Teaching Communication Skills at the Bedside

September 19, 2014

Michael D. Barnett, MD, MS

Laurel B. Kilpatrick, MD

Objectives

1. To appreciate the importance of

communication in the medical encounter &

barriers to effective bedside teaching.

2. To explain the framework approach to

communication skills training.

3. To describe the coaching model and its

applicability to bedside teaching.

4. To demonstrate the use of coaching in

bedside communication teaching.

Good Communication

Numerous studies have shown that good patient-

doctor communication leads to good outcomes:

Patient satisfaction

Family satisfaction

Provider satisfaction

Symptom control

Efficiency

Medico-legal issues

Utilization & costs

Non-adherence

Provider burnout

Mandate

Communication skills training is required in

graduate medical education:

IV.A.5.d) Residents must demonstrate

interpersonal and communication skills that result

in the effective exchange of information and

collaboration with patients, their families, and

health professionals.

ACGME Common Program Requirements

Needs Assessment

Learners actually want more training in

communication skills:

• Discussing bad news

• Discussing prognosis

• Discussing code status

Kolarik R. Pediatrics. 2006; 117(6):1949-54

Michelson KN, et al. J Palliat Med. 2009; 12(5):451-7.

Various Curricula

• 5-hour workshop during 2-day retreat for Medicine

residents @ Duke Alexander SC, et al. Acad Med. 2006; 81(11):1008-12.

• 2-year series of 3-hour workshops for General

Surgery residents @ UMass Larkin AC, et al. J Am Coll Surg. 2010; 211:285-92.

• 12 one-hour sessions with Oncology fellows @ MD

Anderson Epner DE & Baile WF. Acad Med. 2014; 89:578-84.

• 3-day retreat for Neonatology fellows @ UPMC Boss RD, et al. J Perinatol. 2013; 33(8):642-6.

What are barriers to communication

teaching at the bedside?

Potential Barriers

• Lack of faculty training

• Faculty discomfort

• Learners overwhelmed by biomedical

aspects of care

• Learners lack motivation

• Competing demands

• Lack of time

Perron NJ, et al. Med Teacher. 2009; 31:e316-22.

Learning Theory

I hear and I forget

I see and I remember

I do and I understand.

~ Confucius (551-479 BC)

Experiential Learning

Concrete Experience

Reflective Observation

Abstract Conceptualization

Active Experimentation

Premises

1. Communication is essential to the patient-

doctor relationship.

2. Communication is comprised of a series of

specific skills.

3. Communication skills can be taught.

4. Communication experience may be a poor

teacher.

Imperfect Practice

Learners often revert to collecting and/or

exchanging medical information:

• Faculty rarely observe learners

• Learners rarely observe faculty

• “OSCE mentality”

• Communication not seen as “real” medicine

Kurtz, S, et al. Teaching and Learning Communication Skills in Medicine. San

Francisco, CA: Radcliffe Publishing, 2009.

Adult Learning

• Scaffolding

• Contiguity/Anchored learning

• Segmentation

• Desirable difficulties/Goldilocks principle

• Manageable cognitive load

• Self-generation/Discovery

• Feedback

National Research Council Commission on Behavioral & Social Sciences &

Education. How People Learn: Brain, Mind, Experience, and School. Washington,

DC: National Academy Press, 2000.

Ambrose SA, et al. How Learning Works: Seven Research-Based Principles for

Smart Teaching. San Francisco, CA: Jossey-Bass, 2010.

Communication Skills

What are good communication skills?

Framework Approach

S Setting

P Perception

I Invitation

K Knowledge

E Empathy/Emotion

S Summary/Strategy

Baile WF, et al. Oncologist. 2000; 5:302-11.

Explicit Empathy

N Name “I can see that you are frustrated.”

“It seems like you are down today.”

U Understand “I can’t imagine what you’re going through.”

“This is obviously a lot to go through right now.”

R Respect “I see how hard you have been fighting for her.”

“You are good parents; we all see that.”

S Support “I want you to know that I am here for you.”

“We are available anytime if questions come up.”

E Explore “Tell me more about what you’re thinking.”

“How are you doing?”

Smith RC. The Patient’s Story: Integrated patient-doctor interviewing. Boston, MA:

Little, Brown & Co., 1996.

Coaching

Tenets

• Learner-centered relationship

• Safe learning environment

• Honest feedback

• Accountability (results-focused)

West L & Staub FC. Content-Focused Coaching: Transforming Mathematics

Lessons. Portsmouth, ME: Heinemann, 2003.

Coaching Cycle

Pre-Lesson Conference

Lesson Post-Lesson Conference

Call to Action

West L & Staub FC. Content-Focused Coaching: Transforming Mathematics

Lessons. Portsmouth, ME: Heinemann, 2003.

Demonstration

Coaching at the Bedside

1. Ask learner for specific skill to practice (plan) – Guide learner to doable skill based on prior experience

2. Observe learner in action (practice) – Take notes of phrases used & reactions from patients/families

3. Debrief the encounter (reflect) – Guide towards a learning point (clarify “stuck” point)

– Highlight specific skills that learner did well

– Brainstorm skills/phrases to use in the future

4. Ask learner for “take home point” (call to action)

Adapted from “Steps in Primary Teaching Method of the Introduction to Medical

Interviewing Course” by William Cohen, MD of the University of Pittsburgh School of

Medicine.

Communication Coaching

Plan

Practice Reflect

Call to Action

Practice

Instructions

1.Faculty identifies specific skill to practice (plan) – Choose a doable skill based on prior experience

2. Group observes faculty in action (practice) – Take notes of specific words/phrases used & reactions from student

3. Group debriefs the encounter (reflect) – Guide towards a learning point (clarify “stuck” point)

– Highlight specific skills that the faculty did well

– Brainstorm skills/phrases to use in the future

4. Faculty provides “take home point” (call to action)

Pearls

• Keep it learner-centered.

• Be specific.

• Pay attention to emotion of learner.

• Highlight the positives.

• Be careful giving your opinion.

• Remember to get a take home point.

Summary

• Communication is essential to the patient-

doctor relationship & should be a regular

part of our teaching.

• A framework approach helps to guide

learners & teachers.

• Communication teaching can be done

quickly & effectively at the bedside.

• A coaching model can help all of us teach

communication in a learner-centered,

experiential manner.

Questions?