Clinical communication skills year 1 introduction

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Clinical communication skills year 1 introduction

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  • So back to clinical method So far we have really only started the process of how to interview patients and what you are looking for You have interviewed real patients, worked with your associate supervisors on the wards, worked with simulated patients, and had a chance to look at the cardiovascular and respiratory symptoms and signs PowerPoints and videos on the ER Web How has that gone? Confused? Need help? Has it all happened, have you seen your clinical supervisors yet? We now want to move you help you by looking at what information in general you are trying to obtain and how you are going to obtain it. Both in terms of interviewing the patient and examining them And the key areas that we are going to cover are: symptom analysis background information introduction to the physical examination
  • You have been mostly concentrating on initiating the session plus some gathering information, particularly of the narrative. You have also been considering how to provide structure for the patient and how to build the relationship
  • This is a reminder of what information you are looking for. At the end of the day, this is the information you need to present a patient’s story to a colleague or to write information in the notes
  • And we have been giving you an overall structure to help you organise what you are trying to do And by now, I hope you know that you need to do different things in the initiating the session phase from the gathering information phase and you need to intentionally and purposefully employ different skills. You also know that you need to spend a lot of time building the relationship and structuring the whole session Show some evidence for each part!!
  • Particularly concentrate on explaining nature and timing of interview and not a wee chat
  • Now we look at how to get an overview of the issues before exploring any one in more depth. picking up and responding to patient cues shortens rather than lengthens visits (Levinson et al 2000) The importance of screening – why open directive questions about a specific symptom work in the opposite direction than in the gathering information part of the history (Beckman and Frankel) Joos – screening and planning in internal medicine reduces the length of the visit
  • Then I hope most of you have been looking at how to develop the sequence of events by encouraging the narrative and asking open questions. I am sure the value of picking up disease and illness cues has come up as well as summarising both disease and illness resolution of symptoms of chronic headache is more related to the patient’s feeling that they were able to discuss their headache and problems fully at the initial visit with their doctor than to diagnosis, investigation, prescription or referral (The Headache Study Group 1986)
  • consultations using a structured exploration of patients' beliefs about their illness and medication and specifically addressing understanding, acceptance, level of personal control and motivation leads to improved clinical control or medication use even three months after the intervention ceased (Dowell et al 2002) This is the first of the new areas that Paul is going to tell you about. How to analyse each symptom and then discover the relevant systems review. My two additions in terms of process here are: the need to explain to the patient exactly what you want them to help you with . Please always signpost this change in direction by saying something like “I’d like now to discover some more detail about the chest pain that you are having”. the need to always start open and then move closed . So start with “can you tell me more about the chest pain please” and then move into specific closed questions later to gather information about areas you have not discovered yet
  • Again, let us look at content first. All these areas are very important. They provide the context in which the patient’s current problems occur. Please however do not confuse the background information with the patient’s perspective. Ideas concerns and expectations are not the same as the social history for instance. Quote orthopaedic ward and banter about home life but not discovering what the patient was concerned about
  • 2. Do remember not to confuse content with how you obtain it – always start with an open question and move eventually to closed questions as a cone which you repeat repeatedly – first for PMH etc 3. And always remember that even in areas such as past medical history and family history, both disease and illness issues will come out and will need you to be sensitive in exploring further: e.g. my father died of cancer last week, response “good” or “any one else with cancer in the family”
  • Clinical communication skills year 1 introduction

    1. 1. CCS Course Year 1 NRMSMClinical CommunicationThe Calgary Cambridge Guide2012MGM 2012
    2. 2. Clinical Communication Effective clinical communication is central to clinicalcompetence and plays an essential role in high-quality healthcare Communication is a learnt skill Integration is vital (knowledge, communication,practical skills including physical examination,problem solving) Teaching and assessment of clinical communicationhave become formal components of undergraduatemedical curriculaeMGM 2012
    3. 3. Clinical Communication There is overwhelming evidence for the positiveeffect of communication training It enables more effective interviews, enhancedpatient and professional satisfaction AND improvedhealth outcomes for patients eg adherence, patientsafety and medico-legal issues Teaching and research in communication are inter-dependentMGM 2012
    4. 4. Special Issues inCommunication Age-specific areas Cultural and social diversity Handling of emotions and challenging situations Specific clinical contexts eg psychiatry, work inemergency medicine Specific explanation and planning skills eg informedconsent, risk management, health promotion andbehaviour change Dealing with uncertainty Sensitive issues – breaking bad news,bereavement, sexual issues, areas involvingstigmatisation eg child abuse, HIV infection Communication with colleagues and inter-professional communicationMGM 2012
    5. 5. Barriers to effectivecommunication Personal attitudes Language Time constraints Working environment Lack of knowledge and inconsistency Human failings (tiredness, stress)MGM 2012
    6. 6. Calgary-Cambridge GuidesMGM 2012
    7. 7. This is Trinity College……MGM 2012
    8. 8. And back at NRMSM – communication andtopical issues in our context……MGM 2012
    9. 9. Overview of the Calgary-Cambridge Guides These assist in providing a comprehensiveclinical method which can be usedsuccessfully in many contextsMGM 2012
    10. 10. Clinical Method: The “Map”1. What information are you trying to obtain and how you aregoing to do this ?– the basics of:symptom analysis (problem/s)relevant background information – 1stYear(Initiating the session, Gathering information, Building therelationship, Providing structure)2. Introduction to the Physical examination – 2ndand 3rdYear3. Explanation and Planning – includes lifestyle andbehaviour modification, management of disease – some in2ndand 3rdYear, but mainly in the clinical yearsMGM 2012
    11. 11. Initiating the sessionGathering informationPhysical examinationExplanation and planningClosing the sessionProvidingstructureBuilding therelationshipMGM 2012
    12. 12.  The content of the medical interviewPatient’s problem list1.2.3.Exploration of patient’s problems:Biomedical perspectivesequence of events, symptom analysis, relevant systems reviewPatient’s perspectiveideas, concerns, expectations, effects on life, emotions, beliefs, “ICE”Background information - contextPast medical historyFamily historyPersonal and social historyDrug and allergy historySystems reviewMGM 2012
    13. 13. exploration of the patient’s problems to discover the: biomedical perspective  the patient’s perspective background information - contextproviding the correct type and amount of informationaiding accurate recall and understandingachieving a shared understanding: incorporating thepatient’s illness frameworkplanning: shared decision makingInitiating the sessionGathering informationPhysical examinationExplanation and planningClosing the sessionProvidingstructureBuilding therelationshippreparationestablishing initial rapportidentifying the reasons for the consultationmakingorganisationovertattending toflowusingappropriatenon-verbalbehaviourdevelopingrapportinvolvingthe patientensuring appropriate point of closureforward planningMGM 2012
    14. 14. Initiating the interview - establishing rapport Greet and check patient’s name and details Introduce yourself Explain your role as a student Gain consent Explain the nature and timing of interview Ensure patient comfort and appropriatesetting Non-verbal communication is vitalMGM 2012
    15. 15. Initiating the interview – getting an overview Start off with an opening question – use anopen enquiry technique If you only get a brief answer, acknowledgeand ask further information or for narrative Listen attentively - “wait time” is NB Use verbal and non-verbal facilitation Pick up patient’s cues Summarise disease and illness Screen for other complaints Approach is collaborativeMGM 2012
    16. 16. Gathering information – delving deeper Signpost to sequence of events Encourage narrative thread Use open questioning methods Listen attentively Use a facilitative approach – process skills Use more focused open questions Pick up disease and illness cues Clarify and time-frame Summarise disease and illnessMGM 2012
    17. 17. Gathering information – delve even deeper Signpost to: Analysis of each symptom (start with anopen question) Chronological history of events Relevant systems review Signpost to: Questions on “ICE” (ideas, concerns andexpectations) and feelings/beliefs/effectson activities of daily livingMGM 2012
    18. 18. content to be discovered:the bio-medical perspective the patient’s perspective(disease) (illness)sequence of events ideas and concernssymptom analysis expectationsrelevant systems review effectsfeelings and thoughtsbackground information - contextpast medical historydrug and allergy historysocial historyfamily historysystems reviewMGM 2012
    19. 19. Gathering Informationprocess skills for exploration of the patient’s problems(the bio-medical perspective and the patient’s perspective)•patient’s narrative•question style: open to closed cone•attentive listening•facilitative response•picking up cues•clarification•time-framing•internal summary•appropriate use of language•additional skills for understanding patient’s perspectiveMGM 2012
    20. 20. Providing Structure Makes organisation overt Summarises and relates to conceptualframework Moves from one section to another usingsignposting Allows reflection on what “went well” Attends to flow Makes sequence logical Attends to timing and keeping the interview ontrackMGM 2012
    21. 21. Building the Relationship Appropriate non-verbal behaviour – eye contact,expression, posture Ensure note-taking does not interfere withrapport Accept patient’s views Be non-judgemental and sensitive Provide or offer support Involve the patient – share thinking and explainrationale for questions or parts of theexaminationMGM 2012
    22. 22. Closing the Session Give any provisional information clearly(avoid jargon) Check patient understanding and acceptanceof explanation and plans Provide opportunity for questions anddiscussion Summarise the session and contract withpatient re next stepsMGM 2012
    23. 23. PATIENT PRESENTS CUES OF UNWELLNESSDOCTOR SEARCHESTWO PARALLEL AGENDASDOCTOR’S AGENDAHistoryPhysical ExaminationLaboratory InvestigationPATIENT’SAGENDA:IdeasFearsExpectationsEffect on functionDIFFERENTIAL DIAGNOSIS UNDERSTANDING ILLNESSEXPERIENCEINTEGRATIONTHE PATIENT- CENTRED CLINICALMETHODMGM 2012
    24. 24. Summary: Exploration of both thedoctor’s and the patient’sperspective Sequence of events – open enquiry, narrative,LISTEN, clarify and time-frame, respond to cues,summarise and clarify biomedical perspective Further analysis of each problem and systemsreview (more applicable in clinical years) andsignpost to: Discovering the background information – here mayuse increasingly directed questions and signpost to: Further exploration of patient’s perspectiveMGM 2012
    25. 25. How is communication taught? Students are exposed to a range of learningactivities which are experiential in nature Components include active small group learning,observation and review (may include video/audiorecording), constructive feedback and rehearsal withsimulated patients and the group using commonscenarios Communication is integrated into the curriculum,with a spiral approach and increasing complexityMGM 2012
    26. 26. Further details for ourintroductory CCS sessions Personal details and background Clarify Medical terms eg diarrhoea, constipation, stomach-ache Semi-medical terms eg wind, dizziness, indigestion Non-medical terms eg sharp, chronic Diagnosis eg migraine, allergy, asthma Symptoms vs signsMGM 2012
    27. 27. Presenting problemPAIN Duration Site, radiation Severity Character Frequency, periodicity Progression Precipitating/relieving factors Associated symptomsMGM 2012
    28. 28. Systems review General Cardiovascular Respiratory Gastrointestinal Nervous Psychiatric Skin, locomotorMGM 2012
    29. 29. Systems reviewGeneral symptoms These are often non-specific – may indicatevarious conditions or multi-system disease Fatigue Malaise Fever Sleep disturbance Skin, nail or hair changesMGM 2012
    30. 30. Past medical history Severe illnesses, visits to other doctors oradmissions Surgical operations Accidents Pregnancies Medical examinations Occupation, insurance Some examples : rheumatic fever, measles,whooping cough, TB, jaundiceMGM 2012
    31. 31. Medication and allergies Treatment Prescribed OTC Recreational Traditional or alternative Allergies - NBMGM 2012
    32. 32. Family history Ask about parents and siblings first NB not only wrt to current condition but anyillness Specific conditions Genogram, genetic advice Quantifying risk Indication of cause or agentMGM 2012
    33. 33. Personal and social history Home: Ask about spouse and children,domestic arrangements Work: Occupation, environmental factors Habits: Alcohol, tobacco - details Diet: caffeine, salt etc Exercise Other: travel, hobbies, petsMGM 2012
    34. 34. Summary: Objectives oftraining sessions Exploring the “what” of communication Exploring the “how” of communication and using theCalgary-Cambridge guides to help organiseteaching and learning Exploring our own skills and reflecting on these Becoming aware of the structure in the medicalinterview, and of process as well as content Increasing our confidence in our own abilities Deepening our awareness of the patient’sperspective and the importance of doctor-patientcommunication in our own setting/s and the SouthAfrican context as a wholeMGM 2012
    35. 35. Summary: Sessions andAssessment CCS sessions in Year 1 with simulatedpatients You will be assessed in an OSCE (moreemphasis on process skills than on content inYear 1) In the sessions, you will be expected to beable to concisely sum up your assessment ofthe patient’s problem/s after a patient-centredinterview, using…. a basic bio-medical and patient perspective,and providing some background informationor contextMGM 2012
    36. 36. References: Teaching clinical communication: A mainstream activityor just a minority sport? Silverman, J Patient Educationand Counselling 2009; 76: 361-367 UK consensus statement on the content ofcommunication curricula in undergraduate medicaleducation Von Fragstein, Silverman et al MedicalEducation 2008; 42: 1100-1107 Agenda-led Outcome-based Analysis Kurtz SM,Silverman JD, Draper J (2005) Teaching and LearningCommunication Skills in Medicine (Second Edition).Radcliffe Publishing (Oxford and San Francisco) Previous lecture by Dr Mergan Naidoo, Family MedicineMGM 2012
    37. 37. Session 2 – LearningObjectives Exploration of what makes a good doctor From the doctors’ perspective From the patients’ perspective Exploration of the doctor-patient relationship Understanding of the importance of themedical interview/ clinical method Understanding of a patient-centred methodMGM 2012
    38. 38. Discussion with the class Individual motivation for becoming a doctor Any role-models? Discussion of previous medicalencounters....what was it like to be thepatient? On what attributes did you judge the doctor?MGM 2012
    39. 39. Analysis of doctor-patientencounters Initiating the session Gathering information Closing the sessionMGM 2012
    40. 40.  All students will receive a copy of theCalgary-Cambridge guide in this week’ssessions – please retain it as it will be used insubsequent years and in Family Medicine.Bring your guide to all communicationsessions! Thank you for your attention!MGM 2012
    41. 41. Author:Dr Margy MatthewsClinical Skills Co-ordinatorRoom 283 matthewsm@ukzn.ac.zaAdministrator: Wandile Ext 4611 Skills LabMGM 2012

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