Teaching Basic Communication Skills in the Medical Interview Workshop I

1. Teaching Basic Communication Skills in the Medical InterviewWorkshop I A Faculty Development Program for Teachers of International Medical Graduates

2. Workshop Objectives At the end of this workshop, participants will: • Discuss the context of learning and special considerations for IMGs • Discuss the communication skills learning needs of IMGs • Identify the elements that define effective communication, and the evidence for their importance • Outline effective teaching approaches for developing IMGs’ communications skills • Apply a specific model of the medical interview in teaching: The Calgary-Cambridge Guides to the Medical Interview(CCG)

3. International Medical Graduates:Who Are They? • Canadian citizens who pursued medical training outside Canada • Citizens of other countries with medical degrees from institutions outside Canada, in Canada on work visas • Immigrants to Canada with medical degrees from institutions outside Canada, who hope to practice in Canada

4. International Medical Graduates • FACT: In 2002, 23% of physicians practicing in Canada obtained their medical degrees outside of Canada (AIPSO, 2004). • FACT: In 2001/2002, 2,039 of the 8,684 residents training in Canada held MD degrees earned outside of Canada (Association of Canadian Medical Schools, 2003).

5. International Medical Graduates (Cont’d) Of those 2,039 residents: • 74 had obtained their MD at an American program • The most common countries outside of Canada in which residents earned their MD were Saudi Arabia, India, the United Kingdom, Kuwait and Libya

6. About this Module Key Considerations

7. Key Considerations: Communication vs. Language “Language is an extremely challenging and frustrating factor…when I started my residency I had the fear of failure in expressing myself inadequately in front of professors, colleagues and patients.” Sannoufi, 2004

8. Communication vs. Language • Language skills and “medical literacy” are an important issue for IMGs and their teachers • The module “Untangling the Web of Clinical Skills Assessment” contains information to assist teachers in their assessment and feedback of language use in the medical setting • This module focuses on communication/ interviewing skills as opposed to language use

9. Key Considerations: Specific to the Role of the Physician The tasks of the encounter and the related communication strategies and relationship skills are specific to the role of the health care provider This module focuses on the medical interview

10. Small Group Discussion Learning Case Scenarios

11. Discussion Questions • In what ways is this situation similar to working with Canadian Medical Graduates (CMGs)? In what ways is this situation different or specific to the IMG? • What are the strengths of the IMG in this situation? What are the challenges? • What do you think the communication issues might be? • What would you do? How would you approach the learner?

12. Learning Scenarios Scenario 1 Dr AB is an IMG who originally practiced as a general internist for years prior to coming to Canada. He has just started his family medicine residency and is doing a rotation in family medicine. His medical school education was in English and there are no difficulties with spoken language abilities. He is married with five children and his wife stays at home with them. They do not have any family in the area and he often seems pressured to get home at the end of the day promptly. He frequently receives calls from his wife throughout the day while at the office.

13. Learning Scenarios Scenario 1 (continued) His manner is very respectful of both patients and all staff. His case presentations are very ‘crisp’ and to the point and exclusively medical in focus - “just the facts”. He almost always runs on time and tends to get through the visits faster than most residents. After observing his interviews, you suggest to him that he should try to broaden the focus of his assessments. He is quiet throughout the feedback session and looks somewhat puzzled.

14. Learning Scenarios Scenario 2 Dr CD is an IMG who originally practiced as an OB GYN for many years prior to joining her husband in Canada. Her English is fluent but she tends to speak quickly and some patients report having difficulties understanding her as a result of this combined with a slight accent. She is very kind in her manner with patients and works hard to meet their expectations. She often stays later than other residents working on her charts. She is well received by support staff as they find her to be very courteous and conscientious. She tends to be apologetic and somewhat reticent with supervising physicians. Her case presentations are often overly detailed and somewhat lacking in focus – especially in situations where the patient presents multiple issues. You are trying to figure out how to find out what is causing some of her difficulty and to give her some feedback about several of these issues.

15. Learning Scenarios Scenario 3 Dr EF has come to your attention during one of his specialty rotations in the ER. The ER nurses think he has an “attitude problem” with them and that he is somewhat “gruff” with patients. He was an emergency physician for several years in his war-torn country before coming to Canada as a refugee. He is very surprised to hear that there are concerns – especially because he is working in his chosen field. You are his family medicine supervisor and he is going to be starting with you soon; you have spoken with him about the importance of observing him directly and doing some videotape reviews. He doesn’t see why this is necessary; however he is willing to go along with your suggestion.

16. Large Group Discussion Common themes and comments regarding discussion questions: • Similarities and differences? • Strengths and challenges? • Communication issues? • Approaches?

17. Identified Learning Needs • No prior training in communication skills and/or psychiatry • Discomfort/uncertainty with psycho-social issues • Lack of familiarity of Canadian norms • Differences in the doctor-patient relationship: autonomy, authority and patient centredness

18. Identified Learning Needs (Cont’d) • Discomfort and specific need for skill development in approaches to issues such as: • Abortion • Sexuality and sexual orientation • Teen pregnancy • Infertility • Divorce and marital issues • Delivering bad news approaches to death and dying

19. IMG voices “Discussing a patient’s mood problems or reassuring a stressed patient is another difficult aspect of communication skills for an IMG. I still find it hard to know, on some occasions, how to respond to a patient with mood problems. Coming from a conservative culture it is really hard to know what is appropriate to say or do and what is not. I used to feel disabled and frustrated in those challenging situations. I was also concerned about crossing the line of what is acceptable in the doctor-patient relationship. I had to learn empathic phrases like “sorry to hear that”….In my culture such phrases are not used while communicating with patients.” Sannoufi, 2004

20. Faculty voices “Cues or explicit information about homosexuality, marital distress, and substance abuse were all carefully (and appropriately for this resident with his own culture) ignored. The resident’s generally authoritative stance was appropriate to the expectations of patients in his own country, but his North American preceptor perceived him to have a negative attitude toward the marginalized patient population.” Bates & Andrew, 2001

21. Effective Communication and Communication Skills Teaching A Review

22. Effective Communication Skills Good’ doctor-patient communication has a positive impact on patient care outcomes including: • Patient satisfaction • Physician satisfaction • Symptom resolution • Control of chronic illness • Better adherence to medical advice Stewart et al., 1995

23. The Elements of Effective Communication Elements of effective history-taking: • The physician asks many questions about the patient’s understanding of the problem, concerns and expectations and about his/her perception of the impact of the problem on function • The physician asks the patient about his/her feelings • The physician shows support and empathy Stewart et al., 1995

24. The Elements of Effective Communication Elements of effective discussion of the management plan: • The patient is encouraged to ask questions • The patient is provided with information programs and packages • The physician gives clear information along with emotional support • The physician is willing to share decision-making • The physician and patient agree about the nature of the problem and the need for follow-up

25. Effective Teaching of Communication Skills • Dissemination of knowledge (conceptual frameworks, readings, discussion) • Demonstration of skills (observations of live or videotaped interviews) • Practice skills (role-plays, standardized/actual patients) • Direct observation of learner performance with feedback • Supportive and reinforcing role models • Evaluation of communication skills  Kurtz et al., 2003

26. Effective Communications Teaching What have you found to be helpful in your teaching of communication skills to IMG learners?

27. Modifications with IMGs Lack of familiarity with teaching approaches: • May never have been directly observed • May never have been videotaped • May never have received direct feedback • May not appreciate difference between formative and summative evaluation Implication for teachers: Make processes and expectations explicit. Reassure that feedback is geared towards success.

28. Modifications with IMGs (Cont’d) • Medical School education may not have included formal communications/interview skills education Implication for teachers: Assess prior education and provide a conceptual overview of interview and key expectations.

29. Modifications with IMGs (Cont’d) Communication task overload: • IMGs working across languages and cultures may be pre-occupied with proper language use and this may interfere with their ability to attend to other aspects of communication in the interview. Implication for teachers: Introduce new concepts gradually. Avoid trying to do too much at once.

30. The Calgary-Cambridge Guides to the Medical Interview (CCG) A Specific Framework for the Basic Interview

31. The Calgary-Cambridge Guides (CCG) The CCG identifies basic tasks for the interview: • Initiating the session • Gathering information • Providing structure • Building a relationship • Explaining and planning • Closing the session

32. Initiating the Session • Greets patient appropriately • Introduces self • Demonstrates interest, concern and respect • Identifies and confirms problem list or issues (“Anything else you’d like to talk about?) • Negotiates agenda, taking both patient’s and doctor’s perspective into account

33. Gathering Information Exploration of problems: • Encourages patient to tell story of problems • Appropriate use of open-ended and closed questions • Listens attentively • Facilitates patient’s responses • Uses easily understood questions • Clarifies patient’s statements • Establish dates and time-frame of symptoms

34. Gathering Information (Cont’d) Understanding the patient’s perspective: • Determines and acknowledges patient’s ideas (i.e. belief re cause) • Explores concerns (e.g. worries, effect on lifestyle) for each problem • Determines patient’s expectations • Encourages expression of emotions • Picks up verbal and non-verbal clues

35. Providing Structure Making organization overt and attending to flow: • Summarizes at end of a specific line of inquiry • Progresses from one section to another using transitional statements including rationale for next section • Structures interview in logical sequence • Attends to timing and keeping interview on task

36. Building A Relationship • Demonstrates appropriate non-verbal behaviour • Reads, writes notes or uses computer without interfering with rapport • Accepts legitimacy of patient’s view • Empathizes and supports patient • Deals sensitively with embarrassing/disturbing topics and physical pain • Appears confidant, relaxed • Shares thinking with patient when appropriate

37. Explanation and Planning & Closing the Session • Provides the correct amount and type of info • Aids accurate recall and understanding • Achieves a shared understanding • Planning: shared decision making • Forward planning: contracts, safety nets • Ensures appropriate point of closure through summary, final check with patient

38. Putting it into Action… Video Scenario: “In the ER” (Version 2)

39. Key Steps in Delivering Feedback… • Build an environment of trust • Plan ahead and negotiate • Elicit self-assessment • Choose appropriate setting and timing • Focus on the positive • Select specific changeable behaviours • Use a feedback model • Include follow-up plans

40. Now for your feedback session….

41. Workshop Conclusion Teaching Tips…

42. Summary of Teaching Tips • Approach IMGs with an orientation towards success • Be explicit about expectations • Explain the nature of feedback • Avoid overload • Have a clear teaching framework (i.e. the CCG). Share this with learners in advance

43. Teaching Patient-Centred Care and Communication with IMGsWorkshop II A Faculty Development Program for Teachers of International Medical Graduates

44. Workshop Objectives At the end of this workshop, participants will: • Understand the context of learning and special considerations for IMGs • Understand the communication skills learning needs of IMGs • Review the defining features of patient centred care • Explore specific issues in teaching IMGs patient- centred care • Practice observation skills in teaching patient-centred communication

45. Key Concepts • Teaching patient-centredness requireslearner-centeredness • Canadian context means every patient encounter iscross-cultural • Effective communication requiresself-awareness • Good communication is both effective and ethical

46. Perspective Canada is one of the most culturally diverse countries in the world. Every medical encounter in the Canadian setting is “cross-cultural” at some level. The challenge for medical educators is to prepare all learners to communicate effectively in this setting. International Medical Graduates (IMGs) are not alone – we all must bridge the “culture gap”and our communication methods must stand this test.

47. Identified Learning Needs • No prior training in communication skills and/or psychiatry • Discomfort/uncertainty with psycho-social issues • Lack of familiarity of Canadian norms • Differences in the doctor-patient relationship: autonomy, authority and patient centredness

48. Identified Learning Needs (Cont’d) • Discomfort and specific need for skill development in approaches to issues such as: • Abortion • Sexuality and sexual orientation • Teen pregnancy • Infertility • Divorce and marital issues • Delivering bad news approaches to death and dying

49. Identified IMG Learning Needs • During the initial consultations that informed the development of this project, key stakeholders identified the issue of patient-centred care as an area for focus with IMGs. Concern was expressed about the over-emphasis on the “medical model” with a tendency towards “paternalism” rather than “partnership” by many IMGs Steinert, 2003

50. Faculty voices “Cues or explicit information about homosexuality, marital distress, and substance abuse were all carefully (and appropriately for this resident with his own culture) ignored. The resident’s generally authoritative stance was appropriate to the expectations of patients in his own country, but his North American preceptor perceived him to have a negative attitude toward the marginalized patient population.” Bates & Andrew, 2001