communication skill medical profession

1. “Cultural Competency:
Incorporating Communication Skills Training into
Health Professions Curricula”
October 23, 2008
Janice P. Burke, PhD, OTR/L, FAOTA
Professor and Chair,
Department of Occupational Therapy
Dean, Jefferson School of Health Professions
Lauren Collins, MD
Assistant Professor,
Division of Geriatric Medicine
Department of Family and Community Medicine
Jefferson Medical College

2. Objectives
 Express the role of verbal and
nonverbal communication
skills in the patient encounter.
October 23, 2008

3. Objectives
 Adopt new tools for teaching and
assessing communication skills with
health professions students.

4. Objectives
 Devise an action plan for one
strategy to promote training of
culturally and linguistically
competent health care
professionals.

5. Human Interaction is:
• Created in VERBAL and NONVERBAL behaviors
• Culturally bound
• Constructed through rhythm, tempo, kinesic
movements, presentation of self, use of gaze, and use of
space
• A delicate and complicated behavioral coordination

6. Communication: Why is it important?
• Effective communication enhances:
– patient satisfaction
– health outcomes
– adherence to treatment
– job satisfaction
• Patient surveys report that patients want better communication from
their health care providers (Lansky, 1998)
– Breakdown in communication has been shown to be a factor in
malpractice litigation (Beckman, 1994)

7. Communication skills: Why do they matter?
• Increasingly, communication is evaluated to determine a trainee’s
suitability for promotion, graduation, and licensure
– Institute of Medicine, “Improving Medical Education” Report,
2004 names communication as one of six domains
– Many health care organizations are using patient satisfaction
ratings of physician communication skills to help determine
compensation
• Schrimer, 2005; Makoul, et al, 2007.

8. VERBAL BEHAVIORS -
“Taking and Holding the Floor”
Allows Key Figure to:
Manage concurrent demands
Control topic
Control interruptions
Ignoring topics
Control verbal requests

9. NONVERBAL BEHAVIORS
Eye Gaze and Eye Contact
Head Movements
Facial Gestures
Postural Orientation
Body Lean, Body Posture, Postural Change
Interactional Space
Gestures
Hand, Affirmative

10. NONVERBAL BEHAVIORS ARE USED
TO SIGNAL:
• Who should be involved
• The focus of attention and shifts of
attention
• The frame for the activity
• The start and completion of an activity

11. Eye Gaze
Gaze direction
provides information
to co-participants
about what is
important

12. Head Movements
• Used as a signal to encourage a speaker
to continue
• Conveys understanding
• Typically used with eye gaze
• More difficult to interpret when used
without eye gaze

13. Facial Gestures and Touch

14. Eye Contact and Body Posture

15. Postural Orientation

16. Postural Change

17. Interactional Space

18. Forming Interactional Space

19. Teaching Communication Skills

20. Teaching Communication skills
• Kalamazoo Consensus Statement identified seven essential communication tasks:
– Build the doctor-patient relationship – the fundamental task
– Open the discussion
– Gather information
– Understand the patient’s perspective
– Share information
– Reach agreement of problems and plans
– Provide closure
• Kalamazoo Consensus Statement, Acad Med, 2001

21. Teaching Communication Skills: Challenges
• Variability among institutions
– Methods, curricular time, position, depth of materials
• Variable resources
– staff, infrastructure, finances, time, etc

22. Teaching Communication Skills: Approaches
• Approaches have included:
– Lectures
– Workshops
– Role-plays
– Standardized patients
– Videotaped encounters
– Modeling
– Cinemeducation

23. Teaching Communication Skills: Approaches
• Approaches categorized into 4 groups:
– Instruction
• didactic sessions, etc
– Feedback
• assessment/evaluation related to medical interview
– Modeling
• using a model (actor) to demonstrate the behavior
– Skill practice
• participants produce behavior of interest (included monitoring and
skill refinement)
• Anderson, Pat Educ Couns, 1991

24. Teaching Communication Skills
• Students prefer experiential methods and use of benchmarks for
learning communication skills
• Evans et al, 1989; Rees, 2004; Losh et al, 2005, Boyle et al, 2005
• “Focusing on tasks provides a sense of purpose for learning
communication skills. The task approach also preserves the
individuality of [learner] by encouraging them to develop a repertoire
of strategies and skills, and respond to patients in a flexible way.”
• Makoul and Schofield, 1999

25. Teaching Communication Skills: Strategy
• Effective teaching methods:
– Provide evidence of current deficiencies in communication
– Offer evidence base for skills needed to overcome deficiencies
– Demonstrate skills to be learned, elicit reactions
– Provide opportunity to practice skills
– Give constructive feedback on performance, opportunity for reflection
• Maguire et al, BMJ, 2002

26. Teaching Tools: Cinemeducation
• Approach: Cinemeducation
• In a small group format, residents view the movie “The Doctor” starring
William Hurt and discuss issues such as the psychosocial impact of terminal
illness, breaking bad news and stress in a medical marriage.
• Alexander, Fam Med, 2002

27. Teaching Tools: Small Group Discussion
• Approach: case-based seminars and discussion of assigned readings and
writing projects
• Trainees given a case with specific trigger questions for discussion.
Trainees write about their experiences with patients to deepen their own
understanding of issues such as health disparities, medical errors, and
access to care.
• Trainees discuss readings including journal articles, novels, and essays
by physician writers.
• Skills assessed with a 360 evaluation from physicians, nurses, patients
• Sklar D, Acad Emer Med, 2002

28. Teaching Tools: Role-play/Simulated patients
• Model for medical interviewing
• Approach: standardized patients and small group format with role-play
• The specific skills addressed include:
– Establishing rapport (Invite)
– Active listening (Listen)
– Summarizing the patient’s story (Summarizing)
• The learners are given feedback on their skills from the standardized patients
• Boyle D, Acad Med, 2005

29. Teaching Tools: Role-play/Simulated patients
• Model for delivering bad news
• Approach: Trainees taught a mnemonic/model for informing families of a
death. Trainees practice this model via role-play and with simulated patients.
• Simulated survivors provide feedback on death notification skills
• Hobgood C, Harward D, Newton K, Davis W. The Educational Intervention
“GRIEV-ING” Improves Death Notification Skills of Residents. Academic
Emergency Medicine. 2005; 12: 296-301.

30. Teaching Clinical Skills: Summary
• “Perhaps the most important way for an individual to learn
skills and behavior is to practice them, be observed, receive
helpful feedback, reflect on his or her performance, and then
repeat the cycle”
• Branch et al, 2001

31. Assessing Communication Skills

32. Assessment: What is Competence?
• Competence is “not defined solely by the presence or
absence of specific behaviors but rather by the presence
and timing of effective verbal and nonverbal behaviors
within the context of individual interactions with patients
or families”
• Schrimer, 2005

33. Assessing Communication Skills: Challenges
• Assessing communication competence is complex
• Often requires “in-vivo” demonstration
• Is dependent on observable behaviors of the physician but also on
behaviors and perceptions of patients

34. Assessment Methods:
Formative vs. Summative Evaluation
• Formative Evaluation
– May use checklists to assess learning needs, create
learning opportunities, guide feedback and coaching
• Summative Evaluation
– Or use tool administered in a standardized way, rated by
an evaluator, with a predetermined passing score
• Kalamazoo II Report, 2004

35. Assessment Methods
• Checklists
– Most frequently used method
– Involves an observer’s rating of trainee’s performance of
several communication behaviors
– Rater may be self, peer, faculty, or SP
– May be live or recording of previous interaction
• Kalamazoo II Report, 2004

36. Assessment Methods: cont.
• Patient Surveys
– Patients may be the best judge of effectiveness of a HCP’s
interpersonal skills
• Examinations
– Can provide an effective means of testing knowledge about the
process and content of communication tasks and conceptual basis
of interpersonal relationships
• Kalamazoo II Report, 2004

37. Assessment Tools: Specific Types
• Ratings of direct observation with real patients
• Ratings of simulated encounters with standardized patients
• Ratings of video and audiotape interactions
• Patient questionnaire or survey
• Examination of knowledge, perceptions, attitudes
• Kalamazoo II Report, 2004

38. Sample Assessment Tools
• SEGUE Form
• Kalamazoo Essential Elements: The
Communication Checklist
• Humanism Scale
• Davis Observation Guide
• Calgary-Cambridge Observation
Guide
• Roter Interactional Analysis System
• Four Habits Model
• Common Ground Rating Form
• MAAS – Global Rating List for
Consultation Skills of Doctors
• Brown interview Checklist (BIC)
• Rochester Communication Rating
Scale
• Interpersonal Skills Rating Form
• Interpersonal and Communication
Skills Checklist
• The Humanism Scale
• Physicians’ Humanistic Behaviors
Questionnaire
• Parents’ Perceptions of Physicians
Communicative Behavior
• Patient Perception of Patient
Centeredness
• ABIM Patient Assessment

39. Assessment: Challenges
• New domains of assessment
– No validated method of assessing teamwork
– Many communication rating scales, little evidence that one is better than
another
• Standardization
– Individual schools often make own decisions about assessment, so it may
be difficult to compare students
• Impact on learning
– Unintended consequences (i.e. cramming for an exam vs. reflective
learning)
• Assessment and Future Performance
– Hard to document correlation
• Epstein, NEJM, 2007

40. How to Assess: Recommendations
• Multiple methods, environments, contexts
• Organize into repeated, ongoing, contextual and developmental
programs
• Include directly observed behavior
• Use experts to test expert judgment
• Use pass-fail standards that reflect appropriate developmental levels
• Provide timely feedback and monitoring
• Epstein, NEJM, 2007

41. How to choose a tool?
• Tools available at
http://www.acgme.org/outcome/assess/IandC_Index.asp
– External validity, feasibility, psychometric characteristics listed
on website
• Rating of tools available from Schrimer et al, Fam Med, 2005

42. How to choose a tool?
• Kalamazoo II Consensus Recommendations:
– A multi-method approach
– Using faculty instrument to assess communication skills
– Patient survey to assess interpersonal skills
– For summative evaluation, choose instrument with strong reliability and
validity measures
– Choose assessment criteria that are developmentally appropriate
• Schrimer, 2005

43. A Case Study:
Development of an Ethnogeriatric OSCE

44. Case Study: Context
• Incorporating cross-cultural curricula into undergraduate and
graduate medical education has been proposed as a strategy
to increase provider awareness and knowledge of cross-
cultural issues in the medical encounter
• Betancourt, 2003

45. Case Study: Literature Review
• In one review, Loudon identified 17 educational programs for
medical students on cultural diversity
– 6 programs used simulated patients
– 2 programs used videotaped modeling
– Others were lecture or didactic session, role play, panel, case
presentation, small group sessions
– Only half of the programs were required
– Only 1 program included student assessment
• Loudon, 1999

46. Case Study: Literature Review
• Few publications exist on instructional initiatives to enhance
medical students knowledge of cultural diversity
• Review by Loudon highlighted need for programs in
multicultural education as part of medical core curriculum
and as training for medical educators

47. Case Study: Assessing Learner Needs
• Formal needs assessment performed by Deans at the medical school
identified need for enhanced curricula in geriatrics and cultural
competency
• Informal needs assessment performed in conjunction with Family
Medicine Residency Program Director revealed no formal training in
ethnogeriatrics

48. Case Study: Outline Goals/Objectives
• To practice conducting a culturally competent interview with
an older patient with a focus on incorporating
communication skills

49. Case Study: Why Choose an OSCE?
• Objective Structured Clinical Examination (OSCE) is a
practical tool to both prepare students for working with
diverse populations and to assess their performance in cross-
cultural medical interviewing

50. Case Study: Establishing OSCE Goals
• The goal of this case is to evaluate medical students,
residents, and fellows in taking a focused history on a patient
with hyperlipidemia who has issues with trusting Western
medicine

51. Case Study: Establishing OSCE Objectives
• Students will be evaluated by their ability to:
– Elicit a cultural, social, and medical history, including a patient’s health
beliefs and model of their illness
– Use negotiating and problem-solving skills in shared decision-making
with a patient
– Assess and enhance patient adherence based on the patient’s explanatory
model
– Recognize and manage the impact of bias, class, and power on the
clinical encounter
– Demonstrate respect for the patient’s cultural and health beliefs
– Acknowledge their own biases and the potential impact they have on the
quality of health care

52. Case Study: Teaching the ETHNIC mnemonic
• E: Explanation
– (How do you explain your illness?)
• T: Treatment
– (What treatments have you tried?)
• H: Healers
– (Who else have you sought help from for this…?)
• N: Negotiate
– (mutually acceptable options)
• I: Intervention
– (agreed on)
• C: Collaboration
– (with patient, family and healers)
• Kobylarz, J Am Geriatr Soc, 2002

53. Case Study: The OSCE Scenario
• Instructions to the Standardized Patients
• Patient Name: Mr./Mrs. Jackson
• Setting: Office visit
• Scenario:
• Mr./Mrs. Jackson is a 65 year-old patient who is in the office for a follow-up visit after
being diagnosed with hyperlipidemia (high cholesterol) six months ago. At the last visit
about 3 months ago, he/she was told by the physician to start taking Lipitor, a statin, to
reduce his/her cholesterol levels. He/she has not been taking the new medication because
he/she heard that it causes “bad” side effects like muscle pain and maybe even death.
Instead, he/she started to take Red Yeast Rice, a remedy that he/she heard about from
his/her friends at the local senior center to lower cholesterol. His/her daughter is concerned
that he/she is not taking the medication the doctor prescribed and made him/her come back
to see the doctor to discuss this in more detail.
• Opening Line: “My cholesterol is high.”

54. Case Study: Video of Sample SP Encounter
If you would like a copy of the video, please contact
Dr. Lauren Collins at lauren.collins@jefferson.edu.

55. Case Study: Standardized Patient Checklist
History
The student asked: YES NO
1. Any problems taking your medication.
2. If you have any concerns about taking the
medication.
3. How do you Explain your illness.
4. What Treatments have you tried.
5. If you have seen any other Health care providers.
6. About diet.
7. About exercise.
Communication:
The student: asked YES NO
8. Introduced him/herself to me.
9. Affirms use of natural remedies/healers.
10. Assesses willingness to try Lipitor.
11. Discusses possible side effects of treatment
options.
12. Negotiates options of using red yeast rice or
Lipitor.
13. Sought agreement with me about Intervention.
14. Collaborates with patient for follow-up plan.

56. Case Study: Video of SP Feedback
If you would like a copy of the video, please contact
Dr. Lauren Collins at lauren.collins@jefferson.edu.

57. Case Study: Implementing the tool
• Pilot project implemented with 24 trainees (medical students,
residents, fellows)
• Adapted by Clinical Skills team for end of third year OSCE
– Administered to 250 medical students

58. Case Study: Dissemination
• Dissemination - local
– Undergraduate Medical Education @Jefferson
• End of Year OSCE
• End of Clerkship SP scenario
– Graduate Medical Education
• Incorporate into formal FM resident evaluation

59. Case Study: Dissemination
• National
• Post to EPaD GEC website
• Post to POGOE or MedEd portal
• Submit scholarly articles, presentations

60. Case Study: Next Steps
• Modify scenario for use by other Health Professions
• Meet with Health Professions faculty/Clinical Skills Team
• Incorporate into curricula
• Research/evaluation

61. Developing an Action Plan

62. Action Plan: Checklist
• Has a needs assessment been conducted?
• What communicative behaviors are going to be the target of
the intervention?
• Is there clear theoretical rational for the strategies chosen to
effect the desired outcomes?
• Is there an explicit scheme for planned intervention?
• Anderson et al, 1991

63. Action Plan: Checklist, cont.
• Are the resources required to conduct the intervention
available?
• Is there support from the staff that will be involved in the
program?
• Is there a plan for evaluation?
• In preparing reports and publications, are the sample
characteristics, methods, and statistical analyses described
thoroughly?
• Anderson et al, 1991

64. Discussion

65. Online Resources
• http://www.acgme.org/outcome/assess/IandC_Index.asp (ACGME Outcome Project: Advancing
Education in Interpersonal and Communication Skills)
• www.omhrc.gov/clas (National Standards on Culturally and Linguistically Appropriate Services
in Health Care)
• www.aamc.org/meded/edres/cime/vol1no5.pdf (Teaching and Learning of Cultural Competence
in Medical School)
• www.stanford.edu/ethnoger (Stanford’s Core Curriculum in Ethnogeriatrics)
• www.hrsa.gov/culturalcompetence/curriculumguide.htm (Cultural Competence Resources for
Health Care Providers)

66. References
• Alexander M. The Doctor: A Seminal Video for Cinemeducation. Family Medicine 2002;34:92-4.
• Anderson LA, Sharpe PA. Imrpving Patient and Provider Communication: A Synthesis and Review of Communication Interventions. Pat Educ
Couns 1991;17:99-134.
• Betancourt JR. Cross-cultural Medical Education: Conceptual Approaches and Frameworks for Evaluation. Acad. Med., 2003. 78:560-569.
• Boyle D, Dwinnell B, Platt F. Invite, Listen, and Summarize: A Patient-Centered Communication Technique. Acad Med 2005; 80:29-32.
• Branch WT, Kern D, Haidet P, et al. Teaching the Human Dimensions of Care in Clinical Settings. JAMA, 2001;286:1067-1074.
• Duffy FD, Gordon GH, Whelan G, et al. Assessing competence in communication and interpersonal skills: the Kalamazoo II Report. Acad Med,
2004;79:495-507.
• Epstein RM. Assessment in Medical Education. NEJM, 2007;356:37-96.
• Hobgood C, Harward D, Newton K, Davis W. The Educational Intervention “GRIEV-ING” Improves Death Notification Skills of
Residents.Academic Emergency Medicine. 2005; 12: 296-301.
• Fallowfield L, Jenkins, Farwell V, et al. Efficacy of a Cancer Research UK Communication skills training model for oncologists: a randomized
controlled clinical trial. Lancet, 2002;359:650-6.
• Fallowfield L, Lipkin M, Hall A. Teaching senior oncologists communication skills: results from phase I of a comprehensive longitudinal
program in the united Kingdom. J Clin Onc, 1998;16:1961-68.
• Fellowes, D, Wilkinson S, Moore P. Communication skills training for health care professionals working with cancer patients, their families,
and/or carers. Cochrane Database Syst Rev, 2003;2:CD003751.
• Lansky D. Measuring what matters to the public. Health Aff, 1998;17(4):40-41.
• Losh DP, Maukssch LB, Arnold RW, et al. Teaching Inpatient Communication Skills to Medical Students: An Innovative Strategy. Acad Med.
80(2):118-124.
• Maguire P, Pitcheathly C. Key communication skills and how to acquire them. BMJ, 2002;325:697-700.
• Makoul G, Curry RH. The Value of Assessing and Addressing Communication Skills.

67. References
• Loudon BF, Anderson PM, Gill PS, et al. Educating Medical Students for Work in Culturally Diverse Societies. JAMA, 1999;282:875-880.
• Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern
Med, 1993;8(6):318-324.
• Novack DH, Volk D, Drossman DA, et al. Medical interviewing and interpersonal skills teaching in US medical schools. Progress, problems, and promise. JAMA,
1993;263(16).
• Roter DL, Hall JA, Kern DE et al. Improving physicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial. Arch Intern
Med, 1995;155 (17):1877-84.
• Roth CS, Watson KV, Harris IB. A communication assessment and skill-building exercise (CASE) for first year residents. Acad Med, 2002. 77(7):746-7.
• Schrimer Jm, Mauksch L, Lang F, et al. Assessing Communication Competence: A Review of Current Tools. Fam Med, 2005;37(3):184-92.
• Sklar D, Doezema D, McLaughlin S, Helitzer D.Teaching Communications and Professionalism through Writing and Humanities: Reflections of Ten Years of
Experience. Academic Emergency Medicine. 2002; 9: 1360-1364.
• Wagner PJ, Lentz L, Heslop SD. Teaching communication skills: a skills-based approach. Acad Med, 2002:77(11):1164.
• Yedidia MJ, Gillespie CG, Kachur E. Effect of Communications Training on Medical Student Performance. JAMA, 2003;290:1157-1165.
• Zick A, Granieri M, Makoul G. First-year medical students’ assessment of their own communication skills: a video-based, open-ended approach. Patient Educ
Couns, 2007;68(2):161-6.