Workshop: Clinical teaching using innovative technologies

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Workshop Clinical teaching using innovative
technologies

• Henry Averns

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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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Yesterdays doctors
Facts
Syllabus-based curriculum
What does the graduate know?
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Tomorrows Doctors
Competencies
Outcome-based curriculum
What can the graduate do?
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The basic requirements
Basic science Behavioural science Clinical
science Population science
Understanding Application
Scientific method
Knowledge
Attitudes
Skills
Professional Ethical Interprofessional
Clinical skills Communication skills
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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

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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

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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

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Changes in method of teaching over last 20 years
Passive
Active
Didactic
Self directed
Contextual
Sequential
Small groups
Large group
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Principle 1 Integration
Vertical integration across years
Horizontal integration between subjects
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Traditional Curriculum
Biological sciences
Clinical studies
Behavioural science
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Revised curriculum
Basic sciences
Clinical studies
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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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Definition of clinical skills

• Clinical skills refer to the skills required for
  a clinician to manage a complete patient
  encounter. These include
• Communication skills to allow a clinician to take
  a thorough history, and also to understand the
  patients experience of illness, negotiate
  management plans etc.
• Physical examination skills
• 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
• Technical (procedural) skills relevant to
  diagnosis and management
• 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 QueensThe
Calgary Cambridge Model
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Defining objectives

• AFMC Clinical skills document
• Medical Schools 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

• 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)

• 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

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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

• 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

• 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

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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
• 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
•  

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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 patients homes/ITU/ward/old peoples
  homes etc

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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 Patients Perspective
The Biomedical Perspective
Symptoms Signs Investigations Underlying
Pathology Differential Diagnosis
Ideas Concerns Expectations Feelings Effects on
life Understand the patients unique experience
of illness
Integration of the two frameworks Collaborative
explanation and planning shared understanding
and decision making
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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   Explan
ation 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

• Establishing initial rapport
• 1. Greets patient and obtains patients name
  
• 2. Introduces self, role and nature of interview
  obtains consent if necessary
   
• 3. Demonstrates respect and interest, attends to
  patients physical comfort
•  
• Identifying the reason(s) for the consultation
• 4. Identifies the patients 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 patients opening
  statement, without interrupting or directing
  patients response
•  
• 6. Confirms list and screens for further problems
  (e.g. so thats headaches and tiredness
  anything else?)
•  
• 7. Negotiates agenda taking both patients and
  physicians 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
  patients 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?
• 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

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Negotiating the Agenda

• Establish an agenda that respects your and the
  patients 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)

• 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 patients role as a partner in
  the interaction

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Habits to Avoid

• The leading question You dont 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

• Exploration of patients 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
  nonverbally e.g. use of encouragement, silence,
  repetition, paraphrasing, interpretation 
• 12. Picks up verbal and nonverbal cues (body
  language, speech, facial expression, affect)
  checks out and acknowledges as appropriate  
• 13.Clarifies patients 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
• patients ideas (i.e. beliefs re cause)
• patients concerns (i.e. worries) regarding each
  problem
• patients expectations (i.e., goals, what help
  the patient had expected for each problem)
• effects how each problem affects the patients
  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 nonverbal 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 patients 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
  patients involvement (e.g. What Im thinking
  now is.......)
• 29. Explains rationale for questions or parts of
  physical examination that could appear to be
  non-sequitors
  
• 30. During physical examination, explains
  process, asks permission

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Explanation and planning-Broken down into four
sub-sections

• Providing the correct amount and type of
  information.
• Aiding accurate recall understanding.
• Achieving a shared understanding incorporating
  the patients perspective.
• 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 patients 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
• 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 patients perspective.

• Aims
• Encourage interaction, incorporate patients
  perspective, thoughts and feelings.
• Relates explanations to patients illness
  framework.
• Provides opportunities and encourages patient to
  contribute
• Picks up verbal and non-verbal cues
• Elicits patients 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
• 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 youd like to ask or
  anything at all youd 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

• 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 11 learning

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Key concept is integration

• 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

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• 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

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• Advantages of simulated patients
• Rehearsal
• Improvisation
• Standardization
• Customisation
• Specific issues and difficult situations
• Availability
• Time efficiency
• Feedback

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Challenges of of using simulated patients

• 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

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• 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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Group work

• Tables 1 and 2
• recruiting SPs
• where from,
• demographics
• retention
• payment

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