Kazakhstan Health Technology Transfer and Institutional Reform Project Workshop: Clinical teaching using innovative technologies Henry Averns.

Kazakhstan Health Technology Transfer and Institutional Reform Project

Workshop: Clinical teaching using innovative technologies

Henry Averns



Today

• Developing roles for a Standardized patient program

Tomorrow

Wednesday

• Communication skills course design• Introduction to a Standardized patient program

• How to run an OSCE


Yesterday’s doctors

What does the graduate know?

Syllabus-basedSyllabus-basedcurriculumcurriculum

Syllabus-basedSyllabus-basedcurriculumcurriculum


Tomorrow’s Doctors

What can the graduate do?

Outcome-basedOutcome-basedcurriculumcurriculum

Outcome-basedOutcome-basedcurriculumcurriculum


The basic requirements

Scientific method

Scientific method

AttitudesAttitudesSkillsSkills

KnowledgeKnowledge

Basic science

Behavioural science

Clinical science

Population science

Clinical skillsCommunication

skills

Understanding

Application

ProfessionalEthical

Interprofessional


Adults• 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






Changes in method of teaching over last 20 years

PassiveDidactic

Sequential

ActiveSelf directedContextual

Large group Small groups


Principle 1: IntegrationVertical integration = across

yearsVertical integration = across

years

Horizontal integration = between subjects

Horizontal integration = between subjects


Traditional Curriculum

Biologicalsciences

Biologicalsciences

ClinicalstudiesClinicalstudies

Behavioural science

Behavioural science


Revised curriculum

Basic sciencesBasic sciences

Clinical studiesClinical studies


Principle 2: Logical Progression

Material should be presented in a logical order which is discernable by the students

Material should be presented in a logical order which is discernable by the students


Principle 3: Planned Repetition

“Spiral curriculum”



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


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


In groupsPlease discuss for 10 minutes

• When do you start teaching clinical communication skills?

• What resources do you use ?

• Please be prepared to share this


What experiential material is available to you?

• videos of real consultations

• real patients

• simulated patients

• role-play


Part 2


The Communication Curriculum at Queens

The Calgary Cambridge Model


Defining objectives• AFMC Clinical skills document• Medical School’s own curriculum• LMCC objectives

• You will have similar objectives


Resource constraints

TimeTime

SpaceSpaceMoneyMoney

PeoplePeople


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


Year 1• 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


Term 1 (continued)• Vital Signs and Routine Practices• General Appearance, ENT and Lymph Nodes• Examination of the Thyroid

Mid-Term Formative Assessment

• Cardiac Examination• Respiratory Examination • Abdominal Examination • Breast and Axilla Examination• History Taking and Presenting an Oral Report • Review of Skills Learned during the Term

• Student Assessment and Course Evaluations


• 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


Term 2• Neurological exam• Cranial nerves• Ophthalmology• MSK• Sexual history

• Pediatric sessions (x2)• Technical skills (x2)


Also in Term 2• Students conduct full history and physical

examination with a standardised patient or real patients


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


Term 3• Introduction to clinical reasoning (x3)

• Technical skills (x2). Suturing, catheter

• Patient education session

• Findings in real patients

• Simulated patient full history and physical

• Community hospital full hx an px

• Emergency Room visit


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


• We will discuss some of these specific sessions this week when we talk about simulated patients


In groups• Discuss the different assessment methods you

currently use, and their strengths and weaknesses.

• Be prepared to share this


Course Assessment• Assessment Term 1

• 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

– 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


Assessment Term 2

• Early, Mid and Final tutor assessments as for Term 1

• Formative OSCE – no contribution to final score

• Final OSCE



Calgary Cambridge Communication Framework


What I will discuss• What is the Calgary Cambridge Approach?• The guides• Agreeing what we are trying to teach in

Communication


Can communication skills be taught?Can communication skills be taught?

communication is a clinical skill

it is a series of learnt skills

experience alone is a poor teacher


Can communication skills be taught?Can communication skills be taught?

there is conclusive evidence that communication skills can be taught

and that communication skills teaching is retained


Methods of teaching communicationMethods of teaching communication• traditional lectures/interactive lectures + exercises• paper exercises• Video demonstrations

Consultations with simulated patientsConsultations with real patientsPatients 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


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


Why do we need a framework?• Effective history taking is essential to the

practice of high quality medicine

• This requires excellent communication skills


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


The Disease - Illness Model

Gathering InformationGathering Information

Patient Presents ProblemPatient Presents Problem

Parallel Search of Two Frameworks

Parallel Search of Two Frameworks

IdeasConcerns

ExpectationsFeelings

Effects on life

Understand the patient’s unique

experience of illness

IdeasConcerns

ExpectationsFeelings

Effects on life

Understand the patient’s unique

experience of illness

The Patient’s PerspectiveThe Patient’s PerspectiveThe Biomedical Perspective The Biomedical Perspective

SymptomsSigns

InvestigationsUnderlying Pathology

Differential Diagnosis

SymptomsSigns

InvestigationsUnderlying Pathology

Differential Diagnosis

Integration of the two frameworks Collaborative explanation and planning:

shared understanding and decision making

Integration of the two frameworks Collaborative explanation and planning:

shared understanding and decision making



ProvidingStructure

Initiating the Session

Closing the Session

Physical Examination

Explanation and planning

Gathering information

Building the relationship


Providing

Structure

Initiating the Session

preparation

establishing initial rapport

identifying the reason(s) for the consultation

providing the correct amount and type of information

aiding accurate recall and understanding

achieving a shared understanding: incorporating the patient’sillness framework

planning: shared decision making

Closing the Session

Building therelationship

••

•

••

•

•

•

•

•

Gathering information

Physical examination

Explanation and planning

making organisation overt

attending to flow

• exploration of the patient’s problems to discover the:

biomedical perspective the patient’s perspective

background information - context

• ensuring appropriate point of closure• forward planning

using appropriate non-verbal behaviour

developing rapport

involving the patient

•

•


REVISED CONTENT GUIDE TO THE MEDICAL INTERVIEW Patient's Problem List Exploration of Patient's Problems Medical Perspective – disease Patient's Perspective - illness Sequence of events Ideas and beliefs Symptom analysis Concerns Relevant systems review 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


The following slides are also in the handout provided


INITIATING THE SESSION• 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 • 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?”)

• 5. Listens attentively to the patient’s opening statement, without interrupting or directing patient’s

response • 6. Confirms list and screens for further problems (e.g. “so that’s headaches and tiredness; anything

else……?”) • 7. Negotiates agenda taking both patient’s and physician’s needs into account


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


Establishing All the Reasons

• “Is there anything else ....we need to take care of today?....that concerns you today?”

• Patients have an average of 3.6 problems

• In 34/51 visits the doctor interrupted after the first complaint

• In 94% of interviews, after an interruption the patient stopped volunteering information


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?”


Sacred” 7 Characteristics of a Symptom (Morgan and Engel)

• 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


Open-ended Questions• Can you tell me what happened?• “What was that like?”• “Would you tell me about the pain from the

beginning?”


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


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?”


GATHERING INFORMATION

• 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


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


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


Building The Relationship• See Handout


• Non-verbal behaviourNon-verbal behaviour

• 22. Demonstrates 22. Demonstrates appropriate non–verbal behaviourappropriate non–verbal behaviour e.g. eye contact, posture & position, e.g. eye contact, posture & position, movement, facial expression, use of voice 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 23. If reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or rapportrapport

• Developing rapportDeveloping rapport

• 24. Acknowledges patient's views and feelings; accepts legitimacy; is not judgmental24. Acknowledges patient's views and feelings; accepts legitimacy; is not judgmental

• 25. Uses 25. Uses empathyempathy to communicate understanding and appreciation of the patient’s feelings or to communicate understanding and appreciation of the patient’s feelings or predicament predicament

• 26. Provides support: expresses concern, understanding, willingness to help; acknowledges coping 26. Provides support: expresses concern, understanding, willingness to help; acknowledges coping efforts and appropriate self care; offers partnership efforts and appropriate self care; offers partnership

• 27. Deals sensitively with embarrassing and disturbing topics and physical pain, including when 27. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examinationassociated with physical examination

• Involving the patientInvolving the patient

• 28. Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinking now 28. Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinking now is.......”)is.......”)

• 29. Explains rationale for questions or parts of physical examination that could appear to be non-29. Explains rationale for questions or parts of physical examination that could appear to be non-sequitors sequitors

• 30. During physical examination, explains process, asks permission 30. During physical examination, explains process, asks permission


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.


1. Providing the correct amount and type of informationAims; 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


2. Aiding accurate recall and understandingAims; 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• Uses repetition and summarising• Clarity• Uses visual methods if appropriate• Checks patients understanding of information given or plans

made


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


4.Planning: shared decision makingAims; Involve patients in decision making if they wish, increase

patient understanding and commitment

• 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


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


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


Specific Challenges• 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


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


Key concept is integrationa. integration with history taking skillsb. integration with practical skillsc. integration with specialty teachingd. integration with medical records and presentationse. integration with the hidden curriculumf. the crucial role of assessment in integration


• What challenges do you face when integrating your courses?


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?


What experiential material is available to you?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


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


Advantages of simulated patients

Rehearsal

Improvisation

Standardization

Customisation

Specific issues and difficult situations

Availability

Time efficiency

Feedback

Facilitation, instruction and evaluation


Challenges of of using simulated Challenges of of using simulated patientspatients

• Expense• Selection• Hidden agendas• Administrative time• Training

– understanding how patients behave– understanding how to give feedback


Training actorsTraining actorsan 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


• 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


• 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


When working with a facilitatorthe 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



Group work • Tables 1 and 2

– recruiting SPs– where from, – demographics– retention– payment


• Tables 3 and 4– facilities needed to run an SP program;

– staff, – space, – trainers, – cost


Discussion:

• Barriers to the use of SPs in the curriculum


Please review the role development guideline I have provided for

tomorrow’s work


Finally• Educational media

• Resource manuals

• Faculty Development

• Feedback


Teaching the teachersTeaching 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


Ongoing support for facultyOngoing 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

Kazakhstan Health Technology Transfer and Institutional Reform Project Workshop: Clinical teaching using innovative technologies Henry Averns.

Documents

patients response6

patients physical comfort

medical history drug

appropriate opening

biomedical perspective

nature of interview

plan of action

openended question