Communication Competency and Counseling Practicum Mary Dankoski, Ph.D. Kathy Zoppi, Ph.D., M.P.H...
-
Upload
cecilia-simpson -
Category
Documents
-
view
217 -
download
0
Transcript of Communication Competency and Counseling Practicum Mary Dankoski, Ph.D. Kathy Zoppi, Ph.D., M.P.H...
Communication Competency and
Counseling Practicum
Mary Dankoski, Ph.D.Kathy Zoppi, Ph.D., M.P.H
Shobha Pais, Ph.D.Scott Renshaw, M.D.Dustin Wright, M.S.
OBJECTIVES
Attendees will understand… The assessment of communication
competency at resident levels of training
The utility of counseling practicum and competency assessment strategies
Communication In Family Medicine
“Black Box” study (Stange et. al., 1998)
Family assessment – 73% Answering patient questions – 71% Negotiation – 21% Counseling – 16% Patient Education – 18-26%
Distinction between interaction and relationship “Communication skills do not constitute
the doctor-patient relationship” (Candib, 1995, p.213)
Key concept of connection as lens (vs. separation) from feminist theory
Patient and physician are not independent actors, but are mutually influential
Emotional involvement of both is key
National consensus about communication training
Patient-centered care improves health outcomes
(Kalamazoo Consensus statement)
Errors decreased by improved training
(To Err is Human, IOM)
Health Disparities (Unequal Treatment, IOM)
Communication competence As property of
individual Assessment of
individual skills, abilities, or behaviors (rating of trainee)
As property of interaction
Assessment focuses on interactional or dyadic qualities, including adaptation, control, collaboration (rating of interaction)
Communication competence: approaches
Communication skills Conflict management Teamwork Teaching others (pts, students,
peers)Epstein and Hundert, JAMA, 2002
Implication of relational viewpoint of assessment
Focus is longitudinal Focus is cumulative Focus is on participants’ sense of
connection, satisfaction May be observable by non-
participants
Methods for Teaching Communication
Didactic sessions (lectures/demonstrations)
Standardized patients Role play Video-tape review (with real or SP) Co-counseling sessions Observed counseling sessions
Layered levels of communication competence
Content level: topic management, nonverbal cues/clues
Process: pacing, facilitation, congruence, nonverbal matching, affective displays
Meta-process: mindfulness, self-observation, context-sensitivity
Why is communication competence important?
Facilitation of information exchange
Development of a healing relationship
Mutual development of patient and physician (Candib, 1996)
“Ways of Knowing” and Medicine Traditional Medical
Education Procedural and Separate
Knowing Critical thinking, objectivity Limited for learning about person
living the illness May be experienced as distant
and sterile Actively exclude the self
Practicum Training
Connected Knowing Personal experience,
context, empathy Collaboration Use of patient’s language Understanding of patient
perspective Acknowledge effects of
caring on provider(Belenky, Clinchy, Goldberger, & Tarule, 1986; Candib, 1995)
Theoretical Assumptions about Practicum The “art of medicine” lies in ability to
integrate multiple ways of knowing Feminist-relational approach requires
training in equalizing power relationships (Candib, 1995)
Parallel process If we want residents to interact in this way
with their patients, we need to interact in this way with our learners
Group supervision opens the “black box”
Practicum Curriculum Goal
The goal of practicum training is to improve resident physician communication and counseling skills through supervised counseling of patients by peers and behavioral faculty preceptors.
Curriculum Objectives
Residents will increase knowledge of Basic counseling skills and methods Evidence-based behavioral medicine
Residents will improve skills in Responding to patient questions Assessment of psychosocial and family context Integration of biomedical and psychosocial care
Building relationships with patients and families
Curriculum Objectives
Residents will demonstrate attitude change toward
The importance of behavioral care in practice Greater self-confidence in counseling skills Greater mindfulness in patient care
To provide an opportunity for faculty to evaluate resident’s communication and doctor-patient relationship skills
Selection of Patient Cases Residents invite their own patients who…
Are medically or psychosocially complex Have an unclear social situation Are not compliant with medical advice Are difficult to manage or frustrating to
providers Have “more going on here…”
Residents have a ‘gut’ sense about abuse, assault, family unrest, prior psychological conditions
Practicum Format Pre-session (10-15 minutes)
Resident presents brief history of patient Residents states his/her goals for the session Faculty intentionally do NOT make
suggestions Resident counsels patient (25-30 minutes) Mid-session break (10-15 minutes)
Resident reaction Faculty and peer feedback Faculty guidance and direction
Practicum Format
Resident counsels patient (25-30 minutes)
Post-Session (10-15 minutes) Resident reflections
Session goals and expectations What he/she learned about the patient Personal thoughts or reactions to the patient How this information will help care for patient
Peer and faculty feedback
Assessment
Patient feedback (survey or interview?)
Relational rating scale Four Habits analysis of interaction
(research assistant) Faculty feedback Resident-self assessment
The process… Models negotiating a relational
agenda Reduces hierarchical barriers Encourages residents to shift to a
more open dialogue Opens new options for patient care
Residents shift……
FROM Monological
dialogue Focused
information gathering
Doctor driven conversation
‘doing’ mind-set
TO Open dialogue Actively listening
Patient directed conversation
‘supporting’ mind-set
Feedback from Residents
How did this session differ from other visits with this patient?
There was no right/wrong answer; no ‘pill’ would fix the problem [shift away from ‘doing’]
More personal, more time More emotional Patient did most of the talking [active listening,
patient directed] Visit was ‘non-medical’ – I was looking for clues in
her life about what support she will have when she has a child [supportive]
Feedback from Residents
As a result of this visit, is there anything you will do differently next visit? Be more sensitive about not giving my formal talks
but asking patient what she wants to know [patient directed]
Have a greater degree of suspicion when a patient just answers everything is ‘ok’ [supportive]
Pay more attention to psychosocial aspects of my patients
Understand the environment (psychosocial) a little better
Feedback from Residents
What comments/suggestions do you have about the process of live supervision?
It is an excellent idea to do this throughout residency and give feedback before we go into private practice
I like the immediate feedback of live supervision. It keeps me on track during the counseling session.
Allow more debriefing time…also more ‘skeleton’ training in counseling prior would be helpful
Fun, be feel like people (supervisors/peers) have hidden agenda/thoughts that they didn’t share
Feedback from Patients
Was this visit different from previous visits with your doctor? In what ways? Normally examines you, but today he was a
doctor, my friend, a listener, helped me with my problems [active listening, supportive]
The other visits were like examinations…it helps to know people more in depth to understand why a person keeps smoking when they know they shouldn’t
The other one was more medical [patient directed]
Feedback from Patients
Will you do anything differently in relation to your health as a result of your visit today? Made me stop and think: “You count
too, take time for you.” Think it will be easier to talk to him in the future.
6/7 patients reported they will change specific health behaviors because of this visit
Comments from Patients It’s better when you have someone to
talk to. He’s easy to talk to and he’s a good
listener. He doesn’t criticize. I like him. He’s a good doctor. Nice to be offered this because this time
I was really stressed…. I know you can tell him and he
understands and tries to help you.
Future Research Goals Evaluate outcomes: Does practicum improve
Doctor/patient relationship? Patient health outcomes? Patient satisfaction? Resident competency in communication and
relationship skills?