3B.3 Communication
To communicate with patients in a far more interactive and reciprocal way in order to empower them
As Communicators, OBGYN professionals effectively facilitate the relationship with the patient and the dynamic exchanges that occur before, during, and after the medical encounter. By doing so they enable patient-centered therapeutic communication through shared decision-making and effective dynamic interactions with patients, families, caregivers, other professionals, and important other individuals. The competencies of this role are essential for establishing rapport and trust, formulating a diagnosis, delivering information, striving for mutual understanding, and facilitating a shared plan of care. Poor communication can lead to undesired outcomes, and effective communication is critical for optimal patient outcomes. The application of these communication competencies and the nature of the relationship with the patient vary for different specialties and forms of medical practice.
Competency-based communication
At the turn of the century, medical education, inspired by a renewed emphasis on the essential abilities physicians need for optimal patient outcomes and on preparing students for clinical practice, switched from problem-based learning to an outcomes-based or competency-based approach. The CanMEDS competency framework, which was developed in the 1990s, is probably the best-known example of this approach [1]. Nowadays, all Dutch medical-specialist curricula are based on this competency framework [100]. The CanMEDS framework comprises numerous competencies organized thematically around seven meta-competencies or roles that a physician should master. At the heart of the framework lies the physician's role as Medical Expert, complemented by six generic roles such as Communicator, Collaborator, and Manager. As medical experts, physicians integrate all areas of expertise defined by the CanMEDS framework. Thus, expertise that is defined as the superior and stable ability to handle challenging situations [101], is the benchmark for the assessment of physicians' ability to handle clinical situations. Challenging patient-education issues that are mentioned in the CanMEDS framework are: obtaining informed consent; delivering bad news; addressing anger, confusion and misunderstanding; and dealing with non-adherence. The introduction of the CanMEDS framework in undergraduate and postgraduate curricula influenced the teaching of communication skills in several ways. Firstly, since the key competencies of the communicator role explicitly refer to patient-education competencies, the teaching of patient-education skills was gradually implemented in undergraduate curricula [102,103] and in postgraduate courses [104]. However, during their internships, students still focus their attention on history-taking and time-management, and are still not supposed to educate their patients [105]. Secondly, the concept of patient-centeredness was criticized and regarded as being unsuitable as a leading concept for communication programs [14,41]. Today, a functional approach is advocated, in which the physicians' communication tasks and matching skills are derived from the goals and desired outcomes of the consultation [40-42,106]. Thirdly, workplace-based learning
came into focus. Workplace-based learning means that students and residents improve their competencies by applying their knowledge and practicing their skills in supervised clinical situations followed by constructive feedback and reflection. New assessment methods matching workplace-based learning were also developed, such as the mini-clinical evaluation exercise (mini-CEX), the direct observation of procedural skills (DOPS), and multisource feedback [107,108]. All the assessments, feedback, and reflections that a learner has collected are documented in the learner's portfolio. As mentioned previously, communication assessment and feedback based on videoed consultations already existed in primary care and general-practice vocational training. In undergraduate education several initiatives have since been developed using videoed consultations for self-assessment, feedback, and reflection [109]. However, we have found no study that has used videoed consultations for communication assessment and feedback in medical-specialist training.
A functional approach
In order to give in to these criticisms the first (J.W.) and fourth (H.W.) authors developed a goal-directed model of patient education which guided them in the formulation of the teaching objectives for their curriculum and in the construction of an assessment instrument with which they could assess the patient education competency of the residents and give them feedback on their performance. This article describes the so-called CELI model, the CELI assessment instrument and the results of a study of the reliability and validity of the CELI instrument.
1.1. The CELI model of patient education
According to the above definition patient education implies that a physician must not only provide information, but also must help the patient to comprehend and digest the information. Subsequently the physician can help the patient to make a considered decision based on the information, and to adapt his behaviour if
necessary.
The inner oval in Fig. 1 contains the psychological processes which take place in the patient. These are the immediate goals of patient education in a medical consultation. The CELI model which is derived from the classic Yale model of persuasion [13], distinguishes the tasks a physician has to perform in a consultation in order to reach these immediate goals. The outer oval in Fig. 1 represents the consultation in which the physician performs these tasks. These tasks and their matching subcompetencies are Control, Explaining, Listening and Influencing and are clarified below. Appendix A contains an overview of the distinctive skills of the subcompetencies. The medical consultation is a meeting with pre-set goals and the physician is primarily responsible for the attainment of these goals. Therefore, the physician must control the conversational flow. However, control does not mean that the patient is a passive contributor to the consultation. On the contrary, good control implies that the physician invites the patient to actively participate in the conversation [5]. The Control task relates to three aspects of the consultation: (1) control over the situation in order to have an undisturbed and private conversation. In Fig. 1 this control task is positioned outside the outer oval since the physician must perform this task before the consultation starts; (2) governing the conversation in order to reach the pre-set goals [14,15]; (3) fostering the relationship which enables the patient to be attentive and receptive to the provided information [5,16]. Control in the consultation includes activities such as initiating and ending the session, structuring the conversation, building and monitoring rapport, encouraging patient participation and collaboration and using the available time efficiently. Effective Explaining results in patients’ comprehension and recall of the provided information (cognitive digestion). In order to reach these goals the physician must take the pre-existing knowledge and additional information needs into account. He has to present the information in a structured and intelligible manner and he has to check regularly patients’ understanding [5,17]. By Listening to the feelings and opinions of the patient, the physician encourages the patient to digest the information emotionally. Active or attentive listening is promoted as an important competency for physicians as part of a patient-centred style of communication [3,5,18,19]. Influencing means that the physician helps the patient to reach a decision, such as consenting to a medical procedure or change his behaviour, and to act accordingly. In Fig. 1, acting by the patient is positioned outside the outer oval since this behaviour takes place after the consultation.
Although in some models of the medical consultation the function of decision making is separated from the function of influencing the patients’ behaviour [16], in the CELI model these functions are considered as an entity [20]. Nowadays, the shared decision making (SDM)model is promoted as the preferred, patientcentred approach for decisions. Makoul proposed a framework and integrative definition of SDM in which essential and ideal elements (i.e. specific observable behaviours) of SDM are included [21]. According to this model the degree of sharing in the decision process can vary with physicians leading the discussion and making decisions at one end, patients leading the discussion and making decisions at the other, and truly shared discussion and decision making in the middle. The nature of SDM will be qualitatively different as encounters depart from the midpoint and the necessary skills of the physician vary accordingly [21]. Sometimes a direct instruction or recommendation is required [22],while at other times a counselling, motivational or empowering approach is advisable [23]. Occasionally, conflict management skills can be required to influence a patient’s decision and behaviour [24]. Influencing also includes the support which a physician can offer by entering into clear agreements, establishing a contingency plan, providing decision aids [25] or arranging further professional help.
Conclusion and practice implications
The CELI instrument appears to be a reliable and valid instrument for the assessment of physician competency in patient education. The instrument is based on a goal-directed model of patient education in medical consultations which matches the CanMEDS competency framework for the training of physicians [1]. Since the instrument assesses the quality of the performance of distinctive skills and yields performance scores for each of four subcompetencies and for the overall competency in patient education, the CELI instrument can be a valuable tool for feedback and assessment in medical education and in clinical practice.
Appendix A. Summary of patient education skills (uit PEC: W en vdW, thesis Wouda)
C = Control and rapport
– invitational start of the consultation
– summary of the foregoing (resume)
– agreement upon the goal and subjects of the consultation
– guiding the course of the conversation, keeping the prescribed conversational structure
– control of patient’s attention to the conversation
– control of attention and participation when more than one interlocutor is present
– extensive summary when changing to a new subject or closing the consultation
– general verbal and nonverbal presentation of genuineness, empathy, care and competence
– announcing and explaining activities, such as physical examination or writing
– reinforcement of patient behaviour which benefits the conversation and relationship
– social conversation in order to show interest in the patient and put the patient at ease
- a clear and friendly completion of the consultation
E = Explaining
– true in contents, realistic
– use of clear and comprehensible language (choice of words, short sentences)
– concise and structured with an introduction, paragraphs and short summaries
– interactive with pauses for reaction, dosed, guided by response – emotional or other
– fitting in to the frame of reference of the patient
– convincing, vivid with appealing examples, referring to patients’ experiences
– repetition and support with visual aids
– comprehension checks
L = Active listening
– verbal and nonverbal attending behaviour, minimal encourages to talk
– use of silence
– paraphrasing
– reflection of feelings and opinions
– asking correct open and closed questions to elicit facts, feelings and opinions
– acquiring relevant information
– concretizing
– shading and confronting
– summarizing the patient’s story
I = Influencing (= instruction, advice, counselling, shared decisionmaking,
support)
– offering suggestions (and no orders), leaving room for contemplation
– useful and acceptable phrasing of instructions and advice
– reinforcement of patient problem-solving behaviour
– realistic presentation of advice, possibilities, promises and limitations
– taking into account the ‘bad news’ nature of some information and advice
– counselling, assisting with difficult decisions
– constructive negotiation
– rephrasing a problem into a shared problem
– promoting the mutual acknowledgement of feelings and opinions
– phasing the decision process, offering time for contemplation
– making clear agreements and contingency plans
– checks of approval of suggestions, instructions, advice, decisions and agreements
– offering educational material (leaflets, internet) and/or useful contact addresses
– offering personal support or professional help after the consultation