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PLAN of COURSE for
introductory trainers
COURSE

(SamPLE 2 DAY COURSE)

AIMS FOR LEADERS

Provide a supportive environment to explore:

·        Ourselves:

Our own communication skills and our teaching experiences: what works well for us and what doesn’t

What are the blocks and difficulties for us in the consultation and in teaching

Patient centred medicine: empathy through the experience of being a patient

·        The what of communication skills teaching:

Identifying and teaching the skills that make a difference to the consultation

The theory and research evidence that validates these skills

Structuring the skills within the consultation

The Calgary-Cambridge guides as an aide-memoire and summary of structure and skills

Opportunistic learning organised via the guides

How to begin to recognise “patterns” in the consultations that learners need help with

·        The how of communication skills teaching:

What are the blocks to learning this

Principles of communication skills learning

Feedback: the background to Pendleton’s rules, our alternatives of descriptive feedback and agenda-led, outcome-based analysis

How to introduce research evidence and teaching exercises into experiential discussion Video work, role play

How to teach communication skills; ? the opportunity to practise, and receive feedback from an experienced facilitator and a small group

·        How to structure a curriculum:

Summative assessment and the MRCGP video component: how to prepare registrars through high quality teaching

Group work v. 1:1 teaching

 FIRST SESSION 8.00-10.00pm

Meet as a large group, and divide into three small groups

 In small groups

INTRODUCTION                                            Back to top

Welcome to our section of the intro trainers course, on communication skills and c.s.t.

Introduce ourselves and role.

Delicate mesh of your agenda and our thoughts of what we could do; this can only be a taster in 24 hours!

Timetable and any housekeeping.

Plan of the course

Highlight problem of experiencing the methods/being learners and analysing the teaching/being teachers. We will try hard to separate out.

 

EXERCISE 1

ROUND OF NAMES

Your first name, surname and where you are from plus something that is important within yourself that relates to why you want to be a trainer (or one thing that no-one knows about you )

Leader to model

 

Objectives

Objectives of the course on a handout: sorry rather long, look at headings only if too much

Objectives summarised:

 

This is an opportunity to look at your own consultation skills and to think about how you  teach  communication skills to your registrars.

 

A particular objective is to try to identify particular skills that make a difference to the consultation and look at some of the evidence to say that any of it is worthwhile - the what of communication teaching - so that you can take away something positive and concrete at the end. To work out some principles of communication and look at the importance of structure to teaching the consultation.

 

To explore how to teach this to our registrars, explore principles of learning communication skills and to look at exciting new ways of analysing the consultation and giving feedback. How to introduce research and teaching exercises into experiential learning - how to combine experiential and didactic teaching

Mainly looking at video work but also roleplay.

 

Looking at the need to structure a communication skills curriculum and compare groupwork (which is the teaching context ion the VTS) and 1:1 teaching.

 

We also have an opportunity to look at our own strengths, blocks and practical difficulties: how our skills, feelings and pressures combine in the consultation.

 

Summative assessment and the video component of the MRCGP are now with us and require particular skills

 

Our main objective is for us all to share our combined expertise and experiences of communication skills and the teaching of them, and for the facilitators to share the new ideas that we are now using in the cascade communication skills teaching project for trainers, GP registrars and principals throughout the Anglian deanery.

 Explain objectives for first session

·        finding out your needs (your agenda) about your own communication skills and with             your teaching(where you want to go)

·        discovering where we all are now, our starting point (where you are with the         what and the how of teaching)

·        to examine the major issues of communication skills teaching, especially why teach this in the first place

·        to allow us to get to know each other, feel safe together and work supportively together

·        to get sunk in to exploring the consultation together

·        not your videos until tomorrow

 

Explain role as leader to help with their agenda and how they should tell me if I’m going off course: the aim is to build on their experience and add in my knowledge and help us all

Gentleness, equality, remain a learner, humour, accepting (pick up on all they say and

acknowledge), choices, alternatives, offers, admit fallibility, group to sort out differences, manage defensiveness, tentative (it’s tough, good point, I see your point, interesting, here is an alternative), empathy, sensitivity, friendliness

 20.15 EXERCISE 2:   GROUP’S AGENDA            Back to top

What we would like to look at first together is where you would like to go over the next day, to find out your needs and your agenda.

 Pairs listening exercise: explain uses - listening is one of the most important communication skills- rehearsal of skill before bringing to the group, stops people only thinking of their repost, link to consultation

 ·      What is your agenda for the course? What are the problems or issues that you want to discuss?

·      What do you personally want to achieve? What would you like to go away with that you are not sure about now? 

Here are some prompt questions to get you thinking:

what are your concerns about teaching communication skills?

what are you unsure of?

what about your own consulting skills?

what questions have you come with which you want answered?

think too from the registrars’ perspective, what problems do they have?

 Feedback in a round under headings;

·      own communication skill difficulties

·      the what of teaching

·      the how of teaching

Try to say why you personally would like to spend some time exploring whatever areas your needs lie in - what do you feel uncertain about - what problem areas are there for you.

-leaders to contribute here as well and provide balance, make offers etc.- (we will need to be   accepting and supportive)

-produce a list of learning issues for the group for the course and ask if there are any others

-negotiate an agenda for the course

 

This exercise is to produce our agenda for the course

It might produce a list of:

their own communication difficulties,

the what and the how of teaching,

their thoughts and fears of videowork,

their own lack of knowledge and experience.

Mention that we will be looking at two areas specifically as we go - making lists of the what to teach and  how to teach

Leaders to talk about the fact that all of us need help with our own skills let alone our teaching skills and that they must progress hand in hand - they are one and the same.

Also that there is a parallel with this form of learner centred, collaborative teaching and patient centred medicine

 

20.40  MINI-LECTURE            Back to top

 

SUMMARISE ISSUES IN COMMUNICATION SKILLS TEACHING:  put on flip chart

 1.      Why 

are there problems

are there solutions -   is there evidence that CS can overcome these                                                  problems and make a difference to the consultation

2.      Can

can you learn - can they be taught

is it retained

3.      What

can we define what we are trying to teach

is there a curriculum / a structure / content

4.      How

experiential, problem-based

knowledge-based

5.      How to structure learning, structure learning over time, curriculum planning

 

WHY TEACH COMMUNICATION SKILLS

What is the importance of studying this subject, what are the potential gains

 

200,000 consultations in a professional lifetime

The prize on offer: improved clinical competence, not just patient centredness.

Clinical competence = knowledge base, communication skills and problem-solving ability (the essence of good clinical practice)

Communication skills turn theory into practice: a core clinical skill, as important as the PE

A professional skill that needs developing to a professional level - not the same as talking on the street: a delicate balance of

1.    clinical info gathering and giving skills for acc. diagnosis and management

2.    patient centred approach to help the patient with their unique experience of illness

The goals of effective communication: accuracy, efficiency, supportiveness - not just being nice, a much bigger prize on offer

Can we prove this to you?

 

Three questions to ask:

are there problems in doctor patient communication?

are their potential solutions?

can these solutions be taught and learnt?

If the answer to any one of these is no, we can all go home!!!

·        the evidence for there being problems in communication in the consultation (The Toronto Consensus Statement)

 

Do as interactive lecture with questions and answers

e.g.

1.      how many problems do people bring

2.      how many discovered

3.      which is the most important

4.      when do doctors interrupt

5.      what happens if doctors use closed questioning to hypothesis generation

6.      in what percentage of consultations do we underestimate our patients desire for info

7.      how many minutes spent in info giving

8.      percentage who do not adhere

9.      medico-legal complaints related to communication

·        the evidence that communication skills make a difference to outcome, satisfaction and compliance

done as a few examples only again with interaction 

9.05 THE WHAT            Back to top

Before we begin to consider your agenda any further, we think that it’s important to look at some models and frameworks of the consultation. We need ways of structuring our thoughts about the consultation and what is happening within it and to think about the tools of our trade, the communication skills that we use everyday and how they fit into the overall pattern of what we do as doctors, and how we combine them with our knowledge-base, clinical reasoning and problem-solving. We also need to develop some common language to help us as a group to look at this - some mutually understood jargon.

 How can you analyse a consultation unless you have some idea of what you are looking for, unless you have considered how to break it down into elements that you can be looking out for?  

 STRUCTURE AND SKILLS

OK - so we are now in a position to see Why - and what sorts of skills might help us in managing the consultation more effectively - is this enough?

Why not just learn a list?

We need a Structure for various reasons

 Learners

-                 Need to be able to analyse what we are seeing and hearing

-                                 Organising skills into a memorable and useful whole - overall framework within which the skills can be placed and fit together

-                                 We need to help learners to structure their learning so that they can take away something concrete - can get a hold on the various skills that arise randomly and opportunistically in experiential work

-                                 Prevents the consultation from wandering aimlessly and important points from being missed - all too easy for communication to be unsystematic and unproductive.

Teachers

-                                 Also need to pull together the individual skills that they recognise as important learning areas - can often appear to be a disorganised bag of tricks without any overall framework.

-                                 Enables teachers to take an outcome based approach in their teaching

-                                 Allows teachers to ask two central questions of learners: "where are you in the interview?" and "what are you trying to achieve?" Having established a direction, the individual skills then help with the next question, "how might you get there?.

 

Overall…..

·        Important to realise you cannot analyse Skills without a Structure

·        We need to break down the consultation into areas we can describe & recognise

·        Structure of consultation model needs to have a temporal relationship

·        Needs to fit into modern approach using collaborative relationship with patients

We’ve already handed out in the pack our approach to the curriculum of communication skills

The Calgary-Cambridge guide - now forms the regional approach to both communication skills teaching and assessment.

It provides both:            1. a structure or framework   2 a list of skills

We could leave it just there… but before looking at the guides and what they have to offer We’re keen to give you some feel for the importance of listing the skills and generating a structure.

 

So we would like to take you through the exercise that generated the guides over many years - you’ve got 10 minutes! Its also important to mark down where we as a group are starting from so we can measure our own progress over the course in our understanding of the subject.

 exercIse 3: In THREES/fours

From what you’ve read in the handouts and your own thoughts, and perhaps thinking of a recent fairly simple consultation if you like e.g. UTI or sore throat

 STAGE 1

Can you divide the consultation up temporally into 4 or 5 discrete sections - the landmarks of a consultation?

Use plain English without jargon

Try and work out a plan together

 Can you further subdivide each of these discrete areas into up to 4 key objectives that both you and the patient are trying to achieve in each section? What broad areas do you need to consider to accomplish your needs as a doctor and also to help the patient achieve their needs in each section?

 Try and work out a plan together in diagrammatical form on a piece of flipchart - be as inventive as you like

Feedback, compare models

 STAGE 2

What skills do you need to get there?

Add 4 or 5 skills in each section that you think are really worth teaching to registrars

What are the skills that doctors can use to enable the doctor and patient to achieve what they both need

Share the flip charts again

Discuss how these skills and the framework need to be added together to produce an overall guide and how structure and skills fit together

  Describe a need for a temporal approach to describing the consultation

To enable all of this to occur for both you and the patient, the doctor has to take active control, it won’t happen just by chance - we are always in control of the structure. We need a temporal model or framework of the consultation, a structure that we can employ to allow it all to occur.

Show our exploded model on pages one and two of the guide 

Discuss how this fits in with the various models: all the same

Ours is a temporal approach to the consultation which helps put the theoretical models into practice by using the skills of the consultation

Explain how the all important disease-illness model and ours fit over each other.

 Describe the theoretical importance of the collaborative partnership approach.

Need to have in mind an overall concept or model of the doctor-patient relationship.

Mention well backed by evidence: achieves better outcomes. Mutuality - major problems with the alternatives of paternalism and consumerism: skills would be different if paternalistic model.

Show the disease illness model - describe how helpful we find it is in our teaching - not commonly used in England: the central component of the collaborative approach - explains the unique role of doctors to explore both arms and the need to positively enable the patient to enter into the consultation: it won’t happen unless we engineer it.

However we need as communication teachers to sell not just the collaborative model but also effectiveness within our time constraints

Not just supportive but also accuracy and efficiency

Clinical competence - knowledge, comm skills, problem solving

Link re evidence - we won’t cover now but could cover later if you want (as part of buy in)

Need skills to enable you to take an accurate and efficient history and give information to patients as well as those needed to be supportive to the patient - need to consider the skills required for both the disease and illness arms of the model - fortunately the same!

 Summarise the importance of

·        structure

where am I - what do I want to achieve

what are my objectives/outcomes

·        skills

how do I get there?

·        behaviours

      how can I incorporate these skills into my personality?

 behaviour

As we will see, labelling the structure and the skills is still not enough: we need to explore exactly how you ask an open question or try to be empathetic. Later we can return to this and build on it. This is the third part, behaviour. Discuss personality: skills must be incorporated into our personality so that their use becomes natural - unconsciously competent.

 This model uses a skills based approach not a task orientated one. Teaching skills can lead to changes in attitude: that just looking at attitudes does not necessarily give you the skills;

 Importance of HOW we say or do things as opposed to just WHAT we say 

Skills vs. Attitudes

·                    Always been debate how to bridge gap between Drs actual behaviour - and behaviours we know make a positive difference

·                    Where does the block lie - and what is best way of overcoming it

 Dilemma whether is best to approach from Attitudes or Skills end - 2 theories

 For Skills:

·        Communication is a series of Skills not a matter of personality

·        Skills can be learned but still need practice to change behaviour

For Attitudes:

·        The block is often at deeper level of attitudes & emotions

·        Drs may have skills & use outside area of medicine - don't translate skills because of attitudes towards Pts & illness

·        Often relate to training of medicine itself -disease centred

 

Although both ways are important -  Why choose predominantly Skills based

4 reasons:  -

 

1.      Skills is final common pathway for improving communication - even if attitudinal change raises awareness & increases desire to change skills

2.      Skills is important even if there are no attitudinal problems

We can all think of people with the right attitude - but poor interpersonal skills

3.      Skills approach is less threatening to the defensive learner

Tackling skills is much less threatening than attitudes - more likely to achieve change

4.      Skills acquisition can lead to change in attitudes

Learning new skills may change possibilities & attitudes for looking at things

 

Toolbox

Imagine Skills of medicine to be set of tools in Toolbox

 

·        Each tool has specific purpose efficiently

·        Can remove nut with hammer & chisel - better to use polished socket spanner made for job

·        Do not use all the tools all the time - but know where they are & can call for them in difficult situations

 

Toolbox divided into sections - like the sections of the consultation - helps him organise & find the right tool

Having tools is not enough - need to like using them  like mechanic likes to work with cars

Has to practice using tools until mastered them

Look after them - or they get rusty                      Attitudes & Skills go hand in hand

 

This doesn’t negate that we all have different styles and strengths, and that we shall have a chance to look at these aspects of consulting on the course too. Discuss personality: skills must be incorporated into our personality so that their use becomes natural - unconsciously competent. We shall also have a chance to explore why we don’t use the skills even though we know that they work

Individuality v. Skills: how to reconcile these two concepts via practice and rehearsal. Going beyond specific skills into experiential learning

 EXERCISE 4: LOOKING AT A TAPE

Now that we have started to work out a framework, and begun to fit some of the skills into it;

like putting tools away neatly into their correct compartments in a toolbox, we thought it might be fun and useful to look at a tape and try to identify and label some of these skills.

This is an old prepared tape from the Liverpool collection - re immunisation reaction

Look at the first two minutes

We’re not attempting to analyse the skills and structure we’ve just been trying to fit into a conceptual framework - just to get some practice at identifying the skills and where we are in the consultation by “skimming” quickly through a tape.

not how we would normally help a learner with a tape!!

Leader to show the tape through to just before she gets cross.

Show it again so that the group can label the skills.

Then show the anger and try to work out at what point it went wrong

Demonstrate importance of skills, timing and structure: nice bloke, good skills, wrong order

 9.55 pm

SO why not just teach this from prepared tapes - why do we look at your own videos?

brief discussion that communication skills can be taught and that there is a special methodology - return to this later

Needs to be taught

Experience a poor teacher

Gets worse without teaching - ruts

Can be taught

But need to go further than just understanding and identifying the skills

Needs experiential as well as knowledge based methods (not knowledge based methods are banned!) - the final common pathway - will return to this tomorrow and pull together the how to teach then

Needs observation, feedback and rehearsal to change behaviour rather than just understand the skills: need to know how to use a skill, not just know about

Not just videos of ourselves - we all think in general practice that this is the only way - not true: just one of the methods - others include:

1.      video of real consultations

2.      actors (most appropriately used on the half day release)

3.      individual paired roleplay

4.      cases and reverse roleplay  (good for one to one)

5.      direct observation in surgeries, visits, (specially coop visits)

6.      trigger tapes

 CLOSING ROUND            Back to top

Where are we now  (get the group to summarise)

And where to next?

Discuss how tomorrow will run; that trainers’ agendas are paramount

 Tomorrow we will be looking at videos - the raw material for our discussions. Please bring your videos

9.00 - 11.00 AM

How are you feeling so far

Re-establish group

Re-establish agenda, direction that group would like to take, make offers and suggestions

Review charts on wall and progress so far

Opening round on what struck them from yesterday - something important that they would like to share with the group

 

HOW SHOULD WE LOOK AT TAPES

Ask what methods they have used before to look at tapes.

Discuss Pendleton and why an approximation and ? bring out: value of self assessment, observation, feedback (descriptive and non judgmental), positive and negative, valuing, suggestions for alternatives and rehearsal, safety, for the learner's benefit, timed, not too much. Link to self assessment being “diagnostic” for the teacher re registrars self awareness and how this links with this course for the leaders and also the consultation - need a diagnosis before you treat and need to know what the patient knows and thinks before you explain

 

?Brief leader explanation of educational principles of Pendleton’s rules

1.    Self assessment  first

2.    Positive first for safety

3.    Specific - recommendations not criticisms

4.    Excellent starting point and fall back for safety

and limitations of the rules

1.    Artificiality of separation of good and different, of group and participant: safety rather than interaction, overprotective and therefore leading to lack of safety

2.    Discovers agenda of participant very late and therefore not paralleling the consultation (uncertaintyÕanxietyÕblocks communication)

3.    Can spend too long on the good and too little left for helping

4.    Repetitious, takes too long, inefficient

5.    Evaluative: in the registrars mind, differently = bad and +ve can appear patronising

 

So if these are the educational principles behind them, what do we need to preserve if we depart from them?

Ask group to trust in us to demonstrate a new method and then we can discuss it afterwards and look at the advantages and disadvantages.  

how do we structure and organise experiential feedback sessions to maximise learning and safety? to make productive as well as safe

 Why experiential?

Need to know how, not just know (one stage further, to change behaviour)

This does not mean knowledge a bad thing or not helpful: absolutely needed but often up until now ignored in the swing to experiential learning. Didactic lectures, reading up after but particularly the introduction of appropriately timed material all helpful and necessary.

 Experiential needs:

1.      observation,

2.      audio/video,

3.      plus well intentioned useful feedback

4.      rehearsal and practice in safety

to change behaviour rather than just understand the skills: need to know how to use a skill, not just know about: link to sports coaching

 

But remember the problems of experiential teaching compared to a lecture:

unsafe (for learner, not lecturer: exposing yourself, potentially destructive feedback, bound to self-esteem),

unstructured (messy, inefficient, non-productive endpoints),

opportunistic (random, can’t predetermine)

 agenda-led outcome based analysis

A new approach to the teaching of communication skills in medicine

We’ll demonstrate this method in action in the particular context of video-review although it is equally applicable to all experiential methods e.g. working with simulated patients and in roleplay

The advantages of this new approach:

 

Firstly, how it maximises both learning and safety in experiential teaching by providing a method of structuring analysis and feedback which builds and improves on Pendleton’s rules; most importantly it encompasses the principles of adult learning

Secondly, how it encourages a delicate mix of problem-based experiential learning with the opportunistic and appropriately timed introduction of teaching material such as research evidence and specific teaching exercises

Thirdly, how it enables the facilitator to generalise away from the specifics of the observed consultation to allow the group to explore a problem area more widely before again returning to the particular example in question

Fourthly, how it helps structure learning over time, enabling learners to piece together their potentially random and unstructured experiential learning into an overall conceptual framework (for which we use the Calgary - Cambridge observation guides). Learners can thus remember their learning over time and develop an evolving understanding of the communication skills curriculum as a whole

 GO THROUGH PRINCIPLES of agenda-led outcome based analysis SHEET

Our method of analysis of tapes can be summarised as

·        starts with the doctors agenda

·        balanced feedback by the end

·        uses descriptive feedback

·        is outcome based

·        uses the tape as a gift, as raw material for everyone to learn from together so that the participant is not the constant centre of attention

·        introduces teaching exercises and research evidence

·        uses rehearsal to try  out suggestions

 

Explain descriptive feedback:

Good feedback centres on the fundamental rule of communication that it is outcome based - therefore “What were you trying to achieve then, what were you aiming for, what did you try to do to get there, what could you have done differently to help you get there?”.

1. what you are trying to achieve at any point - objectives

2. how you might get there - skills

This method is always looking at the participant’s agenda and how to help. Not good and differently but what worked well and what didn’t work well.

So we must sell feedback in groups as:

1. what you saw 

2. what else did you see

3. reflect back to participant - what do you think 

4. suggestions on what you would like to achieve and

5. how to get there                     Back to top

PRINCIPLES OF AGENDA-LED OUTCOME-BASED ANALYSIS

 

Start with the learner’s agenda

·        ask what problems the learner experienced and what help he would like from the rest of the group

 

Look at the outcomes learner and patient are trying to achieve

·        thinking about where you are aiming and how you might get there encourages problem solving - effectiveness in communication is always dependent on what you are trying to achieve

 

Encourage self assessment and self problem solving first

·        allow the learner space to make suggestions before the group shares its ideas

 

Involve the whole group in problem solving

·        encourage the group to work together to generate solutions not only to help the learner but also to help themselves in similar situations

 

Use descriptive feedback to encourage a non-judgmental approach

·        descriptive feedback ensures that non-judgmental and specific comments are made and prevents vague generalisation

 

Provide balanced feedback

·        encourage all group members to provide a balance in feedback of what worked well and what didn’t work so well, thus supporting each other and maximising learning - we learn as much by analysing why something works as why it doesn’t

 

Make offers and suggestions; generate alternatives

·        make suggestions rather than prescriptive comments and reflect them back to the learner for consideration; think in terms of alternative approaches

 

Rehearse suggestions

·        try out alternative phrasing and practice suggestions by roleplay - when learning any skill, observation, feedback and rehearsal are required to effect change

 

Be well intentioned, valuing and supportive

·        it is the group’s responsibility to be respectful and sensitive to each other

 

Value the interview as a gift of raw material for the group

·        the interview provides the raw material around which the whole group can explore communication problems and issues: group members can learn as much as the learner being observed who should not be the constant centre of attention. All group members have a responsibility to make and rehearse suggestions

 

Opportunistically introduce theory, research evidence and wider discussion

·        offer to introduce concepts, principles, research evidence and wider discussion at opportune moments to illuminate learning for the group as a whole

 

Structure and summarise learning so that a constructive end point is reached

·         structure and summarise the session using the Calgary-Cambridge observation guides to ensure that learners piece together the individual skills that have arisen into an overall conceptual framework


 

THE “SET - GO” METHOD

OF DESCRIPTIVE OUTCOME-BASED FEEDBACK

 

Group members to base their feedback on:

 

1.  What I saw

          descriptive, specific, non - judgmental

 

 

Facilitator to prompt if necessary with either or both of:

 

2what Else did you see

      what happened next in descriptive terms 

 

3.  what do you think John?

       reflecting back to the doctor on the video who is then given an opportunity to

          acknowledge and problem solve himself

 

 

Facilitator then to get the whole group to problem solve

 

1.   Can we clarify what goal we would like to achieve

          outcome-based approach

 

 

2.   Any offers of how we should get there

          suggestions, alternatives to be rehearsed if possible          

 

 


Back to top

Depending on size of group, divide to a learner group and observers

Small group of five/six concentrating on just being learners and not facilitators

Signpost very clearly the need to just experience the method if in the inner group rather than thinking about dissecting the “how” as facilitators (we will look at the how in detail later - the inner group should concentrate on the what only, as if they were simply a learner group)

 

Work with small group

Explain that with a learner group would start with following or similar exercise first

 

EXERCISE: OWN CONSULTING SKILLS 

Let’s summarise the problems with  our own consulting skills from yesterday as a way into this… anyone got anything to add?

(With your own registrar you both might write down and then read out

“Thinking about your own consultation skills, which areas of the consultation work reasonably well for you -

 which aspects do you feel reasonably good / confident about?”

 

“What areas of the consultation don’t work so well for you, do you have difficulty with,  would like other people to help you with on this course?”)

 

 

09.45 - 11.00 FIRST VIDEO SESSION

We have two concurrent aims in our teaching sessions on communication skills when we are working in groups:

•     to help the doctor on the tape with his agenda by involving the whole group including him in problem solving

•     to generalise away from the tape to look at specific areas of communication

These need to be made overt so that the group understands that the tape is being shown to help us all rather than just the doctor showing the tape and that we are grateful for the gift of the raw material to provide something for us to work on.

 

May need to let anyone nervous go first - ?vote on an order, or draw tapes out of a bin.

 

We must ask one participant to particularly look at the consultation from the patient’s point of view and be prepared to act the patient if we wish to try out alternatives or try out specific skills

Acknowledge observers and explain that 10 mins will be reserved at the end of the session or at beginning of next for their feedback on the process and the teaching/facilitation. Discuss with the observers how they record the process so that can feed it back accurately.  It needs to be descriptive.


 

agenda-led outcome-based analysis in practice

 

Prior to watching the interview

·         If using a pre-recorded tape, ask the learner showing the tape to set the scene, describe his prior knowledge of the patient and list the extenuating circumstances! We should know exactly what the learner knew and was feeling when the patient entered the room and no more. If watching a live interview, the group should be given the same information about context as the learner

·         Instruct the group to write down specific words and actions as an aid to descriptive feedback; if using video, jot down exact times or counter numbers

·         Ask one member of the group to watch as if the patient and to roleplay the patient afterwards to enable rehearsal. This is not necessary if a real or simulated patient is present who can help with further rehearsal during feedback

 

After watching the interview

·         Allow the group several minutes to collect their thoughts and identify the one or two most important points they would like to bring up in feedback, making sure to provide a balance between what worked and what was problematical

·         Facilitator to consider where to place feedback on what worked well

·         Acknowledge any feelings of the learner who has been observed

 

Start with the learner who has been observed

·         ‘What areas do you want to highlight as being problems for you, tell us your agenda..’ Write up or summarise agenda items

·         ‘What help would you like from the rest of the group’

·         ‘What outcome would you like to achieve from the feedback session’

·         Facilitator to consider whether to add in his own or the group’s agenda here

·         Negotiate with the learner the best way to look at the interview - choose which area to focus on or replay first

·         Invite the learner to start off looking at his own agenda by reflecting on the relevant part of the interview and asking him to use descriptive feedback to say what worked well and what didn’t work so well - replay those parts if working from videotape

·         Elicit thoughts and feelings of learner and patient, including the outcomes they wanted to achieve at various points in the interview

·         Rehearse with one of the group role-playing the patient or with the simulated or real patient if present

·         Encourage offers and suggestions from the rest of the group and further rehearsal

·         Obtain feedback from patient

     

To the group as a whole

·         Summarise progress so far and ask the group for their help: prompt with Set-Go feedback (see later in this chapter)

·         Rehearse suggestions

·         Add in facilitator’s ideas and thoughts

·         Appropriately introduce theory, research and wider discussion

·         Clarify with learner that his agenda has been covered

·         Ask group for any agenda of their own that we have not covered already

·         Be very careful to balance what worked well and what didn’t work so well by the end

 

Ending

·         Ask what everyone has learned (one thing to take away) and whether the feedback was useful and felt acceptable

·        Pull together and reflect on the “what”: the structure and skills related to the Guide

 

Summarise with one thing learnt by each member of the group,

and one thing which has helped them move forward in looking at the consultation.

Bring in the observers feedback and discuss or signpost that will do next

Leader to summarise and give view of how the group is working; and mirror with teaching and the consultation.

·        Distinguish between structure and skills, concepts and specific skills

·        Summarise and what we have and haven’t covered

·        Relate to the guides

·        ?Discuss feedback method and analysis: advantages and disadvantages over Pendleton

·        Explain my thoughts re session, concerns, dilemmas, my feedback, check re my agenda and theirs, empathy, friendliness, sensitivity; share my insecurities

 

11.00 - 11.15  COFFEE            Back to top

 

11.15- 1.00 2ND VIDEO SESSION

·        Recap - Structure, Skills and Methods used so far  - list what good facilitators do (Flipchart)

·        One thing learnt by each member of the group or has helped them move forward in looking at the consultation

·        Give view of how the group is working; and mirror with teaching and the consultation.

 

Negotiate whether to continue as before or use option of using someone as facilitator or teacher

 

1.0 PM - 2..00 PM  LUNCH

 

2.00 PM - 3.30 PM THIRD VIDEO SESSION

Again, re-establish direction

Review of the "how" - add to list - and the “what” - refer to the guides

 ·        How are they feeling about experiences/methods used so far

·        ? Insights into being a facilitator from last session - Flipchart

·        Summarise any important points generated by last session

 Negotiate Options:

·        If not already - START or Continue using someone as facilitator or teacher

·        Looking at 1-1 teaching - the differences from Group teaching

·        Looking at specific areas of the consultation

·        Looking at personal Teaching Agendas and needs - refer back to Flipcharts made at beginning

1-1 teaching - Demonstrate as teacher or ask or volunteer teacher & 'Shadow' to rest of group

·        What are the differences? Flipchart

·        Problems of random learning vs. planning curriculum

·        How do Learners learn - 4 Stage model

Personal Teaching Agendas

·        Procedural issues - consent, cameras, recording and process

·        Personal Learning needs - learning the repertoire of skills

·        Recognising common patterns of Problems within Consultation

·        Difficulties - responding to defended & conflicted situations

·        Summative Assessment & MRCGP

Specific areas of the Consultation

·        Using the CCOG as learning Aid

·        Looking at a series of Consultations -  similar to RCA & PCA

I

f not done already:

Lecture re can and how to teach communication skills

THE EVIDENCE TO SUPPORT WHY WE DO IT AS WE DO:

 

principles of communication skills teaching

Let’s start with some principles of communication skills teaching: communication skills programmes rely heavily on experiential rather than didactic methods of learning. In particular, almost all use video or audio recordings of interviews with real or simulated patients followed by observation and feedback. But are these experiential methods necessary for learning communication? Do we know that traditional apprenticeship or didactic teaching methods by themselves won’t bring about the same changes in behaviours and skills? Why when experiential methods are potentially more challenging, threatening and less safe for the learner do we insist on their use? Isn’t knowledge of the skills enough without having to practice them as well?

 

CAN YOU TEACH?

A basic clinical skill, a series of learned skills, experience does not teach well, gets worse if not taught, can be taught, is retained, makes a difference

The research evidence:

Can be taught - Maguire, Evans, etc. - plus learning not transferable from info gathering to info giving

Is retained - Maguire, Bowman, Stillman

 

Maguire, Evans - randomised trials to tease apart experiential and didactic components: need for experiential learning to move knowledge into behaviour.

Noticed considerable gains made by students who were taught interviewing skills as part of training course

Set out to identify what specific methods were responsible

4 groups:

1 traditional teaching only

2, 3, 4 were given detailed handouts indicating what information should be obtained and how

2 -given feedback in addition to how they did on video

3, watched video together with feedback

4 - used audio instead

 

2,3, & 4 improved but 1 didn't - Significant improvement in 3 & 4 with superiority in video

 

People who watched video alone - didn't improve as much - showed importance of feedback

 

Led to…what we now know - to be the 5 essential ingredients of experiential teaching

·      written guidelines of the structure and skills

·      observation,

·      audio/video,

·      plus well intentioned useful feedback

·      rehearsal and practice in safety

to change behaviour rather than just understand the skills: need to know how to use a skill, not just know about: link to sports coaching

 

Not just videos of ourselves - we tend to think in postgraduate general practice that this is the only way - not true: just one of the methods - others include:

1.      video of real consultations

2.      actors

3.      roleplay

 Problem based v. Directive

Why not teach via handout of required skills (Maguire suggests detailed written guidelines), obs, feedback, practice; why base on our own tapes? The problem of remedial education, of starting on the seventh floor, of difficult contexts and basic skills. The need for problem-based learning rather than directive learning - start from where the learners are - do not demean 

But remember the problems of experiential teaching compared to a lecture:

unsafe (for learner, not lecturer: exposing yourself, potentially destructive feedback, bound to self-esteem),

unstructured (messy, inefficient, non-productive endpoints),

opportunistic (random, can’t predetermine)

 how to overcome in practical teaching -

1.      how to provide a supportive environment,

2.      how to structure sessions,

3.      how to maximise learning and safety

4.      how to structure learning over time

5.      how to conceptualise learning

6.      how to remain a learner and equal and input learning

7.      how to introduce didactic material such as theory and research

 3.30 - 4.00 TEA

 4.00 - 5.45  FOURTH VIDEO SESSION

 CLOSING ROUNDS

To reflect on the course, our learning, ourselves

To say goodbye to each other

 Thank you for putting yourselves on the line and working so well as a group. Wonderful.

 Round of

One thing that I’d like to take away from this course about communicating skills that I’m going to take back into my practice or teaching?

Feedback on assessment form first. This is not quite the end but it allows us to focus on what we have achieved and allows us to get the formal part out of the way.

Round: one comment that I’d like to make about the course as a whole and or the way that we have worked together

 

Opportunity to look at yourself

Pairs: where are you now and where do you want to be going?

             what might be a next step?

 Round of next steps

 Goodbyes                 Back to top

 OBJECTIVES: COMMUNICATION SKILLS TEACHING

INTRODUCTORY TRAINERS COURSE 1999

 

To bring together a group of participants who have an enthusiastic desire to learn more about their own consultation skills and to extend their thinking about how to teach communication skills to their registrars.

 To provide a supportive environment and the right atmosphere for the group to feel safe with each other, work well together and want to help each other so that we can:

 ·        share our thoughts, concerns and experiences of communication skills and communication skills teaching

 ·        explore together our own consultation skills, identifying those areas that work well for us and those areas which do not seem to work so well, in order to improve our own consultations with patients and to learn how to teach these skills to our registrars 

·        explore the “what” of communication teaching by:

videntifying those skills that make a difference to the consultation

vdiscussing the theoretical and research evidence that validates these skills

vconsidering the importance of structuring these skills within the consultation

vintroducing the Calgary-Cambridge Observation guides to help organise opportunistic learning

 

·        explore the “how” of communication teaching by:

videntifying the principles that help learners to learn communication skills

vexploring different methods of analysing and providing feedback on consultations and experiencing at first hand agenda-led, outcome-based analysis and descriptive feedback

vconsidering how research evidence and teaching exercises can be introduced into experiential discussion

vusing various methods and different models to explore real difficulties in

    consultations e.g. video analysis of consultations, role play, trigger tapes

 

·        consider how to structure a communication skills teaching curriculum by:

vconsidering how we can best prepare our registrars for the consultation components of summative assessment and the MRCGP

vexamining the advantages of group work over 1:1 teaching

 

·        increase our own confidence in our teaching and pass on our enthusiasm for teaching the consultation to our registrars

 

We wish to encourage the group members to identify their own problems and utilise the expertise within the group to help solve them. We aim to provide an atmosphere which will encourage you all to relax and have fun.

 Back to top

 

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