Y Murphy Dr Pt Comm Curriculum 2010 AACH Forum[1]

Evidence-based and Ready to Use Doctor-Patient Communication

Didactic Curriculum

2010 AACH Research and Teaching Forum WorkshopOctober 16, 2010

©Yvonne Murphy, MD, 2010

Author’s Background Medical school in Rochester, New York Several teaching sessions with Dr. George Engel who first

described the biopsychosocial model Family Medicine residency in Rochester, NY; three month

rotation in biopsychosocial medicine Two year fellowship in Family Systems Medicine training as a

marriage and family therapist as well as with Dr. Rick Bohtelo, author of Motivating Healthy Habits

Trained with Tom Campbell, Susan McDaniel, and Dave Seaburn who wrote Family Oriented Primary Care as well as with Cecil Carson, Howard Beckman, and Rich Frankel.

10 years at MacNeal Family Medicine Residency in Berwyn, IL; Co-Director of Behavioral Science & Associate Program Director for Education

Now a little about you.

Name, position, length of time teaching, type of learners (students, residents, etc)

What were you hoping to get out of this session?

Educational Objectives:

Participants will be able to: 1. List commonly encountered clinical circumstances in

medicine where specific doctor-patient communication skills can be described, demonstrated, and practiced.

2. Explain how to use the session outline, slideshow presentation, demonstration materials, and skills checklist to conduct a teaching session for a specific communication skill

3. Describe strategies for incorporating the doctor-patient communication skills didactic series into one’s own educational program.

Overview of the Curriculum©Yvonne Murphy, MD, 2009

16 One Hour Didactic Sessions For use with medical students, residents,

fellows, allied health professionals, or practicing physicians

Each topic can be used individually or all 16 form a comprehensive curriculum

Designed using proven effective educational principles to maximize learning

Each includes research evidence and a reference list of the literature

Most could be expanded to 2-3 hour workshops (see slide #33)

Overview of the CurriculumTopics of the 16 Modules


Agenda Setting Behavior Change Language Barriers Shared Decisions Compliance Empathy Terminating Using EMR

Bad News Advance Directives Chronic Pain Sexual History Angry Patient Medical Errors Family Meetings Patient Satisfaction &

Malpractice Risk

Teaches Skills Required for Creating the Patient Centered Medical Home


Skills listed on the AAFP PCMH Checklist that are covered in this curriculum:

Agenda setting Shared decision making Cultural competence Motivational interviewing Family engagement Use of EMR technology Patient satisfaction

Other communication skills taught are also patient-centered

Fulfills ACGME Competencies ©Yvonne Murphy, MD, 2009

ACGME Competencies addressed: Patient Care: Communicates effectively and

demonstrates caring and respectful behaviors when interacting with patients and their families

Interpersonal and Communication Skills: Communicate effectively with patients, families, and the public across a broad range of socioeconomic and cultural backgrounds

Professionalism: Sensitivity and responsiveness to a diverse patient population…

Fulfills Family Medicine ACGME Requirements


Family Medicine ACGME Requirements addressed: “…demonstrate cultural competence in caring for patients

from varied ethnic and cultural backgrounds.” “Essential elements to be integrated into the teaching of

family care include: …behavioral counseling, human sexuality, end of life issues, …”

(p. 18 ACGME Competencies/Patient Care/Family-Oriented Comprehensive Care Experience)

End of Life issues also listed under The Older Patient (p23) and SBP (p 33). Sexual Health also listed under Gynecology (p 25).

“There must be instruction and development of skills in …the physician/patient relationship, patient interviewing skills, and counseling skills.”

(p 28 ACGME Competencies/Medical Knowledge/Human Behavior and Mental Health)

“Regularly scheduled didactic sessions.”

Contributes to Maintenance of Board Certification


Meeting Board Certification Requirements: March 26, 2009 - The American Board of Medical

Specialties (ABMS) announces adoption of a new set of standards designed to further enhance physician qualification principles assessed through its ABMS Maintenance of Certification® (MOC) program.

Assessment of communication skills as a standard for all physician diplomates with direct patient care - using a Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient survey (or other COMMOC-approved survey), and an approved peer survey

May Decrease Malpractice Risk ©Yvonne Murphy, MD, 2009

Risk Management A key factor in patient’s decision to pursue

litigation is dissatisfaction and breakdowns in communication.

Levinson W. et al. Physician-Patient Communication: The Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons. JAMA. 1997; 277: 553-559.

See references 6-12 of the above article for more articles that support this.

Levinson W. Physician-patient communication: a key to malpractice prevention. JAMA. 1994; 273: 1619-1620.

Beckman HB, et al. The Doctor-plaintiff Relationship: Lessons from Plaintiff Depositions. Arch Int Med. 1994; 154:1365-1370.

Additional Roles of a Doctor-Patient Communication Didactic Curriculum


Addressing Individual Program or Hospital/Institutional Needs: Resident feedback (conferences or program) Patient complaints or situations Institutional or hospital initiatives (JCAHO

initiatives on pain and patient safety/errors) Patient Satisfaction Quickly fill cancellations in lecture schedule

Design – Underlying Educational Principles

Robert Gagne’s Conditions of Learning 1. Gain attention 2. Inform learners of objectives 3. Stimulate recall of prior learning 4. Present the content 5. Provide “learning guidance” 6. Elicit performance (practice) 7. Provide feedback 8. Assess performance 9. Enhance retention and transfer

(c) MH Gelula, 2009; Used with author’s permission

Design – Underlying Educational Principles

Copeland et al: Attributes of the effective medical lecture Engaging the audience Lecture clarity Active Learning

(c) MH Gelula, 2009; Used with Author’s Permission

Overview of Design of Each Module ©Yvonne Murphy, MD, 2009

Engage Present evidence Outline components of the skill Demonstrate skill Practice skill

My philosophy – communication skills can be taught and learned just as other skills such as lumbar puncture where we outline step by step instructions to guide the learner

Overview of Design – Engage ©Yvonne Murphy, MD, 2009

Each session begins with a question or exercise for the audience to activate them and promote recall of prior knowledge:

Give an example of a personal experience with the topic area (such as delivering bad news)

Poll Example from Shared Decision Making: What clinical

decisions did you make with patients in the past day? Make a list

Example from Discussing Advance Care Planning and End-of-Life Care: Use a flip chart to list the audience’s barriers to discussing advance care planning.

Other exercises Cultural Competency Quiz

Overview of Design – Engage ©Yvonne Murphy, MD, 2009

Slide presentations are limited to about 20 minutes.

Activities are changed at regular intervals throughout to promote attention. Introduction with engaging activity and

educational objectives Slides Demonstration of skill (video, live) Practice

Overview of Design – Engage©MH Gelula, 2009; Used with Author’s Permission

(c) MH Gelula, 2009 18

0 10 20 30 40 50 60Minutes into lecture

Effec

tive

Lear

ning

Rest or change in activity

Based on Bligh, 2000

Learning lost withrest or change ofactivity

Learning gained withrest or change ofactivity

Overview of Design – Evidence ©Yvonne Murphy, MD, 2009

Present research findings to support use of that communication skill

Use of evidence-based practices, when possible

NEXT TWO SLIDES ARE EXAMPLES OF THIS FROM THE SHARED DECISION MAKING MODULE

Why use shared decision-making in clinical practice?

(data 10/05 FP Management); ©Yvonne Murphy, MD, 2009

32% patients have chosen NOT to fill a prescription they considered unnecessary

21% have sought a second opinion because they thought their doctor’s recommendations were too aggressive

16% have chosen NOT to undergo a recommended diagnostic test they considered unnecessary

10% have chosen NOT to undergo a recommended surgical procedure

9% have changed doctors because they felt their doctor’s approach was too aggressive

Why use shared decision-making in clinical practice? Evidence


2005 Study Pediatrics Parents presented with two vignettes in case of

2 ½ yo with AOM More satisfaction with shared decision making Decreased use immediate antibiotic (7% vs.

27%)

Overview of Design – Description of Communication Skill


Break down into steps Examples of wording as a guide Checklist used for learning and giving

feedback during practice

NEXT TWO SLIDES ARE EXAMPLES OF THIS FROM THE SHARED DECISION MAKING MODULE

Six Elements of Shared Decision-Making


Physician presents the issue or decision to be made Physician discusses the risks and benefits of each

alternative (non technical language) Physician includes discussion of clinical uncertainties Physician assesses the patient’s (and family’s)

experience, values and priorities among the alternatives Physician assesses patient’s understanding of above

and their desired level of decision making participation Physician allows patient to voice a preference (decide),

makes a recommendation and they come to an agreement

Principles of Use of Shared Decision Making


Avoid adjectives (likely, rare). Describe proportions (one in 10) rather than probability (10% chance).

Use absolute (not relative) risk and patient oriented outcomes.

Frame both positively and negatively (chance of survival & chance of death)

Individualize risk when possible (risk calculators) AAFP Prostate Cancer Screening example

Design – Demonstrate Skill ©Yvonne Murphy, MD, 2009

Participants then identify the Six Elements of Shared Decision-Making in the Demonstration Video: List issue or decision (choices/alternatives) List risks and benefits of

Alternative #1 Alternative #2

List clinical uncertainties List patient’s values/priorities among alternatives How did physician assess patient’s understanding? How did physician allow patient to voice a preference

(decide)?

Design – Demonstrate SkillShared Decision Making Video

This module has a video (available upon request from the author) of the physician discussing whether or not to discontinue antidepressant medication one year after a first episode of major depression which was successfully treated with a 40 year old woman.

Design – Practice Skill ©Yvonne Murphy, MD, 2009

Role play in pairs use skills checklist to give feedback Skills Exercise Scenario # 1 Physician: A 45-year-old man came in as a new patient with a

sprained ankle. At his follow-up visit today, his sprain seems well healed, so you consider offering him some health maintenance screening. He is overweight and put on his Ambulatory History Form that he has a family history of diabetes. You would like to send him for a fasting blood sugar. Discuss this with him using shared decision-making.

Patient: You are a 45-year-old man who hasn’t seen a doctor in many years. You sprained your ankle two weeks ago and so came into FPC for treatment. Today you are at your follow-up visit, and your ankle seems about back to normal. In fact, you didn’t really want to come back. Although you are aware that diabetes runs in your family, you don’t really like to think about having it yourself. As long as you don’t feel sick, you don’t feel you need to go to the doctor or take medications.

NEXT PAGE IS A CHECKLIST USED TO GIVE FEEDBACK

Physician presents the issue or decision to be made with choices/alternatives

Physician gives rationale for patient participating in decision“I’d like us to make this decision together.” “It helps me to know how you feel about this.” “Two different people might choose to do it differently.”

Physician discusses the risks and benefits of alternative #1Avoid adjectives (unlikely, likely, rare) Frame both positively & negatively.Use absolute (not relative) risk and patient oriented outcomes. Describe proportions (one in 10) rather than probability (10% chance).

Physician discusses the risks and benefits of alternative #2Language patient can understand in digestible pieces.

Physician includes discussion of clinical uncertainties“Most people with your condition respond well to this medication but not all.” “The chance that X will help is X.”

Physician surveys and helps the patient clarify their experience, values, and priorities among the alternatives“How do you feel about taking this medicine/having this test/the possible consequences of doing X?” Does patient desire input from family/friends/others?

Physician assesses patient’s understanding of above and the level of participation in decision making desired“So tell me what you have understood so far about the information I’ve given so I can know if I explained it correctly.” “How would you like us to decide?”

Physician allows patient to voice a preference (decide), makes a recommendation, and they come to common agreement

Physician documents conversation and decision in chart

Using the Materials


Components: Session Outline (start with this) Slides Skills exercise

On CD, each topic will have 2-3 documents

-1-2 Word documents -1 PowerPoint

document

Using the Materials:Sample Session Outline


Additional Materials Needed: Arrange in advance for a patient to come live to the session with their physician (faculty or other

physician experienced in shared decision making) to discuss a medical decision. A video taped encounter may be used as well. A video taped encounter of Dr. Murphy and a patient is available by request (contact Dr. Murphy

at [email protected]).

Handout: Slides printed as handout. Outline of Skills Exercise in Shared Decision Making (separate file) Copy of AAFP PSA Decision Aid (as an example of a decision aid)

One Hour Session Outline: 5 min Poll of Audience: -What clinical decisions did you make with patients in the past day or two? -Objectives 10 min Slide presentation on shared decision-making 10 min Live or video demonstration with audience filling in questions on handout. 5 min Debriefing of audience 15 min Skills Exercise (role play) with checklist in pairs;

Time 5 min for role play & 2 min for feedback for each partner 5 min Debrief role play, questions & feedback

Words to the Wise ©Yvonne Murphy, MD, 2009

Many sessions require some preparation for the demonstration in advance

Review the timing of the session, the slides, and prepare a handout

Read some of the references if you don’t have a working knowledge of the topic to facilitate smooth delivery

PRACTICE THE PRESENTATION AHEAD; they are very carefully timed to fit into one hour

Make sure all AV is working before starting Stick to the time allotted for each segment during

the session

A Word about Role Play ©Yvonne Murphy, MD, 2009

Most of the sessions have a role play to practice the skill being taught

I prefer the term “Skills Exercise” to role play and encourage you to use that term as it more accurately describes the purpose

I find it helps to remind learners that it’s better to practice with your colleague than with a real patient the first time you try to use any new skill

I also find that if you are positive and persistent about incorporating this part of the session, your learners will participate

Implementation within my Program ©Yvonne Murphy, MD, 2009

FMRP 12-12-12 + 6 students and 3 fellows Didactics = Noon conference (1 hour) daily Large group (while eating lunch) 18 month repeating curriculum

One per month with a few extra slots Each session presented twice during a resident’s

three year residency

Evidence for Effectiveness ©Yvonne Murphy, MD, 2010

Each module has been presented to a group of medical students, residents, and faculty 3 or more times over past 8 years (except EMR-new module 2010)

Presentations consistently rate 4-5 on a 5 point scale on relevancy, specific objectives, evidence presented, effectively case-based & audio visuals

Each module has been revised at least twice based on feedback and new literature searches


Ratings by educators who have used:

Ease of Use Easy or Very Easy Session outline 88% Slide show 88% Skills exercise 79%

Effectiveness in Teaching Effective or Very Effective Structure of session 96% Information 100% AV materials 91% Skills exercise 91%

N=23-25


FEEDBACK FROM EDUCATORS WHO HAVE USED THIS CURRICULUM (N=25):

010

20

30

40

50

60

70

Somewhat VeryUseful

Ratings ofUsefulness forTeachingCommunicationSkills


Quote from a user of the materials:

“So I followed your materials and presented agenda setting on 3/23. I did a role play with the chief resident. The presentation went very well.

Just want to thank you so much because the materials are excellent, and the varied activities make it so engaging. The residency director liked it. It's been so helpful to me in getting started.”


Quotes from users of the materials:

Informally the residents and faculty have mentioned things like: “Useful”, “Excellent”, and “Wow! I really like this”

Quickly jump-starts their thinking about these particular areas, gives summaries that are easy to implement and practice

Expanding One Hour Format into a 2-3 Hour Workshop


Allows more in depth learning of a particular skill Expand initial engaging activity to include every participant

in the group or have each participant discuss or journal about their personal experience with the topic

Objectives, slide show, and demonstration remain the same

Expand time for discussion of the demonstration Expand the time for skills exercise. Allow 10 minutes for

the role play for each person. These could be done by each pair in front of the group (sequentially instead of simultaneously) with each person in the group filling out the checklist for feedback; Each pair could also repeat the exercise again after receiving feedback to further improve. The role play could also be taped for each learner to review either with the group or on their own.

Implementation in your Program ©Yvonne Murphy, MD, 2009

How/Where would you fit this into your curriculum? Would you implement the entire series or just

select topics? Which ones? Longitudinal versus block/rotation? Small or large group setting Add to curriculum vs eliminate/substitute? Whose buy in would you need?

Administrative Faculty Learners

Assessment of Learned Skills ©Yvonne Murphy, MD, 2010

This curriculum’s main purpose is to teach communication skills, but these are ideas for subsequent assessment:

At the end of a workshop or after some time has elapsed to practice following a one hour session, the skills checklist or outline of the skill could be used as an evaluation tool of either a role play, simulated patient, or live/taped patient encounter involving that skill for the learner.

Many of the skills can be evaluated using a patient survey after a patient encounter.

The skills can be directly observed by supervisors using a standardized checklist (many are available)

To Obtain Additional Copies of the Entire Curriculum on CD

Go to www.fmdrl.org In the search box, type author’s name

Yvonne Murphy and click go Click on the word document entitled

registration form Complete it and

Email to [email protected] Fax to 708-783-0776

Contact Information for Dr. Murphy

I’m happy to answer any questions: Yvonne Murphy, MD Associate Program Director for Education Co-Director Behavioral Science MacNeal Family Medicine Residency Program 3231 S. Euclid Avenue, 5th Floor Berwyn, IL 60402 Fax 708-783-3656 [email protected]

Gratitude

This project was made possible by: My husband Walt and my son Alec Mary Talen, PhD, who provides so much

encouragement Minnie, my administrative assistant My many mentors from residency and fellowship

in Rochester, New York MacNeal Family Medicine Residency Program

Health & Medicine

Y Murphy Dr Pt Comm Curriculum 2010 AACH Forum[1]