QUILT SEMINAR AN APPRAISAL OF COMMUNICATION TEACHING AT POSTGRADUATE LEVEL ACROSS HEALTHCARE CURRICU

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QUILT SEMINARAN APPRAISAL OF COMMUNICATION
TEACHING AT POSTGRADUATE LEVEL ACROSS
HEALTHCARE CURRICULA SRIKANT SARANGI
Cardiff University
Cardiff University, 10 March 2008
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OUTLINE

• Introduction Health Communication Research
  Centre (HCRC) and its Remit
• Patient-centredness and the communicative turn in
  healthcare delivery
• Rethinking communication going beyond skills
  approach
• Background to the Project fact finding (mild)
  intervention in a consultative paradigm
• An overview of work in progress (Phases 1 2)
• Future agenda?

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HEALTH COMMUNICATION RESEARCH CENTRE

• The Health Communication Research Centre (HCRC)
  was established in 1997-98 as an
  interdisciplinary initiative, with a focus on
  Research and Research-led teaching/training in
  healthcare (i) the interactional domain (ii)
  the public domain.
• www.cardiff.ac.uk/encap/hcrc
• healthcom_at_cardiff.ac.uk

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RESEARCH PROJECTS AN OVERVIEW

• Genetic Counselling Genetic Testing
• Genetic explanations, health and identity
• Palliative Care
• Primary Care Antibiotics prescription
• NHS DIRECT WALES (websites and telephone triage)
• HIV/AIDS and Quality of Life
• Obesity in the media
• Illness narratives chronic fatigue syndrome
  young people with IBD, Type 1 Diabetes
• Professional examinations (OSCE, RCGP)
• Problem-Based Learning in medical curriculum
• Wales Asylum Seeking and Refugee Doctors (WARD)
  programme

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HIGHLIGHTS OF HCRC ACTIVITIES

• Annual Conference on Communication, Medicine and
  Ethics (COMET) since 2003
• The Cardiff Lecture Series since 2000 (accessible
  via website www.cardiff.ac.uk/encap/hcrc
• Annual interdisciplinary workshops
• Annual Summer Schools
• Regular Health and Discourse Seminars (HEADS)
• Teaching/supervision input to medical and
  healthcare curricula
• Pilot projects in neglected areas of healthcare
  communication.
• Founding Journal Communication Medicine

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• CONTRIBUTORS TO FIRST ISSUE
• Atkinson, P. (Cardiff University)
• Barrett, R. J. (University of Adelaide)
• Cicourel, A. V. (University of California, San
  Diego)
• Frankel, R. M. and Hourigan, N. (Indiana
  University School of Medicine)
• Hamilton, H. E. (Georgetown University)
• Hydén, L. and Baggens, C. (Linköping University)
  
• Iedema, R., Sorensen, R., Braithwaite, J. and
  Turnbull, E. (University of New South Wales)
• Körner, H., Hendry, O., and Kippax, S.
• Li, H.Z., Krysko, M., Desroches, N.G. and Deagle,
  G. (University of Northern British Columbia)
• Roberts, C. (Kings College London), Sarangi, S.
  (Cardiff University) and Moss, B. (Kings College
  London)
• DISCUSSION FORUM - Mishler, E. G. (Harvard
  Medical School)

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• COMET
• CHRONOLOGY
• 2003 Cardiff
• 2004 Linköping, Sweden
• 2005 Sydney, Australia
• 2006 Cardiff
• 2007 Lugano, Switzerland
• 2008 Cape Town, S Africa
• 2009 Cardiff
• 2010 Boston, USA
• 2111 Nottingham, UK
• 2112 Gent, Belgium

Return
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Return
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• PATIENT-CENTREDNESS
• THE COMMUNICATIVE TURN IN HEALTHCARE DELIVERY

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PATIENT-CENTREDNESS IN HEALTHCARE DELIVERY

• EVIDENCE-BASED MEDICINE (the dominant biomedical
  paradigm)
• NARRATIVE-BASED MEDICINE (cf. ethnomedical
  perspective (Faberga 1975 biopsychosocial
  dimension Engel 1977 cultural hermeneutic
  model Good and Good 1981 voice of the
  lifeworld Mishler 1984)
• PATIENT-ORIENTED EVIDENCE THAT MATTERS (POEM)
• MEDICAL HUMANITIES (ethics, philosophy, art,
  literature, language/communication etc.)

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SETTING THE HEALTH COMMUNICATION SCENE

• Communication as the beneficiary of
  patient-centredness.
• Highlighting of communication issues in the
  reform of undergraduate medical training, based
  on General Medical Councils (2002) Tomorrows
  Doctors.
• Striving for a balance between core and non-core
  training (including Interpersonal Communication
  Skills) also in Continuing Professional
  Development (see Good Medical Practice, GMC
  2001).
• Parallel developments via Royal Colleges and
  other regulatory bodies.

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COMMUNICATION IN HEALTHCARE AGENDA

• Recognition of communication failure leading to
  complaints/litigation
• Medical uncertainties about new illnesses
  demanding new forms of communication
• Increased level of patient access to health
  information (the lay expert, especially in the
  context of chronic illnesses).

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THE COMMUNICATIVE RELATIONSHIP BETWEEN
PROFESSIONAL CLIENT THE CONUNDRUM

• Good Professional Good Communicator?

CLIENT TYPES
Good Communicator Good Professional??
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COMMUNICATION SKILLS FOR AGAINST

• Patient-centred communication skills unveiled
  ideology or ecological practice?
• Artificial separation of consulting skills and
  communication skills in professional literature
  and teaching/training.
• Patient-centred models are measured, for example,
  by the number of open questions asked, levels of
  explanation offered on the assumption that
  patients and healthcare providers share the same
  communicative resources.

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QUESTIONING THE RELEVANCE OF COMMUNICATION SKILLS

• Patients resistance or dispreference Patients
  are primarily concerned with professionals
  technical expertise rather than their
  communication skills. (Burkitt Wright et al 2004)
• Recent critique A triumph of evangelism over
  common sense! There is not much evidence that
  communication skills training makes a difference.
  (Williams and Lau 2004)
• Attempt to throw the Communication Baby with the
  bath water!
• Communication/Discourse studies as an invisible
  discipline.

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COMMUNICATION IS MORE THAN A SET OF DIY SKILLS

• Communication is not a PILL Limitations of
  recipe-style training in A-to-Z of communication
  skills which treats symptoms rather than causes
  one-sided view of communication where the patient
  remains absent potential for de-skilling.
• Communicative Competence is not a driving licence
  that one passes for lifeneed for ongoing
  appraisal to reflect on new challenges.
• Communicative Fallacy Models of medical
  interaction analysis work with a notion of
  form-function equivalence (e.g., open questions
  patient-centredness) and thus ignore context
  sensitivity and the indexical dimension of
  language use.

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A BROADER VIEW OF COMMUNICATION

• Communication is more than information transfer
  from sender to receiver via a transparent medium,
  channel.
• Language form does not determine function.
• There is no one-to-one correspondence between
  language form and function.
• Meaning is context dependent.
• Communication is jointly accomplished moving
  away from a speaker/sender bias.

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PROFESSIONAL PRACTICE AS EXPERT SYSTEM

• Possible relationship between professional
  theories and interaction theories (Peräkylä et al
  2005)
• Different healthcare sites will prioritise
  different interactional features based upon their
  diagnostic and treatment regimes.
• Professionals knowledge of interaction is more
  sophisticated than what textbooks and training
  programmes suggest.
• Interaction is an essential component of the
  healthcare expert system. (Sarangi 2005, in
  press)

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COMMUNICATION IS A REPERTOIRE OF VARIABLES

• C Code (linguistic, visual, non-verbal etc.)
• O Orderliness
• M Message
• M Mediation
• U Understanding
• N Narrative Style Structure
• I Inferencing Intentionality
• C Context (micro- and macro-levels)
• A Audience, Addressee
• T Tone (feeling, evaluation, key etc.)
• I Identity Role
• O Objective/Goal
• N Norms (social, cultural, interpersonal)
• (Sarangi 2004)

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• INTRODUCING THE PROJECT
• PARTICIPATING SCHOOLS/COLLEAGUES

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PARTICIPATING SCHOOLS
School of Medicine Institute of Medical Genetics
School of Pharmacy
School of Healthcare Studies
School of Medicine Palliative Medicine
School of Nursing Midwifery Studies
ENCAP
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PARTICIPATING SCHOOLS COLLEAGUES

• School of English Communication Philosophy
  Professor Srikant Sarangi (Director, HCRC)
• School of Medicine Institute of Medical
  Genetics Professor Angus Clarke (Director of MSc
  in Genetic Counselling) Dr Clara Gaff (Phase 1)
• School of Medicine Palliative Medicine (Phase
  1)
• Dr Anthony Byrne (Director of MSc in Palliative
  Medicine) Professor Ilora Finlay

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PARTICIPATING SCHOOLS COLLEAGUES

• School of Nursing Midwifery Studies Dr Annette
  Lankshear (Director of Graduate Programmes) Dr
  Fran Baley (Phase 1) Ms Linda Cooper (Phase 2)
• School of Healthcare Studies Dr Nikki Phillips
  (Director of MSc in Occupational Therapy,
  Physiotherapy and Radiography) Dr Tina Gambling
  Ms Dinah Sweet Ms Dawn Pickering
• School of Pharmacy Dr Delyth James (Director of
  MSc in Community Pharmacy) Ms Karen Hodson
  (Director of MSc in Clinical Pharmacy)

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MODES OF ENGAGEMENT

• Group Meetings
• Questionnaire data
• Joint data session
• Teaching input
• Co-supervision
• Participation in HEADS seminars,
  Interdisciplinary Workshops, Summer Schools
• Recorded discussions with course directors
• Targeted data sessions (planned)

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• THE SCOPING EXERCISE
• SO FAR

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A CHECK-LIST OF PERSPECTIVES

• The historical context
• Role of professional/regulatory bodies
• The institutional ethos
• How is communication conceptualised
• Linkage between postgraduate and undergraduate
  provision
• Potential for intervention
• Challenges for implementation
• Avenues for teaching/training-led collaborative
  research

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THE HISTORICAL CONTEXT

• Tracing the origin of communication teaching
  within each strand.
• Micro-skills training based on different models
  psychoanalysis, Rogerian therapy, cognitive
  behavioural therapy, psychology etc.
• Patient-centredness as the main trigger for
  foregrounding communication issues
• In Genetic Counselling, given the complexities
  surrounding genetic disorders with no curative
  outcomes, and the long tradition of non-directive
  counselling, the onus has always been on
  communication issues.

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THE ROLE OF PROFESSIONAL BODIES

• The role of Professional bodies such as Royal
  Colleges, GMC, MNC, Department of Health and
  Learned Associations as well as directives
  arising out of government policy in bringing
  about communication teaching. Also
  recommendations from different Inquiries (e.g.,
  Bristol Inquiry).
• Differential positioning of professional bodies
• Communicative consequences resulting from changes
  in the professional sphere (e.g. striving towards
  autonomy from taking doctors orders to
  mastering the art of nursing)
• Levels of communication competencies (e.g. notion
  of advanced communication)

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INSTITUTIONAL ETHOS

• Rationale underlying current provision in
  communication teaching. What is
  included/excluded?
• How does the Cardiff provision compare with
  communication teaching portfolios in other
  comparable institutions?
• Coverage of oral and written language/communicatio
  n sites of communication such as
  professional-patient encounters,
  multi-professional team work).
• Perceived fit between the multi-faceted role of
  communication in professional practice and the
  ways in which such communicative trajectories are
  reflected in the curriculum (e.g., current
  developments in professional practice).

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INSTITUTIONAL ETHOS

• Needs-based, practice-led and research-informed
  (e.g., Pharmacy)
• Remaining responsive to what undergraduates bring
  with them in terms of knowledge, skills,
  attitude.
• Requiring prior exposure to professional practice
  so people make sense of communicative potential
  (e.g., work placement in Genetic Counselling)
• Flexibility to incorporate new input and design
  new assessments, thus allowing the possibility of
  uptake from the current project.

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HOW IS COMMUNICATION CONCEPTUALISED?

• As a skill-set? Confined to oral interaction
  between professionals and clients? Can
  communication skills be taught independent of
  consulting skills? Any evidence that
  communication skills teaching makes a difference?
  If not, is it because how communication is
  reduced to recipe-style skills?
• From communication nowhere/somewhere to
  communication everywhere.
• Communication across the curriculum as a response
  to the limitations of recipe-style skills
  training from itemised skills to skills clusters.

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HOW IS COMMUNICATION CONCEPTUALISED?

• In favour of theme-driven curriculum
  Communication now integral to other modules (e.g.
  diagnostic reasoning, compliance, multi
  agency/multi professional work)
• This marks a shift in communication as a skill to
  communication as a host of variables (gender,
  power, expertise, difficult patient etc.)
• The potential disadvantage associated with the
  shift of communication from figure status to
  ground status
• The risk of taken-for-grantedness in the midst
  of professional concerns
• How to ensure adequate communication analytic
  input?

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LINKAGE BEWEEN UG PG PROVISION

• Progressive calibration of communication
  competencies expected of students at different
  end-points
• I have done that syndrome
• Communication is a joking matter possible
  trivialisation when drawing attention to basics
  without content (e.g., nonverbal, dress code
  etc.)
• The risk of duplication of input, thus making it
  non-cumulative
• Progressively incorporate complex variables
  client-professional to multi-party encounters to
  multi-professional decision making to managing
  difficult consultations (complex diagnosis,
  ethnic/cultural differences etc.)
• More integrated, theme-based at PG level

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• FUTURE AGENDA?

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SUMMARY POINTS

• Healthcare communication is constitutive (not an
  additive layer) of expert knowledge manifest in
  its scientific, clinical and organisational
  dimensions.
• Healthcare professionals have explicit and tacit
  levels of knowledge about interactional
  complexity in their specific professional
  settings.

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SUMMARY POINTS

• Striving towards a balance between check-list
  approach, theoretical approach, experiential
  approach and analytical approach.
• The analytic processes and outcomes are equally
  complex there is a need to recognise different
  forms of analytic expertise and move towards
  discriminatory expertise, where possible.

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POTENTIAL INTERVENTION CHALLENGES

• The success story in MSc Genetic Counselling
  (teaching input and assessment) and its resource
  implications.
• Signs of change (e.g., MSc programmes in Pharmacy
  Community Pharmacy and Clinic Pharmacy New
  Nursing programme in Advanced Practice to include
  a higher dose of communication).
• How to implement an integrated, theme-oriented
  approach to communication at the level of
  teaching/assessment (apparent paradox in specific
  Away Days devoted to communication teaching and
  role-play based prescriptive model for purposes
  of learning and assessment).

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POTENTIAL INTERVENTION CHALLENGES

• Explore further scenario-based teaching (include
  discourse data simulated or real-life embedding
  professional tasks) layers of context and their
  analytic significance comparative cases of
  good and bad communication when things go
  wrong scenarios and their consequence
  apprentice-expert encounters reflective learning
  potential of self role-plays vs.
  others-in-interaction.
• From intuitive sense to analytic sensibility
  shift from how to communicate to how to
  analyse communication in effect transform
  teachers clinical experience to communication
  expertise.
• Targeted data sessions planned as part of
  analytic capacity building in the spirit of
  complementary expertise.

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POTENTIAL INTERVENTION CHALLENGES

• How to translate descriptive, analytic insights
  into communication competencies for assessment
  purposes.
• Reaching beyond already converts
  (communicatively speaking!)
• Widening access via continued participation in
  summer schools, workshops, HEADS seminars.
• Develop bibliographies of communication-based
  studies in each area.
• Maintain a portfolio of co-teaching and
  co-supervision.

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AVENUES FOR COLLABORATIVE RESEARCH

• Value of teaching/training led research agenda,
  triggered by professional concerns.
• Such research will inevitably have impact on
  teaching and professional practice (e.g.,
  Medication Review in Pharmacy).
• Analytic frameworks already exist which can be
  extended to different sites with minimum effort.
• Dissemination of findings in journals and at
  conferences (e.g., integrating communication
  skills and counselling skills in genetic
  counselling courses).

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CHALLENGES FACING THE FUTURE AGENDA

• Negotiation of curricular space for communication
  (e.g., integration as core skill can lead to
  neglect).
• Responsiveness of students to new modes of
  teaching communication.
• Staffing resources SS and training of trainers.
• Difficulty in sustaining the ongoing programme of
  activities the current inter-school scenario (in
  terms of losers and gainers) and lack of support.
• Can the barriers (not obstacles) be addressed
  at the university level?