How To Teach Communication Skills

1. How To Teach Communication Skills Élie AZOULAY MD PhD, Medical ICU, Saint-Louis Hospital, ESICM Barcelona, September 2006

2. Introduction • Communication is an important component of patient care. • Improvements in provider-patient communication can have beneficial effects : patient's key concerns must be directly and specifically solicited and addressed. • To be effective, the clinician must gain an understanding of the patient's perspective on his or her illness. • Traditionally, communication in medical school curricula was incorporated informally as part of rounds and faculty feedback, without a specific focus on skills of communicating. This left important communication gaps. • Ready access to quality information and thoughtful patient-doctor discussions allow to address patients' overall needs and to share complex information.

3. To improve global visit satisfaction, communication skills training programs may need to be longer and more intensive, teach a broader range of skills, provide ongoing performance feedback.

4. A five-point framework • The evidence that clinicians experience communication difficulties • Communication Skills Training Programs • Optimal duration of a training program • Long term impact of Communication Skills Training Programs • Teaching communication skills to ICU clinicians

5. The evidence that clinicians experience communication difficulties • Fallowfield et al. J Clin Oncol. 1998 • It has long been recognized that difficulties in the effective delivery of health care can arise from problems in communication between patient and provider. • < 35% of senior doctors had received communications training. • Time, experience, and seniority had not improved skills. • Most had problems with • giving complex information, • obtaining informed consent, • handling ethnic and cultural differences.

6. Many patients, when they fear that their prognosis is poor, do not ask for precise information and do not hear it if it is provided by the doctor • Study of patients with untreatable small cell lung cancer shows that doctors and patients collude in behaviour that fosters a false optimism about recovery • By focusing on the "treatment calendar" patients ignore the issue of prognosis • Patients' false optimism: • doctors withholding information • lack of communication skills • Are patients victims of doctors' behaviors ?

7. Teaching medical students what they think they already know Fadlon et al. Educ Health (Abingdon). 2004 Mar;17(1):35-41 • Focus groups and a short evaluation questionnaire filled in by 56 first year medical students before and after a workshop in interviewing skills were used. • When communication skills are taught in an informal, unstructured manner, medical students might view this knowledge as unspecialized, repetitive, and even boring. • Introducing a structured model can overcome two kinds of problems: 1) over-confident students are formally introduced to unique aspects of medical interviewing, 2) those who lack confidence are offered a lifeline in the form of a structured model.

8. Methodology from the linguistic research that allows both the quantitative and qualitative study of language. • Analysis of the language of 40 doctors and their patients during 373 complete primary-care consultations. • Doctors do not use jargon suggests that they are aware of the need to avoid it, but it does not follow that they are easily understood by patients. • Some doctors used language associated with social power, implying that consultations may be less democratic than is appropriate. . • There was substantial evidence that the doctors used language to express emotions (eg, anxiety), to diminish threats (eg, words such as "little"), and to reassure patients. It denotes a therapeutic use of language.

9. A five-point framework • The evidence that clinicians experience communication difficulties • Communication Skills Training Programs • Optimal duration of a training program • Long term impact of Communication Skills Training Programs • Teaching communication skills to ICU clinicians

10. Teaching methods • Learner- vs. patient- vs. skill-centered • The cognitive approach aims to improve physicians' knowledge and skills. • The behavioral approach offers learners the opportunity to practice these appropriate skills through practical exercises and role plays. • The affective approach allows participants to express attitudes and feelings that communicating about difficult issues evoke. • And … more !

11. COURSES Theoretical information Patients' or VP rating feedback to doctors Training Programs structured feedback, interactive group demonstrations / exercises discussion in groups of four led by trained facilitators. case discussion, role playing, simulation-based education Problem-defining or emotion-handling skills Posttraining consolidation workshops MATERIALS Video review of interviews, Computer-assisted program Videos or written preparatory information Audiotaping of the consultation Provision of decision aids What Are Communication Skills Training Programs ?

12. Only Training!!!

13. A program to improve physicians' detection of distress in patients (HADS) • One-hour theoretical information course, then randomization to 2 communication skills training programs or to a waiting list: a 2.5-day basic training program consolidated by 6 consolidation workshops (3-hour) • Physicians' ability to detect patients' distress was measured through computing differences between physicians' ratings of patients' distress and patients' self-reported distress. • No change was observed. • There is a need for more than theoretical information

14. Feedback from patients • A crossover study in which trainees were their own control individuals, and standardized patients provided feedback after the first interview. • Trainees improved their informing skills after being provided feedback. • Their skills improved in : • 1) promoting more trust • 2) making parents feel less dependent.

15. Group versus individual Teaching Parish et al. Teach Learn Med. 2006 Spring;18(2):92-8 • With both review formats, most students had a positive learning experience (80%), found it less stressful than they expected (67%), and would not have preferred to do the review the other way (84%). • Students randomized to individual reviews had a significantly higher level of satisfaction with the amount of time for the session and the amount of feedback they received and were more likely to view the session as a positive learning experience. • Students' comments indicated that they appreciated the value of peer review in a group setting.

17. Simulated Crisis to Improve Comm. Skills: oral versus video-assisted oral feedback Savoldelli et al. Anesthesiology. 2006 Aug;105(2):279-85. • Simulated crisis with or without debriefing on nontechnical skills in 42 anaesthesia residents. • Exposure to a simulated crisis without constructive debriefing by instructors offers little benefit to trainees. • The provision of oral feedback, either assisted or not assisted with videotape review, resulted in significant improvement. The addition of video review did not offer any advantage over oral feedback alone.

18. Provision of an audiotape of their primary adjuvant treatment consultation to 628 women newly diagnosed with breast cancer and 40 oncologists from six centers in Canada. . • Patients receiving the consultation audiotape had significantly better recall of having discussed side effects of treatment than patients who did not receive the audiotape. • Audiotape benefit was not significantly related to patient satisfaction with communication, mood state, or quality of life at 12 weeks postconsultation.

19. Beside oral communication: provision of written materials Damian and Tattersall. Lancet. 1991 Oct 12;338(8772):923-5 • Letters provide a permanent record of the consultation, which can be kept for future reference, and encourage greater patient involvement in their care. • RCT in Australia: to assess the role of personal letters to patients outlining their consultation. • Patients receiving letters were more satisfied with the amount of information given, and tended to have greater and more accurate recall of the consultation. • A survey of referring doctors revealed general support for the idea of sending to cancer patients letters.

20. Who may benefit? • Under graduated students • Interns and residents • Fellows • Senior intensivists • Nurses • All other ICU clinicians • … patients ?

21. Communication skills training courses for SENIOR cancer doctors: a study in Nordic countries Finset et al. Psychooncology. 2003 Oct-Nov;12(7):686-93 • Evaluation at baseline/course completion/follow-up after 2 to 6 years in 155 physicians • 94% of the physicians were satisfied with the course. • At follow-up they reported that they had learnt basic skills (i.e. to listen and to pose open-ended questions). • Communication skills courses for senior clinicians with no previous formal training in this field should emphasise basic communication skills as well as the handling of difficult situations in doctor-patient interaction.

22. 88.2 90.8 0.64 85 91 0.13 67.7 72.5 0.47 64.5 69.4 0.47 20 (18-25) 21 (18-25) 0.67 21 (14-27) 22 (16-22) 0.97 13 (9-16) 13 (9-16) 0.74 8 (5-13) 9 (5-12) 0.90 Parameters All patients Juniors Seniors P Comprehension of · 89.5 Diagnoses · 88.5 Prognosis · 70.1 Treatments · 67 All three items understood Satisfaction · 20 (18-25) CCFNI score HAD score Global score 21 (14.7-27) Anxiety score 13 (9-16) Depression score 9 (5-12)

23. Effect of communications training on medical student performance. Yedidia et al. JAMA. 2003 Sep 3;290(9):1157-65 • Comprehensive communications curricula were developed at 3 US medical schools using an established educational model for teaching and practicing core communication skills and engaging students in self-reflection on their performance. • 138 randomly selected medical students in the comparison cohort, and 155 students in the intervention cohort. Standardized patients assessed student performance. • Communications curricula significantly improved third-year students' overall communications competence as well as their skills in relationship building, organization and time management, patient assessment, and negotiation and shared decision making-tasks that are important to positive patient outcomes.

24. Doctor-nurse substitution in primary care Laurant et al. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271. • To evaluate patient outcomes (satisfaction), process of care, and resource utilisation including cost. • Meta-analysis of 25 articles (16 studies) • No differences were found in health outcomes for patients, process of care, resource utilisation or cost. • Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than did doctors. • Appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients.

25. And the Patient?Improving patients' communication with doctors:a systematic review of intervention studies. Harrington et al. Patient Educ Couns. 2004 Jan;52(1):7-16 • 25 studies designed to increase patients' participation in medical consultations. • Overall, half of the interventions resulted in increased patient participation. However, of the 10 written interventions only two reported a significant increase in question-asking or patient satisfaction. • There were significant improvements in other outcomes: • perceptions of control over health, • preferences for an active role in health care, • recall of information, • adherence to recommendations and attendance.

26. A five-point framework • The evidence that clinicians experience communication difficulties • Communication Skills Training Programs • Optimal duration of a training program • Long term impact of Communication Skills Training Programs • Teaching communication skills to ICU clinicians

27. 8 hour intervention

28. Optimal duration of training programs • A 8-hour intervention from John HopkinsRoter et al. Arch of Intern Med. 1995 Sep 25;155 • Patients of trained physicians reported reduction in emotional distress for as long as 6 months. • A 24-h psychological training program on comm. skills • Razavi et al. Eur J Cancer. 1993;29A(13):1858-63. • significant effect on attitudes, especially on those related to self concept, and on the level of occupational stress. • A 3-day program improve nurses' communication skills • Wilkinson et al. Psychooncology. 2003 Dec;12(8):747-59 • training can lead to clinically relevant behavioural change and improvements in perceived confidence in communication and dissemination of skills.

29. A five-point framework • The evidence that clinicians experience communication difficulties • Communication Skills Training Programs • Optimal duration of a training program • Long term impact of Communication Skills Training Programs • Teaching communication skills to ICU clinicians

31. Posttraining consolidation workshopsfacilitate the transfer of acquired skills to clinical practice. Razavi et al. J Clin Oncol. 2003 Aug 15;21(16):3141-9 • RCT: Efficacy of six 3-hour consolidation workshops conducted after a 2.5-day basic training program • Training efficacy was assessed through audiotaped interviews at baseline and after consolidation workshops • Communication skills and patients' perceptions of communication skills were assessed using a questionnaire. • Communication skills improved significantly in the consolidation-workshop group: • increase in open questions, decrease in premature reassurance • increase in acknowledgements, empathy, and in negotiations. • Patients interacting with physicians who benefited from consolidation workshops reported higher scores concerning their physicians' understanding of their disease.

32. A five-point framework • The evidence that clinicians experience communication difficulties • Communication Skills Training Programs • Optimal duration of a training program • Long term impact of Communication Skills Training Programs • Teaching communication skills to ICU clinicians

33. The Intensive Care Unit • A place where we care for severely ill patients, with uncertain prognoses. • A place where we are facing to relatives with distress who need assistance and information • A place where (too) many people work, not always together • A place where we have the task to implement difficult decisions • A place where death is frequent, and still frequently perceived as a failure

34. If you think that this is the ICU-waiting room, please open the doors The crowded Flow, Montreal

35. Behind the doors …

36. Family satisfaction = communication skills Junior doctors Contradictions The role of each one Referring physician Time

37. S T O P

39. Proactive process of communication: just an example of intervention • An initial formal multidisciplinary meeting was held within 72h including the physician, nurse, house officer and the family. • The meeting had four primary objectives: • 1) to review the medical facts and options for treatment; • 2) to discuss the patient’s perspectives on death and dying, dependence, loss of function, and the acceptability of the risks and ICU discomforts • 3) to agree on a care plan; • 4) to agree on criteria of success of this care plan. • The timing of subsequent meetings was “a-la-carte”. • A weekly multidisciplinary case review was held.

40. 4-y follow-up

42. Interventional studies of intensive communication with families of patients dying in the ICU diminished the use of ineffective treatments. • Lilly CM, et al. Am J Med 2000;109(6):469-75. • Dowdy MD, et al. Crit Care Med 1998;26(2):252-9. • Schneiderman et al. Crit Care Med 2000;28(12):3920-4. • Studdert et al. Intensive Care Med 2003;29(9):1489-97 • Burns JP, et al. Crit Care Med 2003;31(8):2107-17. • (Advance directives did not)

43. Family-centered care during the family conference • Effectiveness of the information provided • Empowerment about surrogacy • Involvement in care if family is willing • Shared decision-making model • Prevention of caregiver breakdown

46. Conclusion • Most current trainings are inadequate or not evaluated. • The literature confirms the usefulness of learner-centred, skills-focused, and practice-oriented communication skills training programs organised in small groups of a maximum 6 participants and lasting at least 20 hours. • However, it is unlikely that any future advances will negate the need and value of compassionate and empathetic two-way communication between clinician and patient. • Educational programs should be rigorously evaluated to identify best educational practices. • A lot is still to do in the intensive care units, the oncology literature is certainly a model to learn and teach from.

47. Thank you for your attention