Communication Competency and

Counseling Practicum

Mary Dankoski, Ph.D.Kathy Zoppi, Ph.D., M.P.H

Shobha Pais, Ph.D.Scott Renshaw, M.D.Dustin Wright, M.S.

OBJECTIVES

Attendees will understand… The assessment of communication

competency at resident levels of training

The utility of counseling practicum and competency assessment strategies

Communication In Family Medicine

“Black Box” study (Stange et. al., 1998)

Family assessment – 73% Answering patient questions – 71% Negotiation – 21% Counseling – 16% Patient Education – 18-26%

Distinction between interaction and relationship “Communication skills do not constitute

the doctor-patient relationship” (Candib, 1995, p.213)

Key concept of connection as lens (vs. separation) from feminist theory

Patient and physician are not independent actors, but are mutually influential

Emotional involvement of both is key

National consensus about communication training

Patient-centered care improves health outcomes

(Kalamazoo Consensus statement)

Errors decreased by improved training

(To Err is Human, IOM)

Health Disparities (Unequal Treatment, IOM)

Communication competence As property of

individual Assessment of

individual skills, abilities, or behaviors (rating of trainee)

As property of interaction

Assessment focuses on interactional or dyadic qualities, including adaptation, control, collaboration (rating of interaction)

Communication competence: approaches

Communication skills Conflict management Teamwork Teaching others (pts, students,

peers)Epstein and Hundert, JAMA, 2002

Implication of relational viewpoint of assessment

Focus is longitudinal Focus is cumulative Focus is on participants’ sense of

connection, satisfaction May be observable by non-

participants

Methods for Teaching Communication

Didactic sessions (lectures/demonstrations)

Standardized patients Role play Video-tape review (with real or SP) Co-counseling sessions Observed counseling sessions

Layered levels of communication competence

Content level: topic management, nonverbal cues/clues

Process: pacing, facilitation, congruence, nonverbal matching, affective displays

Meta-process: mindfulness, self-observation, context-sensitivity

Why is communication competence important?

Facilitation of information exchange

Development of a healing relationship

Mutual development of patient and physician (Candib, 1996)

“Ways of Knowing” and Medicine Traditional Medical

Education Procedural and Separate

Knowing Critical thinking, objectivity Limited for learning about person

living the illness May be experienced as distant

and sterile Actively exclude the self

Practicum Training

Connected Knowing Personal experience,

context, empathy Collaboration Use of patient’s language Understanding of patient

perspective Acknowledge effects of

caring on provider(Belenky, Clinchy, Goldberger, & Tarule, 1986; Candib, 1995)

Theoretical Assumptions about Practicum The “art of medicine” lies in ability to

integrate multiple ways of knowing Feminist-relational approach requires

training in equalizing power relationships (Candib, 1995)

Parallel process If we want residents to interact in this way

with their patients, we need to interact in this way with our learners

Group supervision opens the “black box”

Practicum Curriculum Goal

The goal of practicum training is to improve resident physician communication and counseling skills through supervised counseling of patients by peers and behavioral faculty preceptors.

Curriculum Objectives

Residents will increase knowledge of Basic counseling skills and methods Evidence-based behavioral medicine

Residents will improve skills in Responding to patient questions Assessment of psychosocial and family context Integration of biomedical and psychosocial care

Building relationships with patients and families

Curriculum Objectives

Residents will demonstrate attitude change toward

The importance of behavioral care in practice Greater self-confidence in counseling skills Greater mindfulness in patient care

To provide an opportunity for faculty to evaluate resident’s communication and doctor-patient relationship skills

Selection of Patient Cases Residents invite their own patients who…

Are medically or psychosocially complex Have an unclear social situation Are not compliant with medical advice Are difficult to manage or frustrating to

providers Have “more going on here…”

Residents have a ‘gut’ sense about abuse, assault, family unrest, prior psychological conditions

Practicum Format Pre-session (10-15 minutes)

Resident presents brief history of patient Residents states his/her goals for the session Faculty intentionally do NOT make

suggestions Resident counsels patient (25-30 minutes) Mid-session break (10-15 minutes)

Resident reaction Faculty and peer feedback Faculty guidance and direction

Practicum Format

Resident counsels patient (25-30 minutes)

Post-Session (10-15 minutes) Resident reflections

Session goals and expectations What he/she learned about the patient Personal thoughts or reactions to the patient How this information will help care for patient

Peer and faculty feedback

Assessment

Patient feedback (survey or interview?)

Relational rating scale Four Habits analysis of interaction

(research assistant) Faculty feedback Resident-self assessment

The process… Models negotiating a relational

agenda Reduces hierarchical barriers Encourages residents to shift to a

more open dialogue Opens new options for patient care

Residents shift……

FROM Monological

dialogue Focused

information gathering

Doctor driven conversation

‘doing’ mind-set

TO Open dialogue Actively listening

Patient directed conversation

‘supporting’ mind-set

Feedback from Residents

How did this session differ from other visits with this patient?

There was no right/wrong answer; no ‘pill’ would fix the problem [shift away from ‘doing’]

More personal, more time More emotional Patient did most of the talking [active listening,

patient directed] Visit was ‘non-medical’ – I was looking for clues in

her life about what support she will have when she has a child [supportive]

Feedback from Residents

As a result of this visit, is there anything you will do differently next visit? Be more sensitive about not giving my formal talks

but asking patient what she wants to know [patient directed]

Have a greater degree of suspicion when a patient just answers everything is ‘ok’ [supportive]

Pay more attention to psychosocial aspects of my patients

Understand the environment (psychosocial) a little better

Feedback from Residents

What comments/suggestions do you have about the process of live supervision?

It is an excellent idea to do this throughout residency and give feedback before we go into private practice

I like the immediate feedback of live supervision. It keeps me on track during the counseling session.

Allow more debriefing time…also more ‘skeleton’ training in counseling prior would be helpful

Fun, be feel like people (supervisors/peers) have hidden agenda/thoughts that they didn’t share

Feedback from Patients

Was this visit different from previous visits with your doctor? In what ways? Normally examines you, but today he was a

doctor, my friend, a listener, helped me with my problems [active listening, supportive]

The other visits were like examinations…it helps to know people more in depth to understand why a person keeps smoking when they know they shouldn’t

The other one was more medical [patient directed]

Feedback from Patients

Will you do anything differently in relation to your health as a result of your visit today? Made me stop and think: “You count

too, take time for you.” Think it will be easier to talk to him in the future.

6/7 patients reported they will change specific health behaviors because of this visit

Comments from Patients It’s better when you have someone to

talk to. He’s easy to talk to and he’s a good

listener. He doesn’t criticize. I like him. He’s a good doctor. Nice to be offered this because this time

I was really stressed…. I know you can tell him and he

understands and tries to help you.

Future Research Goals Evaluate outcomes: Does practicum improve

Doctor/patient relationship? Patient health outcomes? Patient satisfaction? Resident competency in communication and

relationship skills?