Transcript Clinical teaching using innovative technologies Henry Averns

Workshop: Clinical teaching
using innovative technologies
Henry Averns
Kazakhstan Health Technology Transfer and Institutional Reform Project
Kazakhstan Health Technology Transfer and Institutional Reform Project
Today
• Communication skills course design
• Introduction to a Standardized patient program
Tomorrow
• Developing roles for a Standardized patient
program
Wednesday
• How to run an OSCE
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Yesterday’s doctors
Syllabus-based
curriculum
What does the graduate know?
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Tomorrow’s Doctors
Outcome-based
curriculum
What can the graduate do?
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The basic requirements
Basic science
Understanding
Behavioural
science
Application
Clinical science Knowledge
Scientific
method
Population
science
Skills
Clinical skills
Communication
skills
Attitudes
Professional
Ethical
Interprofessional
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Adults
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Have a specific purpose in mind
are voluntary participants in learning
require meaning and relevance
require active involvement in learning
need clear goals and objectives
need feedback
need to be reflective
Kazakhstan Health Technology Transfer and Institutional Reform Project
Adults
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Have a specific purpose in mind
are voluntary participants in learning
require meaning and relevance
require active involvement in learning
need clear goals and objectives
need feedback
need to be reflective
Kazakhstan Health Technology Transfer and Institutional Reform Project
Adults
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Have a specific purpose in mind
are voluntary participants in learning
require meaning and relevance
require active involvement in learning
need clear goals and objectives
need feedback
need to be reflective
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Changes in method of teaching over last
20 years
Passive
Didactic
Sequential
Large group
Active
Self directed
Contextual
Small groups
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Principle 1: Integration
Vertical integration = across
years
Horizontal integration =
between subjects
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Traditional Curriculum
Behavioural
science
Biological
sciences
Clinical
studies
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Revised curriculum
Clinical studies
Basic sciences
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Principle 2: Logical Progression
Material should be
presented in a logical
order which is
discernable by the
students
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Principle 3: Planned Repetition
“Spiral curriculum”
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Kazakhstan Health Technology Transfer and Institutional Reform Project
Definition of clinical skills
• Clinical skills refer to the skills required for a clinician to manage a
complete patient encounter. These include
o Communication skills to allow a clinician to take a thorough history, and
also to understand the patient’s experience of illness, negotiate management
plans etc.
o Physical examination skills
o Clinical reasoning skills, including data gathering and interpretation;
development of a differential diagnosis and the ability to synthesize this
data into a management plan appropriate to the individual patient
o Technical (procedural) skills relevant to diagnosis and management
o All of the above skills require underlying foundational medical expert
knowledge
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How to teach communication skills – lessons
from the evidence
• Systematic definition of the skills
• observation of learners
• video or audio recording and review
• well-intentioned feedback
• rehearsal
• active small group learning
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In groups
Please discuss for 10 minutes
• When do you start teaching clinical
communication skills?
• What resources do you use ?
• Please be prepared to share this
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What experiential material is available to you?
• videos of real consultations
• real patients
• simulated patients
• role-play
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Part 2
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The Communication Curriculum at
Queens
The Calgary Cambridge Model
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Defining objectives
• AFMC Clinical skills document
• Medical School’s own curriculum
• LMCC objectives
• You will have similar objectives
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Resource constraints
Time
People
Money
Space
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Course Design
• The course is based around 10 groups each
made up of 10 students and 2 tutors
• It runs for a half day per week for two years
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Year 1
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Term 1
Introduction to Interviewing
Beginning the Interview
History of the Present Illness & Questioning &
Listening
• The Patient's Perspective
• Completing the History and Putting it all
Together
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Term 1 (continued)
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Vital Signs and Routine Practices
General Appearance, ENT and Lymph Nodes
Examination of the Thyroid
Mid-Term Formative Assessment
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Cardiac Examination
Respiratory Examination
Abdominal Examination
Breast and Axilla Examination
History Taking and Presenting an Oral Report
Review of Skills Learned during the Term
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Student Assessment and Course Evaluations
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• Faculty-delivered lecture (30 – 45 minutes)
flowed by tutor-led small group learning.
• Tutor resources:
– A dedicated website
– A resource manual
– A term schedule which includes a description of
each session
– The physical examination manual
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Term 2
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Neurological exam
Cranial nerves
Ophthalmology
MSK
Sexual history
• Pediatric sessions (x2)
• Technical skills (x2)
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Also in Term 2
• Students conduct full history and physical
examination with a standardised patient or
real patients
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Year 2
• The main objectives of year two include:
 Development of clinical reasoning
 Education of patients about disease and
medication
 Difficult conversations eg breaking bad news
 Written reports
 Oral reporting
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Term 3
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Introduction to clinical reasoning (x3)
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Technical skills (x2). Suturing, catheter
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Patient education session
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Findings in real patients
• Simulated patient full history and physical
• Community hospital full hx an px
• Emergency Room visit
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Term 4
• Technical skills (x2) : Chest tube, blood gases, IVI
insertion
• Mini OSCE
• Pediatrics – neonatal examination
• Real patient findings
• Community hospital full history and physical
• Clinical education Centre history and physical with
simulated patients
• Breaking bad news session
• Male genital examination
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• We will discuss some of these specific sessions
this week when we talk about simulated
patients
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In groups
• Discuss the different assessment methods you
currently use, and their strengths and
weaknesses.
• Be prepared to share this
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Course Assessment
• Assessment Term 1
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Student self assessment week one, mid term, end of term
Tutor formative assessment mid term (downloadable forms)
Tutor final assessment
4 “individual assessments” all mandatory and summative
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Basic hx assessed by Standardised patients (SPs)
BP, pulses, and lymph nodes assessed by nurses
Cardiac hx and px assessed by Residents and SPs
Respiratory hx and px assessed by Residents and SPs
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Assessment Term 2
• Early, Mid and Final tutor assessments as for
Term 1
• Formative OSCE – no contribution to final
score
• Final OSCE
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Calgary Cambridge Communication
Framework
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What I will discuss
• What is the Calgary Cambridge Approach?
• The guides
• Agreeing what we are trying to teach in
Communication
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Can communication skills be taught?
communication is a clinical skill
it is a series of learnt skills
experience alone is a poor
teacher
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Can communication skills be taught?
 there is conclusive evidence that
communication skills can be
taught
 and that communication skills
teaching is retained
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Methods of teaching communication
• traditional lectures/interactive lectures + exercises
• paper exercises
• Video demonstrations
Consultations with simulated patients
Consultations with real patients
Patients stories of the illnesses
• web-based/e-learning
• clinic/ward teaching with real patients
• Visits to patient’s homes/ITU/ward/old peoples’ homes etc
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Traditional Medical History
• Chief complaint
• History of the present complaint
• Past medical history
• Family history
• Personal and social history
• Drug and allergy history
• Functional enquiry
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Why do we need a framework?
• Effective history taking is essential to the
practice of high quality medicine
• This requires excellent communication skills
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The Interview is Our Main Diagnostic
Tool
• 60-80% of medical diagnoses are made after
the interview alone
• The interview determines the physical exam
and investigations
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The Disease - Illness Model
Patient Presents Problem
Gathering Information
Parallel Search of Two
Frameworks
The Biomedical Perspective
The Patient’s Perspective
Symptoms
Signs
Investigations
Underlying Pathology
Ideas
Concerns
Expectations
Feelings
Effects on life
Differential Diagnosis
Understand the
patient’s unique
experience of illness
Integration of the two frameworks
Collaborative explanation and planning:
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shared understanding and decision making
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Initiating the Session
Gathering information
Providing
Structure
Building the
relationship
Physical Examination
Explanation and planning
Closing the Session
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Initiating the Session
• preparation
• establishing initial rapport
• identifying the reason(s) for the consultation
Gathering information
Providing
• exploration of the patient’s problems to discover the:
Structure
 biomedical perspective
• making
organisation
overt
Building the
relationship
 the patient’s perspective
 background information - context
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using
appropriate
non-verbal
behaviour
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developing
rapport
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involving
the patient
Physical examination
• attending to
flow
Explanation and planning
• providing the correct amount and type of information
• aiding accurate recall and understanding
• achieving a shared understanding: incorporating the patient’s
illness framework
• planning: shared decision making
Closing the Session
• ensuring
appropriate
point
of closure
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Health
Technology
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and Institutional Reform Project
• forward planning
REVISED CONTENT GUIDE TO THE MEDICAL INTERVIEW
Patient's Problem List
Exploration of Patient's Problems
Medical Perspective – disease
Sequence of events
Symptom analysis
Relevant systems review
Patient's Perspective - illness
Ideas and beliefs
Concerns
Expectations
Effects on life
Feelings
Background Information - Context
Past Medical History
Drug and Allergy History
Family History
Personal and Social History
Review of Systems
Physical Examination
Differential Diagnosis - Hypotheses
Including both disease and illness issues
Physician's Plan of Management
Investigations
Treatment alternatives
Explanation and Planning with Patient
What the patient has been told
Plan of action negotiated
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The following slides are also in the
handout provided
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INITIATING THE SESSION
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ESTABLISHING INITIAL RAPPORT
1. Greets patient and obtains patient’s name
2. Introduces self, role and nature of interview; obtains consent if
necessary
3. Demonstrates respect and interest, attends to patient’s physical comfort
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Identifying the reason(s) for the consultation
4. Identifies the patient’s problems or the issues that the patient wishes to address with
appropriate opening question (e.g. “What problems brought you to the hospital?” or “What would
you like to discuss today?”)
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5. Listens attentively to the patient’s opening statement, without interrupting or directing patient’s
response
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6. Confirms list and screens for further problems (e.g. “so that’s headaches and tiredness; anything
else……?”)
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7. Negotiates agenda taking both patient’s and physician’s needs into account
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Identifying the Reason(s) for the Visit
• (“Why are you here, today?”)
• Begin with an open-ended question
• Listen attentively, without interruption, to the
patient’s opening statement
• Confirm and screen for more problems
• Negotiate an agenda for the visit
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Establishing All the Reasons
• “Is there anything else ....we need to take care
of today?....that concerns you today?”
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Patients have an average of 3.6 problems
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In 34/51 visits the doctor interrupted after
the first complaint
• In 94% of interviews, after an interruption the
patient stopped volunteering information
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Negotiating the Agenda
• • Establish an agenda that respects your and
the patient’s priorities for the encounter:
• “It sounds as though you have several
problems but it seems the most important one
to you is the arthritis...However, the chest pain
sounds concerning to me ...shall we focus on
those two today?”
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Sacred” 7 Characteristics of a
Symptom
(Morgan and Engel)
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location: site and radiation
quality or character
quantity or severity
chronology: onset, duration, frequency
setting or circumstances in which it occurs
aggravating and alleviating factors
associated manifestations
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Open-ended Questions
• Can you tell me what happened?
• “What was that like?”
• “Would you tell me about the pain from the
beginning?”
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Benefits of Open-ended Questions
• Contribute to better early diagnostic
reasoning
• Helps identify the illness framework
• Leads to more efficient explanation and
planning
• Give the clinician time to think and listen
• Establishes the patient’s role as a partner in
the interaction
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Habits to Avoid
• The leading question: – “You don’t have any
chest pain do you?”
• The multiple question: – “Do you have pins
and needles, a rash or diarrhea?”
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GATHERING INFORMATION
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Exploration of patient’s problems
8. Encourages patient to tell the story of the problem(s) from when first started to the present in own
words (clarifying reason for presenting now)
9. Uses open and closed questioning technique, appropriately moving from open to
closed
10. Listens attentively, allowing patient to complete statements without interruption and leaving space
for patient to think before answering or go on after pausing
11. Facilitates patient's responses verbally and non–verbally e.g. use of encouragement, silence,
repetition, paraphrasing, interpretation
12. Picks up verbal and non–verbal cues (body language, speech, facial expression, affect); checks
out and acknowledges as appropriate
13.Clarifies patient’s statements that are unclear or need amplification (e.g. “Could you explain what
you mean by light headed")
14. Periodically summarises to verify own understanding of what the patient has said; invites patient
to correct interpretation or provide further information.
15. Uses concise, easily understood questions and comments, avoids or adequately explains jargon
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17. Actively determines and appropriately
explores:
patient’s ideas (i.e. beliefs re cause)
patient’s concerns (i.e. worries) regarding each
problem
patient’s expectations (i.e., goals, what help the
patient had expected for each problem)
effects: how each problem affects the patient’s
life
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PROVIDING STRUCTURE
• Making organisation overt
• 19. Summarises at the end of a specific line of inquiry to
confirm understanding before moving on to the next section
• 20. Progresses from one section to another using
signposting; includes rationale for next section
• Attending to flow
• 21. Structures interview in logical sequence
• 22. Attends to timing and keeping interview on task
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Building The Relationship
• See Handout
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Non-verbal behaviour
22. Demonstrates appropriate non–verbal behaviour e.g. eye contact, posture & position,
movement, facial expression, use of voice
23. If reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or
rapport
Developing rapport
24. Acknowledges patient's views and feelings; accepts legitimacy; is not judgmental
25. Uses empathy to communicate understanding and appreciation of the patient’s feelings or
predicament
26. Provides support: expresses concern, understanding, willingness to help; acknowledges coping
efforts and appropriate self care; offers partnership
27. Deals sensitively with embarrassing and disturbing topics and physical pain, including when
associated with physical examination
Involving the patient
28. Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinking now
is.......”)
29. Explains rationale for questions or parts of physical examination that could appear to be nonsequitors
30. During physical examination, explains process, asks permission
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Explanation and planning
-Broken down into four sub-sections;
1. Providing the correct amount and type of
information.
2. Aiding accurate recall & understanding.
3. Achieving a shared understanding:
incorporating the patient’s perspective.
4. Planning: shared decision making.
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1. Providing the correct amount and type
of information
Aims;
to give comprehensive and appropriate information
for individual patients; to neither restrict or overload
• Chunks and checks
• Assesses patient’s starting point
• Asks patient what other information would be
helpful
• Gives explanation at appropriate times
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2. Aiding accurate recall and understanding
Aims;
To make information easier for the patient to remember and
understand
• Organises explanation.
• Uses explicit categorisation or signposting e.g. there are three
important things I would like to discuss
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Uses repetition and summarising
Clarity
Uses visual methods if appropriate
Checks patients understanding of information given or plans
made
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3. Achieving a shared understanding:
incorporating the patient’s perspective.
Aims;
Encourage interaction, incorporate patients
perspective, thoughts and feelings.
• Relates explanations to patient’s illness framework.
• Provides opportunities and encourages patient to
contribute
• Picks up verbal and non-verbal cues
• Elicits patient’s beliefs, reactions and feelings
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4.Planning: shared decision making
Aims;
Involve patients in decision making if they wish, increase
patient understanding and commitment
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Shares own thoughts, ideas, dilemmas
Involve patient by making suggestions rather than directives
Encourages patient to contribute their thoughts
Negotiates
Offers choices
Checks with patient
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CLOSING THE SESSION (PRELIMINARY
EXPLANATION & PLANNING)
• 33. Gives any preliminary information in clear well organised
manner, avoids or explains jargon
• 34. Checks patient understanding and acceptance of explanation
and plans; ensures that concerns have been addressed
• 35. Encourages patient to discuss any additional points and
provides opportunity to do so (eg. “Are there any questions you’d
like to ask or anything at all you’d like to discuss further?”)
• 36. Summarises session briefly
• 37. Contracts with patient re next steps for patient and physician
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In groups
• What Issues Have you Come across with
students’ history taking?
• In groups discuss common areas where
students could improve and then we will
discuss them
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Specific Challenges
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culture and social diversity
gender
dealing with emotions
age related issues – the elderly, children
the three way interview
breaking bad news
the sexual history
the psychiatric interview
the telephone interview
low literacy patients
sensory impaired patients
death and dying, bereavement
complaints
ethics
health promotion and prevention
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How to Teach Communication Skills
• systematic delineation and definition of the
skills
• observation of learners
• video or audio recording and review
• feedback
• rehearsal
• active small group or 1:1 learning
Kazakhstan Health Technology Transfer and Institutional Reform Project
Key concept is integration
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f.
integration with history taking skills
integration with practical skills
integration with specialty teaching
integration with medical records and presentations
integration with the hidden curriculum
the crucial role of assessment in integration
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• What challenges do you face when integrating
your courses?
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In groups
• Discuss either a positive or a negative
experience you or a friend has had with the
medical profession
• Are there any themes here?
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What experiential material is available to you?
• videos of consultations with either a real patient or a
simulated patient
• direct observation with consultations with real patients
• role-play with simulated patients
Kazakhstan Health Technology Transfer and Institutional Reform Project
Disadvantages of real patients
 Rehearsal
 Improvisation: not ‘emotionally’ real in this repeat situation
 Standardization
 Customisation
 Specific issues and difficult situations
 Availability – restricted types of patients
 Time efficiency
 Feedback
 Facilitation, instruction and evaluation
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Advantages of simulated patients
 Rehearsal
 Improvisation
 Standardization
 Customisation
 Specific issues and difficult situations
 Availability
 Time efficiency
 Feedback
 Facilitation, instruction and evaluation
Kazakhstan Health Technology Transfer and Institutional Reform Project
Challenges of of using simulated patients
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Expense
Selection
Hidden agendas
Administrative time
Training
– understanding how patients behave
– understanding how to give feedback
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Training actors
an actor needs:
• to respect and be empathic with students, putting
himself in their shoes
• to be committed to helping students to improve their
consultation skills
• to be committed to being part of the teaching team
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• to be disciplined, reliable and to behave
professionally at all times
• to be able to focus on the interview process
and identify skills used or missing
• to be flexible with individual students and
to be able to improvise
• to give appropriate, accurate, sensitive and
constructive feedback
Kazakhstan Health Technology Transfer and Institutional Reform Project
• to be able to reward students for
demonstrating empathy, open questions,
picking up cues and giving the patient time
to think, by disclosing more information
• to be familiar with and committed to the
theoretical basis for the teaching (the
Calgary-Cambridge approach)
• to be familiar with the roles he or she is
asked to play
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When working with a facilitator
the actor must:
• work very closely with the facilitator and
anticipate his or her needs
• move in and out of role appropriately when
asked
• give feedback as directed by the facilitator
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Kazakhstan Health Technology Transfer and Institutional Reform Project
Group work
• Tables 1 and 2
– recruiting SPs
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where from,
demographics
retention
payment
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• Tables 3 and 4
– facilities needed to run an SP program;
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staff,
space,
trainers,
cost
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Discussion:
• Barriers to the use of SPs in the curriculum
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Please review the role development
guideline I have provided for
tomorrow’s work
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Finally
• Educational media
• Resource manuals
• Faculty Development
• Feedback
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Teaching the teachers
Three agendas for facilitators:
•Enhancing their own communication skills
•Increasing their knowledge base about
communication skills theory and research
•Enhancing their teaching and facilitation skills
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Ongoing support for faculty
• tel/email support
• web site - with theory, teaching plans, videos
of teaching etc
• observation and feedback, individual and
group teaching either at regular facilitation
training days or locally
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