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Clinical communication skills year 1 introduction
1. CCS Course Year 1 NRMSM
Clinical Communication
The Calgary Cambridge Guide
2012
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2. Clinical Communication
Effective clinical communication is central to clinical
competence and plays an essential role in high-
quality healthcare
Communication is a learnt skill
Integration is vital (knowledge, communication,
practical skills including physical examination,
problem solving)
Teaching and assessment of clinical communication
have become formal components of undergraduate
medical curriculae
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3. Clinical Communication
There is overwhelming evidence for the positive
effect of communication training
It enables more effective interviews, enhanced
patient and professional satisfaction AND improved
health outcomes for patients eg adherence, patient
safety and medico-legal issues
Teaching and research in communication are inter-
dependent
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4. Special Issues in
Communication
Age-specific areas
Cultural and social diversity
Handling of emotions and challenging situations
Specific clinical contexts eg psychiatry, work in
emergency medicine
Specific explanation and planning skills eg informed
consent, risk management, health promotion and
behaviour change
Dealing with uncertainty
Sensitive issues – breaking bad news,
bereavement, sexual issues, areas involving
stigmatisation eg child abuse, HIV infection
Communication with colleagues and inter-
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5. Barriers to effective
communication
Personal attitudes
Language
Time constraints
Working environment
Lack of knowledge and inconsistency
Human failings (tiredness, stress)
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8. And back at NRMSM – communication and
topical issues in our context……
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9. Overview of the Calgary-
Cambridge Guides
These assist in providing a comprehensive
clinical method which can be used
successfully in many contexts
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10. Clinical Method: The “Map”
1. What information are you trying to obtain and how you are
going to do this ?– the basics of:
symptom analysis (problem/s)
relevant background information – 1st
Year
(Initiating the session, Gathering information, Building the
relationship, Providing structure)
2. Introduction to the Physical examination – 2nd
and 3rd
Year
3. Explanation and Planning – includes lifestyle and
behaviour modification, management of disease – some in
2nd
and 3rd
Year, but mainly in the clinical years
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11. Initiating the session
Gathering information
Physical examination
Explanation and planning
Closing the session
Providing
structure
Building the
relationship
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12.
The content of the medical interview
Patient’s problem list
1.
2.
3.
Exploration of patient’s problems:
Biomedical perspective
sequence of events, symptom analysis, relevant systems review
Patient’s perspective
ideas, concerns, expectations, effects on life, emotions, beliefs, “ICE”
Background information - context
Past medical history
Family history
Personal and social history
Drug and allergy history
Systems review
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13. exploration of the patient’s problems to discover the:
biomedical perspective the patient’s perspective
background information - context
providing the correct type and amount of information
aiding accurate recall and understanding
achieving a shared understanding: incorporating the
patient’s illness framework
planning: shared decision making
Initiating the session
Gathering information
Physical examination
Explanation and planning
Closing the session
Providing
structure
Building the
relationship
preparation
establishing initial rapport
identifying the reasons for the consultation
making
organisation
overt
attending to
flow
using
appropriate
non-verbal
behaviour
developing
rapport
involving
the patient
ensuring appropriate point of closure
forward planning
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14. Initiating the interview - establishing rapport
Greet and check patient’s name and details
Introduce yourself
Explain your role as a student
Gain consent
Explain the nature and timing of interview
Ensure patient comfort and appropriate
setting
Non-verbal communication is vital
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15. Initiating the interview – getting an overview
Start off with an opening question – use an
open enquiry technique
If you only get a brief answer, acknowledge
and ask further information or for narrative
Listen attentively - “wait time” is NB
Use verbal and non-verbal facilitation
Pick up patient’s cues
Summarise disease and illness
Screen for other complaints
Approach is collaborative
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16. Gathering information – delving deeper
Signpost to sequence of events
Encourage narrative thread
Use open questioning methods
Listen attentively
Use a facilitative approach – process skills
Use more focused open questions
Pick up disease and illness cues
Clarify and time-frame
Summarise disease and illness
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17. Gathering information – delve even deeper
Signpost to:
Analysis of each symptom (start with an
open question)
Chronological history of events
Relevant systems review
Signpost to:
Questions on “ICE” (ideas, concerns and
expectations) and feelings/beliefs/effects
on activities of daily living
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18. content to be discovered:
the bio-medical perspective the patient’s perspective
(disease) (illness)
sequence of events ideas and concerns
symptom analysis expectations
relevant systems review effects
feelings and thoughts
background information - context
past medical history
drug and allergy history
social history
family history
systems review
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19. Gathering Information
process skills for exploration of the patient’s problems
(the bio-medical perspective and the patient’s perspective)
•patient’s narrative
•question style: open to closed cone
•attentive listening
•facilitative response
•picking up cues
•clarification
•time-framing
•internal summary
•appropriate use of language
•additional skills for understanding patient’s perspective
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20. Providing Structure
Makes organisation overt
Summarises and relates to conceptual
framework
Moves from one section to another using
signposting
Allows reflection on what “went well”
Attends to flow
Makes sequence logical
Attends to timing and keeping the interview on
track
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21. Building the Relationship
Appropriate non-verbal behaviour – eye contact,
expression, posture
Ensure note-taking does not interfere with
rapport
Accept patient’s views
Be non-judgemental and sensitive
Provide or offer support
Involve the patient – share thinking and explain
rationale for questions or parts of the
examination
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22. Closing the Session
Give any provisional information clearly
(avoid jargon)
Check patient understanding and acceptance
of explanation and plans
Provide opportunity for questions and
discussion
Summarise the session and contract with
patient re next steps
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23. PATIENT PRESENTS CUES OF UNWELLNESS
DOCTOR SEARCHES
TWO PARALLEL AGENDAS
DOCTOR’S AGENDA
History
Physical Examination
Laboratory Investigation
PATIENT’S
AGENDA:
Ideas
Fears
Expectations
Effect on function
DIFFERENTIAL DIAGNOSIS UNDERSTANDING ILLNESS
EXPERIENCE
INTEGRATIO
N
THE PATIENT- CENTRED CLINICAL
METHOD
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24. Summary: Exploration of both the
doctor’s and the patient’s
perspective
Sequence of events – open enquiry, narrative,
LISTEN, clarify and time-frame, respond to cues,
summarise and clarify biomedical perspective
Further analysis of each problem and systems
review (more applicable in clinical years) and
signpost to:
Discovering the background information – here may
use increasingly directed questions and signpost to:
Further exploration of patient’s perspective
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25. How is communication taught?
Students are exposed to a range of learning
activities which are experiential in nature
Components include active small group learning,
observation and review (may include video/audio
recording), constructive feedback and rehearsal with
simulated patients and the group using common
scenarios
Communication is integrated into the curriculum,
with a spiral approach and increasing complexity
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26. Further details for our
introductory CCS sessions
Personal details and background
Clarify
Medical terms
eg diarrhoea, constipation, stomach-ache
Semi-medical terms
eg wind, dizziness, indigestion
Non-medical terms
eg sharp, chronic
Diagnosis
eg migraine, allergy, asthma
Symptoms vs signs
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28. Systems review
General
Cardiovascular
Respiratory
Gastrointestinal
Nervous
Psychiatric
Skin, locomotor
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29. Systems review
General symptoms
These are often non-specific – may indicate
various conditions or multi-system disease
Fatigue
Malaise
Fever
Sleep disturbance
Skin, nail or hair changes
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30. Past medical history
Severe illnesses, visits to other doctors or
admissions
Surgical operations
Accidents
Pregnancies
Medical examinations
Occupation, insurance
Some examples : rheumatic fever, measles,
whooping cough, TB, jaundice
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31. Medication and allergies
Treatment
Prescribed
OTC
Recreational
Traditional or alternative
Allergies - NB
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32. Family history
Ask about parents and siblings first
NB not only wrt to current condition but any
illness
Specific conditions
Genogram, genetic advice
Quantifying risk
Indication of cause or agent
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33. Personal and social history
Home: Ask about spouse and children,
domestic arrangements
Work: Occupation, environmental factors
Habits: Alcohol, tobacco - details
Diet: caffeine, salt etc
Exercise
Other: travel, hobbies, pets
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34. Summary: Objectives of
training sessions
Exploring the “what” of communication
Exploring the “how” of communication and using the
Calgary-Cambridge guides to help organise
teaching and learning
Exploring our own skills and reflecting on these
Becoming aware of the structure in the medical
interview, and of process as well as content
Increasing our confidence in our own abilities
Deepening our awareness of the patient’s
perspective and the importance of doctor-patient
communication in our own setting/s and the South
African context as a whole
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35. Summary: Sessions and
Assessment
CCS sessions in Year 1 with simulated
patients
You will be assessed in an OSCE (more
emphasis on process skills than on content in
Year 1)
In the sessions, you will be expected to be
able to concisely sum up your assessment of
the patient’s problem/s after a patient-centred
interview, using….
a basic bio-medical and patient perspective,
and providing some background information
or context
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36. References:
Teaching clinical communication: A mainstream activity
or just a minority sport? Silverman, J Patient Education
and Counselling 2009; 76: 361-367
UK consensus statement on the content of
communication curricula in undergraduate medical
education Von Fragstein, Silverman et al Medical
Education 2008; 42: 1100-1107
Agenda-led Outcome-based Analysis Kurtz SM,
Silverman JD, Draper J (2005) Teaching and Learning
Communication Skills in Medicine (Second Edition).
Radcliffe Publishing (Oxford and San Francisco)
Previous lecture by Dr Mergan Naidoo, Family Medicine
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37. Session 2 – Learning
Objectives
Exploration of what makes a good doctor
From the doctors’ perspective
From the patients’ perspective
Exploration of the doctor-patient relationship
Understanding of the importance of the
medical interview/ clinical method
Understanding of a patient-centred method
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38. Discussion with the class
Individual motivation for becoming a doctor
Any role-models?
Discussion of previous medical
encounters....what was it like to be the
patient?
On what attributes did you judge the doctor?
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40. All students will receive a copy of the
Calgary-Cambridge guide in this week’s
sessions – please retain it as it will be used in
subsequent years and in Family Medicine.
Bring your guide to all communication
sessions!
Thank you for your attention!
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So back to clinical method So far we have really only started the process of how to interview patients and what you are looking for You have interviewed real patients, worked with your associate supervisors on the wards, worked with simulated patients, and had a chance to look at the cardiovascular and respiratory symptoms and signs PowerPoints and videos on the ER Web How has that gone? Confused? Need help? Has it all happened, have you seen your clinical supervisors yet? We now want to move you help you by looking at what information in general you are trying to obtain and how you are going to obtain it. Both in terms of interviewing the patient and examining them And the key areas that we are going to cover are: symptom analysis background information introduction to the physical examination
You have been mostly concentrating on initiating the session plus some gathering information, particularly of the narrative. You have also been considering how to provide structure for the patient and how to build the relationship
This is a reminder of what information you are looking for. At the end of the day, this is the information you need to present a patient’s story to a colleague or to write information in the notes
And we have been giving you an overall structure to help you organise what you are trying to do And by now, I hope you know that you need to do different things in the initiating the session phase from the gathering information phase and you need to intentionally and purposefully employ different skills. You also know that you need to spend a lot of time building the relationship and structuring the whole session Show some evidence for each part!!
Particularly concentrate on explaining nature and timing of interview and not a wee chat
Now we look at how to get an overview of the issues before exploring any one in more depth. picking up and responding to patient cues shortens rather than lengthens visits (Levinson et al 2000) The importance of screening – why open directive questions about a specific symptom work in the opposite direction than in the gathering information part of the history (Beckman and Frankel) Joos – screening and planning in internal medicine reduces the length of the visit
Then I hope most of you have been looking at how to develop the sequence of events by encouraging the narrative and asking open questions. I am sure the value of picking up disease and illness cues has come up as well as summarising both disease and illness resolution of symptoms of chronic headache is more related to the patient’s feeling that they were able to discuss their headache and problems fully at the initial visit with their doctor than to diagnosis, investigation, prescription or referral (The Headache Study Group 1986)
consultations using a structured exploration of patients' beliefs about their illness and medication and specifically addressing understanding, acceptance, level of personal control and motivation leads to improved clinical control or medication use even three months after the intervention ceased (Dowell et al 2002) This is the first of the new areas that Paul is going to tell you about. How to analyse each symptom and then discover the relevant systems review. My two additions in terms of process here are: the need to explain to the patient exactly what you want them to help you with . Please always signpost this change in direction by saying something like “I’d like now to discover some more detail about the chest pain that you are having”. the need to always start open and then move closed . So start with “can you tell me more about the chest pain please” and then move into specific closed questions later to gather information about areas you have not discovered yet
Again, let us look at content first. All these areas are very important. They provide the context in which the patient’s current problems occur. Please however do not confuse the background information with the patient’s perspective. Ideas concerns and expectations are not the same as the social history for instance. Quote orthopaedic ward and banter about home life but not discovering what the patient was concerned about
2. Do remember not to confuse content with how you obtain it – always start with an open question and move eventually to closed questions as a cone which you repeat repeatedly – first for PMH etc 3. And always remember that even in areas such as past medical history and family history, both disease and illness issues will come out and will need you to be sensitive in exploring further: e.g. my father died of cancer last week, response “good” or “any one else with cancer in the family”