Jan C. Wouda

Education in patient–physician communication: How to improve effectiveness?

OBJECTIVE Despite educational efforts expertise in communication as required by the CanMEDS competency framework is not achieved by medical students and residents. Several factors complicate the learning of professional communication. METHODS We adapted the reflective-impulsive model of social behaviour to explain the complexities of learning professional communication behaviour. We formulated recommendations for the learning objectives and teaching methods of communication education. Our recommendations are based on the reflective-impulsive model and on the model of deliberate practice which complements the reflective-impulsive model. Our recommendations are substantiated by those we found in the literature. RESULTS The reflective-impulsive model explains why the results of communication education fall below expectations and how expertise in communication can be attained by deliberate practice. The model of deliberate practice specifies learning conditions which are insufficiently fulfilled in current communication programmes. CONCLUSION The implementation of our recommendations would require a great deal of effort. Therefore we doubt whether expertise in professional communication can be fully attained during medical training. PRACTICE IMPLICATIONS We propose that the CanMEDS communication competencies not be regarded as endpoints in medical education but as guidelines to improve communication competency through deliberate practice throughout a professional career.

Assessment of physician competency in patient education: Reliability and validity of a model-based instrument

OBJECTIVE Establish the inter-rater reliability and the concept, convergent and construct validity of an instrument for assessing the competency of physicians in patient education. METHODS Three raters assessed the quality of patient education in 30 outpatient consultations with the CELI instrument. This instrument is based on a goal-directed model of patient education and assesses distinctive skills for patient education categorized in four subcompetencies. The inter-rater reliability was calculated. The concept validity was explored by factor analysis. The convergent validity was established by a comparison with two measures of patient-centred behaviour. The construct validity was explored by relating the subcompetencies with physician gender and patient satisfaction. RESULTS The inter-rater reliability for the subcompetencies varied between 0.65 and 0.91. The factor analysis distinguished the four subcompetencies. All subcompetencies correlated with the measures of patient-centred behaviour. Female physicians performed better than male physicians on three subcompetencies. Positive correlations were found for three subcompetencies and patient satisfaction. CONCLUSION The CELI instrument appears to be a reliable and valid instrument. However, further research is needed to establish the generalizability and construct validity. PRACTICE IMPLICATION The CELI instrument is a useful tool for assessment and feedback in medical education since it assesses the performance of distinctive skills.

Pathways towards designing effective medical communication curricula

Already in 1957 in his book ‘‘The doctor, his patient and the illness’’ Michael Balint stressed the importance of good patient– physician communication [1]. He recognized that the interpersonal behaviour of the physician could have a healing impact on the patient, regardless of the treatment, and he asked for recognition of the emotional as well as the physical aspects of a patient’s complaint. He was probably the first to advocate the skills of attentive listening to patients. Since then, the teaching of communication skills became more and more implemented in medical schools and communication teachers tried to establish which communication skills are essential for practising physicians and should be taught to medical students. In 1991 the first (Toronto) consensus statement about the content of a medical communication curriculum appeared [2] followed by many other consensus statements [3–9]. The first consensus statements were mainly based on the opinions of experts in the field, but gradually empirical research of favourable outcomes of skill performance also determined the content of statements. However, consensus statements were mainly formulated for medical curricula. Consensus statements for non-medical professions were much less developed and consensus statements for inter-professional communication education did not exist. Thus, a group of EACH members developed a more comprehensive consensus statement which contains learning objectives for patient–provider communication as well as for inter-professional communication and for communication in health care teams. In this issue of PEC Bachmann et al. [10] present this consensus statement which includes 61 learning objectives for a Health Professions Core Communication Curriculum (HPCCC) for all undergraduate education in health care in Europe. The consensus statement is built on the opinions of 121 communication experts from 15 professional fields and 16 European countries. Although a consensus statement can be a useful tool for the structuring of learning objectives that are to be dealt with in a communication curriculum, a mere list of learning objectives can also be a drawback since it does not take into account the context in which the skills have to be performed and assessed. Therefore, Street and de Haes [11] propose in this issue of PEC a functional model of medical communication which specifies seven key communication goals and desired outcomes that need to be accomplished in order to have quality health care. These seven key functions represent the communication tasks and identify the corresponding skills students are expected to learn in order to accomplish desired outcomes. The functional approach offers an advantage for the teaching and assessment of health care communication over a consensus approach, since it stresses that

How to attain expertise in clinical communication

Several factors complicate the attainment of expertise in clinical communication. Medical curricula and postgraduate training insufficiently provide the required learning conditions of deliberate practice to overcome these obstacles. In this paper we provide recommendations for learning objectives and teaching methods for the attainment of professional expertise in patient education. Firstly, we propose to use functional learning objectives derived from the goals and strategies of clinical communication. Secondly, we recommend using teaching and assessment methods which: (1) contain stimulating learning tasks with opportunities for immediate feedback, reflection and corrections, and (2) give ample opportunity for repetition, gradual refinements and practice in challenging situations. Video-on-the-job fits these requirements and can be used to improve the competency in patient education of residents and medical staff in clinical practice. However, video-on-the-job can only be successful if the working environment supports the teaching and learning of communication and if medical staff which supervises the residents, is motivated to improve their own communication and didactic skills.

Professional: A Sexologist Who Overstepped the Mark – How to Handle the Therapeutic Relationshop in Psychosocial Care

For therapists, who work according to the biopsychosocial model (BPS model), conversations with the patient are their main tool used for diagnostics and interventions. Other forms of communication—such as questionnaires, written information, and websites—can be used as supplementary material. To ensure that his or her conversations with a patient are effective and efficient, the therapist must build up a good relationship with that patient. This chapter is about the characteristics of the care relationship generated by the biopsychosocial model. We will be focusing mainly on the characteristics of the therapeutic relationship. The care relationship as the basis for a diagnostic conversation will be discussed only in passing.

Communicator: The Gynecologist Who Could Not Convince His Patients

The first meeting with a patient is usually devoted to identifying the patient’s health problem or healthcare needs. The biopsychosocial (BPS) model works with a broad definition of “the problem.” The gynecologist, midwife, etc.—for the sake of brevity, from this point on, we will use the term “health professional”—try to gain as complete as possible a picture of the reason why the patient has come, the medical problem (diagnosis), and any additional problems or issues the patient may have, whether they are physical, mental, or social. In other words, the health professional not only pays attention to the physical manifestations of a complaint but also assesses the patient’s care request. On the basis of this assessment, the health professional maps out the mental and social components, causes, and consequences of the problem. In this chapter, we will focus exclusively on the educational information and guidance you give your patients in this context.

A Historical Perspective on Patient Education in Clinical Practice and in Medical Education

Over the last 50 years, communication skills training (CST) has been a regular part of medical education in most Western countries. However, until recently, CST programs mainly focused on the skills of history-taking, and patient-education skills were less addressed. With patient education, we refer to the use of educational methods, such as the provision of information, advice, and behavior modification techniques, to influence the patients’ knowledge, opinions, and health and illness behavior in order to ensure that the patient is able to collaborate effectively in deciding on the care that she or he receives and can make the best possible contribution to that care. Furthermore, CST programs in medical and other healthcare education are usually limited to training activities isolated from clinical practice. As a consequence, most healthcare staff has been insufficiently prepared for their patient-education tasks in clinical practice. In order to understand the deficiencies in patient-education skills of healthcare workers, especially of those adhering to the biopsychosocial model of care, this chapter provides a historical overview of patient education in clinical practice and in medical training. The critical-reflections paragraph that concludes this chapter contains some recommendations to remedy these deficiencies.

Collaborator: A Midwife Who Had a Conflict with an Obstetrician—How to Transform “Contact Tics” into “Co Tactics”

Although professional collaboration is nowadays recognized as of vital importance for the quality and safety of health care (organizations), this is especially the case in psychosomatic obstetrics and gynecology (POG). The scientific fundament for the psychosomatic approach is the biopsychosocial (BPS) model. As the name indicates, the key characteristic of this model is the combination of insights from several disciplines, including biology, psychology, and sociology. This requires the ability to collaborate with colleagues with different backgrounds in order to establish true co-creation in highly reliable teams and organizations. Because mistakes are unavoidable, collaboration relies on correction mechanisms to transform “contact tics” into “co tactics.” To do this, healthcare professionals must be willing and able to make their egos subservient to the treatment team. On the other hand, this ecosystem must be able to adapt to overarching cultural and scientific changes, which means that healthcare professionals must also create learning organizations by collaborating with each other. At the end of this chapter, we will discuss the learning organization concept in more detail. First we will focus on collaboration as defined in the CanMEDS approach.