Teaching and learning consultation skills for paediatric practice

Children's Perspectives on Outpatient Physician Visits: Capturing a Missing Voice in Patient-Centered Care

Actively involving children in their healthcare is a core value of patient-centered care. This is the first study to directly obtain children's detailed perspectives on positive and negative aspects of outpatient physician visits in a primary care setting (e.g., checkups) and their preferred level of participation. Individual interviews were conducted with 167 children (female n = 82, male n = 85; ages 7-10, Mage = 8.07 years, SD = 0.82). Open-ended questions were used so that children's responses were not confined to researchers' assumptions, followed by close-ended questions to meet specific objectives. Quantitative content analysis, correlations, logistic regression, and Cochran's Q were used to explore the data. Children were highly fearful of needle procedures (61%), blood draws (73%), pain (45%), and the unknown (21%). Children indicated that they liked receiving rewards (32%) and improving their health (16%). Children who were more fearful during physician visits wanted more preparatory information (ExpB = 1.05, Waldx2(1) = 9.11, p = 0.003, McFadden's R2 2 = 0.07) and more participation during the visit (ExpB = 1.04, Waldx2(1) = 5.88, p = 0.015, McFadden's R2 2 = 0.03). Our results can inform efforts to promote positive physician visit experiences for children, reduce procedural distress, and foster children's ability to take an active role in managing their health.

The Me first communication model

This article explores communication and decision-making with children and young people in healthcare. Children and young people report that healthcare professionals are good at explaining and helping them to understand what will happen to them, but that they do not feel involved in decision-making about their care or treatment. To improve communication with children and young people, they need to be involved in decision-making about their care and treatment. In partnership with children, young people and healthcare professionals Common Room Consulting, Great Ormond Street Hospital for Children NHS Foundation Trust and Health Education England have co-produced a communication model, Me first, to support decision-making with children and young people in healthcare. This article introduces the Me first model and explores how it can be applied in clinical practice.

Empathy in vaccination counselling: a survey on the impact of a three-day residential course

BACKGROUND

In an era of hesitance to use vaccines, the importance of effective communication for increasing vaccine acceptance is well known. This study aimed to assess the impact of a three-day residential course concerning empathy and counselling abilities on patients' ratings of the level of empathy of physicians and nurses working in vaccination centers.

METHODS

The empathy of healthcare providers was evaluated using the Adapted Consultation and Relational Empathy (CARE) Measure. The survey involved 20 healthcare workers, doctors, and nurses in three immunization services of a Local Health Unit in South Italy. Before and after attending the course, all of them administered the questionnaire to 50 consecutive parents of vaccinated children. Statistical tests were used to assess the homogeneity of pre- and post -course samples, to measure the level of empathy perceived by parents in doctors and nurses in pre- and post-course evaluations, and to compare the average CARE Measure scores among groups.

RESULTS

Analysis of the questionnaires showed an increase of "excellent" scores and statistically significant differences between the pre- and post -course median values. Statistically significant differences between doctors and nurses were shown in almost all questions pre-course and in only four questions post-course.

CONCLUSIONS

This study demonstrated that a residential course is effective at improving patient-rated empathy of doctors and nurses working in vaccination centers and could result in an increase of parents' adherence to vaccination programs.

Measuring empathy in pediatrics: validation of the Visual CARE measure

Background

Empathy is a key element of “Patient and Family Centered Care”, a clinical approach recommended by the American Academy of Pediatrics. However, there is a lack of validated tools to evaluate paediatrician empathy. This study aimed to validate the Visual CARE Measure, a patient rated questionnaire measuring physician empathy, in the setting of a Pediatric Emergency Department (ED).

Methods

The empathy of physicians working in the Pediatric ED of the University Hospital of Udine, Italy, was assessed using an Italian translation of the Visual Care Measure. This test has three versions suited to different age groups: the 5Q questionnaire was administered to children aged 7–11, the 10Q version to those older than 11, and the 10Q–Parent questionnaire to parents of children younger than 7.

The internal reliability, homogeneity and construct validity of the 5Q and 10Q/10Q–Parent versions of the Visual Care Measure, were separately assessed. The influence of family background on the rating of physician empathy and satisfaction with the clinical encounter was also evaluated.

Results

Seven physicians and 416 children and their parents were included in the study. Internal consistency measured by Cronbach’s alpha was 0.95 for the 10Q/10Q–Parent versions and 0.88 for the 5Q version. The item-total correlation was > 0.75 for each item. An exploratory factor analysis showed that all the items load onto the first factor.

Physicians’ empathy scores correlated with patients’ satisfaction for both the 10Q and 10Q–Parent questionnaires (Spearman’s rho = 0.7189; p < 0.001) and for the 5Q questionnaire (Spearman’s rho = 0.5968; p < 0,001). Trust in the consulting physician was lower among immigrant parents (OR 0.43. 95% CI 0.20–0.93).

Conclusions

The Visual Care Measure is a reliable second-person test of physician empathy in the setting of a Pediatric Emergency Room. More studies are needed to evaluate the reliability of this instrument in other pediatric settings distinct from the Emergency Room and to further evaluate its utility in measuring the impact of communication and empathy training programmes for healthcare professionals working in pediatrics.

Effects of pre-consultation lists on the communicative behavior of children with cancer and their caregivers

Abstract This cross-sectional study present effects of pre-consultation lists on caregivers' and children's communicative behavior. Thirty-two dyads caregiver-child took part in this research, divided in three groups concerning the study design: Baseline 1, Intervention phase, and Baseline 2. Children and caregivers were individually interviewed before consultations on pediatric cancer treatment, in order to list doubts, expectations, and estimated issues to the medical visit. These themes were written down on a sheet of paper, attached to the child´s medical record cover, and would then be used as a memo in the following consultation. Results show that pre-consultation lists produced no effects on children's behavior, however the procedure was associated to specific doubts discussed by caregivers regarding dietary recommendations, coping with side effects, child development, biological aspects of cancer, and school activities. This study presents a low cost procedure that may contribute to tailor communication in pediatric settings.

Communication as a Bridge to Build a Sound Doctor-Patient/Parent Relationship

Effective communication is essential to establish a good doctor-patient/parent relationship and practice high quality medicine. It is indeed the key to build confidence, faith and trust of the parents to augment the process of healing. Most parental complaints of dissatisfaction and mismanagement originate due to lack of communication or because of abrasive, cold or callous attitude of the doctor or members of the health care team and not due to lack of knowledge and skills or unsatisfactory management of the patient. The patients and parents must feel all times that they are treated with respect and dignity. We should consider patients as our clients and handle them with due confidence, humility, concern and empathy. It is important to communicate with the parents by literally coming down to their level and by maintaining an eye-to-eye contact. We should not judge, belittle or argue with the parents and handle them with due courtesy and consideration. We should be careful, tactful and diplomatic in deciding not only "what to tell the parents" but also "how to tell it". The parents should be told about the condition of the child in a simple, easy-to-understand language without any medical jargons. We should be pragmatic but honest in communicating the true medical status of the child but nevertheless try to keep the hope alive which has tremendous healing capabilities. We should not allow the technology to further dehumanize medicine and try to resurrect the declining image of the medical profession. It is desirable that all the medical and nursing colleges in the country should initiate regular education programs in the fields of social and behavioral sciences, art of communication and medical ethics for graduate and postgraduate medical and nursing students.

Teaching pediatric communication skills to medical students

BACKGROUND

Delivering effective clinical pediatric communication skills training to undergraduate medical students is a distinct and important challenge. Pediatric-specific communication skills teaching is complex and under-researched. We report on the development of a scenario-based pediatric clinical communication skills program as well as students' assessment of this module.

METHODS

We designed a pediatric clinical communication skills program and delivered it five times during one academic year via small-group teaching. Students were asked to score the workshop in eight domains (learning objectives, complexity, interest, competencies, confidence, tutors, feedback, and discussion) using 5-point Likert scales, along with free text comments that were grouped and analyzed thematically, identifying both the strengths of the workshop and changes suggested to improve future delivery.

RESULTS

Two hundred and twenty-one of 275 (80%) student feedback forms were returned. Ninety-six percent of students' comments were positive or very positive, highlighting themes such as the timing of teaching, relevance, group sizes, and the use of actors, tutors, and clinical scenarios.

CONCLUSION

Scenario-based teaching of clinical communication skills is positively received by students. Studies need to demonstrate an impact on practice, performance, development, and sustainability of communications training.

Using professional interpreters in undergraduate medical consultation skills teaching

The ability to work with interpreters is a core skill for UK medical graduates. At the University of Sheffield Medical School, this teaching was identified as a gap in the curriculum. Teaching was developed to use professional interpreters in role-play, based on evidence that professional interpreters improve health outcomes for patients with limited English proficiency. Other principles guiding the development of the teaching were an experiential learning format, integration to the core consultation skills curriculum, and sustainable delivery. The session was aligned with existing consultation skills teaching to retain the small-group experiential format and general practitioner (GP) tutor. Core curricular time was found through conversion of an existing consultation skills session. Language pairs of professional interpreters worked with each small group, with one playing patient and the other playing interpreter. These professional interpreters attended training in the scenarios so that they could learn to act as patient and family interpreter. GP tutors attended training sessions to help them facilitate the session. This enhanced the sustainability of the session by providing a cohort of tutors able to pass on their expertise to new staff through the existing shadowing process. Tutors felt that the involvement of professional interpreters improved student engagement. Student evaluation of the teaching suggests that the learning objectives were achieved. Faculty evaluation by GP tutors suggests that they perceived the teaching to be worthwhile and that the training they received had helped improve their own clinical practice in consulting through interpreters. We offer the following recommendations to others who may be interested in developing teaching on interpreted consultations within their core curriculum: 1) consider recruiting professional interpreters as a teaching resource; 2) align the teaching to existing consultation skills sessions to aid integration; and 3) invest in faculty development for successful and sustainable delivery.

Attitudes and perceptions of rheumatologists regarding consultation skills training for specialist trainees: a qualitative study

Within rheumatology specialty training, direct observation and formal assessment of consultation skills rarely occur. This study explored the attitudes and perceptions of rheumatology specialist registrars (SpRs) and consultants regarding consultation skills training and potential barriers to its successful implementation in the context of specialist training. Semi-structured interviews with rheumatology consultants and focus groups with rheumatology SpRs were conducted in four UK deanery regions. All participants value consultation skills training and believe it requires observation of trainees consulting. The skills of consultant trainers in providing feedback on consulting skills are sometimes sub-optimal. Direct, real time observation of trainees is difficult and happens infrequently. Recording consultations is a potentially attractive alternative. Important issues regarding the successful implementation of videotaped consultations include time constraints, consistency in the assessment of consultation skills, and expertise in providing constructive feedback that is individualised and tailored to the trainee's learning needs.

Social communication skills of chiropractors: implications for professional practice

OBJECTIVE

Social communication skills are critical in the health professions. The aim of this study was to measure and identify professional practice predictors of social communication skills of practicing chiropractors.

METHODS

The study population was derived from a group of doctors of chiropractic who participated in a practice-based research program. Participating chiropractors agreed to complete a survey detailing the chiropractor's sex, years in practice, practice type, size of the practice community, typical weekly practice volume, and an instrument to measure skills of social communication. Regression analysis was applied to identify associations between independent variables and responses to the social skills instrument.

RESULTS

Results suggested that selected characteristics of clinical practice may be associated with clinician's social skills of communication. The weekly volume of patients to the practice emerged as a salient explanatory factor of overall social communication skills and as a factor individually for dimensions of social expressivity and social control. The practice arrangement (solo vs group) proved important in terms of respondent emotional control scores. Similarly, the solo vs group practice variable was associated with higher levels of emotional sensitivity; however, this association was mediated by the sex of the doctor of chiropractic; men reported lower levels of emotional sensitivity than women.

CONCLUSIONS

The findings of this study suggest associations between dimensions of social communication skills, practice characteristics, practice arrangements, and sex that may inform the efforts of educators as they endeavor to better prepare health professionals for practice in a wide spectrum of settings.

Enhancing communication skills for pediatric visits through on-line training using video demonstrations

BACKGROUND

Training in communication skills for health professionals is important, but there are substantial barriers to individual in-person training for practicing clinicians. We evaluated the feasibility and desirability of on-line training and sought suggestions for future courses.

METHODS

Based on successful in-person curricula for communication skills and our previous on-line curricula, we created an on-line course consisting of 28 modules (4.75 hours CME credit) about communication skills during pediatric visits that included a mental health concern; each module included a brief case, a multiple choice question, an explanation, and a 1-2 minute video demonstrating key skills. Specific communication skills included: greeting, setting an agenda, discussing diagnosis and treatment, and managing negative interactions. The course was announced by emails in spring, 2007; the course was available on-line for 60 days; we aimed to enroll 50 clinicians. Outcomes were analyzed for those who evaluated the course within 75 days of its initial availability.

RESULTS

Overall, 61 clinicians registered, of whom most were nurses (N = 24), physicians (N = 22), or psychologists or social workers (N = 12). Of the 36 (59%) clinicians who evaluated the course, over 85% agreed that all course objectives had been met; over 90% reported greater confidence in greetings and agenda-setting; and over 80% reported greater confidence in discussing diagnosis and treatment and managing negative interactions. Nearly all, 97% would recommend the course to other clinicians and trainees. Suggestions for improvement included a library of additional video vignettes and written materials to accompany the on-line training.

CONCLUSION

On-line training in communication skills for pediatric mental health visits is feasible, desirable and associated with increased confidence in key skills. Positive feedback from clinicians suggests that a comparison of on-line versus in-person training is warranted.

Triadic communication in the primary care paediatric consultation: a review of the literature

BACKGROUND

Children aged 6-12 years are usually seen in primary care with an adult carer. It is a government and professional priority for doctors to try and involve these children in their medical consultations.

AIM

To ascertain the evidence available on the amount and type of involvement that children in the 6-12 year age group have in their primary care consultations when the consultation was held with a child, a GP, and an adult.

DESIGN OF THE STUDY

Literature review.

METHOD

Data sources included MEDLINE, CINAHL, EMBASE, and ERIC, The Cochrane library, PsychINFO, Web of Science and Wilson's Social Science abstracts, hand searching for references, and contact with authors.

RESULTS

Twenty-one studies were selected for inclusion in the study. Children were found to have little quantitative involvement in their own consultations. They may take part during information gathering but are unlikely to participate in the treatment planning and discussion parts of the consultation.

CONCLUSION

Children in the 6-12 year age group have little meaningful involvement in their consultations.

Parent and child perspectives on physician communication in pediatric palliative care

Objective:

Despite growing recognition of the importance of communication with children with life-limiting illnesses and their families, there has been limited research that includes the child's perspective. The purpose of the current study was to identify the aspects of physician communication that children with life-limiting illnesses and their parents perceived to be facilitative or obstructive in pediatric palliative care.

Methods:

This qualitative study reports on the first 20 parent and child pairs of pediatric oncology and cardiology patients (mean age 14.25 years, range 9-21 years) with a poor prognosis (physician reported likely <20% chance of survival beyond 3 years) from two children's hospitals and one pediatric hospice in Los Angeles, California. Perspectives on physician communication were elicited from children's and parents' individual narratives, recorded, coded, and analyzed using qualitative grounded theory methodology.

Results:

Both children and parents identified five domains of physician communication deemed to be highly salient and influential in quality of care. These included relationship building, demonstration of effort and competence, information exchange, availability, and appropriate level of child and parent involvement. Parents identified coordination of care as another important communication domain. The characteristics of physicians that were deemed most harmful to satisfying communication included having a disrespectful or arrogant attitude, not establishing a relationship with the family, breaking bad news in an insensitive manner, withholding information from parents and losing their trust, and changing a treatment course without preparing the patient and family.

Significance of results:

The six positive communication domains are areas for clinicians to recognize and monitor in communicating with children and families in the pediatric palliative care setting. Knowledge of the qualities of communication that are satisfying to and valued by children and their parents have the potential to lead to more effective communication around the difficult decisions faced by physicians, parents, and children with life-threatening conditions.

Curriculum factors influencing knowledge of communication skills among medical students

BACKGROUND

Communication training builds on the assumption that understanding of the concepts related to professional communication facilitates the training. We know little about whether students' knowledge of clinical communication skills is affected by their attendance of communication training courses, or to what degree other elements of the clinical training or curriculum design also play a role. The aim of this study was to determine which elements of the curriculum influence acquisition of knowledge regarding clinical communication skills by medical students.

METHODS

The study design was a cross-sectional survey performed in the four Norwegian medical schools with different curricula, spring 2003. A self-administered questionnaire regarding knowledge of communication skills (an abridged version of van Dalen's paper-and-pencil test) was sent to all students attending the four medical schools. A total of 1801 (59%) students responded with complete questionnaires.

RESULTS

At the end of the 1st year of study, the score on the knowledge test was higher in students at the two schools running communication courses and providing early patient contact (mean 81%) than in the other two medical schools (mean 69-75%, P < or = 0.001), with students studying a traditional curriculum scoring the lowest. Their scores increased sharply towards the end of the 3rd year, during which they had been subjected to extensive patient contact and had participated in an intensive communication course (77% vs. 72% the previous year, P <or = 0.01). All students scored generally lower in academic years in which there was no communication training. However, at the end of the final year the difference between the schools was only 5% (81% vs. 86%, P < or = 0.001).

CONCLUSION

The acquisition of knowledge regarding communication skills by medical students may be optimised when the training is given together with extensive supervised patient contact, especially if this teaching takes place in the initial years of the curriculum.

Characteristics of communication guidelines that facilitate or impede guideline use: a focus group study

Background

The quality of doctor-patient communication has a major impact on the quality of medical care. Communication guidelines define best practices for doctor patient communication and are therefore an important tool for improving communication. However, adherence to communication guidelines remains low, despite doctors participating in intensive communication skill training. Implementation research shows that adherence is higher for guidelines in general that are user centred and feasible, which implies that they are consistent with users' opinions, tap into users' existing skills and fit into existing routines. Developers of communication guidelines seem to have been somewhat negligent with regard to user preferences and guideline feasibility. In order to promote the development of user centred and practicable communication guidelines, we elicited user preferences and identified which guideline characteristics facilitate or impede guideline use.

Methods

Seven focus group interviews were conducted with experienced GPs, communication trainers (GPs and behavioural scientists) and communication learners (GP trainees and medical students) and three focus group interviews with groups of GP trainees only. All interviews were transcribed and analysed qualitatively.

Results

The participants identified more impeding guideline characteristics than facilitating ones. The most important impeding characteristic was that guidelines do not easily fit into GPs' day-to-day practice. This is due to rigidity and inefficiency of communication guidelines and erroneous assumptions underpinning guideline development. The most important facilitating characteristic was guideline structure. Guidelines that were structured in distinct phases helped users to remain in control of consultations, which was especially useful in complicated consultations.

Conclusion

Although communication guidelines are generally considered useful, especially for structuring consultations, their usefulness is impaired by lack of flexibility and applicability to practice routines. User centred and feasible guidelines should combine the advantages of helping doctors to structure consultations with flexibility to tailor communication strategies to specific contexts and situations.