Clinical Education and Skills Development

1. Clinical Education and Skills Development Dave Tomson and Amy Lloyd 23 October 2013

2. Clinical Education and Skills Development Introduction and aims • Education and skills development • Cornerstone of implementation • Training workshops one of the most successful (and copied) MAGIC interventions • Brief decision support tools one of most popular MAGIC interventions • Aims of session • Learn more about advanced SDM skills training workshops • Learn more about brief decision support tools • Understand the relationship between skills, tools and attitudes • Explore the challenges of providing education and skills training at scale

3. Clinical Education and Skills Development Starter for 10 • In the end it is the clinician’s job to advise a patient on the best treatment, and encourage them to choose this. • Patients should only be involved in decisions about alternative treatments when the alternatives are equally effective.

4. Attitudes are ALL Clinical Education and Skills Development • Take homes • Clinician attitudes are critical to successful implementation of SDM • Increasing emphasis in the training program • Variety of exercises needed 4

5. Clinical Education and Skills Development Decision Support Tools • What are they? • Provide evidence based information and support for patients facing decisions about care or treatment • Make explicit the decision and options being considered • Enable a personalised focus • Why use them? • In 86 trials evaluating decision support tools that cover 35 different screening or treatment decisions, use has led to: • Greater knowledge Greater participation in decision-making • More accurate risk perceptions Fewer people remaining undecided • Greater comfort with decisions Fewer patients choosing major surgery • Stacey et al. • Cochrane Database of Systematic Reviews, 2011

6. Clinical Education and Skills Development Brief Decision Support ToolsOption Grids Brief Decision Aids (BDAs) • Description: • Brief comparison of treatment or screening options in relation to patients FAQs, on one side of A4. • No. developed: • 22 English Grids (plus 24 US and Spanish versions) • Available at: • www.option grid.org, • www. patient.co.uk • No. downloaded: • ~100 for each / month • Evaluation: • Very positive feedback from patients and clinicians. Trials in process. • Description: • Brief but more comprehensive comparison of risks and benefits of options, on 2-6 sides of A4. • No. developed: • 15 BDAs • Available at: • www.patient.co.uk • No. downloaded: • ~100 for each / month • Evaluation: Very positive feedback from patients and clinicians. In online survey, 70% of clinicians learnt something from them.

7. Clinical Education and Skills Development Take a look • From the position of a clinician / patient • How might you use these? • What do you like, what works less well? • What might the pitfalls be?

8. Clinical Education and Skills Development • How they might be used • Help orientate clinician and patient around “What matters to me” • Provide accurate EBM information • As an addition to clinician usual discussion (not substitute) • To generate SHARED decision making • How not to use them • Use as information leaflet only, rather than tool to facilitate discussion • Read to patient: more extensive monologue not dialogue • Forget to ask them what’s important to them • Only try and improve your SDM when you have a tool • KEY LEARNING: • Brief tools easier to develop and less resistance to implementation but You need skills to use tools. • You can do excellent SDM without tools • You can check out our playful ‘decision aids about decision aids’ in your own time! 8

9. SDM model for clinical practice Clinical Education and Skills Development 9

10. Skills trainingNumbers etc Feedback 672 trained in SDM skills: 352 primary care 242 secondary care 78 in external organisations 22 trained as SDM trainers: 2 fully trained 20 have had taster session External: SDM skills in undergraduate curriculum Training hospital clinical tutors Products: 1/2/3 hour training packages Risk communication Workbook and trainers handbook “There is an entire science/structured approach behind the letters SDM and this session opens the door and illustrates what this is all about” “I need to ask different questions to increase shared decisions. I need to change my approach” “I spend more time eliciting patients' personal preferences for treatment options and understanding their preferences.” Clinical Education and Skills Development 10

11. Clinical Education and Skills Development Skills training • Take homes • Tools can help but skills are more important • Build on the many skills clinicians already have • You need some time – 2 hours is a minimum • Attitudinal work and micro skills rehearsal work are critical • Max of 24 in a session and need experienced trainers • Varied content: learner specific and generic scenarios both helpful • Practice with and without tools • Training is highly rated but is an ‘insufficient dosage’ for consolidated behaviour change in most clinicians • Skill sets in specialist and generalist practice are slightly different

12. Clinical Education and Skills Development Challenges and next steps • SDM training • Better understand what is needed for primary and secondary care • Stand alone or embedded within a suite of skills for 21st century practice? • Next steps in undergraduate curriculum? • Next steps in post graduate? • How to do at scale? • Fidelity and Quality?

13. Clinical Education and Skills Development Key Learning • Skills trump tools • Attitudes trump all • And it all needs to be part of a whole change management programme.