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Using the Patient Centered Observation Form: Evaluation of an online training program
... Health research studies increasingly include direct observation methods [1][2][3][4][5]. Observation provides unique information about human behavior related to healthcare processes, events, norms and social context. ...
... Interviews or surveys are limited to what participants share. Observation is particularly useful for understanding patients', providers' or other key communities' experiences because it provides an "emic," insider perspective and lends itself to topics like patient-centered care research [1,5,6]. This insider perspective allows researchers to understand end users' experiences of a problem. ...
... The template prompts the observer to record whether a phenomenon occurred, its frequency, and sometimes its duration or quality. See Keen [5] or Roter [24] Fix et al. All templates should include key elements like the date, time and recorder. ...
Objective
To provide health research teams with a practical, methodologically rigorous guide on how to conduct direct observation.
Methods
Synthesis of authors’ observation-based teaching and research experiences in social sciences and health services research.
Results
This article serves as a guide for making key decisions in studies involving direct observation. Study development begins with determining if observation methods are warranted or feasible. Deciding what and how to observe entails reviewing literature and defining what abstract, theoretically informed concepts look like in practice. Data collection tools help systematically record phenomena of interest. Interdisciplinary teams--that include relevant community members-- increase relevance, rigor and reliability, distribute work, and facilitate scheduling. Piloting systematizes data collection across the team and proactively addresses issues.
Conclusion
Observation can elucidate phenomena germane to healthcare research questions by adding unique insights. Careful selection and sampling are critical to rigor. Phenomena like taboo behaviors or rare events are difficult to capture. A thoughtful protocol can preempt Institutional Review Board concerns.
Innovation
This novel guide provides a practical adaptation of traditional approaches to observation to meet contemporary healthcare research teams’ needs.
... Fourth, by making pain control a patients' rights issue, The Joint Commission emphasized symptomatic treatment of pain over clinical investigation of the causes. 3 The Joint Commission did not follow the principles of evidence-based medicine in enacting its pain management guidelines and did little to prevent or decrease opioid use once the epidemic became apparent. ...
... The authors used information selectively from a US General Accounting Office study of OxyContin and Purdue Pharma to imply that Purdue had a close relationship with The Joint Commission. 3 The US General Accounting Office report actually said, "From 1996, when OxyContin was introduced to the market, to July 2002, Purdue has funded over 20,000 pain-related educational programs through direct sponsorship or financial grants." The Joint Commission was only 1 among thousands of organizations that received funds to develop educational programs. ...
... Barsky identified these late-arising concerns as a challenge because they were "hidden" until the last moment of the encounter. 3 Because patients frequently present with multiple concerns, 4 and there is no evidence that the first concern is the most important from their perspective, 4,5 we concluded that the most effective approach is to solicit all the patient's concerns at the beginning of the visit and then negotiate what to focus on in the time allotted. In our study, because physicians did not seek additional concerns once they interrupted the patient's opening statement, we advised not to interrupt during the solicitation process and continue soliciting concerns until the patient said they had no more concerns to discuss. ...
To the Editor In his A Piece of My Mind article,¹ Mr Mauksch asserted that physicians may have to interrupt patients at times to maintain efficient and effective care. He inferred that our 1984 article, “The Effect of Physician Behavior on the Collection of Data,”² is responsible for spreading the misconception that interruption is always inappropriate.
... Based on literature reviews of models of doctor-patient communication commonly used in medical education, [16][17][18] and the authors' knowledge of additional models used in family medicine in particular, respondents were ask to identify which, if any, of these models are used to guide the communication curriculum in their residency program. Options listed for participants to choose from included: Kalamazoo, 16 Calgary Cambridge, 17 SEGUE, 23 4 Habits, 24 MAAS, 25 Arizona (ACIR), 26 Common Ground, 27 Macy, 28 Patient Centered Observation (Mauksch), 29 other, and no specific model is used. Participants were also asked to indicate the different teaching methods used in their communication curriculum including the number of hours dedicated to teaching communication using different methods for each post-graduate year. ...
... The majority of residency programs (34%) used Mauksch's patientcentered observation model for their communication curriculum. 29 A quarter of programs do not use a standard model of doctor-patient to guide their communication curriculum. The remaining programs used other readily available doctor-patient communication models (14%), with the motivational interviewing model 30 as most commonly identified (5%). ...
... family medicine professional conferences. 29,31 The second aim of the current study was to determine the most common methods to teach communication skills in family medicine residencies and found that teaching methods varied considerably across programs. Though most programs indicated using lecture to teach communication skills, a passive and less effective education method, most programs also indicated incorporating more active methods like direct observation, video review, and smallgroup work for at least some of their curriculum. ...
Background and objectives:
Communication skills are essential to medical training and have lasting effects on patient satisfaction and adherence rates. However, relatively little is reported in the literature identifying how communication is taught in the context of residency education. Our goal was to determine current practices in communication curricula across family medicine residency programs.
Methods:
Behavioral scientists and program directors in US family medicine residencies were surveyed via email and professional organization listservs. Questions included whether programs use a standardized communication model, methods used for teaching communication, hours devoted to teaching communication, as well as strengths and areas for improvement in their program. Analysis identified response frequencies and ranges complemented by analysis of narrative comments.
Results:
A total of 204 programs out of 458 family medicine residency training sites responded (45%), with 48 out of 50 US states represented. The majority of respondents were behavioral scientists. Seventy-five percent of programs identified using a standard communication model; Mauksch's patient-centered observation model (34%) was most often used. Training programs generally dedicated more time to experiential teaching methods (video review, work with simulated patients, role plays, small groups, and direct observation of patient encounters) than to lectures (62% of time and 24% of time, respectively). The amount of time dedicated to communication education varied across programs (average of 25 hours per year). Respondent comments suggest that time dedicated to communication education and having a formal curriculum in place are most valued by educators.
Conclusions:
This study provides a picture of how communication skills teaching is conducted in US family medicine residency programs. These findings can provide a comparative reference and rationale for residency programs seeking to evaluate their current approaches to communication skills teaching and develop new or enhanced curricula.
... We utilize a standardized instrument, the Patient-Centered Observation Form (PCOF) [34] adopted from family medicine residency training, for students to give and receive feedback. The PCOF, developed by Mauksch et al. [34], is employed to further students' learning, foster professional identity development and as a preparation for summative component competency evaluations through Objective Structured Clinical Evaluations (OSCEs). ...
... We utilize a standardized instrument, the Patient-Centered Observation Form (PCOF) [34] adopted from family medicine residency training, for students to give and receive feedback. The PCOF, developed by Mauksch et al. [34], is employed to further students' learning, foster professional identity development and as a preparation for summative component competency evaluations through Objective Structured Clinical Evaluations (OSCEs). Students meet monthly in pairs with the TCC Program Director to review videotaped patient encounters, perform their self-evaluation, and provide feedback to each other. ...
Background
The Transformative Care Continuum (TCC) emerged in 2018 at Ohio University’s Heritage College of Osteopathic Medicine, combining a three-year medical education track with a three-year family medicine residency. TCC aligns evolving family physician roles through the Kern model, AMA’s Master Adaptive Learner model, Health Systems Science Training, and Kirkpatrick’s evaluation model.
Methods
The TCC curriculum emphasizes intensive coaching, clinical encounter video evaluation, reflection, and case-log review. It fosters longitudinal clinical integration, community engagement, and a dynamic learning atmosphere. Students receive rigorous patient-centered communication training and engage in residency-based quality improvement projects, targeting care gap closure and community health in an accelerated 3-year program.
Outcomes
Assessment of TCC graduates demonstrates advanced team communication, leadership, and project management skills, with entrustable professional activities (EPA) scores meeting or surpassing those of traditional program graduates. Projects led by students have yielded notable clinical enhancements, national recognition, and significant philanthropic funding for non-medical determinants of health. Finally, there is an overall increase in scholarly activity and leadership roles within the residency programs that have engaged these students.
Discussion
Lessons reveal intrinsic challenges and heightened academic demands for students and residency programs. Additional educational support for students may be necessary, though costly. Limitations in residency slots and faculty availability as student educators potentially hinder scalability. Ongoing faculty training, cultural support, and early integration of digital systems for curriculum management and evaluation are vital for success. Obtaining patient satisfaction, health outcomes, and program measures remains challenging due to privacy concerns and approval processes between institutions.
Conclusion
Programs like TCC effectively prepare students for family physician leadership and change management roles through tailored learning, longitudinal experiences, health systems training, and addressing critiques of traditional medical education. Continuous feedback and robust communication strategies are essential for program improvement, fostering well-prepared family physicians committed to health system enhancement.
... At least a dozen VR/observation templates and rating scales have been developed to support supervisors' review of patient encounters. These forms, which are typically connected to larger curricular programs that provide training in the art of facilitating patientcentered care, include Common Ground Instrument (Lang et al., 2004), Patient Centered Observation Form (PCOF) (Keen et al., 2015), and the four habits coding scheme (Krupat et al., 2006). With a focus on the presence or absence of clinician behaviors (i.e., eye contact, use of open-ended questions, balance of technology use with patient interaction), suggesting that for most training programs, the purpose of the VR is to confirm whether or not clinicians in training possess a number of behaviors consistent with the behaviors of a "good clinician". ...
... While the Accreditation Council for Graduate Medical Education (ACGME, 2022) does not operationalize EI in their milestones for family medicine physicians, expectations for "Professionalism" and "Interpersonal and Communication Skills, " are consistent with Bradberry and Greaves' skills. Historically, VR practices have focused on observable behaviors that convey social awareness and relational management EI skills [i.e., eye contact, balancing technology use with warm introduction and greeting, as included on the PCOF (Keen et al., 2015)]; the training we have developed for our residency program incorporates the self-awareness and self-management skills of EI. We propose that EI is a framework from which to conceptualize family medicine residents' ability to emotionally connect with patients. ...
Video Review (VR) is a well established educational tool for developing the practice of patient-centered care in family medicine residents. There are a number of behaviorally-based checklists that can be use in both live observation as well as VR of clinical encounters to identify and promote behaviors associated with patient-centered care, most of which also overlap with behaviors associated with Emotional Intelligence (EI). We propose a VR that is structured less on a seek-and-find of clinician behaviors and more as a self-reflective exercise of how the clinician presents in the room alongside how they were feeling during that encounter. We believe that this exercise promotes the first two skills of EI (self-awareness and self-management) and then provides a foundation on which to build the second pair of skills (social awareness and relationship management). This perspective paper offers guidance, including stepwise instruction, on how to facilitate such a VR curriculum.
... Communication training tools address some, but not all, of these broader medical education challenges. Some tools use behaviorally-anchored checklists, record qualitative data (Keen et al., 2015) and offer coaching on specific communication skills (Brock et al., 2011) or a broader patient encounter framework (Kurtz et al., 2003). These approaches emphasize repeated observation of skills in real-time, to identify strengths, habits, and professional blind spots (Gawande, 2011;Mauksch et al., 2008). ...
... Our embedded communication coaches also collaborate with residency program directors about systemic or programmatic issues that may contribute to resident burnout and brainstorm wellness-promoting opportunities. Our program builds on other communication training tools (Brock et al., 2011;Keen et al., 2015;Kurtz et al., 2003) through the: (1) depth of individualized feedback delivered in a step-wise fashion over time to promote sustainable behavior change, and (2) embedded coaches who can address systemic and cultural issues to promote professionalism competencies and wellness (e.g., accessibility/acceptability of mental health care for residents, mentoring match). Finally, our psychologist coaches recognize many benefits to this work, including diversity of role and function, novel application of skills, the appreciation of the residents and faculty, and the recognition of psychologists as leaders within academic health centers. ...
Many factors influence resident physician communication, including rigorous training demands that can contribute to professionalism issues or burnout. The University of Rochester Physician Communication Coaching program launched for attendings in 2011, and expanded to residency programs within 11 clinical departments of our institution. In this model, psychologists serve as coaches, drawing on their expertise in communication skills, behavior change, and wellness promotion. These coaches conduct real-time observation of patient encounters, coding communication with an expanded Cambridge-Calgary Patient-Centered Observational Checklist. Residents receive a written report with individualized feedback. From 2013 to 2020, 279 residents were coached. Since 2018, residents have been formally surveyed for feedback (n = 70 surveys completed; 61% response rate), with 97% rating the experience Very Helpful or Helpful. Of the 70 completed surveys, 54 (77%) included qualitative feedback that has also been positive. Due to the feasibility and growing demand for communication coaching from other residency and fellowship programs, in 2018 two authors (SM and LD-R) developed a 2-year, part-time program to train communication coaches.
... 7 The PCOF is a two-page checklist that breaks down the patient visit into well-defined components that are supported by measurable, discrete clinician behaviors. [8][9][10] In 2009, the University of Minnesota Department of Family Medicine and Community Health (UMN-DFMCH) charged its residency programs to implement a patientcentered communication curriculum using the PCOF. [8][9][10] Although the PCOF is one of the most commonly used forms used for assessing patient-centered communication, there is limited published data on how programs have implemented use of the PCOF and its impact on resident communication skills. ...
... [8][9][10] In 2009, the University of Minnesota Department of Family Medicine and Community Health (UMN-DFMCH) charged its residency programs to implement a patientcentered communication curriculum using the PCOF. [8][9][10] Although the PCOF is one of the most commonly used forms used for assessing patient-centered communication, there is limited published data on how programs have implemented use of the PCOF and its impact on resident communication skills. We conducted a mixed-methods study aimed at characterizing the experiences of five residency programs over 7 years of PCOF implementation and use. ...
Background and objectives:
For years, family medicine has taught patient-centered communication through observations and observation checklists. We explored the utility of one checklist, the Patient-Centered Observation Form (PCOF), to teach and evaluate patient-centered communication in our family medicine residencies.
Methods:
We conducted a mixed-method study of five University of Minnesota Family Medicine Residencies' seven years of experience teaching and evaluating residents' patient-centered communication skills. All programs have a behavioral health (BH) faculty-led observation curriculum that uses the PCOF to assess resident skills and give feedback. We conducted a BH faculty focus group and interviews, generated themes from the BH responses, and then queried family medicine (FM) faculty regarding these themes through an online survey.
Results:
Ten BH faculty participated in the focus group/interviews, and 71% (25/35) of FM faculty completed the survey about themes derived from the BH interviews. The residencies complete between 1 to 11 observations per resident per year. Since implementation, four programs have continuously used the PCOF due to its versatility, design as a formative rather than summative feedback tool, and relative ease of use. BH faculty believe longitudinal observations with the PCOF resulted in improved resident patient-centered communication. Most importantly, all faculty described a shift in family medicine culture toward patient-centered communication. Time for observations and feedback is the primary curricular barrier.
Conclusions:
Our findings support the utility of the PCOF for teaching and evaluating patient-centered communication in family medicine training.
... Family Centered Observation Form. Direct observation using the validated patient-centered observation form (PCOF) is a routine part of this residency program's training (Keen et al., 2015). In this study, however, we used the Family Centered Observation Form (FCOF), a modified version of the PCOF that includes additional FO elements (Felix, 2016). ...
Introduction:
Family-oriented care is at the heart of family medicine (FM) practice, yet research suggests an unmet need for family skills training in FM residencies. The purpose of this study is to evaluate family-oriented (FO) attitudes and observed skills of FM residents before and after completion of a longitudinal family skills curriculum.
Method:
We assessed FO attitudes and observed skills of second-year FM residents (N = 12) using the "Family in Medicine" Q-sort exercise (Q-sort) and the Family-Centered Observation Form (FCOF) before and after completion of the family systems "Practicum" portion of a 20-week psychosocial medicine curriculum. Residents were observed in 19 pre- and 15 post-Practicum encounters.
Results:
With regard to attitudes, 10 of 12 (83%) residents had a moderate to strong affinity for the FO viewpoint pre-Practicum; 9 of 12 (75%) maintained or strengthened their FO viewpoint post-Practicum. With regard to observed skills, FO visit content increased post-Practicum; 10/15 (67%) post-Practicum encounters included FO comments or questions compared to 5/19 (26%) pre-Practicum encounters.
Discussion:
In this curriculum evaluation, we found our FM residents to have strong baseline FO attitudes that generally became stronger after a family skills curriculum. FO behaviors increased post-Practicum, though were still demonstrated relatively infrequently, which may be related to a variety of factors. Future directions include increasing experiential FO learning opportunities during Practicum and revising and validating the FCOF. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Pairing online videos of best and usual practices provides a means for clinicians to identify core skills prior to practicing them. 34 Use of training videos of simulated visits with patients followed by practice of skills are a powerful tool for improving communication skills. 35 While we applied this training to office blood pressure counselling, we believe this approach is relevant to most office based counseling. ...
Patient-centered communication is a means for engaging patients in partnership. However, patient centered communication has not always been grounded in theory or in clinicians' pragmatic needs. The objective of this report is to present a practical approach to hypertension counselling that uses the 5As framework and is grounded in theory and best communication practices.
... It was created by the university-affiliated graphic artist. 11 Standardized learner training PowerPoint: The standardized learner training PowerPoint (Appendix F) was used for the first standardized learner training. It introduced the concept of the OSTE, provided structural and logistical details about the OSTE, and described the general roles the learners would be playing on the day of the OSTE. ...
Introduction
Objective standardized teaching exercises (OSTEs) are widely used to develop professional competencies, especially in the health care professions. An OSTE involves exposing different providers to the same, time-limited scenario that is concurrently observed and/or recorded for either formative or summative evaluation. As there are limited resources available for creating a resident-specific OSTE, especially those applicable to family and community medicine residents, we created and evaluated a resident OSTE (R-OSTE) for second- and third-year family and community medicine residents.
Methods
This R-OSTE involved two cases. The first featured Taylor, a third-year medical student resistant to feedback. The second featured Kris, a first-year resident nervous about approaching the attending on duty. Our R-OSTE had residents teaching interpersonal skills to trained actors in a standardized learner role.
Results
Residents in the teaching role were formatively evaluated by peer observers (fellow residents) and standardized learners on interpersonal domains such as communication and professionalism. Learners gave residents an average performance rating of 4.9 on a 1 to 6 scale with 1 = Very Poor and 6 = Excellent. Residents also evaluated the OSTE itself, rating their experience on multiple teaching-related statements. Eighty-six percent of residents agreed this exercise was an appropriate development activity for family medicine residents. Overall, our R-OSTE was rated highly for relevance to teaching by the residents.
Discussion
The residents were rated highly by both peer observers and standardized learners. However, there was little variability in peer observer scores, indicating the need for an alternative method of measurement.
... Observation form. Source: Adapted from Patient Centered Observation Form.4 ...
Social class and privilege are hidden variables that impact the physician-patient relationship and health outcomes. This article presents a sample of activities from three programs utilized in the community health curriculum to teach resident physicians about patients within context, including how social class and privilege impact physician-patient relationships and patient health. These activities address resident physicians' resistance to discussion of privilege, social class, and race by emphasizing direct experience and active learning rather than traditional didactic sessions. The group format of these activities fosters flexible discussion and personal engagement that provide opportunities for reflection. Each activity affords opportunities to develop a vocabulary for discussing social class and privilege with compassion and to adopt therapeutic approaches that are more likely to meet patients where they are.
... Use of an observation tool 54 establishes a shared vocabulary and ultimately shared cognition while providing means for structuring feedback. 55 After initial training, teamlets spend time observing one another on the basis of brief "average" and "better" videos of simulated patient sessions that teamlets created. This training fosters shared cognition, open communication, cooperation, coordination, and team skills development. ...
Background
Team science has been applied to many sectors including health care. Yet there has been relatively little attention paid to the application of team science to developing and sustaining primary care teams. Application of team science to primary care requires adaptation of core team elements to different types of primary care teams.
Core Team Elements
Six elements of teams are particularly relevant to primary care: practice conditions that support or hinder effective teamwork; team cognition, including shared understanding of team goals, roles, and how members will work together as a team; leadership and coaching, including mutual feedback among members that promotes teamwork and moves the team closer to achieving its goals; cooperation supported by an emotionally safe climate that supports expression and resolution of conflict and builds team trust and cohesion; coordination, including adoption of processes that optimize efficient performance of interdependent activities among team members; and communication, particularly regular, recursive team cycles involving planning, action, and debriefing. These six core elements are adapted to three prototypical primary care teams: teamlets, health coaching, and complex care coordination.
Conclusion
Implementation of effective team-based models in primary care requires adaptation of core team science elements coupled with relevant, practical training and organizational support, including adequate time to train, plan, and debrief. Training should be based on assessment of needs and tasks and the use of simulations and feedback, and it should extend to live action. Teamlets represent a potential launch point for team development and diffusion of teamwork principles within primary care practices.
Behavioral science has been an integral part of the family medicine curriculum since the inception of the specialty. Its inclusion prepares family physicians to provide patient-centered care, communicate with empathy and compassion, exercise cultural humility, and manage mental health issues commonly seen in primary care. Behavioral science curricula will also train clinicians to increase their self-awareness and reflective practices so that they might develop skills to manage stress and maintain well-being in the face of the challenges inherent in health care. Building on the Accreditation Council for Graduate Medical Education (ACGME) Family Medicine Residency Program Requirements, this chapter will provide guidance on what to include in a behavioral medicine curriculum, and various methods for its dissemination.
Background
Efficient doctor-patient communication is essential for improving patient care. The impact of educational interventions on the communication skills of male and female students has not been systematically reviewed. The aim of this review is to identify interventions used to improve communication skills in medical curricula and investigate their effectiveness in improving the communication skills of male and female medical students.
Methods
A systematic review of the literature was conducted using the PRISMA guidelines. Inclusion criteria were as follows: used intervention strategies aiming to improve communication skills, participants were medical students, and studies were primary research studies, systematic reviews, or meta-analyses.
Results
2913 articles were identified based on search terms. After title, abstract, and full-text review, 58 studies were included with interventions consisting of Training or Drama Courses, Curriculum-Integrated, Patient Learning Courses, and Community-Based Learning Courses. 69% of articles reported improved communication skills for both genders equally, 28% for women more than men, and 3% for men more than women. 16 of the 58 articles reported numerical data regarding communication skills pre-and post-intervention. Analysis revealed that post-intervention scores are significantly greater than pre-intervention scores for both male (p < 0.001) and female students (p < 0.001). While the post-test scores of male students were significantly lower than that of female students (p = 0.01), there is no significant difference between genders for the benefits, or difference between post-intervention and pre-intervention scores (p = 0.15), suggesting that both genders benefited equally.
Conclusion
Implementation of communication training into medical education leads to improvement in communication skills of medical students, irrespective of gender. No specific interventions benefitting male students have been identified from published literature, suggesting need of further studies to explore the phenomenon of gender gap in communication skills and how to minimize the differences between male and female students.
This article explores the clinical applications of Audiology Practice Standards Organization (APSO) Standards 2 and 13, both of which keep us fully focused on the patient-as-person. The topics within Standard 2 include audiologists' interpersonal communication skills, specifically clarity (ensuring patient comprehension) and empathy (understanding the patient's experiences). Standard 2 also addresses the topic of health literacy, which has been recently expanded to consider not only the degree to which individuals are able to find, understand, and use information and services to inform health-related decisions but also how organizations equitably support those necessary skills. The characteristics and benefits of services provided in patient- and family-centered care contexts are also described. Standard 13 addresses audiologists' support toward overall successful adjustment as defined by the patient, including both technical and personal adjustment to amplification, nontechnical communication issues, and rehabilitation support using readily available technologies. A new assessment protocol that includes goal setting and intervention is described, as well as a patient-centered intervention strategy involving discussion of personally meaningful photographs. Both standards provide a necessary balance to our technology-reliant profession.
Objective
Workforce development is essential for the dissemination of team-based integrated behavioral healthcare. There is limited literature on training family medicine residents to function within an integrated behavioral health (IBH) system. The purpose of this pilot study was to assess the feasibility and value of an IBH competency-based curriculum for family medicine residents across multiple programs.
Methods
Residency programs were recruited using professional listservs and networks to test a competency-based, multi-modal curriculum for preparing residents to practice IBH in primary care. Faculty instructors who led the workshop were invited to complete semi-structured interviews to examine the feasibility and appropriateness of the curriculum. Interview data were analyzed using thematic analysis to identify, analyze, and report patterns. Residents completed a survey of perceived IBH skill and knowledge before and after training. A paired-sample t-test was used to determine significant differences pre- and post-training.
Results
All five instructors completed interviews. Results suggest IBH training is valuable. Instructors gave specific feedback on online modules, implementation flexibility, and adjusting faculty development to differing levels of experience. Nineteen of forty residents (48%) completed anonymous pre-, post-, and retrospective-training surveys. Residents reported an increase in competence after training.
Conclusion
The results of this pilot suggest that IBH training implementation is feasible, desirable, timely, and may improve resident ability to work on an IBH team. Training should accommodate variations in program structure and faculty expertise.
Background
Providing a person-centered care (PCC) education program to nursing students is necessary. This study aims to determine the impact of a design-thinking based education program on how nursing students perceive PCC.
Methods
Five 2-h lessons were offered to 105 fourth-year nursing students in South Korea. Each randomly assigned group of eight or nine students was instructed to develop a plan to address the problems/dissatisfaction experienced by patients during hospitalization. The Individualized Care Scale—nurse's version was used to measure student's perception of PCC before and after the education program.
Results
After the program the students exhibited significant improvements in how they viewed supporting patient individuality, with that score increasing by 0.44 (from 3.64 to 4.08; p < 0.0001), and maintaining patient individuality while providing care, with that score increasing by 0.34 (from 3.71 to 4.05; p < 0.0001). Among subdomains, the most notable change was in how the students viewed the personal life situation of patients, and its impact on patients' healthcare outcomes.
Conclusion
This education program, based on the design-thinking approach, was effective in improving the perceptions of nursing students about PCC. Expanding such PCC education programs for nursing school students should therefore be considered.
Introduction:
Most interventions to date regarding breaking bad news focus on late-stage disease or disclosing a cancer diagnosis. Little attention has been given to delivery of chronic metabolic disease diagnoses such as prediabetes/type 2 diabetes.
Methods:
Informed by the American Diabetes Association standards of care and formative research conducted by our research team, we developed this curriculum through the six-step approach to curriculum development. The curriculum consists of a 2- or 3-hour intervention that teaches medical decision-making, interpersonal communication, and clinical documentation in the context of prediabetes and type 2 diabetes followed by role-play and clinical practice.
Results:
Across three cohorts, 53 clinicians completed the curriculum. Across the three iterations, learners rated the curricular intervention as worthwhile and delivered at an appropriate level. In a community hospital setting, learners scored significantly higher on a knowledge check than did a control group of six clinicians (p < .001). Learners in the community hospital also indicated high response efficacy and self-efficacy. At the academic medical center, simulated patients indicated high measures on the Diabetes Health Threat Communication Questionnaire.
Discussion:
The moment of diagnosis presents a key opportunity to affect patients' perceptions of the disease. This curriculum guides clinicians in making the most of diagnosis delivery. Pairing of qualitative, patient-centered research alongside the iterative curriculum design process allows the curriculum to be adaptable and scalable to multiple settings and learner types.
Primary care trainees must learn how to communicate effectively with patients during brief outpatient encounters, and direct observation and feedback is necessary to improve these skills. At the same time, programs are seeking more interprofessional learning opportunities for skills that transcend professions. We sought to assess the feasibility of implementing a direct observation tool, the Patient Centered Observation Form (PCOF), for communication training across three professions at the graduate level. The PCOF was introduced to trainees at an interprofessional workshop, while faculty completed PCOF training online or in person. Following use of the PCOF, we surveyed participants to determine if using the PCOF increased a) trainee-reported confidence in providing patient-centered communication, and b) faculty-reported confidence in giving feedback about patient-centered communication. The PCOF appears to be a useful adjunct to standard precepting for teaching patient-centered communication skills, extending beyond medical residents to pharmacy residents and less so, to advanced practice nursing students. In addition, PCOF training and implementation can successfully occur simultaneously across disciplines, leveraging resources and encouraging interprofessional learning.
Existe un amplio consenso respecto al hecho de que hay una brecha entre las habilidades propias del siglo XXI que el mercado laboral demanda a los nuevos profesionales y las habilidades que estos adquieren en el ámbito de la educación superior. Diversos estudios demuestran que la habilidad de comunicación es de las más demandas por los empleadores, a la vez que una de las más precarias entre los recién egresados. El objetivo del presente trabajo fue establecer el estado actual de la investigación respecto a instrumentos de medición de la habilidad de comunicación en estudiantes de educación superior. Se realizó una revisión sistemática de la literatura especializada en instrumentos para medir la habilidad de comunicación en estudiantes con base en el método Prisma. Fueron revisados textos publicados desde 2014 a la fecha en las bases de datos Scopus y Web of Science.
As the population ages, more Americans are moving into nursing homes/long-term care facilities. Per Accreditation Council for Graduate Medical Education 2017 guidelines, family medicine residents are required to gain experience and competence working in long-term care facilities; however, this unique environment poses several challenges for residents to hear the wishes of their patients over the demands of the patient’s medical care team and family members. Also, many patients in long-term care facilities have sensory impairments (e.g., poor eyesight, deafness) and/or cognitive deficits (e.g., dementia). One solution for hearing the patient’s voice over the demands of medical professionals and family members is to train physicians on how to overcome communication barriers with their patients. This article will discuss solution-focused approaches to reducing the barriers of sensory and cognitive impairments through the use of adaptive communication behaviors and adaptive equipment. Ways to improve communication between physicians, nursing-home staff, and patients’ family in order to improve the care patients receive in long-term care facilities will also be addressed. These recommendations are designed to assist with reducing physician frustration, increasing each patient’s input in medical decision-making, and improving communication across the patient care team.
Context:
The National Consensus Project for Quality Palliative Care Clinical Practice Guidelines recommend that palliative care clinicians work together as interprofessional teams. We created and piloted a 9-month curriculum that focused on 3 related domains: (1) patient-centered, narrative communication skills; (2) interprofessional team practice; and (3) metrics and systems integration. The multifaceted curriculum was delivered through 16 webinars, 8 online modules, 4 in-person workshops, reflective skill practice, written reflections, and small group online discussions.
Objectives:
Report evaluations of the course content and skill self-assessments from 24 interprofessional palliative care clinicians.
Methods:
Participants rated each learning activity and completed a retrospective pre-post test skill assessment. Learning gains were measured as the difference in the percentage of participants reporting "strong" or "highly competent" skill levels at baseline and the end of the course. Participants also provided examples of how they used the skills in practice.
Results:
Participants achieved an average learning gain of 50% across all domains, and in each domain communication (54%), interprofessional team practice (52%), and metrics and systems integration (34%). They also gave high ratings for the curriculum content (overall mean [standard deviation] rating of 5.5 (0.7) out of 6). Examples of practice impacts included improved skills in responding to emotions, understanding the equal importance of all professions on their team and incorporating different perspectives into their practice, and learning about outcome measurement in palliative care.
Conclusion:
This curriculum demonstrated success in increasing perceived skills for interprofessional palliative care clinicians in advanced communication, team practice, and metrics and system integration.
In May 1999, 21 leaders and representatives from major medical education and professional organizations attended an invitational conference jointly sponsored by the Bayer Institute for Health Care Communication and the Fetzer INSTITUTE: The participants focused on delineating a coherent set of essential elements in physician-patient communication to: (1) facilitate the development, implementation, and evaluation of communication-oriented curricula in medical education and (2) inform the development of specific standards in this domain. Since the group included architects and representatives of five currently used models of doctor-patient communication, participants agreed that the goals might best be achieved through review and synthesis of the models. Presentations about the five models encompassed their research base, overarching views of the medical encounter, and current applications. All attendees participated in discussion of the models and common elements. Written proceedings generated during the conference were posted on an electronic listserv for review and comment by the entire group. A three-person writing committee synthesized suggestions, resolved questions, and posted a succession of drafts on a listserv. The current document was circulated to the entire group for final approval before it was submitted for publication. The group identified seven essential sets of communication tasks: (1) build the doctor-patient relationship; (2) open the discussion; (3) gather information; (4) understand the patient's perspective; (5) share information; (6) reach agreement on problems and plans; and (7) provide closure. These broadly supported elements provide a useful framework for communication-oriented curricula and standards.
Time management concerns may inhibit primary care physicians from regularly eliciting a complete list of patient concerns. An educational intervention integrating time management skills with full elicitation of patient concerns to reach mutual agreement on the interview focus was piloted and evaluated. Ten family medicine residents and 7 faculty were randomly assigned to control and experimental (EF) groups. EF physicians read the protocol and watched an educational video. Data came from 162 patient encounters.
The results showed that EF physicians charted more problems and more follow-up requests but did not use more of their appointment times. EF providers rated their patients as more satisfied and were as satisfied as controls. Patients of EF providers were more satisfied, perceived more complete problem elicitation and collaborative prioritization.
These promising pilot data indicate a need to do an expanded study of the EF protocol. Ideas for research and training are discussed.
Patients want all their concerns heard, but physicians fear losing control of time and interrupt patients before all concerns are raised.
We hypothesized that when physicians were trained to use collaborative upfront agenda setting, visits would be no longer, more concerns would be identified, fewer concerns would surface late in the visit, and patients would report greater satisfaction and improved functional status.
Post-only randomized controlled trial using qualitative and quantitative methods. Six months after training (March 2004-March 2005) physician-patient encounters in two large primary care organizations were audio taped and patients (1460) and physicians (48) were surveyed.
Experimental physicians received training in upfront agenda setting through the Establishing Focus Protocol, including two hours of training and two hours of coaching per week for four consecutive weeks.
Outcomes included agenda setting behaviors demonstrated during the early, middle, and late encounter phases, visit length, number of raised concerns, patient and physician satisfaction, trust and functional status.
Experimental physicians were more likely to make additional elicitations (p < 0.01) and their patients were more likely to indicate agenda completion in the early phase of the encounter (p < 0.01). Experimental group patients and physicians raised fewer concerns in the late encounter phase (p < 0.01). There were no significant differences in visit length, total concerns addressed, patient or provider satisfaction, or patient trust and functional status
Collaborative upfront agenda setting did not increase visit length or the number of problems addressed per visit but may reduce the likelihood of "oh by the way" concerns surfacing late in the encounter. However, upfront agenda setting is not sufficient to enhance patient satisfaction, trust or functional status. Training focused on physicians instead of teams and without regular reinforcement may have limited impact in changing visit content and time use.
Training in relationship skills relies heavily on role modeling: students observing clinicians at work. This study explored student and faculty perceptions of student learning about relationship skills in hospital and ambulatory settings.
Qualitative data from focus groups and long interviews were coded by the authors through an iterative dialogic process. Participants were 15 faculty and 35 medical students in clinical training in a New Zealand medical school.
Teaching of doctor-patient relationship skills was highly variable, rarely explicit, and heavily dependent on role modeling. Students noted variable focus on relational skills between rotations, incongruity between preclinical training and the behaviors observed in clinical environments, and a need to discern which relational skills were facilitative. Role models who transparently shared their personal experiences of doctoring were more effective in helping students learn relationship skills.
Role modeling alone is insufficient for helping students acquire exemplary doctor-patient relationship skills. Role models must explicitly reflect upon the complex intricacies of interacting with patients to help students understand and incorporate specific skills. Lack of transparency is a barrier to quality role modeling that may be mitigated in ambulatory, primary care settings.
The phrase "patient-centered care" is in vogue, but its meaning is poorly understood. This article describes patient-centered care, why it matters, and how policy makers can advance it in practice. Ultimately, patient-centered care is determined by the quality of interactions between patients and clinicians. The evidence shows that patient-centered care improves disease outcomes and quality of life, and that it is critical to addressing racial, ethnic, and socioeconomic disparities in health care and health outcomes. Policy makers need to look beyond such areas as health information technology to shape a coordinated and focused national policy in support of patient-centered care. This policy should help health professionals acquire and maintain skills related to patient-centered care, and it should encourage organizations to cultivate a culture of patient-centeredness.
Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients' distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight. Mindfulness informs all types of professionally relevant knowledge, including propositional facts, personal experiences, processes, and know-how, each of which may be tacit or explicit. Explicit knowledge is readily taught, accessible to awareness, quantifiable and easily translated into evidence-based guidelines. Tacit knowledge is usually learned during observation and practice, includes prior experiences, theories-in-action, and deeply held values, and is usually applied more inductively. Mindful practitioners use a variety of means to enhance their ability to engage in moment-to-moment self-monitoring, bring to consciousness their tacit personal knowledge and deeply held values, use peripheral vision and subsidiary awareness to become aware of new information and perspectives, and adopt curiosity in both ordinary and novel situations. In contrast, mindlessness may account for some deviations from professionalism and errors in judgment and technique. Although mindfulness cannot be taught explicitly, it can be modeled by mentors and cultivated in learners. As a link between relationship-centered care and evidence-based medicine, mindfulness should be considered a characteristic of good clinical practice.
Most patients who experience illness symptoms develop an explanatory model. More frequently than physicians realize, these attributions involve serious and potentially life-threatening medical conditions. Only a minority of patients spontaneously disclose or "offer" their ideas, concerns, and expectations. Often patients suggest or imply their ideas through "clues." Active listening is a skill for recognizing and exploring patients' clues. Without this communication skill, patients' real concerns often go unrecognized by health care professionals. Qualitative techniques including videotape analysis, postinterviewing debriefing, and interpersonal process recall were used to identify types of clues. We propose a taxonomy of clues that includes (1) expression of feelings (especially concern or worry), (2) attempts to understand or explain symptoms, (3) speech clues that underscore particular concerns of the patient, (4) personal stories that link the patient with medical conditions or risks, and (5) behaviors suggestive of unresolved concerns or unmet expectations. This clue taxonomy will help physicians recognize patients' clues more readily and thereby improve their active listening skills. A deeper understanding of the true reasons for the visit should result in increased patient satisfaction and improved outcomes.
Patients often present clues (direct or indirect comments about personal aspects of their lives or their emotions) during conversations with their physicians. These clues represent opportunities for physicians to demonstrate understanding and empathy and thus, to deepen the therapeutic alliance that is at the heart of clinical care. A paucity of information exists regarding how physicians address the psychological and social concerns of patients.
To assess how patients present clues and how physicians respond to these clues in routine primary care and surgical settings.
Descriptive, qualitative study of 116 randomly selected routine office visits to 54 primary care physicians and 62 surgeons in community-based practices in Oregon and Colorado, audiotaped and transcribed in 1994.
Frequency of presentation of clues by patients during office visits, nature (emotional vs social) and content of clues, and nature of physician responses to clues, coded as positive or missed opportunity.
Fifty-two percent and 53% of the visits in primary care and surgery, respectively, included 1 or more clues. During visits with clues, the mean number of clues per visit was 2.6 in primary care and 1.9 in surgery. Patients initiated approximately 70% of clues, and physicians initiated 30%. Seventy-six percent of patient-initiated clues in primary care settings and 60% in surgical settings were emotional in nature. In surgery, 70% of emotional clues related to patients' feelings about their biomedical condition, while in primary care, emotional clues more often related to psychological or social concerns (80%) in patients' lives. Physicians responded positively to patient emotions in 38% of cases in surgery and 21% in primary care, but more frequently they missed opportunities to adequately acknowledge patients' feelings. Visits with missed opportunities tended to be longer than visits with a positive response.
This study suggests that physicians in both primary care and surgery can improve their ability to respond to patient clues even in the context of their busy clinical practices. JAMA. 2000;284:1021-1027
During the medical interview, clinicians frequently overlook the patient's perspective on illness (PPI), ie, the patient's explanations and concerns about the presenting symptoms and expectations for the encounter. Without special efforts, the PPI surfaces spontaneously in only about one fourth of medical interviews. We determined whether asking the patient a series of sequenced questions would elicit the PPI and what effect such questioning would have on patient and physician satisfaction and on the length of the clinical encounter.
Fifty-five interviews in a family practice clinic setting were studied by videotape and post-interview debriefings. On a random basis, 29 patients were asked sequenced questions at the end of the history, while 26 experienced usual medical interviews. Measures of patient and physician satisfaction were compared by descriptive statistics and the Mann-Whitney test for ordinal data.
In response to sequenced questioning, 44% of patients revealed specific, significant concerns that had not been otherwise disclosed. Among patients without prior contact with their provider, satisfaction with the encounter was significantly higher when the sequenced questions were used than when they were not; perception of time spent in discussion with the physician was also higher. Paradoxically, resident physicians expressed lower confidence that they had helped the patient when the sequenced questions were used to elicit the PPI.
Use of sequenced questions to elicit the PPI results in significant sharing of new information and increased patient satisfaction and requires only a modest investment of time.
The assessment of communication competence has become a major priority of medical educational, policy, and licensing organizations in the United States and Canada. Multiple tools are available to assess communication competence, but there are few studies that compare the tools.
A consensus panel of six family medicine educators evaluated 15 instruments measuring the physician-patient interview. The primary evaluation criteria came from the Kalamazoo Consensus Statement (KCS), which derived from a multidisciplinary panel of experts that defined seven essential elements of physician-patient communication. We evaluated psychometric properties of the instruments and other assessment criteria felt to be important to family physicians (exploring family issues, interview efficiency, and usability/practicality).
Instruments that received the highest ratings on KCS elements were designed for faculty raters and varied in their practicality/usability ratings and psychometric properties. Few instruments were rated high on psychometric properties or exploring family issues.
The process successfully reviewed and provided a framework for assessing communication skills instruments. There is a need to expand the study, including use of a larger cohort of reviewers to provide more validity to the results and minimize potential biases.
To present preliminary evidence for the reliability and validity of the Four Habits Coding Scheme (4HCS), an instrument based on a teaching model used widely throughout Kaiser Permanente to improve clinicians' communication skills.
One hundred videotaped primary care visits were coded using the 4HCS, and the data were assessed against a previously available data set for these visits, including the Roter Interaction Analysis System (RIAS), back channel responses, measures of nonverbal behavior, length of visit, and patients' post-visit assessments.
Levels of inter-rater reliability were acceptable, and the distribution of ratings across items indicated that physicians' modal responses varied widely. Correlations between 4HCS ratings, RIAS, back channel responses, and non-verbal measures provided evidence of the instrument's construct validity.
The Four Habits Coding Scheme, an instrument that combines both evaluative and descriptive elements of physician communication behavior and is derived from a conceptually based teaching model, has the potential to be of utility to researchers and evaluators as well as educators and clinicians.
The Four Habits Coding Scheme provides a template for both guiding and measuring physician communication behaviors.
E lectronic health records (EHRs) are clearly part of family medicine's future. However, the information available on EHRs to date has focused on the practicalities of buying and implementing a system. Minimal attention has been paid to understanding how family physicians use EHRs with patients in the examination room. In our work both as clinicians practicing with EHR systems and as researchers studying the communication patterns of physicians using EHRs with patients, we have observed how EHR use in examination rooms can inhibit physicians from focusing on their patients. 1,2 Even skilled physicians commonly use troubling behaviors such as looking predominantly at the computer monitor during office visits, typing while patients are talking about intimate concerns, reading silently from the monitor while patients sit idly, using templates to lead interviewing rather than listening to patient narratives, and turning their backs to patients in spite of the availability of mobile computer monitors. These behaviors need not be the norm. In fact, EHRs have the potential to enhance in-office communication with patients. To accomplish this, however, physicians will need to bring the best of both EHRs and patient-centered interviewing to the examination room. With a thoughtful approach, you can maintain your focus on the patient.
Humanistic care is regarded as important by patients and professional accrediting agencies, but little is known about how attitudes and behaviors in this domain are taught in clinical settings. To answer this question, the authors studied how excellent clinical teachers impart the behaviors and attitudes consistent with humanistic care to their learners.
Using an observational, qualitative methodology, the authors studied 12 clinical faculty identified by the medical residents enrolled from 2003 to 2004 as excellent teachers of humanistic care on the inpatient medical services at four medical universities in the United States (University of Minnesota Medical School, Emory University, University of Rochester School of Medicine, and Baylor College of Medicine). Observations were conducted by the authors using standardized field notes. After each encounter, the authors debriefed patients, learners (residents and medical students), and the teaching physicians in semistructured interviews.
Clinical teachers taught primarily by role modeling. Although they were highly aware of their significance as role models, they did not typically address the human dimensions of care overtly. Despite the common themes of role modeling identified, each clinical teacher exhibited unique teaching strategies. These clinical teachers identified self-reflection as the primary method by which they developed and refined their teaching strategies.
Role modeling is the primary method by which excellent clinical teachers try to teach medical residents humanistic aspects of medical care. Although clinical teachers develop unique teaching styles and strategies, common themes are shared and could be used for the future development of clinical faculty.
Recent guidelines from the Association of American Medical Colleges and from the Accreditation Council for Graduate Medical Education strongly suggest that communications teaching and assessment be part of medical education at all levels. This study's objective was to validate an instrument to assess communications skills. This instrument, Common Ground, is linked to the core, generic communication skills emphasized by the consensus statements of Toronto and Kalamazoo.
A total of 100 medical students were recruited from two medical schools and tested with four-station, communications-focused objective structured clinical examinations. Using Common Ground, trained raters performed checklist and global rating assessments. Experts globally assessed 20 representative interviews.
Inter-rater reliability for Common Ground was 0.85 for the overall global ratings and 0.92 for the overall checklist assessment. Generalizability coefficient was 0.80 for 50 minutes of testing. The correlation between the ratings of trained raters and a panel of communication experts was 0.84.
The Common Ground assessment instrument assesses core communication skills with sufficient reliability, validity, and generalizablity to make decisions on medical students' performance.
While there is consensus about the value of communication skills, many physicians complain that there is not enough time to use these skills. Little is known about how to combine effective relationship development and communication skills with time management to maximize efficiency. Our objective was to examine what physician-patient relationship and communication skills enhance efficiency.
We conducted searches of PubMed, EMBASE, and PsychINFO for the date range January 1973 to October 2006. We reviewed the reference lists of identified publications and the bibliographies of experts in physician-patient communication for additional publications.
From our initial group of citations (n = 1146), we included only studies written in English that reported original data on the use of communication or relationship skills and their effect on time use or visit length. Study inclusion was determined by independent review by 2 authors (L.B.M. and D.C.D.). This yielded 9 publications for our analysis.
The 2 reviewers independently read and classified the 9 publications and cataloged them by type of study, results, and limitations. Differences were resolved by consensus.
Three domains emerged that may enhance communication efficiency: rapport building, up-front agenda setting, and acknowledging social or emotional clues.
Building on these findings, we offer a model blending the quality-enhancing and time management features of selected communication and relationship skills. There is a need for additional research about communication skills that enhance quality and efficiency.
Context Patients often present clues (direct or indirect comments about personal
aspects of their lives or their emotions) during conversations with their
physicians. These clues represent opportunities for physicians to demonstrate
understanding and empathy and thus, to deepen the therapeutic alliance that
is at the heart of clinical care. A paucity of information exists regarding
how physicians address the psychological and social concerns of patients.Objectives To assess how patients present clues and how physicians respond to these
clues in routine primary care and surgical settings.Design, Setting, and Participants Descriptive, qualitative study of 116 randomly selected routine office
visits to 54 primary care physicians and 62 surgeons in community-based practices
in Oregon and Colorado, audiotaped and transcribed in 1994.Main Outcome Measures Frequency of presentation of clues by patients during office visits,
nature (emotional vs social) and content of clues, and nature of physician
responses to clues, coded as positive or missed opportunity.Results Fifty-two percent and 53% of the visits in primary care and surgery,
respectively, included 1 or more clues. During visits with clues, the mean
number of clues per visit was 2.6 in primary care and 1.9 in surgery. Patients
initiated approximately 70% of clues, and physicians initiated 30%. Seventy-six
percent of patient-initiated clues in primary care settings and 60% in surgical
settings were emotional in nature. In surgery, 70% of emotional clues related
to patients' feelings about their biomedical condition, while in primary care,
emotional clues more often related to psychological or social concerns (80%)
in patients' lives. Physicians responded positively to patient emotions in
38% of cases in surgery and 21% in primary care, but more frequently they
missed opportunities to adequately acknowledge patients' feelings. Visits
with missed opportunities tended to be longer than visits with a positive
response.Conclusion This study suggests that physicians in both primary care and surgery
can improve their ability to respond to patient clues even in the context
of their busy clinical practices.
Purpose:
To test educational methods that continue communication training into the fourth year of medical school.
Method:
The authors disseminated and evaluated an advanced communication elective in seven U.S. medical schools between 2007 and 2009; a total of 9 faculty and 22 fourth-year students participated. The elective emphasized peer learning, practice with real patients, direct observation, and applications of video technology. The authors used qualitative and quantitative survey methods and video review to evaluate the experience of students and faculty.
Results:
Students reported that the elective was better than most medical school clerkships they had experienced. Their self-confidence in time management and in the use of nine communication skills improved significantly. The most valued course components were video review, repeated practice with real patients, and peer observation. Analysis of student videos with real patients and in role-plays showed that some skills (e.g., agenda setting, understanding the patient perspective) were more frequently demonstrated than others (e.g., exploring family and cultural values, communication while using the electronic health record). Faculty highly valued this learner-centered model and reported that their self-awareness and communication skills grew as teachers and as clinicians.
Conclusions:
Learner-centered methods such as peer observation and video review and editing may strengthen communication training and reinforce skills introduced earlier in medical education. The course design may counteract a "hidden curriculum" that devalues respectful interactions with trainees and patients. Future research should assess the impact of course elements on skill retention, attitudes for lifelong learning, and patients' health outcomes.
Direct observation of residents for training and assessment is a core recommendation in medical education policy initiatives. Limited research exists about the impact of direct observation on precepting, and we are unaware of any research examining the impact of interdisciplinary precepting on trainees or preceptors. Over the past 3 years we have implemented an Interdisciplinary Direct Observation Precepting Model (IDOPM). Residents are directly observed via closed-circuit television by a behavioral scientist and family physician team.
Surveys and focus groups were used to examine the impact of the IDOPM. Authors analyzed survey responses and focus group transcripts using an immersion/crystallization approach to arrive at themes.
Between February and June 2009, 24 residents, 14 physician faculty, and eight behavioral science faculty members participated in 19 IDOPM clinics. Eighty-two percent of residents and 95% of faculty responded to surveys. Key findings were (1) Residents and faculty report addressing topics that are not usually discussed in traditional precepting, including communication skills, time management, electronic medical record use, responding to emotional complexity, and physical exam skills, (2) The model reinforced a biopsychosocial approach to care, (3) Residents report ambivalent feelings about being observed, and (4) Faculty value the team approach to strengthen training and promote faculty development.
The IDOPM addresses many core skills that are overlooked in traditional precepting encounters. Interdisciplinary direct observation may strengthen faculty ability to provide formative competency assessment in preparing residents to work in the complex world of primary care.
In the health professions we expect practitioners and trainees to engage in self-regulation of their learning and practice. For example, doctors are responsible for diagnosing their own learning needs and pursuing professional development opportunities; medical residents are expected to identify what they do not know when caring for patients and to seek help from supervisors when they need it, and medical school curricula are increasingly called upon to support self-regulation as a central learning outcome. Given the importance of self-regulation in both health professions education and ongoing professional practice, our aim was to generate a snapshot of the state of the science in medical education research in this area.
To achieve this goal, we gathered literature focused on self-regulation or self-directed learning undertaken from multiple perspectives. Then, with support from a multi-component theoretical framework, we created an overarching map of the themes addressed thus far and emerging findings. We built from that integrative overview to consider contributions, connections and gaps in research on self-regulation to date.
Based on this reflective analysis, we conclude that the medical education community's understanding about self-regulation will continue to advance as we: (i) consider how learning is undertaken within the complex social contexts of clinical training and practice; (ii) think of self-regulation within an integrative perspective that allows us to combine disparate strands of research and to consider self-regulation across the training continuum in medicine, from learning to practice; (iii) attend to the grain size of analysis both thoughtfully and intentionally, and (iv) most essentially, extend our efforts to understand the need for and best practices in support of self-regulation.
Many clinicians have called for an increased emphasis on the patient's role in clinical decision making. However, little is known about the extent to which physicians foster patient involvement in decision making, particularly in routine office practice.
To characterize the nature and completeness of informed decision making in routine office visits of both primary care physicians and surgeons.
Cross-sectional descriptive evaluation of audiotaped office visits during 1993.
A total of 1057 encounters among 59 primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons; 2 to 12 patients were recruited from each physician's community-based private office.
Analysis of audiotaped patient-physician discussions for elements of informed decision making, using criteria that varied with the level of decision complexity: basic (eg, laboratory test), intermediate (eg, new medication), or complex (eg, procedure). Criteria for basic decisions included discussion of the nature of the decision and asking the patient to voice a preference; other categories had criteria that were progressively more stringent.
The 1057 audiotaped encounters contained 3552 clinical decisions. Overall, 9.0% of decisions met our definition of completeness for informed decision making. Basic decisions were most often completely informed (17.2%), while no intermediate decisions were completely informed, and only 1 (0.5%) complex decision was completely informed. Among the elements of informed decision making, discussion of the nature of the intervention occurred most frequently (71 %) and assessment of patient understanding least frequently (1.5%).
Informed decision making among this group of primary care physicians and surgeons was often incomplete. This deficit was present even when criteria for informed decision making were tailored to expect less extensive discussion for decisions of lower complexity. These findings signal the need for efforts to encourage informed decision making in clinical practice.
To assess the impact on full-time faculty's own clinical skills and practices of sustained clinical skills bedside teaching with preclerkship students.
This was a longitudinal, qualitative study of faculty who provide dedicated ongoing bedside clinical skills teaching for preclerkship medical students. Interviews were conducted during 2003 to 2007 with 31 faculty of the Colleges program at University of Washington School of Medicine. Content analyses of interview transcripts were performed.
Teachers perceived a strong positive impact of teaching on their own clinical skills. Six themes were associated with the influence of bedside teaching on teachers' skills and practices. One related to deterrents to change (e.g., reliance on tests/specialists) that narrowed teachers' practice skills prior to starting bedside teaching. Three related to expansion of the process of clinical care resulting from bedside teaching: expanded knowledge and skills, deconstructing the clinical experience (e.g., deepening, broadening, slowing one's practice), and greater self-reflection (e.g., awareness of being a role model). Two were perceived outcomes: improved clinical skills (e.g., physical examination) and more mindful practices (e.g., self-confidence, patient-centered).
Teachers perceived profound positive impact on their clinical skills from teaching preclerkship students at the bedside. Further studies are needed, including comparing teaching preclerkship students with teaching advanced students and residents, to assess whether teaching at other levels has this effect.
To categorize physician communication demonstrating understanding of what patients want to know and skill in conveying that information. Physicians underestimate how much information patients want and patients rarely seek information during clinic visits. Transparent communication is advocated to facilitate patient understanding and support autonomy, informed decision-making and relationship development.
Analysis and coding of 263 audiotaped interactions between 33 primary care physicians and their patients in eight community-based, primary care clinics in Washington State, USA.
Physicians proactively used five types of process transparency to preview speech and actions. Four types of content transparency were used to explicate diagnosis and treatment, demystify medical language and concepts, and interpret biomedical information. Physicians spent the greatest proportion of clinic time explicating medical content.
The primacy of information exchange over process-oriented, relational communication was demonstrated. Proactive transparency appears promising to increase understanding and collaboration.
In patient-centered care where collaboration is the ideal, transparency in its various forms is a critical ingredient. Without much communicative effort, physicians who proactively communicated that an examination was over, that they were leaving the exam room briefly so patients could dress provided information that appeared to address patient uncertainty and demonstrated empathy and respect.
Using grounded theory as an example, this paper examines three methodological questions that are generally applicable to all qualitative methods. How should the usual scientific canons be reinterpreted for qualitative research? How should researchers report the procedures and canons used in their research? What evaluative criteria should be used in judging the research products? We propose that the criteria should be adapted to fit the procedures of the method. We demonstrate how this can be done for grounded theory and suggest criteria for evaluating studies following this approach. We argue that other qualitative researchers might be similarly specific about their procedures and evaluative criteria.
To explore student and faculty perceptions of how students are learning doctor-patient relationship skills in their clinical medical education.
Exploratory qualitative study involving data from interviews and focus groups with students and interviews with teaching faculty.
Respondents reported that pre-clinical relationship skills curricula were not well-coordinated with clinical curricula. Within the clinical curriculum, respondents perceived a disparity between general practice and hospital-based attachments. Teaching of relationship skills on the wards was highly variable, rarely explicit, and primarily dependent on role-modelling. In contrast, general practice runs included explicit teaching with feedback that reinforced skills taught in the pre-clinical curriculum. Respondents recommended increased focus on and assessment of students' interpersonal skills within clinical settings.
Pre-clinical and clinical relationship skills curricula were not coordinated. The tension between service commitments and student teaching in hospital-based attachments contributed to an insufficient focus on communication and relationship skills acquisition and did not reinforce teaching in pre-clinical and ambulatory clinical settings.
The teaching of doctor-patient relationship skills can be augmented by coordinating pre-clinical and clinical curricula and by requiring observation and structured feedback related to explicit criteria of student skills acquisition across all clinical learning experiences.
Most medical educators have little or no training in teaching and assessing medical communication, and they are not consistent in what they teach. The authors set out to reach consensus in our educational community on a lexicon of communication terms for use in teaching physician-patient communication skills to second-year medical students.
An interdisciplinary medical school physician-patient communication committee assembled 23 important terms and agreed on definitions for each term. Thirty core preclinical faculty representing nine medical specialties reviewed the lexicon. Faculty were surveyed about lexicon definitions, barriers to use, and methods of using during educational encounters.
All preclinical faculty members agreed on 19 out of 23 definitions and most respondents agreed on the definitions of the remaining four terms. Sixty-nine percent of respondents said they used the terms during their teaching encounters.
Implementing a process to create a shared language around physician-patient communication may help unify and enhance faculty educational efforts. We were able to establish that medical educators can agree on the content of a medical communication lexicon for use with students. The use of defined and consistently used terms in multiple venues may reduce ambiguity, standardize teaching, enhance recognition of communication skills, and promote effective reinforcement and remediation by faculty.
Evidence suggests that most medical educators have little or no training in teaching and assessing medical communication and that they are not consistent in what they teach. Asking a community of faculty to share responsibility for creating a communication lexicon may be an efficient and effective way to educate faculty and unify their educational effort.
No abstract available. (C) 1990 Association of American Medical Colleges
Throughout this century there have been many efforts to reform the medical curriculum. These efforts have largely been unsuccessful in producing fundamental changes in the training of medical students. The author challenges the traditional notion that changes to medical education are most appropriately made at the level of the curriculum, or the formal educational programs and instruction provided to students. Instead, he proposes that the medical school is best thought of as a "learning environment" and that reform initiatives must be undertaken with an eye to what students learn instead of what they are taught. This alternative framework distinguishes among three interrelated components of medical training: the formal curriculum, the informal curriculum, and the hidden curriculum. The author gives basic definitions of these concepts, and proposes that the hidden curriculum needs particular exploration. To uncover their institution's hidden curricula, he suggests that educators and administrators examine four areas: institutional policies, evaluation activities, resource-allocation decisions, and institutional "slang." He also describes how accreditation standards and processes might be reformed. He concludes with three recommendations for moving beyond curriculum reform to reconstruct the overall learning environment of medical education, including how best to move forward with the Medical School Objectives Project sponsored by the AAMC.
Patients recall or comprehend as little as half of what physicians convey during an outpatient encounter. To enhance recall, comprehension, and adherence, it is recommended that physicians elicit patients' comprehension of new concepts and tailor subsequent information, particularly for patients with low functional health literacy. It is not known how frequently physicians apply this interactive educational strategy, or whether it is associated with improved health outcomes.
We used direct observation to measure the extent to which primary care physicians working in a public hospital assess patient recall and comprehension of new concepts during outpatient encounters, using audiotapes of visits between 38 physicians and 74 English-speaking patients with diabetes mellitus and low functional health literacy. We then examined whether there was an association between physicians' application of this interactive communication strategy and patients' glycemic control using information from clinical and administrative databases.
Physicians assessed recall and comprehension of any new concept in 12 (20%) of 61 visits and for 15 (12%) of 124 new concepts. Patients whose physicians assessed recall or comprehension were more likely to have hemoglobin A(1c) levels below the mean (< or = 8.6%) vs patients whose physicians did not (odds ratio, 8.96; 95% confidence interval, 1.1-74.9) (P =.02). After multivariate logistic regression, the 2 variables independently associated with good glycemic control were higher health literacy levels (odds ratio, 3.97; 95% confidence interval, 1.09-14.47) (P =.04) and physicians' application of the interactive communication strategy (odds ratio, 15.15; 95% confidence interval, 2.07-110.78) (P<.01).
Primary care physicians caring for patients with diabetes mellitus and low functional health literacy rarely assessed patient recall or comprehension of new concepts. Overlooking this step in communication reflects a missed opportunity that may have important clinical implications.
Patients seek empathy from their physicians. Medical educators increasingly recognize this need. Yet in seeking to make empathy a reliable professional skill, doctors change the meaning of the term. Outside the field of medicine, empathy is a mode of understanding that specifically involves emotional resonance. In contrast, leading physician educators define empathy as a form of detached cognition. In contrast, this article argues that physicians' emotional attunement greatly serves the cognitive goal of understanding patients' emotions. This has important implications for teaching empathy.
While evaluating bedside teaching by attending physicians on the Mayo Clinic's general internal medicine hospital services, the author learned that peer review enhances an understanding of teaching for both observers and subjects of peer review. In this article the author offers five insights derived from his and two colleagues' observations of bedside teaching during a six-month period in 2002. These are (1) the value of peer review to observers, (2) the apparently unlimited number of teaching strategies, (3) the prevalence of missed opportunities to provide feedback to learners, (4) the art of asking questions effectively, and (5) the possible relationship between a teacher's maturity and successful bedside teaching. Regarding the art of asking questions, he encountered four common problems (e.g., the underutilization of questions), but also found that accomplished teachers pursue a course of co-discovery by asking questions alongside their learners. Finally, he learned that experienced attending physicians often demonstrate teaching sessions focused on psychosocial aspects of care, the use of simple questions, and a willingness to expose their own inadequacies.
Persistent evidence suggests that the communication skills of practicing physicians do not achieve desired goals of enhancing patient satisfaction, strengthening health outcomes and decreasing malpractice litigation. Stronger communication skills training during the clinical years of medical education might make use of an underutilized window of opportunity-students' clinical years-to instill basic and important skills. The authors describe the implementation of a novel curriculum to teach patient-centered communication skills during a required third-year, six-week family medicine clerkship. Curriculum development and implementation across 24 training sites in a five-state region are detailed. A faculty development effort and strategies for embedding the curriculum within a diverse collection of training sites are presented. Student and preceptor feedback are summarized and the lessons learned from the curriculum development and implementation process are discussed.
At the University of Washington, a group of medical educators defined a set of communication skills, or "benchmarks," that are expected of second-year medical students conducting history and physical examinations on hospitalized patients. In order to teach the skills listed in the communication benchmarks, an educational strategy was devised that included training sessions for 30 medical teachers and the development of an innovative videotape tool used to train the teachers and their students. The benchmarks were designed in 2003 for the developmental level of the students and were based on key communication concepts and essential elements of medical communication. A set of five short videotaped scenarios was developed that illustrated various segments of a student history and physical examination. Each scenario consisted of an "OK" version of communication and a "better" version of the same scenario. The video scenarios were used in teaching sessions to help students identify effective communication techniques and to stimulate discussion about the communication benchmarks. After the training sessions, teachers and students were surveyed to assess the effectiveness of the educational methods. The majority of students felt that the educational design stimulated discussion and improved their understanding of communication skills. Faculty found the educational design useful and 95% felt that the curriculum and videotape contributed to their own education. The development of communication benchmarks illustrated with short videotaped scenarios contrasting "OK" with "better" communication skills is a useful technique that is transferable to other institutions.
Recent literature has described how the capacity for concurrent self-assessment-ongoing moment-to-moment self-monitoring-is an important component of the professional competence of physicians. Self-monitoring refers to the ability to notice our own actions, curiosity to examine the effects of those actions, and willingness to use those observations to improve behavior and thinking in the future. Self-monitoring allows for the early recognition of cognitive biases, technical errors, and emotional reactions and may facilitate self-correction and development of therapeutic relationships. Cognitive neuroscience has begun to explore the brain functions associated with self-monitoring, and the structural and functional changes that occur during mental training to improve attentiveness, curiosity, and presence. This training involves cultivating habits of mind such as experiencing information as novel, thinking of "facts" as conditional, seeing situations from multiple perspectives, suspending categorization and judgment, and engaging in self-questioning. The resulting awareness is referred to as mindfulness and the associated moment-to-moment self-monitoring as mindful practice-in contrast to being on "automatic pilot" or "mindless" in one's behavior. This article is a preliminary exploration into the intersection of educational assessment, cognitive neuroscience, and mindful practice, with the hope of promoting ways of improving clinicians' capacity to self-monitor during clinical practice, and, by extension, improve the quality of care that they deliver.
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