Communication Competency

and Counseling Practicum

Mary Dankoski, Ph.D.

Kathy Zoppi, Ph.D., M.P.H
Shobha Pais, Ph.D.
Scott Renshaw, M.D.
Dustin Wright, M.S.
OBJECTIVES
 Attendees will understand…
 The assessment of communication
competency at resident levels of training
 The utility of counseling practicum and
competency assessment strategies
Communication In Family
Medicine
 “Black Box” study (Stange et. al., 1998)

 Family assessment – 73%

 Answering patient questions – 71%
 Negotiation – 21%
 Counseling – 16%
 Patient Education – 18-26%
Distinction between
interaction and relationship
 “Communication skills do not constitute the
doctor-patient relationship” (Candib, 1995,
p.213)
 Key concept of connection as lens (vs.
separation) from feminist theory
 Patient and physician are not independent
actors, but are mutually influential
 Emotional involvement of both is key
National consensus about
communication training
 Patient-centered care improves health
outcomes
 (Kalamazoo Consensus statement)
 Errors decreased by improved training
 (To Err is Human, IOM)
 Health Disparities
 (Unequal Treatment, IOM)
Communication competence
 As property of  As property of
individual interaction
 Assessment of  Assessment focuses
individual skills, on interactional or
abilities, or dyadic qualities,
behaviors (rating of including adaptation,
trainee) control,
collaboration (rating
of interaction)
Communication competence:
approaches
 Communication skills
 Conflict management
 Teamwork
 Teaching others (pts, students, peers)
Epstein and Hundert, JAMA, 2002
Implication of relational
viewpoint of assessment
 Focus is longitudinal
 Focus is cumulative
 Focus is on participants’ sense of
connection, satisfaction
 May be observable by non-participants
Methods for Teaching
Communication
 Didactic sessions
(lectures/demonstrations)
 Standardized patients
 Role play
 Video-tape review (with real or SP)
 Co-counseling sessions
 Observed counseling sessions
Layered levels of
communication competence
 Content level: topic management,
nonverbal cues/clues
 Process: pacing, facilitation,
congruence, nonverbal matching,
affective displays
 Meta-process: mindfulness, self-
observation, context-sensitivity
Why is communication
competence important?
 Facilitation of information exchange
 Development of a healing relationship
 Mutual development of patient and
physician (Candib, 1996)
“Ways of Knowing” and
Medicine
 Traditional Medical  Practicum Training
Education
Connected Knowing
 Procedural and Separate 

 Personal experience, context,

Knowing empathy
 Critical thinking, objectivity  Collaboration
 Limited for learning about person  Use of patient’s language
living the illness  Understanding of patient
 May be experienced as distant and perspective
sterile  Acknowledge effects of caring
 Actively exclude the self on provider
(Belenky, Clinchy, Goldberger, & Tarule, 1986; Candib, 1995)
Theoretical Assumptions about
Practicum
 The “art of medicine” lies in ability to
integrate multiple ways of knowing
 Feminist-relational approach requires training
in equalizing power relationships (Candib, 1995)
 Parallel process
 If we want residents to interact in this way with
their patients, we need to interact in this way
with our learners
 Group supervision opens the “black box”
Practicum Curriculum Goal

The goal of practicum training is to

improve resident physician
communication and counseling skills
through supervised counseling of
patients by peers and behavioral
faculty preceptors.
Curriculum Objectives
 Residents will increase knowledge of
 Basic counseling skills and methods
 Evidence-based behavioral medicine
 Residents will improve skills in
 Responding to patient questions
 Assessment of psychosocial and family context
 Integration of biomedical and psychosocial care
 Building relationships with patients and
families
Curriculum Objectives
 Residents will demonstrate attitude
change toward
 The importance of behavioral care in practice
 Greater self-confidence in counseling skills
 Greater mindfulness in patient care

 To provide an opportunity for faculty to

evaluate resident’s communication and
doctor-patient relationship skills
Selection of Patient Cases
 Residents invite their own patients who…
 Are medically or psychosocially complex
 Have an unclear social situation
 Are not compliant with medical advice
 Are difficult to manage or frustrating to providers
 Have “more going on here…”
 Residents have a ‘gut’ sense about abuse,
assault, family unrest, prior psychological
conditions
Practicum Format
 Pre-session (10-15 minutes)
 Resident presents brief history of patient

 Residents states his/her goals for the session

 Faculty intentionally do NOT make suggestions

 Resident counsels patient (25-30 minutes)

 Mid-session break (10-15 minutes)
 Resident reaction

 Faculty and peer feedback

 Faculty guidance and direction

Practicum Format
 Resident counsels patient (25-30
minutes)
 Post-Session (10-15 minutes)
 Resident reflections
 Session goals and expectations
 What he/she learned about the patient
 Personal thoughts or reactions to the patient
 How this information will help care for patient
 Peer and faculty feedback
Assessment
 Patient feedback (survey or interview?)
 Relational rating scale
 Four Habits analysis of interaction
(research assistant)
 Faculty feedback
 Resident-self assessment
The process…
 Models negotiating a relational agenda
 Reduces hierarchical barriers
 Encourages residents to shift to a more
open dialogue
 Opens new options for patient care
Residents shift……
FROM TO
 Monological dialogue  Open dialogue
 Focused information  Actively listening
gathering
 Doctor driven  Patient directed
conversation conversation
 ‘doing’ mind-set  ‘supporting’ mind-
set
Feedback from Residents
How did this session differ from other visits
with this patient?
 There was no right/wrong answer; no ‘pill’ would fix the
problem [shift away from ‘doing’]
 More personal, more time
 More emotional
 Patient did most of the talking [active listening, patient
directed]
 Visit was ‘non-medical’ – I was looking for clues in her life
about what support she will have when she has a child
[supportive]
Feedback from Residents
As a result of this visit, is there anything you will do
differently next visit?
 Be more sensitive about not giving my formal talks but
asking patient what she wants to know [patient
directed]
 Have a greater degree of suspicion when a patient
just answers everything is ‘ok’ [supportive]
 Pay more attention to psychosocial aspects of my
patients
 Understand the environment (psychosocial) a little
better
Feedback from Residents
What comments/suggestions do you have
about the process of live supervision?
 It is an excellent idea to do this throughout residency and
give feedback before we go into private practice
 I like the immediate feedback of live supervision. It keeps
me on track during the counseling session.
 Allow more debriefing time…also more ‘skeleton’ training in
counseling prior would be helpful
 Fun, be feel like people (supervisors/peers) have hidden
agenda/thoughts that they didn’t share
Feedback from Patients
Was this visit different from previous visits with
your doctor? In what ways?
 Normally examines you, but today he was a doctor,
my friend, a listener, helped me with my problems
[active listening, supportive]
 The other visits were like examinations…it helps to
know people more in depth to understand why a
person keeps smoking when they know they
shouldn’t
 The other one was more medical [patient directed]
Feedback from Patients
Will you do anything differently in
relation to your health as a result of your
visit today?
 Made me stop and think: “You count too,
take time for you.” Think it will be easier to
talk to him in the future.
 6/7 patients reported they will change
specific health behaviors because of this
visit
Comments from Patients
 It’s better when you have someone to talk to.
 He’s easy to talk to and he’s a good listener.
He doesn’t criticize.
 I like him. He’s a good doctor.
 Nice to be offered this because this time I
was really stressed….
 I know you can tell him and he understands
and tries to help you.
Future Research Goals
 Evaluate outcomes: Does practicum improve
 Doctor/patient relationship?

 Patient health outcomes?

 Patient satisfaction?

 Resident competency in communication and

relationship skills?