K r i s t e n C... D a n a B u i c...

“How did I do?”: Giving useful
feedback on communication skills in
real clinical encounters
Kristen Chasteen MD, Henry Ford Hospital
Dana Buick MD, Angela Hospice
Michael Mendez MD, Henry Ford Hospital
DISCLOSURE
• We have no financial or other conflicts of interest
related to this presentation. We will not be
discussing any off-label use of medications.
ACKNOWLEDGEMENT
• Back AL, Arnold RM, Tulsky JA, Baile WF, Edwards K. "Could I add something?":
Teaching communication by intervening in real time during a clinical
encounter. Acad Med. 2010;85(6):1048-1051.
www.vitaltalk.org
DEMONSTRATION
• Floyd Johnson
• 23 yo M admitted to the ICU 3 days ago with AMS,
fever, neck stiffness
• Diagnosed with meningococcal meningitis
• Intubated for airway protection
• No improvement with antibiotics; remains
unresponsive
• MRI of the brain shows diffuse meningeal irritation,
edema, and multiple areas of cerebral infarction
• Meeting with Floyd’s mom today with the goal of
discussing this serious news
DEBRIEF
• Who has been in a situation where you were
observing someone else and the communication
was not going well?
• What did you do?
• What is challenging about intervening? What do
you say to the learner afterward?
SESSION OBJECTIVES
• Recognize that effective communication is a
teachable skill
• Describe an approach to teaching communication
skills in real clinical encounters
• Pre-encounter planning
• Intervening during the encounter
• Providing feedback after the encounter
EFFECTIVE COMMUNICATION
• Innate?
• Teachable Skill?
• How do we teach communication?
• Lectures
• Role-modeling/Observation
• Deliberate practice with timely, constructive feedback
• Deliberate practice and feedback on
communication skills does change behavior
• Residents, fellows, practicing physicians, interdisciplinary
team (physicians, nurses, social workers, psychologists,
chaplains and medical interpreters )
Fallowfield L. Br J of Cancer. 2003
Szmuilowicz E. J Pall Med. 2010
Back AL. Arch Intern Med. 2007
Meyer EC. J Perinatol. 2007
ROADMAP FOR TEACHING IN
REAL-TIME
Goal
Before the
•
Identify learning goal
encounter
•
[suggest a learner’s portion of the encounter, if applicable]
•
Negotiate Interruption
During the
•
Make specific observations usable for feedback
encounter
•
Intervene politely if needed
•
Give control back to the learner if appropriate
After the encounter •
Ask for learner self-assessment
•
Elicit positives and reinforce
•
Elicit learner’s challenges
•
Offer your own observation if learner self-assessment is
incomplete
•
Brainstorm ideas for how to respond differently
•
Take-home lesson
DEMO: BEFORE THE ENCOUNTER
• Identify learning goal
• [suggest a learner’s portion of the encounter, if
applicable]
• Negotiate Interruption
BEFORE THE ENCOUNTER
Goal
What to say
Identify a learning goal
“What communication skill do you want
to work on in this next encounter?”
“Where have you felt stuck in the past?”
[suggest a learner’s portion of the “How about if you lead the conversation
encounter, if applicable]
about [X] and I’ll discuss [Y]?”
Negotiate Interruption
“If you feel stuck, look over at me or ask
if I have anything to add; I might also join
in if I have concerns that that the patient
needs something.”
CHALLENGES?
• Challenge: Learner cannot name a learning goal
• Strategy: Name common issues that other learners
face
• Challenge: Learner is anxious
• Strategy: Respond to learner emotion with
empathy. Discuss a small learning goal so learner
can achieve success.
RATIONALE
• Learners are more engaged when they are working
toward goals they have chosen
• Allows discussion of specific communication skills
ahead of time so the learner is prepared
• Helps assess the learner’s skill level and allows for
negotiating that the learner do part of the
encounter if needed
• Normalizes the process of faculty intervention as
expected and helpful for the learner and patient
DEMO: DURING THE ENCOUNTER
• Ensure the patient knows the learner is the primary
speaker
• Make specific observations usable for feedback
• Intervene politely if needed
• Give control back to the learner if appropriate
DURING THE ENCOUNTER
Goal
What to say
Ensure the patient knows the learner is “We work together, so as
the primary speaker
[learner] explains things I may
add a point occasionally.”
Make specific observations usable for
feedback
Take notes with specific
words/phrases
How to intervene politely
“May I add a something here?”
How to give control back to the
learner
“[Learner], could I ask you to
finish up by talking about the
next steps from here.”
HOW TO YOU DECIDE WHEN/IF YOU
INTERVENE?
• Is the patient at risk of being harmed?
• Is the learner emotionally overwhelmed or clearly
struggling to find the right words?
• Is the learner aware that things are not going well?
• Does the learner have the ability to get out of the situation?
RATIONALE
• Learners need to practice; passive observation is
not effective alone
• Patients/families need effective communication
and emotional support
• Interrupting and taking over without warning can
make the learner embarrassed and cause the
patient to lose trust in the learner
• Polite intervention and returning the encounter to
the learner can best meet the learner and patient’s
needs
DEMO: AFTER THE ENCOUNTER
Ask for learner self-assessment
Elicit positives and reinforce
Elicit learner’s challenges
Offer your own observation if learner self-assessment
is incomplete
• Brainstorm ideas for how to respond differently
• Elicit a take-home lesson
•
•
•
•
AFTER THE ENCOUNTER: FEEDBACK
Goal
What to say
Ask for learner self-assessment
“When you tried what you wanted to
practice, how did it go?”
Elicit positives and reinforce
“What went well?”
Elicit learner’s challenges
“Looking back, anything that you would have
done differently?”
“Where did you feel stuck?”
Offer your own observation if learner
“I noticed that after you said X, the patient
self-assessment is incomplete
did/said Y. Did you notice that?”
Brainstorm ideas for how to respond
“Let’s discuss some ideas for how you might
differently
respond differently next time.”
Elicit a take-home lesson
“What did you learn from this encounter that
you will do differently next time?”
CHALLENGES?
• Challenge: I noticed 5 areas where they could
improve
• Strategy: Stick to learner-directed feedback on 1-2
things. Make note of the other items for next time.
• Challenge: What if the learner doesn’t notice where
they went wrong?
• Strategy: “I noticed that after you said [x], the
patient did/said [Y]. Did you notice that?”
RATIONALE
• The role of feedback is to help a learner consistently
use high quality communication skills in future
encounters
• Highlight specific positive skills that they are using so the
learner knows to use them more frequently
• Provide specific suggestions for what the learner could
improve for the next time
• Learners will only be able to process 1-2 pieces of
feedback on what to improve at a time without
feeling overloaded
SUMMARY
• Effective communication skills can be taught
• Deliberate practice is one way to teach
communication skills successfully and can be
incorporated into real clinical encounters
• Pre-encounter : planning and learning goal
• During the encounter: Careful observation and polite
intervention if needed
• After the encounter: Specific, feedback on what went well
and one thing that could be done better next time
HOW WILL YOU CHANGE YOUR
TEACHING?
REFERENCES
1.
2.
3.
4.
5.
6.
7.
Ambrose S, Bridges M, DiPietro M. How Learning Works: Seven Research-Based Principles
for Smart Teaching. 1st ed. Jossey-Bass; 2010.
Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving
bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167(5):453460.
Back AL, Arnold RM, Tulsky JA, Baile WF, Edwards K. "Could I add something?": Teaching
communication by intervening in real time during a clinical encounter. Acad Med.
2010;85(6):1048-1051.
Fallowfield L, Jenkins V, Farewell V, Solis-Trapala I. Enduring impact of communication
skills training: Results of a 12-month follow-up. Br J Cancer. 2003;89(8):1445-1449
Meyer EC, Brodsky D, Hansen AR, Lamiani G, Sellers DE, Browning DM. An
interdisciplinary, family-focused approach to relational learning in neonatal intensive
care. J Perinatol. 2011;31(3):212-219. Thomas JD, Arnold RM. Giving feedback. J Palliat
Med. 2011;14(2):233-239.
Szmuilowicz E, el-Jawahri A, Chiappetta L, Kamdar M, Block S. Improving residents' endof-life communication skills with a short retreat: A randomized controlled trial. J Palliat
Med. 2010;13(4):439-452.
Thomas JD, Arnold RM. Giving feedback. J Palliat Med. 2011;14(2):233-239.
RECOMMENDED READING
THANK YOU!
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Rana Awdish – [email protected]
Dana Buick - [email protected]
Kristen Chasteen – [email protected]
Michael Mendez – [email protected]
Maria Kokas
Cari Williamson