, residents, junior drs, senior drs all

improved improved Specialists as likely to benefit as primary care Specialists as likely to benefit as primary care

drsdrs

Aspegren, 1999Aspegren, 1999

Evidence: Veterinary MedicineEvidence: Veterinary Medicine

Significant improvement in veterinary students’ Significant improvement in veterinary students’ communication skills with increasing levels of communication skills with increasing levels of training (p<.0001)training (p<.0001)

No significant difference between no training No significant difference between no training and intermediate trainingand intermediate training

Clients’ recall highest in student group with Clients’ recall highest in student group with highest level of communication traininghighest level of communication training

Latham CE, Morris A Veterinary Record Latham CE, Morris A Veterinary Record (2007)(2007)

Common (mis)perceptionsCommon (mis)perceptions

Experience is a good teacher of communication Experience is a good teacher of communication skillsskills

Experience alone tends to be a limited teacher Experience alone tends to be a limited teacher

of communication skillsof communication skills It is a great reinforcer of habit - just doesn’t It is a great reinforcer of habit - just doesn’t

discern well between good and bad habitsdiscern well between good and bad habits

Our perception may be flawedOur perception may be flawed

What gets us into trouble is not what we What gets us into trouble is not what we don’t know. It’s what we know for sure don’t know. It’s what we know for sure

that just ain’t so.that just ain’t so.Mark TwainMark Twain

Taught skill retention Taught skill retention vs development with experience alonevs development with experience alone

Doctors 5 years out of medical school still strong in Doctors 5 years out of medical school still strong in information gathering (taught) but weak in explanation and information gathering (taught) but weak in explanation and planning skills (experience only) planning skills (experience only) discovering pt’s views/expectations 70% no attempt discovering pt’s views/expectations 70% no attempt negotiation negotiation 90% no attempt 90% no attempt encouraging questions encouraging questions 70% no attempt 70% no attempt repetition of advice repetition of advice 63% no attempt 63% no attempt checking understanding checking understanding 89% no attempt 89% no attempt categorizing information categorizing information 90% no attempt 90% no attempt

Maguire et al 1986Maguire et al 1986

Evidence-based Rationale Evidence-based Rationale Veterinary MedicineVeterinary Medicine

Data gatheringData gathering Primarily closed questionsPrimarily closed questions No open-ended questions in 25% of interviewsNo open-ended questions in 25% of interviews

EmpathyEmpathy Empathy statements in only 7% of appointmentsEmpathy statements in only 7% of appointments

Shaw, Adams, Bonnett, Roter 2003, 2004Shaw, Adams, Bonnett, Roter 2003, 2004

What are we assessing?What are we assessing?

Behavior = what we do anywayBehavior = what we do anyway vsvs

Professional competence =Professional competence = awareness & attention awareness & attention intentionality intentionality ability to reflect on & articulate with precisionability to reflect on & articulate with precision

and it’s evidence basedand it’s evidence based

Goal = to enhance communication in practice Goal = to enhance communication in practice

to a professional level of competenceto a professional level of competence

What are we assessing?What are we assessing?

Skills*Skills* Attitudes, beliefs, valuesAttitudes, beliefs, values Capacities (eg, compassion, integrity, flexibility, Capacities (eg, compassion, integrity, flexibility,

mindfulness) mindfulness)

In what circumstances?In what circumstances? Difficult situations (complex case, breaking bad news, death and Difficult situations (complex case, breaking bad news, death and

dying, medical error, adverse outcomes)dying, medical error, adverse outcomes) Everyday run-of-the-mill consultations, client education, Everyday run-of-the-mill consultations, client education,

preventionprevention

Types of Communication SkillsTypes of Communication Skills

Content skills - what you say, info you gather & giveContent skills - what you say, info you gather & give

Perceptual skills - what you think, clinical reasoning Perceptual skills - what you think, clinical reasoning - what you feel - what you feel

- attitudes, biases, intentions, assumptions - attitudes, biases, intentions, assumptions

Process skills - how you question, respond, explain, plan Process skills - how you question, respond, explain, plan - how you structure talk- how you structure talk - how you relate to patients- how you relate to patients - nonverbal skills/behaviour- nonverbal skills/behaviour

Do we know Do we know what skills are worth assessing?what skills are worth assessing?

Many models available: Many models available: Calgary-Cambridge GuidesCalgary-Cambridge Guides Patient-Centered ModelPatient-Centered Model Macy ModelMacy Model SEGUE FrameworkSEGUE Framework Bayer-Fetzer Essential ElementsBayer-Fetzer Essential Elements MAAS-GlobalMAAS-Global

Numerous approaches to assessing Numerous approaches to assessing

communication are out therecommunication are out there Boon H and Stewart M (1998) Patient-physician communication Boon H and Stewart M (1998) Patient-physician communication

assessment instruments 1986 to 1996 in review. assessment instruments 1986 to 1996 in review. Patient Education Patient Education and Counseling. 35: 161-76.and Counseling. 35: 161-76.

Cushing A (2002) Assessment of non-cognitive factors. In: GR Cushing A (2002) Assessment of non-cognitive factors. In: GR Norman, CPM van der Vleuten and KJ Newble (eds) Norman, CPM van der Vleuten and KJ Newble (eds) International International Handbook of Research in Medical EducationHandbook of Research in Medical Education. Kluwer Academic . Kluwer Academic Publishers, Dordrecht.Publishers, Dordrecht.

MacLeod H (2004) MacLeod H (2004) Physician performance assessment and Physician performance assessment and communication skills assessmentcommunication skills assessment. Unpublished review of the . Unpublished review of the literature from 1990 to 2003. Task Force on Physician literature from 1990 to 2003. Task Force on Physician Communication Skills Assessment and Enhancement in Canada, Communication Skills Assessment and Enhancement in Canada, Medical Council of Canada, Ottawa, OntarioMedical Council of Canada, Ottawa, Ontario

Kurtz S, Silverman J, Draper J (2005) Assessing learners’ Kurtz S, Silverman J, Draper J (2005) Assessing learners’ communication skills. In communication skills. In Teaching and Learning Communication Teaching and Learning Communication Skills in Medicine (2nd ed). Skills in Medicine (2nd ed). Radcliffe Publishing: Oxford & SanRadcliffe Publishing: Oxford & San FranciscoFrancisco

CALGARY-CAMBRIDGE GUIDES CALGARY-CAMBRIDGE GUIDES FRAMEWORK FOR THE MEDICAL CONSULTATIONFRAMEWORK FOR THE MEDICAL CONSULTATION

Initiating the Session

Gathering Information

Physical Examination

Explanation/Planning

Closing the Session

Providing Structure

Building the Relationship

Kurtz, Silverman, Draper (2005)

Calgary-Cambridge Guides Calgary-Cambridge Guides Communication Process SkillsCommunication Process Skills

56 process skills organized around framework 56 process skills organized around framework (plus (plus Options in Expl & Pl Options in Expl & Pl section = 15 more process section = 15 more process & content skills:)& content skills:)

Backbone of communication teaching and Backbone of communication teaching and learninglearning

Cross-disciplinary & cross-cultural applicationCross-disciplinary & cross-cultural application

SEE HANDOUTSEE HANDOUT

Same process skills for an array Same process skills for an array of communication issuesof communication issues

Conflicted or difficult situationsConflicted or difficult situations Gender issuesGender issues Cultural issuesCultural issues Generational differencesGenerational differences Ethical dilemmasEthical dilemmas Performance reviewsPerformance reviews

Advantages of GuidesAdvantages of Guides Accessible summary of research evidenceAccessible summary of research evidence Comprehensive delineation of skills Comprehensive delineation of skills Memory aid to keep skills in mind, organizedMemory aid to keep skills in mind, organized Framework for systematic skill developmentFramework for systematic skill development Basis for comprehensive feedback & evaluationBasis for comprehensive feedback & evaluation

Core content for training faculty, creating consistencyCore content for training faculty, creating consistency Common foundation for programs at all levels – basis for Common foundation for programs at all levels – basis for

coherent, helical curricula from undergrad through CEcoherent, helical curricula from undergrad through CE

Same skills pertain to effective teaching or communication Same skills pertain to effective teaching or communication with colleagues with colleagues

What are we assessing?What are we assessing?

Knowledge – do you know it?Knowledge – do you know it? Competence – can you do it?Competence – can you do it? Performance – do you (choose to) do it in practice?Performance – do you (choose to) do it in practice? Results – what happens to pts, to drs?Results – what happens to pts, to drs?

Miller 1990Miller 1990

What forms can assessments take?What forms can assessments take?

Knowledge – do you know it?Knowledge – do you know it? MCQ, essay/short answer, oral, MCQ, essay/short answer, oral, Objective Structured Video Exam…Objective Structured Video Exam…

What forms can assessments take?What forms can assessments take?

Competence – can you do it?Competence – can you do it? OSCE using standardized simulated clientsOSCE using standardized simulated clients

• Stand alone communication stationsStand alone communication stations• Communication stations integrated with PE, medical problem Communication stations integrated with PE, medical problem

solving, solving, Real interviews: Real interviews:

• Series of live interviews with examiner present Series of live interviews with examiner present • Series of self-selected videotapes/DVDs submitted for expert Series of self-selected videotapes/DVDs submitted for expert

assessmentassessment Web-based OSCE (physicians link to simulated Web-based OSCE (physicians link to simulated

patient whom they interview online) patient whom they interview online)

What form can assessments take?What form can assessments take?

Performance – do you (choose to) do it in practice?Performance – do you (choose to) do it in practice? Videotapes/DVDs submitted with assessors randomly Videotapes/DVDs submitted with assessors randomly

choosing tapes to be assessedchoosing tapes to be assessed Undercover simulated clientsUndercover simulated clients Real clients’ assessmentsReal clients’ assessments Client and clinician do immediate assessment of same Client and clinician do immediate assessment of same

individual interview individual interview Colleagues’ assessments Colleagues’ assessments

Results – what happens to pts, clients, drs?Results – what happens to pts, clients, drs? Self assessment/report Self assessment/report Chart auditsChart audits Follow up studies re compliance, outcomes of care, etc.Follow up studies re compliance, outcomes of care, etc.

Objectives of AssessmentObjectives of Assessment

MotivationMotivation Drives what gets learned and taughtDrives what gets learned and taught Legitimizes importance of a subjectLegitimizes importance of a subject Encourages acceptance by otherwise skeptial Encourages acceptance by otherwise skeptial

students and faculty students and faculty Progress check, certification that is valid Progress check, certification that is valid

and reliableand reliable Educational impactEducational impact

Formats for Feedback Formats for Feedback

quantitative______________________ __ _qualitative

evaluative feedback_________ descriptive feedback

number scores, good/bad “here’s what I see”

global_____________________ _________ __detailed

Two types of assessmentTwo types of assessment

FormativeFormative SummativeSummative

What does it take to learn What does it take to learn clinical communication skills, change?clinical communication skills, change?

Knowledge doesn’t translate directly into performanceKnowledge doesn’t translate directly into performance Essentials needed to learn skills, change:Essentials needed to learn skills, change:

Systematic delineation & definition of skillsSystematic delineation & definition of skills Observation of learners communicating (video)Observation of learners communicating (video) Well-intentioned, detailed, descriptive feedbackWell-intentioned, detailed, descriptive feedback Practice and repeated rehearsal of skillsPractice and repeated rehearsal of skills Planned reiteration and deepening of skills Planned reiteration and deepening of skills

Small group or one-on-one format Small group or one-on-one format

Teaching and learning communication Teaching and learning communication skills is differentskills is different

Closely bound to self concept Closely bound to self concept No one starts from scratchNo one starts from scratch No achievement ceilingNo achievement ceiling More complex than simpler procedural skillsMore complex than simpler procedural skills

Stages in skills learning/changeStages in skills learning/change not a linear progressionnot a linear progression

Consciously skilledConsciously skilled

AwkwardAwkward

Fully assimilatedFully assimilated

Wackman et al 1976Wackman et al 1976

Beginning AwarenessBeginning Awareness

What makes for effective feedback?What makes for effective feedback?

1st Principles of Effective Communication1st Principles of Effective Communication Ensures interaction not just transmissionEnsures interaction not just transmission Reduces unnecessary uncertaintyReduces unnecessary uncertainty Requires planning, thinking in terms of outcomesRequires planning, thinking in terms of outcomes Demonstrates dynamism (engagement, Demonstrates dynamism (engagement,

flexibility, responsiveness)flexibility, responsiveness) Follows helical vs linear modelFollows helical vs linear model

Same principles apply to effective teachingSame principles apply to effective teaching

What makes for effective feedback?What makes for effective feedback?

Agenda-Lead Outcome-Based Analysis Agenda-Lead Outcome-Based Analysis (ALOBA)(ALOBA)

Approaches to communicationApproaches to communication

Shot-Put ApproachShot-Put Approach the well-conceived, well-delivered message is all that the well-conceived, well-delivered message is all that

mattersmatters emphasis on telling, interaction/feedback not in pictureemphasis on telling, interaction/feedback not in picture

Frisbee ApproachFrisbee Approach 2 central concepts2 central concepts

• confirmation = to recognize, acknowledge or endorse confirmation = to recognize, acknowledge or endorse anotheranother

• mutually understood common groundmutually understood common ground emphasis on interaction, feedback, relationshipemphasis on interaction, feedback, relationship

A Barbour 2000

Example of an Integrated OSCEExample of an Integrated OSCEUniversity of CalgaryUniversity of Calgary

Day of examDay of exam1 Interview with SC - videotaped1 Interview with SC - videotaped

examiner scores content checklistexaminer scores content checklist SC completes written feedback form (after interview)SC completes written feedback form (after interview)

2 Student thought time2 Student thought time3 Presentation of case to examiner with problem list, 3 Presentation of case to examiner with problem list,

hypotheses, & ideas for PEhypotheses, & ideas for PE4 Performance of selected PE related to interview (PE 4 Performance of selected PE related to interview (PE

unrelated to interview tested at other stations)unrelated to interview tested at other stations)5 PE results given to student - student gives ideas re 5 PE results given to student - student gives ideas re

investigations investigations 6 Investigation results given to student - student gives ideas 6 Investigation results given to student - student gives ideas

re differential diagnosis re differential diagnosis

Integrated OSCE Integrated OSCE conticonti

Within 12 days of exam:Within 12 days of exam: Pairs of students meet with expert examiner to assess Pairs of students meet with expert examiner to assess

communication process skills (Calgary-Cambridge communication process skills (Calgary-Cambridge Guides) Guides) 1 View student’s videotaped interview, stopping tape 1 View student’s videotaped interview, stopping tape

periodically periodically 2 Self, peer, and expert assessment (yes, yes but, no)2 Self, peer, and expert assessment (yes, yes but, no)3 Compare results (not about reaching consensus)3 Compare results (not about reaching consensus)4 Mini-tutorial re problem skills, strengths, next steps4 Mini-tutorial re problem skills, strengths, next steps5 Compare process skills with content checklist, 5 Compare process skills with content checklist,

hypotheses and differential, SC feedbackhypotheses and differential, SC feedback

Individually tailored remedial for unsatisfactory Individually tailored remedial for unsatisfactory students; retake of exam (x2 possible)students; retake of exam (x2 possible)

Concluding thoughtsConcluding thoughts

Communication is core clinical skillCommunication is core clinical skill Skills are appropriate focus for teaching and assessmentSkills are appropriate focus for teaching and assessment Build on what’s already available (research, teaching and Build on what’s already available (research, teaching and

assessment models in human and vet medicine)assessment models in human and vet medicine) Include educational impact in design of assessmentInclude educational impact in design of assessment Train faculty and learners to participate in feedback Train faculty and learners to participate in feedback

process to enhance communication learning process to enhance communication learning Integrate communication with other clinical skills teaching Integrate communication with other clinical skills teaching

and assessment and assessment