Wemke Veldhuijzen

Much variety and little evidence: a description of guidelines for doctor-patient communication

Aim  To explore the quality of the content of communication skills training programmes, we analysed and assessed guidelines for doctor–patient communication used in communication programmes for general practitioner (GP) trainees.

“Doctor, please tell me it’s nothing serious”: an exploration of patients’ worrying and reassuring cognitions using stimulated recall interviews

BackgroundMany patients who consult their GP are worried about their health, but there is little empirical data on strategies for effective reassurance. To gain a better understanding of mechanisms for effective patient reassurance, we explored cognitions underlying patients’ worries, cognitions underlying reassurance and factors supporting patients’ reassuring cognitions.MethodsIn a qualitative study, we conducted stimulated recall interviews with 21 patients of 12 different GPs shortly after their consultation. We selected consultations in which the GPs aimed to reassure worried patients and used their videotaped consultation as a stimulus for the interview. The interviews were analysed with thematic coding and by writing interpretive summaries.ResultsPatients expressed four different core cognitions underlying their concerns: ‘I have a serious illness’, ‘my health problem will have adverse physical effects’, ‘my treatment will have adverse effects’ and ‘my health problem will negatively impact my life’. Patients mentioned a range of person-specific and context-specific cognitions as reasons for these core cognitions. Patients described five core reassuring cognitions: ‘I trust my doctor’s expertise’, ‘I have a trusting and supporting relationship with my doctor’, ‘I do not have a serious disease’, ‘my health problem is harmless’ and ‘my health problem will disappear.’ Factors expressed as reasons for these reassuring cognitions were GPs’ actions during the consultation as well as patients’ pre-existing cognitions about their GP, the doctor-patient relationship and previous events. Patients’ worrying cognitions were counterbalanced by specific reassuring cognitions, i.e. worrying and reassuring cognitions seemed to be interrelated.ConclusionsPatients described a wide range of worrying cognitions, some of which were not expressed during the consultation. Gaining a thorough understanding of the specific cognitions and tailoring reassuring strategies to them should be an effective way of achieving reassurance. The identified reassuring cognitions can guide doctors in applying these strategies in their daily practice.

Managing the complexity of doing it all: an exploratory study on students’ experiences when trained stepwise in conducting consultations

BackgroundAt most medical schools the components required to conduct a consultation, medical knowledge, communication, clinical reasoning and physical examination skills, are trained separately. Afterwards, all the knowledge and skills students acquired must be integrated into complete consultations, an art that lies at the heart of the medical profession. Inevitably, students experience conducting consultations as complex and challenging. Literature emphasizes the importance of three didactic course principles: moving from partial tasks to whole task learning, diminishing supervisors’ support and gradually increasing students’ responsibility. This study explores students’ experiences of an integrated consultation course using these three didactic principles to support them in this difficult task.MethodsSix focus groups were conducted with 20 pre-clerkship and 19 clerkship students in total. Discussions were audiotaped, transcribed and analysed by Nvivo using the constant comparative strategy within a thematic analysis.ResultsConducting complete consultations motivated students in their learning process as future physician. Initially, students were very much focused on medical problem solving. Completing the whole task of a consultation obligated them to transfer their theoretical medical knowledge into applicable clinical knowledge on the spot. Furthermore, diminishing the support of a supervisor triggered students to reflect on their own actions but contrasted with their increased appreciation of critical feedback. Increasing students’ responsibility stimulated their active learning but made some students feel overloaded. These students were anxious to miss patient information or not being able to take the right decisions or to answer patients’ questions, which sometimes resulted in evasive coping techniques, such as talking faster to prevent the patient asking questions.ConclusionThe complex task of conducting complete consultations should be implemented early within medical curricula because students need time to organize their medical knowledge into applicable clinical knowledge. An integrated consultation course should comprise a step-by-step teaching strategy with a variety of supervisors’ feedback modi, adapted to students’ competence. Finally, students should be guided in formulating achievable standards to prevent them from feeling overloaded in practicing complete consultations with simulated or real patients.

‘No need to worry’: an exploration of general practitioners’ reassuring strategies

BackgroundIn view of the paucity of evidence regarding effective ways of reassuring worried patients, this study explored reassuring strategies that are considered useful by general practitioners (GPs).MethodsIn a study using a qualitative observational design, we re-analysed an existing dataset of fifteen stimulated recall interviews in which GPs elaborated on their communication with patients in two videotaped consultations. Additionally we held stimulated recall interviews with twelve GPs about two consultations selected for a strong focus on reassurance.ResultsTo reassure patients, GPs pursued multiple goals: 1. influencing patients’ emotions by promoting trust, safety and comfort, which is considered to be reassuring in itself and supportive of patients’ acceptance of reassuring information and 2. influencing patients’ cognitions by challenging patients’ belief that their symptoms are indicative of serious disease, often followed by promoting patients’ belief that their symptoms are benign. GPs described several actions to activate mechanisms to achieve these goals.ConclusionsGPs described a wealth of reassuring strategies, which make a valuable contribution to the current literature on doctor-patient communication. This detailed description may provide practicing GPs with new tools and can inform future studies exploring the effectiveness of reassurance strategies.

Vaardig communiceren : ervaringen van aios en opleiders

SamenvattingGiroldi E, Veldhuijzen W, Geelen K, Muris J, Bareman F, Bueving H, Van der Weijden T, Van der Vleuten C. Vaardig leren communiceren met patiënten: ervaringen van aios en opleiders. Huisarts Wet 2017;60(11):558-9. De huisartsopleiding onderschrijft het belang van ‘vaardige arts-patiënt communicatie’ – communicatie die zich voegt naar de situatie – en is bezig het curriculum daaraan aan te passen. In een aantal focusgroepinterviews, onderwijsbijeenkomsten en individuele interviews onderzochten we hoe aios (arts-in-opleiding tot specialist) vaardige communicatie leren en hoe opleiders hen daarbij kunnen ondersteunen. We vonden dat aios via een iteratieve leercyclus een persoonlijk communicatierepertoire ontwikkelen. Opleiders kunnen dit leerproces ondersteunen door aios concrete voorbeeldzinnen aan te reiken die ze kunnen uitproberen, om vervolgens samen te evalueren hoe deze uitgepakt hebben.

Developing skilled doctor–patient communication in the workplace: a qualitative study of the experiences of trainees and clinical supervisors

To inform the development of recommendations to facilitate learning of skilled doctor–patient communication in the workplace, this qualitative study explores experiences of trainees and supervisors regarding how trainees learn communication and how supervisors support trainees’ learning in the workplace. We conducted a qualitative study in a general practice training setting, triangulating various sources of data to obtain a rich understanding of trainees and supervisors’ experiences: three focus group discussions, five discussions during training sessions and five individual interviews. Thematic network analysis was performed during an iterative process of data collection and analysis. We identified a communication learning cycle consisting of six phases: impactful experience, change in frame of reference, identification of communication strategies, experimentation with strategies, evaluation of strategies and incorporation into personal repertoire. Supervisors supported trainees throughout this process by creating challenges, confronting trainees with their behaviour and helping them reflect on its underlying mechanisms, exploring and demonstrating communication strategies, giving concrete practice assignments, creating safety, exploring the effect of strategies and facilitating repeated practice and reflection. Based on the experiences of trainees and supervisors, we conclude that skilled communication involves the development of a personal communication repertoire from which learners are able to apply strategies that fit the context and their personal style. After further validation of our findings, it may be recommended to give learners concrete examples, opportunities for repeated practise and reflection on personal frames of reference and the effect of strategies, as well as space for authenticity and flexibility. In the workplace, the clinical supervisor is able to facilitate all these essential conditions to support his/her trainee in becoming a skilled communicator.

Reaction to Jonathan Silverman

Silverman, Kurz and Draper [1] argue that in the discussion of our paper ‘‘Communication guidelines as a learning tool: An exploration of user preferences in general practice’’ [2] we incorrectly refer to the Calgary Cambridge guides [3] as an example of a guideline which has no temporal sequence. We agree that we should have mentioned that part of the Calgary Cambridge guides indeed has a temporal sequence. The Calgary Cambridge guides are mostly temporally organised, but not strictly so. In our paper, we state that with regard to the structure of a guideline, the users in our study prefer that recommendations are organised in conceptually different, chronological parts, each with different tasks. This statement refers to all recommendations within a guideline. Our users perceive the combination of chronologically organised recommendations and recommendations for the entire consultation within one guideline, as is done in the Calgary Cambridge Guides, as a cognitive burden. One might argue, and I expect that Silverman, Kurz and Draper probably would, that fitting all recommendations in a temporal sequence, lowers the validity of guidelines, as they evidently consider some of their recommendations relevant in all parts of a consultation. As we point out in the discussion of our paper, there seems to be a tension between our users’ preference for low complexity of communication guidelines, and their suggestions to improve the validity of communication guidelines by making them more situation specific, which would probably make guidelines more complex. A similar tension may exist between user-preferences for a completely temporal organisation of recommendations and users’ demands for more valid guidelines.